Many years ago I was asked if I wanted to be an expert witness/consultant in court cases involving paramedics. I declined. One of the reasons I declined was because I wrote a blog about being a paramedic that included descriptions of calls where things didn’t go as they do on TV (or as the public might expect). I imagined being cross-examined by an attorney. “So you are an expert on paramedicine, but isn’t it true that you yourself are guilty of (long list of failures)…”
They still wanted me, so I then sent them a blog post titled “Your Honor” which detailed a call I was on where I dropped a patient and one where I found myself with an empty oxygen tank. In the post, I imagined court room scenes.
“Your honor,” the prosecuting attorney declares “his oxygen tank was empty.”
Mic drop. (Patient drop.)
After sending the post to the firm, I never heard back from them.
Several years later, another attorney contacted me and wanted me to review a case in which she explained on the phone, a pregnant woman suffered cardiac arrest. The ambulance responded. The patient was in asystole. They did CPR for a bit, and then loaded her onto a stretcher. The ambulance broke down in the driveway. It was fifteen minutes before they could get it going. The woman was declared dead in the ED. I tried to explain to the attorney that the patient likely was already dead, and there was nothing the paramedics could have done. Getting a dead person to the hospital fifteen minutes earlier was not going to save her life. Don’t hold the paramedics at fault just because the ambulance broke down. She was upset I would not at least review the medical records. She was convinced the paramedics were to blame for the death. I gave her the name of someone I knew who did these cases, and was more than happy to punish medics who didn’t live up to the highest standards.
When I applied for the job I hold now as an EMS coordinator, in my interview, I was given a case where a longtime paramedic failed to pace a patient when it was indicated, and I was asked how I would discipline the paramedic. My response was that after fully reviewing the case, I would need to determine the degree to which this was a system failure as opposed to a personal failure of negligence. People make mistakes, I said. I have made many myself. Systems need to be set up to help individuals avoid mistakes. I would reeducate the paramedic, but I would also hold refreshers for all the medics on pacing, both the indications and mechanics of the skill. And no, I would not suspend the medic’s medical control. The only circumstances I would advocate for that would be lying, deliberate and gross negligence, or a pattern of failures.
They must have liked my answer because I got the job.
A Colorado jury found two paramedics guilty of negligent homicide for administering ketamine to a young man who they believed was suffering from excited delirium. The prosecution expert witnesses claimed the paramedics were at fault for the young man’s death because they relied on police accounts of the man’s behavior, instead of conducting their own assessment. They failed to take vitals signs before giving the young man too high a dose of ketamine–a drug the attorney claimed they shouldn’t have been giving in the first place for a condition–excited delirium–that has been discredited as an excuse to sedate minorities in police custody.
The Defense experts responded. While the term of excited delirium has been controversial, the fact is that the medics had been taught about it and their protocol said administer ketamine in the case of excited delirium. True, the medics gave too high a dose after overestimating the patient’s weight, which can happen. As a defense expert said, they don’t carry scales on an ambulance. The defense expert also told the jury that paramedics don’t have to actually lay their hands on a patient to assess them. You can tell a lot about airway, breathing and circulation just by looking at someone, the expert said.
I watched the case as if I were on trial myself. I have on many occasions arrived on scenes where police were holding violent patients down, and I have administered sedatives to these patients without first taking a blood pressure or pulse, which are often difficult/impossible to do when the patient is violent. My view on the case was the young man died tragically, more due to an overdone police response, including a choke hold, than paramedic negligence.
I was contacted on this subject of paramedics administering ketamine for a reporter for a nationally known newspaper a couple years ago. I told her that such a scene was not usual. I told her that according to the NEMSIS data bank, Ketamine had been administered by EMS over 100,000 times that year. (Not all of these were for sedation; ketamine is also used for pain management but surely several ten thousands were for sedation.) I never heard back from her and never saw the article she was working on.
Should the paramedics have trusted the police officers’ accounts of the patient’s behavior? That advice is part of the assessment, the experts argued. I agree. Sometimes I trust what is told to me by witnesses, sometimes I don’t. I have ignored these accounts at times, and occasionally had peril ensue because of it. A patient who did not appear violent at the moment I arrived later tried to push me down a flight of stairs after I’d asked the police to let him up. A woman who onlookers said had collapsed and they had done CPR on, looked perfectly fine, and then five minutes later, there I was alone in the back of the ambulance doing CPR, having dismissed the other responding crew.
In EMS we deal with the unknown and are often on the verge of chaos. No two calls are the same. Decisions are made sometimes in split seconds. You have to go with your gut. It isn’t like TV. And then recalling every detail of what you saw and why you did what you did is not always that easy. The fog of EMS.
I was deposed for a call where a man was suing another man over a drunken fall down a flight of stairs during a party. I was grilled about everything I saw on the call. (The injured man lay unconscious at the bottom of the basement stairs with party goers stepping around him like a scene from Weekend at Bernie’s.) The more questions they asked me about that night the harder it was to remember everything I saw and did. Had I gone or had my partner gone for the c-collar? Who took his blood pressure? What were the people in the party doing? What did the host say to me? How steep were the stairs? In the end I was asked to summarize my memory of the events. “Somethings I remember well,” I said, “Some not so well, other, not at all.” One attorney beamed, the other smacked her forehead with her open palm.
I am not excusing poor paramedicine, I am only saying that the outcome in this Colorado case would likely have been the same for many other paramedics had their number been called that night.
Elijah McClain did not die because of the bad intent of individuals; he died because of a flawed system that caused someone to call 911 and police to engage and tangle with him, including using a choke hold, and paramedics, trained in administering ketamine to people with “excited delirium” to do just that. Being a paramedic is a hard job, as is being a police officer. Punishing the individuals in this case will not result in the needed changes.* You have to address the system.
I concluded my Your Honor blog post was follows:
Lawyers are just starting to turn toward paramedics and ambulance companies. I have, at times, thought about going to law school. As a paramedic lawyer I might be a hot commodity. But what would that entail, using my knowledge to show how some other medic screwed up. I could do that, but I could also illegally dump toxic waste for a couple hundred dollars a barrel. Maybe I could represent paramedics and ambulance companies, using my knowledge to show shit does happen, and people do the best they can with what they have. On the other hand, the EMS system could be better than it is. Maybe people have a right to sue. I mean, who do you want coming to your house? I guess there are always two sides — what you should expect and what the world delivers. Lawyers are there to argue each way.
Its a shame in the end it is always individuals who pay for the failings of the system. If there is a take home message, it is, as paramedics, we have to do the very best we can. The world is watching as it should be. The increasing threat of criminal suits for bad medical outcomes may scare some of us out of the field. For the rest, it is just another hazard of the job we love, along with risk of personal harm from physical trauma, infectious disease, emotion burnout and PTSD. Someone needs help, we answer the call.
* In the George Floyd case where the police office kneeled on Mr. Floyd’s neck and did not get off, despite warnings, I support the sentencing against that individual.