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Death at Sugarloaf - Page 2

post #31 of 49
Quote:
Originally Posted by swellhunter View Post

Once a qualified EMT or Paramedic makes the "internal bleeding" call the ambulance should have been out of the question immediately.  Now you are dealing with "golden hour" and a helicopter should have been called immediately.

 

 

There was no helicopter available due to weather conditions that day.

post #32 of 49

Thankfully internet forums aren't judge, jury, and executioner. They'd make any Texas governor look like a sissy if they were. 

post #33 of 49
Thread Starter 

My last post in this thread I swear unless specifically asked to comment...

 

Hoped to get back in here and add an addendum to my last post before someone else had a chance to jump in without bumping the thread (almost put quotes around bumping...but given the above refrained, if anyone ever outlaws parenthesis, I will become keyboard mute...to the delight of some....or possibly many).

 

As of right now, the only credible (or for that matter not so credible) suspicion I have is that the hospital/ambulance company may not have adequate or functioning internal review triggers.  Seems that anytime there is an en route death, there should be an automatic internal review (icu deaths, no matter how expected are reviewed if they occur within 24 hours).  Again note that triggering an internal review does not imply any wrongdoing whatsoever, simply a well functioning system

 

I would amend what I would have expected from the hospital (who owns the ambulance company ) spokesman from "We are aware of the situation and are conducting a review"  to "We are aware of the situation and are conducting a review, as we would any en route death" as opposed to the actual quote of  "The bottom line is this: the hospital was caught completely off guard here as we were not even contacted by any family member"  (For Whiteroom I have no idea how to differentiate hypothetical quotes from  real ones, would hope the context was enough.  Maybe I need to pull out the Chicago manual for a refresher).

 

BUT NONE OF THAT IS WHAT I AM SO CURIOUS ABOUT (it will all come out in the wash...several months from now)

 

What I am curious about, and have asked above without response (perhaps very reasonably), is what would the very experienced patrollers in this forum do/think in a very bizzare, hypothetical situation suggested by the original story (WHETHER OR NOT ANYTHING LIKE IT HAPPENED IN THIS CASE)...

 

-You are sitting in the aid station after having shipped to EMS a critical patient, decompressing after an adrenalin rush.  The hill is closing down, and then ambulance returns to you with  "Ummm...he died, we brought him back here." (Again these are not actual quotes for anyone thinking they might be).  Has this ever happened?  What would you do/say?

 

-You have "officially" (dammit whiteroom I can't type without the quotes) handed over a patient "up" to an ambulance crew but the patient is still in your aid room.  You are witnessing care that you think inappropriate (not talking "I wouldn't do it that way", rather "WTF are they doing?!"), do you say something?  Some patrollers are as, if not more qualified than many ambulance personnel.  If you wouldn't feel comfortable speaking up yourself is there a doc present on your hill that would, could or should  speak up.  Would you trust "your" doc (or are they a semi-retired dermatologist), do they have enough experience that you would grab them and say "Doc....I think they are doing some screwy shit over there?"

 

 

 

post #34 of 49

In the capacity of a ski area rescue patroler, it would be unprecedented to have a patient previously transferred to a "Higher level of care" returned.

 

However,  there are some interesting protocols  (at least hearsay) when the patient is "dead".  The health care industry, including Emergency Medical Response, would rather not be involved with "non-health" issues.  A mortician would be better suited.

Transfer arranged by the coroner's office. 

 

It would be interesting to know the facts.

 

 

 

post #35 of 49
Quote:
Originally Posted by Alveolus View Post

My last post in this thread I swear unless specifically asked to comment...

 

Hoped to get back in here and add an addendum to my last post before someone else had a chance to jump in without bumping the thread (almost put quotes around bumping...but given the above refrained, if anyone ever outlaws parenthesis, I will become keyboard mute...to the delight of some....or possibly many).

 

As of right now, the only credible (or for that matter not so credible) suspicion I have is that the hospital/ambulance company may not have adequate or functioning internal review triggers.  Seems that anytime there is an en route death, there should be an automatic internal review (icu deaths, no matter how expected are reviewed if they occur within 24 hours).  Again note that triggering an internal review does not imply any wrongdoing whatsoever, simply a well functioning system

 

I would amend what I would have expected from the hospital (who owns the ambulance company ) spokesman from "We are aware of the situation and are conducting a review"  to "We are aware of the situation and are conducting a review, as we would any en route death" as opposed to the actual quote of  "The bottom line is this: the hospital was caught completely off guard here as we were not even contacted by any family member"  (For Whiteroom I have no idea how to differentiate hypothetical quotes from  real ones, would hope the context was enough.  Maybe I need to pull out the Chicago manual for a refresher).

