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Striking a Patient is Never Warranted

2K views 32 replies 20 participants last post by  NONAME762 
#1 ·
http://www.jems.com/Columnists/Maggiore/articles/243804/

Striking a Patient is Never Warranted
By W. Ann Maggiore

Many EMS services have adopted a "zero tolerance" policy in the wake of allegations of patient abuse by EMS providers. This case, with a series of appeals to higher courts, demonstrates that a court will uphold a termination for striking a patient.

Clifton Noland was a paramedic with the Maryland Aviation Administration, which is part of the Maryland Department of Transportation. He received satisfactory employment evaluations from 1988 to 1992; in 1993 and 1994 he received superior ratings. From 1995 to 1998, he received "exceeds standards" ratings on his performance reviews.

According to the unpublished case, the service issued a Workplace Violence Policy in May of 1997. Each employee was asked to read and sign a copy, certifying that they had read the policy and would comply with it, as a condition of employment. On March 30, 1999, Noland's unit received a call at the Baltimore/Washington Airport, where they were stationed. A police officer requested assistance in transporting a combative psychiatric prisoner to the North Arundel Hospital. The EMTs put on latex gloves and brought their stretcher into the police station, where the patient was in a cell. The police informed Noland that the patient was spitting and drinking water from the toilet in his cell. Noland returned to his unit and obtained protective face shields.

As the police opened the cell, the patient spit onto one of the officers' face, neck and chest. After the paramedics asked that the patient be placed prone on the stretcher, the police restrained the patient with handcuffs, but supine rather than prone as the paramedics had requested. Noland placed a face shield on the patient, secured him to the gurney and began moving him from the police station.

The patient, shouting expletives and threats to kill the paramedics, managed to dislodge the face shield and spit at Noland. Noland struck the patient in the face with a closed fist and then reattached the face shield. The police officers and the second paramedic observed the blow and made no comments. As they continued to push the gurney from the station to the ambulance, the patient again dislodged the face shield and spit at Noland. Noland struck the patient a second time with a closed fist. The patient did not sustain any visible injury, and the paramedics did not report the incident to the hospital staff.

They completed their run report, but did not include any statements about Noland striking the patient. No one reported the incident to the service's EMS Coordinator or to the shift supervisor. However, the second paramedic did discuss the incident with the EMS Coordinator and asked whether it should have been reported. The EMS Coordinator told him that it should have been reported and then reported it to the Division Chief. The Chief instructed the EMS Coordinator to obtain written statements from all witnesses.

Dr. Phillip Phillips, the service medical director, was informed of the incident on April 15, 1999, and immediately suspended Noland's medical control. The next day, the Maryland Institute of Emergency Medical Services System suspended Noland's license for a year as the fire department began its investigation. The investigation was completed a few days later, and the second paramedic was also suspended without pay for five days for failing to report the incident.

Noland was terminated on July 2, 1999, for striking the patient and for failing to report the incident. Noland appealed his termination, and an Administrative Law Judge heard the proceedings on April 20, 2000. The ALJ concluded that Noland did not violate the policy, because he had testified that he struck the patient not out of anger, but instead "to prevent or reduce possible exposure to an infectious disease." However, the judge did conclude that Noland had used excessive force, and had failed to report the incident, recommending a suspension rather than termination. Dr. Phillips and the Fire Chief testified that it is never warranted to strike a patient.

The judge, while admitting that the service could terminate Noland, recommended against termination because of his prior record being free of discipline. Administration appealed, and a final administrative decision was issued on July 27, 2000, with a finding that Noland had, in fact, violated the Workplace Violence policy. Noland appealed to the Circuit Court, which overturned the termination based on a finding that it was disproportionate to the offense. Management again appealed, and the Court of Appeals ultimately held that the circuit court was not authorized to overturn the termination.

