vs. )
) PINELLAS COUNTY BOARD OF COUNTY ) COMMISSIONERS, OFFICE OF THE ) MEDICAL DIRECTOR, )
Respondent. )
Case No. 03-1274
Pursuant to notice, a final hearing in this case was held on June 19, 2003, in St. Petersburg, Florida, before Carolyn S. Holifield, Administrative Law Judge of the Division of Administrative Hearings.
For Petitioner: Robert F. McKee, Esquire
For Respondent: Robert D. Hall, Jr., Esquire
The issues in this case are whether Petitioner committed the alleged violations and, if so, should her paramedic license be revoked.
By letter dated March 28, 2003, the Pinellas County medical director advised Petitioner that her Pinellas County Paramedic Certificate was conditionally revoked. The medical director took this action because Petitioner allegedly withheld proper patient care to a shooting victim and, subsequently, falsified a Patient Care Report regarding the shooting victim in violation of Pinellas County Emergency Medical Services rules, regulations and protocols. Petitioner is charged with violating Emergency Medical Services Protocols 2.3 and 10.8 and specified Pinellas County Emergency Medical Services rules and regulations.
Petitioner denied the allegations and timely requested a formal hearing. The matter was forwarded to the Division of Administrative Hearings for assignment of an Administrative Law Judge to conduct the hearing and prepare a recommended order.
At hearing, Respondent presented the testimony of Petitioner Linda Mancini-Taylor; Toni Lanahan, a firefighter/paramedic; Brian Brooks, an emergency medical technician; Jeffrey Bernard, executive director of the Office of the Medical Director, Pinellas County Emergency Medical
Services; and Laurie Romig, M.D., the medical director of the Pinellas County Emergency Medical Services. Respondent's Exhibits 1, 3, 4, 6-9, and 11 were received into evidence.
Petitioner testified on her own behalf and called one witness, Brian Campbell, an emergency medical technician. Petitioner offered no exhibits into evidence.
The Transcript of the proceeding was filed on July 14, 2003. At the conclusion of the hearing, the parties agreed to file proposed recommended orders ten days after the Transcript was filed. Prior to that date, at Petitioner's request, the time for filing proposed recommended orders was extended to August 1, 2003. The parties timely filed Proposed Recommended Orders under the extended the time frame, which have been considered in preparation of this Recommended Order.
All citations are to Florida Statutes (2002) unless otherwise indicated.
At all times relevant to this proceeding, Petitioner was employed as a paramedic by the City of Gulfport and worked as a paramedic for the Gulfport Fire Department. In this capacity, Petitioner worked under the auspices of the medical director for Pinellas County Emergency Medical Services (Pinellas County EMS).
Petitioner was a paramedic from 1997 until March 2003.
Prior to that time, from 1991 until 1997, she worked as an emergency medical technician (EMT).
On February 20, 2003, Petitioner, along with Lt. Brian Campbell and Firefighter/EMT Dennis Jackson, were called to respond to the scene of a shooting. Petitioner was the only paramedic on the scene and, therefore, the only person on the scene certified by the Office of the Medical Director (OMD) to provide advanced cardiac life-saving treatment. Petitioner received the call at 12:22 a.m., and arrived at the patient's side at 12:30 a.m.
When Petitioner arrived at the patient's side, she observed a white male, approximately 20 years old, lying on his back in the street. His skin color was ashen, his mouth and eyes were wide open, and his pupils were fixed and dilated. Upon physical examination, Petitioner could not detect a pulse and observed two small holes in the patient's trunk. At that point, Petitioner did not know whether the two holes represented two separate entry wounds or one entry and one exit wound. Petitioner observed a trail of blood, at least a block long, leading to the patient, but there was not a lot of blood around the patient.
Petitioner attached an electrocardiogram (ECG) monitor to the patient to monitor the electrical activity of his heart.
When Petitioner first turned on the ECG monitor, she observed four ticks of electrical activity within a 14-second span.
Petitioner testified that based on her observation and physical examination of the patient, she believed that the electrical activity exhibited on the ECG monitor was not pulseless electrical activity (PEA), but rather "artifact" caused by her manipulation of the patient. Petitioner further testified that, thereupon, she stopped touching the patient and observed that the ECG read-out went mostly flat, showing only occasional ticks.
Petitioner testified that these occasional ticks, as observed on the ECG monitor, indicated to her that the patient was in asystole. Shortly thereafter, Petitioner declared the patient dead.
After Petitioner declared the patient dead, she prepared a Patient Care Report (Report or Patient Care Report) while still on the scene. In the Report, Petitioner wrote that she found a white male laying on the ground with an apparent small entrance wound in his upper chest and a possible small exit wound near his back rib. She further noted that the patient's temperature was normal, that his eyes were fixed and dilated, that he was not breathing (apneic), and that he had no discernible pulse.