 

BUT NONE OF THAT IS WHAT I AM SO CURIOUS ABOUT (it will all come out in the wash...several months from now)

 

What I am curious about, and have asked above without response (perhaps very reasonably), is what would the very experienced patrollers in this forum do/think in a very bizzare, hypothetical situation suggested by the original story (WHETHER OR NOT ANYTHING LIKE IT HAPPENED IN THIS CASE)...

 

-You are sitting in the aid station after having shipped to EMS a critical patient, decompressing after an adrenalin rush.  The hill is closing down, and then ambulance returns to you with  "Ummm...he died, we brought him back here." (Again these are not actual quotes for anyone thinking they might be).  Has this ever happened?  What would you do/say?

 

-You have "officially" (dammit whiteroom I can't type without the quotes) handed over a patient "up" to an ambulance crew but the patient is still in your aid room.  You are witnessing care that you think inappropriate (not talking "I wouldn't do it that way", rather "WTF are they doing?!"), do you say something?  Some patrollers are as, if not more qualified than many ambulance personnel.  If you wouldn't feel comfortable speaking up yourself is there a doc present on your hill that would, could or should  speak up.  Would you trust "your" doc (or are they a semi-retired dermatologist), do they have enough experience that you would grab them and say "Doc....I think they are doing some screwy shit over there?"

 

 

 


OK, I'll bite

 

Question 1:  I would ask why they had returned with a body.  Given that the EMS teams I work with are professional, protocol driven, and subject to oversight, I expect they would have a reasonable answer.  Probably some protocol, or set of facts of which I was unaware. 

 

Qestion 2:  First, understand the relationship between patrollers, EMS, and physicians.  While one field may have more qualifications, they are not more qualified outside of their field.  There is nobody more qualified then a patroller on the hill, a medic in an ambulance, or a doctor in his or her field.  Would I get one of the docs on my patrol?  No.   They are good patrollers, and good doctors.  They have no control over what an ambulance crew does.  If I truly thought harm was being done to a patient, I would contact the medical control doc at the hospital, who does have input into the care provided by EMS.

 

Actually, you can basically apply the first answer to the second question as well.

 

Oddly, this question usually come to patrollers from another direction:  What do you do when somebody who thinks they know better than you, flaunts their credentials, and interferes with the care of your patient?  Not unheard of for a doctor/nurse/paramedic/emt/whatever to misunderstand what is actually happening, and to get in the way.  Not common, but patrollers are taught to expect it, and how to manage it.

 

post #36 of 49
Thread Starter 

Hope this doesn't really count as posting.  Just dropping off an update.  Perhaps I should change my oath from "I swear I will never post in this thread again unless specifically requested" to "I swear I will never comment in this thread again unless specifically requested"

 

Rescue law expert: Don’t rush to judgment in case of Sugarloaf skier’s death

Posted Jan. 18, 2012, at 6:23 p.m.
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David Morse, of Kingston, Nova Scotia died in a skiing accident at Sugarloaf ski resort on Thursday, Jan. 12, 2012.
 
David Morse, of Kingston, Nova Scotia died in a skiing accident at Sugarloaf ski resort on Thursday, Jan. 12, 2012.

An expert in fire and rescue law said Wednesday the public should wait until an investigation into the death of skier David Morse is finished before rushing to judgment about his controversial case.

The words of caution by Curt Varone — a longtime firefighter, lawyer and author who is familiar with the Carrabassett Valley area — came on a day when the state medical examiner’s office released the official cause of death for Morse.

Mark Belserene, administrator of the medical examiner’s office, said Morse, 41, of Nova Scotia died of chest trauma, a diagnosis that doesn’t come as unexpected in the case. Belserene said chest trauma is generally defined as injuries to an individual’s ribs or the organs behind them, unlike the lower torso, which is an individual’s abdomen.

Morse hit a tree on the Lower Timberline Trail on Sugarloaf Mountain last Thursday afternoon, suffering severe injuries, although he was conscious and alert when Ski Patrol reached him. Morse’s widow, nurse practitioner Dana Morse, since has said emergency medical responders were slow to treat for internal bleeding — not initially listening to his chest or starting an IV — and the NorthStar ambulance driver left her on the side of the road on the way to the hospital after she asked to hold her dying husband’s hand.