This case, released in 2005, illustrated that EMS managers are willing to take their workplace violence policies seriously, and that they are willing to go the extra mile to enforce them. This case took several years to make its way through the administrative tribunals and into the court system with a series of appeals. The question that the courts struggled with was whether the employee's overall employment history should be considered in light of a single offense for which termination is permissible. The courts wanted to insure that the "punishment fits the crime." Ultimately, the courts relied on the testimony of the medical director and the fire chief — that there is no circumstance that warrants the striking of a patient.


More articles by this author

W. Ann Maggiore, JD, NREMT-P, is an attorney and a paramedic in Albuquerque, N.M. She has been a full-time paramedic, an assistant fire chief and a state EMS administrator. Currently, she practices law full time, defending physicians, police and EMS personnel against lawsuits. She is a frequent lecturer on EMS legal issues at national conferences and holds a clinical faculty appointment at the University of New Mexico School of Medicine, where she teaches legal issues to faculty, residents and paramedic students. Contact her via e-mail at desertrose1@wildblue.net.
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My reply to the author:

Dr. Maggiore,

Having just read your column, "Striking a Patient is Never Warranted," I must disagree. Your blanket statement does not recognize the human right of self defense. While most readers are intelligent enough to read between the lines, your published statement has set a standard.

If a patient should suddenly attack me with a lethal weapon, such as a knife or gun, or commence a determined physical assault, I believe that striking the patient is certainly warranted; being struck will be the least of his worries. I am prepared to use whatever force is necessary to protect my life.

If my service should feel the need to terminate my employment over such an incident, at least they will not have to serve notice to my gravesite.

On another note, was the Paramedic also a Law Enforcement Officer? I was under the impression that all Paramedics employed by the State of Maryland were Troopers. If so, was this not a factor?

Alan W. Rose
 
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#2 ·
I've personally seen a petite female (whacked out on dope) become so instantly and explosively violent AKA so totally ballistic/agressive that it took two Medics and two hefty police officers to finally get her restrained on the stretcher.
Her "friends" had tossed her out of their moving car into the street.

The entire ambulance was rocking back & forth once they got her inside and she had gouged one officer across the face (in his eye area) with her finger~nails.
That officer could EASILY have lost his sight in that one eye.

These people who are high on certain drugs act worse than rabid raccoons.
 
#29 ·
Agreed. One of the most painful altercations I was in involved a petite "lady of evening" and a set of metal stiletto heels. She was so juiced up that while an officer was cuffing her she was able to push off of him and plant both heels into my chest (drop kick). Vests were not issued to us back in the dark-ages, so I ended up with two orange-sized knots under my collar bone. The melee that followed looked like two grizzly bears fighting a panther in a parking lot.
 
#3 ·
I have successfully used Aikido to "calm" individuals (patients, family members of patients, etc) which are a bit "excited" many times without fail.... This way one can avoid resorting to strikes and the liability that goes with them.....

It is unfortunate that sometimes the violent individual will "hurt themselves" (fallling, etc) when attempting to continue an assault
on someone who is trying to help them...... However, it is less unfortunate than having to receive medical care myself.....

It is good to advise the offender that it is in their interest to discontinue the assault or they may injure themselves by falling on the slick floor....

If they are armed, then alternative methods are in order of course.....
 
#4 ·
What a bunch of weenies.
You've got a crazy guy that drinks water from toilets spitting at everyone and raising cain.

That should have warranted an azz whoopin right there on the spot...and I dont mean a gentle one.

You've got an paramedic with way abover average ratings and no disciplinary action on record. He did what he had to do to stop the assault on himself. Clear and simple.

You have at least one judge saying yeah, he shouldnt have done it, but it aint worth firing him over it. Then you have two politically correct,touchy feely fools that feel they must use ZERO tolerance on any patient that is trying to kill everyone around them. :rant:

The heck with any one elses rights, lets cater to the crazy man that is a liablity to society and as crazy as the day is long.:rant:

Pitiful. Absolutley pitiful.:nono: :rant: :aargh4:
 
#28 ·
What a bunch of weenies.
You've got a crazy guy that drinks water from toilets spitting at everyone and raising cain.