Petitioner also noted in the Report that the patient was in asystole within one minute after the ECG pads were attached, but she failed to note the initial four ticks she observed, which may have represented PEA.
In the Report, Petitioner noted that at 12:30 p.m., the patient was hooked up to the monitor; at 12:31 p.m., he was asystolic; and at 12:32, she confirmed the patient dead.
Upon completing the Report at the fire station, Petitioner attached to the Report the last of several ECG strips she had intermittently printed while at the patient's side. The ECG printout that Petitioner attached to the Report depicted a classic "flat line" indicative of asystole or no electrical activity. Petitioner discarded each of the ECG strips that contained some indicia of electrical activity.
A Patient Care Report is a legal document that Petitioner is required to complete by law. By signing the Report, Petitioner acknowledged that the information contained in the Report was true and accurate.
Later, on the morning of February 20, 2003, when the employees' shifts at the fire station were changing, Petitioner and Toni Lanahan (Lanahan), a firefighter/paramedic coming on duty, talked about the shooting incident. That such conversation occurred is undisputed. However, there was conflicting testimony as to what Petitioner told Lanahan during
that conversation. According to Lanahan, Petitioner told her that when she (Petitioner) arrived at the scene, the patient looked dead but she hooked him up to the ECG monitor, that he had a rhythm but she did not work him, and that she turned off the monitor. Petitioner testified that she did not tell Lanahan that the patient had a heart rhythm, but only that the patient "was dead" and that she did not work him.1
About two hours after her conversation with Petitioner, Lanahan retrieved stored ECG code summary data of the patient described above.2 When Lanahan reviewed the ECG code summary, she saw that the patient had a presenting ECG rhythm showing approximately 40 beats per minute of PEA with gradually slowing PEA for the entire seven minutes depicted in intervals on the ECG summary.
Based on her review of the ECG record of the gunshot wound patient, Lanahan believed that in this situation, the OMD protocols mandated that immediate resuscitative treatment be administered.
Lanahan then reported these concerns to her emergency medical services (EMS) Coordinator, Lt. Marenkovic, who in turn, reported the incident to Gulfport Fire Chief Brian Brooks. Chief Brooks notified the OMD of the possible violations of its protocols by Petitioner.
The OMD initiated an investigation, which included reviewing the written statements of Petitioner, Lt. Campbell, and EMT Jackson; the ECG code summary for the incident; Petitioner's Report; and the transcripts of the sworn interviews of Petitioner, Lt. Campbell, and EMT Jackson taken by the Gulfport Fire Department.
After reviewing the above-referenced documents, Dr. Laurie Romig (Dr. Romig), the medical director of the Pinellas County EMS, decided to revoke Petitioner's certification. This decision was based on Dr. Romig's determination of the following: (1) Petitioner violated numerous protocols in the Medical Operations Manual, both administrative and direct patient care protocols; and
(2) Petitioner attempted to make the situation appear differently from what it turned out to be, and that, apparently, she did that on purpose.
Specifically, Dr. Romig charged Petitioner with violating Pinellas County Emergency Medical Services Protocol 2.3, Sections 5 and 6, and Protocol 10.8 and the
following Pinellas County Emergency Medical Services Rules and Regulations: Sections XIII-3-b, related to falsification or inappropriate alteration of emergency medical services records; XIII-3-e, related to theft or dishonesty in performance of duty; XIII-3-i, related to demonstrated ability, failure or refusal to
adhere to established protocols and standards as established by the authority; and XIII-3-k, related to just cause, including unbecoming behavior or unprofessional conduct reflecting a poor system image.
The Pinellas County emergency protocols are written requirements that paramedics must follow when administering emergency treatment to patients. The protocols are published in a document entitled Pinellas County Medical Operations Manual, which is approved by the medical director and distributed to all Pinellas County EMS paramedics. Petitioner received a copy of the most recent medical operations manual in January 2003.
EMS Protocol 5.10 prescribes treatment for patients presenting with PEA. As defined in Protocol 5.10, PEA is "any semi-organized electrical activity that can be seen on a monitor screen although the patient lacks a palpable, radial, brachial, or carotid pulse." When PEA is present in a patient,
Protocol 5.10 mandates that immediate life-saving treatment be implemented.
The patient initially had electrical activity.
Nonetheless, Petitioner did not follow Protocol 5.10. According to Petitioner's testimony, she believed that the patient was asystolic and, thus, the protocol related to PEA was inapplicable to the shooting victim. Petitioner's belief was not supported by the ECG report.
Protocol 5.4 delineates the procedures to be followed in the treatment of asystole. In the book utilized for Pinellas County EMS paramedic training, "asystole" is defined as a cardiac arrest rhythm associated with no discernible electrical activity on the ECG ("flat line"). Significantly, Protocol 5.4 and Protocol 5.10, discussed in paragraph 21, require that resuscitative efforts be started immediately and that such resuscitative efforts and treatment be terminated by the paramedic only "after 10 minutes of continuous asystolic arrest with appropriate interventions."