Dana Morse’s account of what she called a “comedy of horrors” — f irst published by the Halifax-based newspaper The Chronicle Herald — triggered public intrigue and an internal investigation by Franklin Community Health Network, the group that owns the ambulance service and the Farmington hospital it was taking Morse to.

Ralph Johnson, chief information officer for the Franklin Community Health Network, and David Robie, executive director of NorthStar, have not returned calls or emails by the Bangor Daily News. Jill Gray, the network’s community relations manager, responded to an initial BDN email with a prepared statement Tuesday saying it “would be premature for us to respond to allegations reported by the press” until the group is finished with its internal probe.

Curt Varone is a former Providence, R.I., firefighter, a lawyer licensed to practice in Rhode Island and Maine, and author of two books about fire and rescue law. He is a legal columnist for Firehouse magazine and for his personal website, FireLawBlog.com, where he posted a column this week about the Morse case.

“We’ve got to get down to the facts about what happened,” Varone told the BDN in a Wednesday evening telephone interview. “Did the transporting EMS unit en route to a hospital leave a patient’s family member by the side of the road? If that did happen, what were the grounds? As a fire service leader, I’m struggling to come up with grounds to justify that. I’m not saying they didn’t have grounds, but we’d need to know what those grounds were.”

Varone said before the public knows what the hospital’s internal review finds, “it’s not helpful to speculate.” But he said it will be important for the hospital to release its findings openly, a step medical facilities are not often required to take.

“This is something that has captured the public’s attention, and the hospital, just like any other entity, has an obligation to tell the public, ‘This is what happened — we did an investigation and, you might not like what happened, but here are the results,’” Varone said.

Dana Morse told the BDN on Tuesday she believes the hospital probe will reveal that the details published in The Chronicle Herald story “are not even touching the surface.”

Franklin Community Health Network officials have said they first learned about Dana Morse’s complaints through calls from reporters.

Varone said the widow’s story leaves the hospital group and public facing many difficult questions.

“How could a couple of medics have gone through this ordeal — especially if it happened the way the widow said it happened — and not report it to their supervisors?” he said.

 

post #37 of 49


 

Quote:
Originally Posted by Steve2ski View Post

A lot of accusations here, since when does anyone other than a Dr. have the authority to pronounce a death, hmmmmm...............interesting

These accusations from a Nurse Practitioner, wanting to hold the patients hand with no other effort to intervene. Something doesn't sound right.

A more complete protocol of determining death and body disposition of the patient/deceased in field operations. Especially para. 5.

 

Here is a 2004 protocol
 

http://www.smcgov.org/vgn/images/portal/cit_609/6760785Operations10.pdf

 

 

post #38 of 49

Today's statement from the hospital from the Portland News:  http://www.wmtw.com/news/30262309/detail.html  

According to the Chronicle Herald, Maine Emergency Medical Services is investigating:  http://thechronicleherald.ca/novascotia/53974-maine-agency-plans-review-details-ns-man-s-death

 

Now we wait.

 

Joe 

post #39 of 49

This reminded me of an incident that ocurred at Sugarloaf way back around February or March 1970.  I was on the patrol and was working on the east side of the mountain off of the Gondola.  I arrived sponataneously on the scene of an accident.  A witness said that a man skiing at a high rate of speed where 3 trails came together had crashed into a teenaged boy, knocking him out.  The boy was on his feet and wondering around dazed and confused when I got there.  I sent somebody to the bottom of the nearest life to get somebody with a sled down to me.  I got the boy settled down with a bag of snow on his obvious head bump.  Then I started questioning him, who he was, where he was starying, phone numbers and all that.  He was 14 years old and dropped off at the hill, staying with his aunt in Kingfield for the weekend. 

 

When I got him to the patrol room he was vomitting, going in and out of consciousness and forgetting all the information I already had written down.  It was clear he had a skull fracture and progressive bleeding.  I handed him off, did my report and went back out on the hill.  It was getting near to closing and a call came for me on the mountain phones, to come immediately to the patrol room.   When I got to the patrol room I was told a story that seemed pretty strange to me.I was told that the ambulance company refused to transport him without a "responsible adult guardian" to the hospital more than 50 miles away.  They said  "You are the only person here with station wagon.  This boy needs to get to the hospital urgently".  He was mostly unconscious at this point. 