That should have warranted an azz whoopin right there on the spot...and I dont mean a gentle one.

You've got an paramedic with way abover average ratings and no disciplinary action on record. He did what he had to do to stop the assault on himself. Clear and simple.

You have at least one judge saying yeah, he shouldnt have done it, but it aint wirth firing him over it. Then you have two politically correct,touchy feely fools that feel they must use ZERO tolerance on any patient that is trying to kill everyone around them. :rant:

The heck with any one elses rights, lets cater to the crazy man that is a liablity to society and as crazy as the day is long.:rant:

Pitiful. Absolutley pitiful.:nono: :rant: :aargh4:
You hit this one squarely on the head HotGuns.
What I never saw while reading the entire first thread is the instigator in all of this commotion was NOT a patient!!! He was a PRISONER from the nutjob ward. The EMT who was disciplined and later fired was defending himself from a wacko prisoner NOT a patient. Furthermore at some point the second EMT needed his butt kicked by the first EMT just on general principal. I was glad to see EMT#2 get suspended for 5 days for being a jerkoff.

Those 2 judges of the touchy-feely politically correct crowd should be terminated or thrown out a window 3 stories up.
 
#6 ·
Dr. Phillips and the Fire Chief testified that it is never warranted to strike a patient.
What a crazy sweeping statement. I sure don't condone violence just because it's the easy option but heck - there are some folks where pretty severe methods are needed to control them and ensure safety of the team.
 
#15 ·
Something Is Missing Here...



You don't see Dr. Phil or Judge X working with the patient do you?

Had a kid in our high school who was quick with the F.U.'s...the principal said that we needed to understand this kid...tough home environment you see...

Well, one day the kid was in the hallway and the principal was trying to move the 'crowd', when this kid put on his 'smarta**' routine. The principal told him to settle down...but the kid told him what he could S**K and added in a few F.U.'s...

Boom...3 days out of school...
Mmmmmm, somehow it was different then...I didn't notice any attempt to try and understand this kid then!

Analogy...
I guess when you are out of work it's a recession, but when I'm out of work it's a depression...Mmmmmm.

OMO

ret:urla9ub:
 
#7 ·
Not to get all touchy-feely liberal on you guys, but isn't the primary law of medicine "First do no harm"? I'd like to think the EMT after already being warned that he was dealing with a spitter, could think of some way to deal with the situation rather than hitting his patient. Perhaps some wide tape to cover his mouth, or toss a pillow case over his head.

It seems obvious the guy was not in his right mind, and the EMT should have used some better judgement.
 
#12 ·
"First do no harm"--I'm not trying to "add fuel to the fire" one way or the other, I'm simply asking...do other persons besides physicians in the medical profession take the Hippocratic Oath?
 
#8 ·
Being spit on is pretty rough, it triggers in a instance, violent reaction in most people - even more so than being pushed, or punched. As a nurse, I've been spit on a few times and come close to losing my cool.

That said, I have to agree with the author that (unless it is in self-defense) there is never a reason to strike a patient, espically with a closed fist. The cops should have four pointed the person face down in the first place.
 
#9 ·
The face shield the paramedic put on the pt was the "first do no harm" step (completed)...after that, it's "go home alive and intact"

I'd be pretty pissed at the 2nd paramedic for not discussing it with the first...not "hey...hypothetically....(proceed to dime out paramedic #1)"

As far as the zero tolerance policy--the rest of the world does not adhere to said policy...it's a violent and dangerous world out there that laughs at "zero tolerance policies" and BGs take that as license to do whatever they want, knowing they can sue and get awarded damages or get plain get away with beating a public servant.

