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By Orlando Blanco
In many respects, the response to this medical emergency
was quite different from those in most cardiac arrest cases.
In fact, the response was nothing short of overwhelming. As
soon as the main medical center was alerted, the hospital
staff providing medical coverage for the tournament quickly
dispatched a number of nurses, an ER physician, and other
CPR-trained personnel to the scene, both on foot and by golf
cart. By this time, initial CPR had been started by bystanders
and was eventually taken over by medical providers assigned
to the tournament.
Even an anesthesiologist and cardiologist who were attending
the tournament assisted in the resuscitation effort. The anesthesiologist
intubated the patient with equipment that could only have
been provided by the ambulance. This became an important reference
point in the arrival time of the ambulance unit, despite contrary
testimony of eye witnesses. The cardiologist, who had seen
the ambulance pulling up to the scene and followed it, eventually
rendered assistance in monitoring the patient's cardiac rhythm.
He likewise proved to be an important defense witness, testifying
that the patient was not extremely cyanotic upon his arrival,
which directly followed the ambulance's own arrival at the
scene. This testimony directly disputed the plaintiffs' theory
that the patient had been down for an extended period of time
and, according to some witnesses (family and friends), had
turned completely blue or cyanotic.
Despite an emergency response that clearly exceeded the typical
pre-hospital EMS response for cardiac arrest, this emergency
involved one key distinguishing factor. The emergency had
taken place at a mass gathering where a response cardiac
arrest was foreseeable and planned for. As a result, every
planning and coordination decision within the context of this
event was carefully scrutinized and attacked by the plaintiffs.
The plaintiffs' complaint against the ambulance company specifically
alleged a breach of the following duties:
- "Failing to promptly respond to a cardiac arrest of a
player participant at the tournament who required immediate
defibrillation and oxygen."
- "Failing to properly and adequately communicate and coordinate
with paramedics and other emergency personnel covering the
tournament to assure an immediate response."
- "Failing to properly and adequately plan, chart, designate,
and locate paramedics and emergency medical personnel for
immediate and accurate response by an ACLS unit with defibrillation
and oxygen."
- " Failing to properly locate ambulances in a position
and location throughout the tournament so as to most efficiently
and promptly respond to medical emergencies, especially
those requiring defibrillation and oxygen."
- " Failing to properly design and plan emergency vehicle
route that would be clear of road blocks, obstacles, games,
crowds, and other congestion."
- " Failing to properly and quickly effect communication
to confirm the location of the injury and failing to respond
to the appropriate court location and to properly confirm
the location of a cardiac arrest before proceeding to the
wrong court."
A quick response to any cardiac arrest is the goal of every
emergency medical service provider. The response time for
a cardiac arrest is rarely challenged in a court of law, because
of lack of foreseeability. Although cardiac arrest is certain
to occur some time and somewhere in the general population,
the exact time and place is generally unpredictable. In this
case, the plaintiffs were not faced with the nearly impossible
task of proving foreseeability. Indeed, it was precisely because
the tournament promoters foresaw the possibility of cardiac
arrest that they contracted for the ACLS coverage. This fact
became one of the main tenets of the plaintiffs' theory.
In summary, this multi-dimensional case provides a rare look
at a number of medical/legal liability issues presented in
a real world case. What follows
is a discussion of those issues woven into the context of
the facts of this unique and multidimensional liability case.
A Real-Life Expose of Changing Liability
Issues for Ambulance Companies
The case, as described in part one of this article, presents
a unique look at the following liability issues:
- EMS coverage for mass gatherings;
- Standards and guidelines: The use of EMS Studies: Sword
or Shield?; and ,
- The importance of understanding documentation of EMS runs.
EMS Coverage for Mass Gatherings
The majority of EMS providers have covered events that could
reasonably qualify as mass gatherings. Most providers simply
adopt their community standard operating orders or protocols
to provide whatever coverage the mass-gathering requires.
There is good reason for this. Currently, there exists no
uniform or widely recognized standards for providing emergency
coverage to mass gatherings.
Despite this fact, EMS providers must be prepared to meet
challenges in court predicated in many respects upon a higher
standard of care. Specifically, the EMS provider at a mass
gathering is very likely to meet strict scrutiny of response
times. The reason is straightforward, as in the litigation
discussed previous- the area of coverage in a mass gathering
is typically limited and always pre-designated. Long before
the event, the EMS provider knows (or should know) the approximate
area of coverage, the nature of the event, and the size of
the crowd expected.
Accordingly, it is crucial for the EMS medical coverage provider
at a mass gathering to have significant input into the decisions
on the number of units available and the nature of coverage
(i.e., BLS versus ACLS). The majority of mass gatherings covered
by the EMS provider are not huge events on the scale of the
Olympics or a Super Bowl. More often than not, the EMS provider
will be given little notice before the event. The notice may
be as simple as being contracted to provide a unit for a local
marathon race, school football game, or an annual community
gathering. Because an event's sponsor often decides the number
of units to cover the event. The EMS provider is left with
little, if any, input into this very crucial decision. It
is imperative that the provider analyze the nature and size
of the event prior to the mass gathering to determine the
number of units required for event coverage. Whether or not
the EMS provider participates in the decision on the number
of units for covering a specific event, a plaintiff's counsel
will surely make this a pivotal issue in any litigation in
which the ambulance's response time is at issue.
Deciding the type of coverage to provide for a mass gathering
(i.e., BLS versus ACLS) is equally important. Again, the sponsor
of the event may decide that BLS is sufficient. The EMS provider
must carefully analyze the event and the resources available
to determine which type of coverage should be available for
the particular mass gathering.
The provider should not rely exclusively on the desires of
the sponsor to decide the type or the number of units necessary
to cover a mass gathering event. Because of budgetary constraints,
sponsors will often make this decision based on costs alone.
Once a company has committed to provide event coverage. Litigation
opponents will make every attempt to hold the EMS company
responsible for having provided the type of coverage available
at the mass gathering.
For example, the Gus Macker Tournament enterprise
had specifically contracted for two ACLS units and one on-call
back-up located outside the city limits. The units were to
cover the tournament, encompassing an area of coverage of
nine blocks by eight blocks. Both of the plaintiffs experts
challenged the decision to bring only two ACLS units for the
tournament. Aerial photographs depicting both the geographical
area as well as the crowd size were used in an attempt to
convince the jury that the ACLS coverage was inadequate. The
plaintiff's challenge was buttressed by the fact that the
two ACLS units provided the only mobile defibrillators for
the tournament. Because the plaintiffs' emergency could only
be relieved with a defibrillator, the number of units provided
to cover the tournament was attacked by the plaintiffs and
their expert witnesses.
The lesson to be learned from that case is that every EMS
provider must be directly involved in all significant decisions
relating to EMS services for a mass gathering event. Although
no uniform or widely recognized standard exists for managing
mass gatherings, the very nature of such events and the medical
coverage provided is likely to subject the EMS provider to
a heightened standard of care.
The concluding segment of this article will discuss the use
of EMS studies in litigation and the importance of the documentation
of the EMS run.
Orlando Blanco is an attorney who has been actively engaged
in the defense of the EMS community on Michigan. He has successfully
tried to conclusion a number of lawsuits against ambulance
companies involving vehicular accidents, care and treatment
cases involving issues of mass gathering medical coverage
by EMS.
Editor's Note: This article has been edited to fit the format
of the AIJ. To request a complete, unedited version, please
contact the American Ambulance Association's Resource Library.
Proceed to Part
III
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