 

I was totally freaked by this.  They said "He has no other alternative.  You would be protected under the 'good samaritan laws.  It is very urgent for him to get to the hospital and you are the only one here with a vehicle that can carry him on the Stokes Litter.  Give us your keys and we will get it all set to go as soon are ready for the steet".  By this time if he said anything it was nonsense.  He didn't know who he was, where he was or why or how. They called the hospital to let them know we were on the way.  ON the way out the door they said "Remember, bleeding brain.  Drive very smoothly, no bumps."  At that time of year the potholes went in 18 inches from the shoulder.

 

I got him to the hospital in about 70 minutes, as smooth as I could.  They unloaded him without a comment. They did not want to say a word about this.  That was something terribly weird, that NOBODY on the mountain the next day, nobody at the hospital, nobody at all was willing to say one word about it.  I retrieved the litter and headed back for a late dinner.  I checked in on him a couple of days later and they were just letting him out of the hospital.  He was ok by then but head injuries can be so uncertain.

 

I was just blown away that the ambulance company would or could refuse to transport an injured child to the hospital.  And then the total silence surrounding the whole thing was just weird.  The mountain, like any small community was a hotbed of gossip.  I wasn't even asked for a report the next day.

post #40 of 49

 

Quote:
Originally Posted by HHTELE View Post


 

"I'm really not very pro-litigation, but it's a good thing for the defendants (I'm assuming there will be a lawsuit) that I won't be sitting on the jury."  On the other hand, as a member of the jury, you could make your decision based on facts.

 

"A lot of accusations here, since when does anyone other than a Dr. have the authority to pronounce a death, hmmmmm...............interesting"  I am not sure about since when, but paramedics in Maine can cease resuscitation efforts with approval of medical control.

 

"Well, so far the hospital and ambulance companies are pretty much "Umm...What? We are looking into it."  The actual response was:  “Today we have launched our own internal review of what happened in this very tragic situation,” she said. “Until we conduct that review, it would be premature for us to respond to the allegations reported by the press.”  Not quite sure how this equates to "Umm...What?"

 

I am not defending the actions of Sugarloaf Patrol, or Northstar Ambulance.  I don't know what they did.  I do know that Sugarloaf Patrol is an excellent patrol with high standards and comitted staff.  I know that Northstar is well versed in dealing with trauma in a remote setting.  I also know that the story, as it has been presented, simply does not make sense.  Maybe there was negligence or malfeasance on the part of Patrol or EMS.  I don't know, and neither do any of the folks who have been critical.

 

There are children without a father, and a wife without a husband.  Why compound the tragedy by placing blame before the facts are known?

 

 

 

 

 

Not all that surprised about the outcome, or minimal coverage.  Or the fact that nobody who publicly expressed outrage followed the story, then tried to assure that [eople have the facts.


Paramedics who are not only incompetent, but cruel enough to throw a grieving wife out of an abulance in a blizzard makes a great story.

What actually happened is tragic and boring. 



http://www.necn.com/04/04/12/Punitive-action-not-warranted-in-Maine-s/landing_health.html?&apID=0c860388ed0a4be187db7c6b6fea84a5

 

 

Edit: fix quote tag. 

post #41 of 49

Why am I not surprised the official whitewash investigateion found no one at fault?

 

"In reviewing medical reports for the investigation, an outside expert, Dr. Michael Baumann, head of Maine Medical Center's emergency room, concluded that there may have been a short period when the severity of Morse's condition wasn't apparent because he was talking and responding to questions, the report said."

 

Give me a f*ing  break!

 

And,

 

"The investigation didn't look into Dana Morse's claim that the ambulance driver abandoned her on the side of the road when she thought he was stopping to let her get in the back of the ambulance with her husband, and the report didn't make any conclusion regarding it."

 

It's a he said she said, so no more could be expected.

 

 

post #42 of 49

 

Quote:
Originally Posted by Ghost View Post

Why am I not surprised the official whitewash investigateion found no one at fault?

 

In my experience, the people who investigate EMS actions are contientious and and pretty critical.  EMS is not a field in which there is some sort of "protect your own" mentality. This investigation will be a matter of public record, and will be subject to scrutiny.  Any particular reason you believe the Maine EMS Investigation Committee to be corrupt?  

 

A well respected ER doc, unconneced with the issue reviewed the case.  Any thoughts as to why he would be involved in the cover up?

 

 

 

"In reviewing medical reports for the investigation, an outside expert, Dr. Michael Baumann, head of Maine Medical Center's emergency room, concluded that there may have been a short period when the severity of Morse's condition wasn't apparent because he was talking and responding to questions, the report said."