These EMS supervisors need to get out of their office and do a couple of runs over a holiday weekend...remind them where they came from (if they were ever line medics)
 
#27 ·
These EMS supervisors need to get out of their office and do a couple of runs over a holiday weekend...remind them where they came from (if they were ever line medics)
Exactly. I have a friend who is a firefighter paramedic. She has told me that there are lots of calls they will not go on until police have arrived. (She works in a town that's essentially a craphole.) That should tell you something about what often faces these emergency responders.
 
#10 ·
It seems obvious the guy was not in his right mind, and the EMT should have used some better judgement.
Having have dealt that way with a few whackos at the ER, that it would appear that he used some great restraint.

Sometimes dealing with an angered ,violent drug induced mentally disturbed person is like trying to put a sheet on a tornado.

Its never as easy as it sounds.
 
#16 ·
No doubt striking with a closed fist was poor judgement, and seems to be counter to the Paramedic's claim that he did not intend to "strike" the patient.

"First do no harm"--I'm not trying to "add fuel to the fire" one way or the other, I'm simply asking...do other persons besides physicians in the medical profession take the Hippocratic Oath?
The Hippocratic Oath is not required. Paramedics don't take it. There is an EMT's Oath, which is similar, but not required.

I have copied some information below. Regarding the bold sections:

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses

Being a Christian, not gonna happen.
A well respected EMS Physician recently quoted these sections, but he was also complaining that some EMS students didn't like his Physician level instruction in Anatomy and Physiology, because it contradicted with their Christian beliefs. (NOT starting a religious thread here!) But he was OK swearing to mythical gods. Sheesh!

Similarly I will not give to a woman an abortive remedy. Conveniently left out of the "Modern Version."

So every Physician that does abortions violates the Classical Oath.

http://en.wikipedia.org/wiki/Hippocratic_Oath

"...It is a common misconception that the phrase primum non nocere, “first, do no harm” is included in the Hippocratic Oath. It is not, but seems to have been derived through Galen from Hippocrates’s Epidemics in which he wrote, “Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things—to help, or at least to do no harm.”


http://www.pbs.org/wgbh/nova/doctors/oath_classical.html

Hippocratic Oath -- Classical Version

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

http://www.pbs.org/wgbh/nova/doctors/oath_modern.html

Hippocratic Oath—Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
 
#13 ·
what i don't get is the work place violence angle you read our policy and it says coworkers management doesnt say anything about customers or anyone else

there have been issues where customers have attacked repair men one just recently thankfully it has happened to me
 
#32 ·
Cops consider it assault 8 days a week.
 
#18 ·
Thanks, paramedic70002! Good information!
 
#19 ·
As a paramedic for 22 years, followed by (and currently practicing) 18 years a s a Physician Assistant, I have been involved with more than my shere if unrowdy pt, both those in charge of their faculities, and those who were not. I understand the abger with being spit in the face, especially given the venom that this pt was spewing. The fact that you have to be concerned about pathogens is also part of the equation. But it comes down to the fact that you will never be justified striking a pt that is bound to a stretcher. I've been threatened, and I have had to defend myself. But if you hit this person, you're guilty of assault. I've known offecers who would have locked him up on the spot, if not on the first, at least by the 2nd. At the very least, they would have said something the first time. If I had been the paramedic, and asked that he pt be secured on his abdomen, I would have insisted on it. I would not have moved the stretcher until he was prone. The smartest thing to do is to prevent the situation from happening.
 
#25 ·
. But it comes down to the fact that you will never be justified striking a pt that is bound to a stretcher. .
That's pretty much the bottom line. It doesn't matter if you are the best EMT that ever lived, if you punch someone who is tied down you really have to expect to get in a ton of trouble.

Again, having people tied face down in this sitation is pretty basic procedure. At my hospital anyone who is four-pointed has to be tied face down per policy.