Even if Petitioner's assertion that the patient was asystolic is accepted, she failed to provide the required resuscitative efforts and/or treatments prescribed by Protocol 5.4. Petitioner did not prematurely terminate resuscitative efforts, she never implemented them.
Protocol 5.15 prescribes the treatment and transport considerations for "patients with cardiac arrest secondary to trauma, regardless of presenting cardiac rhythm." The protocol provides that such patients should be transported to the closest hospital emergency facility. Contrary to the requirements in Protocol 5.15, the patient was not transported to a hospital emergency facility.
Protocol 2.3 requires paramedics, when possible, to contact and consult with On-line Medical Control (OLMC) in any
case in "which a deviation from protocol has been made intentional or otherwise." The OLMC is a system which allows paramedics to contact the OMD and consult with a medical doctor regarding a situation in the field.
Petitioner clearly deviated from Protocols 5.4 and/or 5.10, by failing to initiate and implement the resuscitation procedures required by both protocols, and Protocol 5.15, by failing to have the patient transported to a
hospital emergency facility, yet she never contacted the OLMC as mandated by Protocol 2.3.
Petitioner acknowledged that she did not follow either Protocols 5.4 or 5.10, both of which required immediate resuscitative efforts. Petitioner testified that instead, she followed Protocol 10.8, which provides an exception to the protocols that require initiation of resuscitative efforts. Petitioner contends that Protocol 10.8 provided the basis for her withholding resuscitation from the patient.
Protocol 10.8 requires that cardiopulmonary cerebral resuscitation (CPCR) be initiated "in all cases when the patient is found in cardiopulmonary arrest unless one of the exclusion or special situation criteria applies." The exclusion criteria provides that CPCR may be withheld if the patient has, "in conjunction with apnea, pulselessness and asystole on the ECG," an "obviously unsurvivable trauma." If CPCR is withheld,
Protocol 10.8 requires that exclusion criteria be fully documented and described.
Protocol 10.8 does not define "obviously unsurvivable trauma." However, according to Dr. Romig, the term connotes catastrophic injuries observable by an untrained eye.
Dr. Romig, an expert in emergency medicine and traumatic cardiac arrest, testified that nothing about this patient, based on her review of the records and documents, indicated that the patient had suffered an "obviously unsurvivable trauma." Also,
Lt. Campbell, an EMT certified for 12 years, who was at the scene, testified that although the patient "looked dead," he could not say that the patient suffered an "obviously unsurvivable trauma" because the patient showed only a small bullet wound to the chest and a "little bit" of blood on his (the patient's) clothing.
The weight of the evidence showed that the patient had not suffered an obviously unsurvivable trauma.
However, even accepting Petitioner's testimony that she believed that the patient had suffered an obviously unsurvivable trauma, she failed to comply with Protocol 10.8. If Petitioner, in fact, relied on Protocol 10.8 in deciding to not administer CPCR, she was required to document and describe the exclusionary criteria, which was the basis of her decision
to withhold CPCR. Petitioner failed to provide any such documentation and, thus, violated Protocol 10.8.
In addition to violating the above-noted protocols, Petitioner was dishonest in the performance of her duties as a paramedic and also falsified EMS records.
The ECG summary showed that despite the patient's having electrical cardiac activity of at least 40 beats, Petitioner turned off the ECG machine and pronounced the patient dead. After pronouncing the patient dead, she then turned the ECG machine on again, and intermittently printed activity on four separate occasions until reaching a reading showing no electrical cardiac activity. By engaging in this conduct, Petitioner was dishonest in the performance of her duties.
Paramedics are required to truthfully and accurately complete the Patient Care Records of patients for whom they provide emergency medical services.
Here, the ECG summary showed PEA of over 40 beats per minute initially and diminished electrical activity for over eight minutes total, six minutes of which were after Petitioner had already pronounced the patient dead. Petitioner initially saw a rhythm of four beats or ticks in a 14-second period, which was a beat rate of 40 and showed on the ECG strip as 42. Although the initial reading of approximately 40 beats and PEA was clearly visible during the entire nearly eight minutes
depicted on the six-second intervals shown on the ECG code summary, this was omitted from Petitioner's Report.