 

Give me a f*ing  break!

 

Does your patrol manage a lot of major trauma?  Are they all obvious?  Were you trained that everything that is bad, looks bad?  If so, you were not well trained.  Sometimes apparently stable patients deteriorate quickly.

 

And,

 

"The investigation didn't look into Dana Morse's claim that the ambulance driver abandoned her on the side of the road when she thought he was stopping to let her get in the back of the ambulance with her husband, and the report didn't make any conclusion regarding it."

 

It's a he said she said, so no more could be expected.

 

Actually, its more of a "she said, he heard" kind of deal.  A distrought wife in a terrible situation was misunderstood.  The patroller thought she wanted to be with her children.  that's reasonable.

 

I am a patroler, EMT, and ER nurse.  I have no tolerance for laziness, incompetence, or poor patient care. If there are incompetent, malicious EMS pesonell out there, I want them gone. I don't know the EMS personell involved.  I don't know which patrollers were involved or if I know them- I do know a few at SL. 

 

It's just that the story, as it was originally portrayed didn't ring true.  Not that incompetence doesn't exist, it does.  It's just that this story didn't make sense to me, or anybody I know familiar with these systems.  Imagine if you saw an oil spill being reported on TV, and you knew a bunch of petrolium engineers, who all agreed that the story didn't make sense. 

 

 

So- I am curious.  What is your knowledge or experience that gives you your perspective?  Have you seen this stuff on your patrol, or whithin your EMS system?. 

 

Also- lay it out.  How do you think things really happened? 

 

 

 

post #43 of 49

I am guessing it went down a lot closer to the eye-witness account, which i can only assume was apparently discounted as being biased by the independent investigator.

 

http://thechronicleherald.ca/novascotia/52238-widow-emts-took

 

BTW the Patrol did an excellent Job according to all accounts.

 

Basic first aid training covers the ABCs, then prioritizes core and extremities.  I wouldn't splint someones arm while I ignored them bleeding to death.

post #44 of 49

 

Quote:
Originally Posted by Ghost View Post

I am guessing it went down a lot closer to the eye-witness account, which i can only assume was apparently discounted as being biased by the independent investigator.

 

By eyewitness account, I assume you mean the patient's wife.  Accounts from people as stressed as she was are known to be potentially inacurate.  But, at least some of her account is corroborated by the investigation.  For example, she was let out of the vehicle when she really wanted to go to the back.  That is terrible, and I am sure the driver feels bad that he misunderstood her.  Surely you can envision a scene in which she was less than artculate, and a reasonable person doing the best he could misunderstood her.

 

As far has her ICU experience and her perspective of how things should be done:  ICU nurse don't know much about pre-hospital care.  I am trained in both, and have trained a few docs and nurses in pre-hospital care.  Trust me, it's a different ball game. I mean no disrespect to her, or her experience.     

 

http://thechronicleherald.ca/novascotia/52238-widow-emts-took

 

BTW the Patrol did an excellent Job according to all accounts.

 

Actually, since the complaint was against EMS, that's what the investigation focused on.  Her perspective was they did a good job.  They probably did.  They have a good rep, and the patrollers I know there are solid.

 

 

Basic first aid training covers the ABCs, then prioritizes core and extremities.  I wouldn't splint someones arm while I ignored them bleeding to death.

 

And neither would a trained paramedic.  And, according to this investigation they didn't.  That would have been a violation of their protocols.  And would just be weird.  Medics like dealing with major emergencies in the same way firefighters like putting out fires.  They generally appreciate the opportunity to use their advanced training, and don't do that by ignoring life threatening injuries.

 

Given your confidence in how this really occured, and that you are posting on a patrol forum, I really thought you might have some experience in these matters.

 

But, back to my question.  In your version, how and why did this all happen? 

 

Why did the patroller let her out?  She never gave any insight as to that, just that she wanted to get in the back, but was left on the roadside.  He says he thought she was asking to be let out on the access road so she could be with her kids.  What's your version?

 

Three professionals tasked with determining whether protocols were followed, including correct prioritization, concluded that they were.  The medical director of the ER in a level 1 trauma center agrees. In your version, the paramedic splinted an arm, ignoring the fact that the patient was bleeding out.  Why?  Incompetence, laziness?  Just didn't like the patient?  In your mind, how did this play out?

 

Also- Gven your belief that Maine EMS, the attorney generals's office, and DR Bauman were involved in this "whitewash", who would you have trusted to investigate this?