Don't forget, cops fight with bad guys/perps/suspects, for medical personal we are dealing with patients, if there is an issue of saftey let the police or security handle it. While I am allowed to restrain people (after which I have an hour to get the doc to write me an order) if the person is combative, I always call security. In a physical confrontation, once you throw a closed fist, (vs a take down hold or a push) you have just taken to a very serious level.
 
#20 ·
I will go out on a limb here and agree , Striking a patent is NEVER WARRENTED , I have done warrents for a lot of things but never that , So if emergancy med techs cant do it , stand back boys and let the LE do it , or lets just go ahead and commision them as special or reserve officers and give them the legal standing for the powers they have needed for a long time .
 
#33 ·
I can't understand why you guys keep calling the whack job a patient when starting out he was in police custody. In my book that makes him a prisoner. The EMT originally wanted the prisoner strapped to the stretcher in the prone position. For whatever reason the cops didn't. He was nonetheless a prisoner not a patient. Since cops consider spitting on them assault what makes the cops special in this regard and not an EMT?
 
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#21 ·
Hasn't it now been proven possible to contract HIV if an HIV Pos or Full Blown AIDS individual spits or gets their blood into an eye?
Just wondering as I think I read that it's possible to become HIV Pos if that ever happens.
 
#22 ·
Possible but highly unlikely. There would have to be gross visible blood in the spit, and an open wound on the receiver. Lots of other variables as well, like virulence, resistance, post-exposure treatment.
 
#23 ·
Paramedic70002, your reply to the author was excellent. You are absolutely right; and when I read the "never justified" assertion, I immediately was asking, "Wait a minute, what about if the patient is committing a physical attack on the paramedic?! The paramedic just has to stand there and take it and cannot defend himself using blows?!" That's absurd. I'd like to see the administrative agency get sued for someone being severely injured because he was following "policy" and felt he could not defend himself from a violent attack because it was counter to the employee handbook rules!

In this specific case, I can't say I fully agree that the punches were justified, but I can easily imagine situations where physical force would be justified beyond any doubt. Paramedics can be physically attacked just like any other human beings. Cops can fight back -- but not paramedics? That's just idiotic.

And the idea that people wanted soo soooo badly to fire a guy for ONE transgression when he was, by all accounts, an EXEMPLARY PARAMEDIC -- that's just asinine. How many patients will be harmed by the absence of this guy, who otherwise would have been the beneficiaries of his excellent skills and knowledge? So what is the greater good served by? Terminating his employment or a stern warning and letting him continue to do good?
 
#24 ·
I think that paramedics should be allowed to "restrain" their pts. My fiance is a paramedic and she is only about 5'2" 110 lbs. but she has ways of controlling unruly pts. There is an unwritten policy that we are not allowed strike a pt. while at work. However i would hate to be the one on the receiving end if anyone attacked a member of my Engine company.
 
#30 ·
Dang. This post is 7 years old.

Since then, I've been involved in a few "altercations" involving so called "patients" that needed to be transported.

I've been called to the scene numerous times to secure it. Since this post, my view has changed considerably.
Its been my experience that none of the EMT's want to get spit on, kicked, poked, punched, scratched or any multitude of indignities that they occasionally endue when attempting to transport some fool that is too stupid to breath air and walk at the same time.

If a some crack or meth head wants to play Billy badass with the EMT's I'm all for letting them beat them into submission. if it were me over the station, my EMTS would have Tasers and be encourage to use them on stupid people that want to fight. Keep Tasing them until they submit.

Who ever thought of the "zero tolerance" on hitting a patient is a pink liberal idiot that I have no use for as a human being. Get them out there doing the same job and see how they act. Of course, they may curl up in the fetal position and suck their thumb and wait for the police to bail their tails out.

If I get to the scene and an EMT tells me that they just had to pop knots all over someone in self defense, I'm only going to ask them one question..." are you all right"? I'm going to give them the benefit of the doubt.

I'm tired of this zero tolerance bull hockey. Someone can whoop on you and if you fight back you are guilty of self defense. Wrong. I'm not buying it.
 
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