Petitioner omitted from the patient's Record the ECG readings that showed electrical activity. Instead, Petitioner reported that at the time she declared the patient dead, he was in "asystole" when, in fact, the ECG summary showed PEA. Moreover, Petitioner documented the Report with an asystole ECG strip reflecting a "flat line" reading printed some six or seven minutes after the reported time of death.3
Petitioner admitted during her sworn statement and at this proceeding that she deliberately did not attach to the Report any part of the ECG strip that reflected the interim electrical activity. Petitioner testified that the ECG strips showing interim electrical activity could raise doubts about the propriety of the treatment she gave this patient in a future criminal trial or other investigation.4
The medical director is required by law to ensure that Pinellas County EMS personnel provide quality care and are not a danger to the safety of the county's citizens, residents, or visitors. Here, Petitioner violated the protocols related to the standard of care for patients and completion of reports and rules and regulations related to dishonesty in the performance of duties and to falsification of records. These infractions are a possible threat to public health and safety of residents
of and visitors to Pinellas County. As such, they constitute just cause to conditionally revoke Petitioner's Pinellas County Paramedic Certificate.
The conditional revocation allows Petitioner to reapply for a paramedic certificate in two years. Such recertification may include a one-year probationary period, with monitoring by the medical director to include a review of all trauma-run reports.
Petitioner's Pinellas County Emergency Medical Technician Certification was not revoked and she retains that
certification.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties to this action pursuant to Sections 120.57 and Subsection 120.68(8).
Pursuant to Subsection 401.265(1), the medical director "must supervise and assume direct responsibility for the emergency medical technicians and paramedics operating for that emergency medical services system."5 As the medical director of the Pinellas County EMS, Respondent supervises and assumes direct responsibility for EMTs and paramedics in that system.
Respondent alleges that Petitioner violated Pinellas County Emergency Medical Services Protocols 2.3 and 10.8 and the
following Pinellas County Emergency Medical Services Rules and Regulations: Sections XIII-3-b, related to falsification or inappropriate alteration of emergency medical services records; XIII-3-e, related to theft or dishonesty in performance of duty; XIII-3-i, related to demonstrated ability, failure or refusal to adhere to established protocols and standards as established by the authority; and XIII-3-k, related to just cause, including unbecoming behavior or unprofessional conduct reflecting a poor system image. For these alleged violations, Respondent seeks to conditionally revoke Petitioner's certification as a paramedic in Pinellas County, Florida.
To prevail, Respondent must prove the allegations against Petitioner by clear and convincing evidence. Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987); and Evans Packing Co. v.
Department of Agriculture and Consumer Services, 550 So. 2d 112 (Fla. 1st DCA 1989). Respondent has met its burden.
Respondent proved by clear and convincing evidence that Petitioner improperly withheld patient care to a shooting victim; that she falsified or inappropriately altered Pinellas County EMS records; that she was dishonest in the performance of her duties; that she was unable, failed to, or refused to adhere to established protocols and standards as established by the medical director; and that just cause exists warranting the
conditional revocation of Petitioner's Pinellas County Paramedic Certificate.
RECOMMENDED that Respondent enter a final order finding Petitioner guilty of the violations alleged in the Notice of Revocation dated March 28, 2003, and upholding revocation of Petitioner's Pinellas County Paramedic Certificate.
DONE AND ENTERED this 1st day of October, 2003, in Tallahassee, Leon County, Florida.
CAROLYN S. HOLIFIELD
Filed with the Clerk of the Division of Administrative Hearings this 1st day of October, 2003.
1/ The conflict in testimony regarding the conversation between Petitioner and Lanahan need not be resolved because it is not dispositive of the case. However, the record indicates that this conversation was the basis of Lanahan's decision to retrieve and review the archival ECG records of the incident,
which was the subject of the conversation. Moreover, regardless of what Petitioner told Lanahan, Petitioner admitted that she, in fact, had initially observed electrical activity or heart rhythms in the patient.
2/ This action by Lanahan was not unusual. She regularly retrieved and reviewed such records to see what procedures were used on patients in various situations and to determine what she would have done in that situation. Lanahan viewed this as a means of sharpening and evaluating her own skills as a paramedic.
3/ The ECG strip attached to the Report was the only ECG strip that showed a true "flat line" asystole.
4/ Petitioner acknowledged that in a sworn statement made during the OMD investigation, she gave the following reason for attaching the particular ECG strip to the Report: "But I also know I'm going to court and I'm going to have people ask me, 'Is this really asystole, because it doesn't look like what I know as asystole.' Then I would have to explain that . . . if I go to court, I don't want to have to explain those beats personally. I know what they mean, a doctor knows what they mean, but a lawyer doesn't know what they mean necessarily. So I put a flat line."
5/ The emergency medical services personnel, including paramedics, operate under the medical license of the medical director. Pursuant to Section 401.265(3), "[a]ny medical director who in good faith gives oral or written instructions to certified medical services personnel for the provision of emergency care shall be deemed to be providing emergency medical care or treatment for purposes of s. 768.13(2)."
Robert D. Hall, Jr., Esquire Tracey Jaensch, Esquire
Robert F. McKee, Esquire Kelly & McKee
Emergency Medical Services Group, Inc. Pinellas County EMS
15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