 

 

 

 

 

post #45 of 49

I'm not going to argue with you.  You are entitled to your opinion, and I'm entitled to mine.  In your opinion the emergency care he got (splinting his elbow) after schmucking himself into a tree, complaining of severe abdominal pain, and having a medical professional suggest that he be treated for internal bleeding was "according to protocol".  Maybe it was (Hey, I don't know, maybe, if it looks like they are going to bleed out on the way to the hospital, they prefer to waste a half hour before putting him in the ambulancerolleyes.gif). Do I think they broke any rules for which they could be prosecuted? No, probably not; I'm sure they were trained to follow the rules.  In my opinion, the medical care he got still sucked, protocol or no protocol.  In answer  to your question, I think (only those that were there know) they ditched the nurse because they were tired of having her try to tell them how to do their job. With 20 years experience and 10 in the ICU, she probably has seen a few trauma cases too, and was no doubt concerned over the lack of proper examination and lack of care of the internal bleeding.

 

On the other hand, he hit the tree all by himself and probably would have died anyway without the (imho and in the nurses's too,  poor) medical care.  I wouldn't blame anyone for trying to help me,

 

And that's my last word on it, unless you come with some better bait.

post #46 of 49

Ghost-

 

Nope- no more bait.  You have pretty well laid out your point of view, and explained it as well as it can be explained.  Thank you.

 

My goal in posting wasn’t to change your opinion.  

 

I wanted to post the link because I thought people would be interested in how the story played out.  The people accused of wrongdoing responded professionally and responsibly by not publicly defending their actions.  They let the system do its job.  Unfortunately, the results of the investigation were not nearly as widely published as the accusations, but that is to be expected.  I would guess that the majority of people who read the initial story, never got the conclusion. I imagine that if the investigation had substantiated the complaints, the story would have gotten a lot more mileage.

 

I only picked your post because it was one of several people who I thought had come to premature conclusions, despite the story not making much sense, and not ringing true to folks with experience in this type of incident.

 

I was hoping that reviving this thread would cause people to look back at their initial reaction, and compare it to what they know now.  Sometimes when a person gets new information, they form new opinions.  

post #47 of 49

 

Quote:
Originally Posted by HHTELE View Post

The people accused of wrongdoing responded professionally and responsibly by not publicly defending their actions.  They let the system do its job.  

 

Why be such a Party-Pooper???

 

Convoluted, overly complex conspiracy theories are so much more fun than simple, boring ol' facts.  rolleyes.gif

post #48 of 49

After my stint at Sugarloaf, I ended up in the insurance business migrating to software development, consulting, plan review and so on.  One of the things we did was evaluate docs and clinics for care quality.  One of my fellow consultants was on the Joint Commission on  Hospital Acreditation - Ambulatory care committee.  Failure to check BP with a chest injury seems like a very serious breach of standards to me.  I'm no doc.  I'm a data geek consultant and ex-Sugarloaf Patroller.  However, we enforced standards right down to hand washing at offices and clinics, and followed up on member (of insured group) complaints.  We got rid of docs from the PPO for repeated infractions to try to prevent future problems by providers that take shortcuts.  Somehow this whole thing just doesn't sound right.

post #49 of 49

 

Quote:
Originally Posted by Fredddd View Post

After my stint at Sugarloaf, I ended up in the insurance business migrating to software development, consulting, plan review and so on.  One of the things we did was evaluate docs and clinics for care quality.  One of my fellow consultants was on the Joint Commission on  Hospital Acreditation - Ambulatory care committee.  Failure to check BP with a chest injury seems like a very serious breach of standards to me.  I'm no doc.  I'm a data geek consultant and ex-Sugarloaf Patroller.  However, we enforced standards right down to hand washing at offices and clinics, and followed up on member (of insured group) complaints.  We got rid of docs from the PPO for repeated infractions to try to prevent future problems by providers that take shortcuts.  Somehow this whole thing just doesn't sound right.

 

Yeah.  There ought to be some kind of investigation. 

The team should include EMS professionals well versed in protocol and standard of care.

Law enforcemnt should get involved, maybe even the attorney generals office.

Then, they should go over every bit of documentation, and interview all parties involved.

 

When all is said and done, the entire thing should be independently reviewd by an independent expert.

 

Then, and olnly then, will we have any insight as to whether this unfortunate man got decent care.


Edited by HHTELE - 5/1/12 at 9:43am
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