Complacency Kills … Patients and Careers
The case of Wright v City of Los Angeles is a crucial illustration of the legal ramifications regarding a paramedic’s duty to act. However, before I tackle this case study, I would like to share one of my personal experiences that has taught me a lesson in being a EMS provider.
I did my paramedic internship at Los Angeles City, Rescue 66, in the spring of 1989. My preceptors, Mike Samudio and Kelly McKee, were clinically tough, but very fair. What I remember, and appreciate, the most is that they spent the extra time and energy to make sure that I could truly understand the paramedic’s role from the patient’s perspective. In this mindset, even the 20th patient should receive the same amount of attention, respect and care as the first.
As it is with many interns, I became too comfortable with my preceptors and my skills about half way though my internship and it led to one particular incident that I can still remember vividly. On one late night, I was especially tired and cranky and had to respond to a call involving (another) young woman who was distraught over something her boyfriend had done. She was in no distress and a very thorough assessment — including an EKG — revealed nothing more than big trouble for her boyfriend when he returned.
So, with the captain, engine company, family members, and preceptors watching, I presented her with disposition options: we could take her to the hospital if she desired or she could stay home with her family and see her private doctor in the morning. I should have stopped at those two options, but of course, I did not. I smugly presented her with this third option: “…or we could take you to Disneyland. That always makes me feel better.”
I could literally see the words as they left my mouth and hit the air. The damage was done. The simultaneous looks of disappointment on my preceptors’ faces said it all. When the dust settled, and there was a lot of dust, Kelly McKee pulled me aside and calmly gave me some of the best advice I have ever received.
“Dave,” he said, “you’re not going to like everyone you come in contact with and sometimes you’re going to be tired and may not want to be there, but as long as you are there, remember that complacency kills. The minute you begin to treat people differently or cut corners, someone is going to die…and it could be you.”
I have never forgotten that lesson. I have passed that wisdom on to every intern I’ve ever precepted and have tried to apply it in my daily life. Now, I pass it on to you. I’m sharing this story to provide you a bridge between conceptuality and tangibility; to encourage some reflection on your own career as we analyze a case where complacency did in fact kill.
Wright v City of Los Angeles¹
On May 19, 1979, witnesses saw an individual beating and slamming a man by the name of Jerry Wright against the side of a car as Wright screamed, “Help, police, I'm being robbed.” Moments later, another man who witnessed the scene came out of a nearby apartment and struck the assailant, causing him to fall beneath the car. Wright then entered his vehicle and started the engine. causing it to roll backward then forward before it stopped.
Two police officers arrived on scene and drew their guns on Wright and ordered him to come out of the car. Wright did not comply and remained slouched in the driver's seat. The officers opened the passenger door and pulled Wright out, but he remained unresponsive. One of the officers handcuffed his hands behind his back and left him lying on his stomach on a grass parkway, with his head leaning over the sidewalk. It was reported that one of the officers kicked him between his neck and shoulders and moved his head back onto the grass.
Witnesses heard Wright loudly complaining that his head and whole body hurt and that he needed an ambulance. The police called for paramedics. Two paramedics arrived and a police officer directed one to Wright and the other to the man still lying in the street. The paramedic who treated Wright later testified that he did not recall being told of Wright’s complaint of pain and his request for an ambulance. He knew that there had been a fight, but never specifically asked the police officers why EMS had been called.
The paramedic approached Wright and asked him what had happened; Wright did not respond. He asked Wright if he was hurt and Wright replied that he was not hurt. The paramedic failed to ask Wright any further orientation questions. Instead, he did what he called “the 60-second examination,” a brief visual examination of the body to determine if there was a life-threatening situation. It was the only examination he did. He did not check pulse or blood pressure and he did not recall touching Wright’s skin. Then the paramedic tacitly told a police officer that Wright should see a doctor first if he was to be taken to jail, and then proceeded to leave the scene.
Wright died at the scene a very short time later from Sickle Cell Crisis. The paramedic was found liable and the plaintiffs were awarded millions.
Wright v. City of Los Angeles has become a landmark case for determining an EMS providers’ duty to act. Referencing from my last column, Are You Just Down the Street From a Lawsuit, the Zepeda case established that staging away from certain non-secured situations did not violate the provider’s duty to act — particularly because the paramedics never initiated patient contact before the police arrived. The finding also concluded that the potential threat to their lives excused any constructive duty to act. In Wright’s case, however, the scene was secure and the paramedic had initiated patient care. The constructive duty to act became an absolute duty to act by approaching, asking questions, and making a substantive disposition.
When it comes to a provider’s duty to act, almost every jurisdiction follows the same essential rules: The provider has a duty to act as would a reasonable provider with the same level of training and skill, in the same locality, and under the same or similar circumstances. Acting reasonably is not rocket science, yet so many providers continue to stumble around the standard, guided by what they think they know rather than what they actually know.
In this instance, a “reasonable” paramedic would have asked more about the circumstances which led to the response. A reasonable paramedic would have been motivated by the indication of a fight to do a physical assessment, including vital signs. A reasonable paramedic would have wanted to know the patient’s medical history in order to gather as much information as possible to reach an informed conclusion (much like a lawyer). A reasonable paramedic knows that there can be more to an assessment than what is seen.
One of the first questions posed to the jury in reaching a verdict for the case was: did the paramedic have a duty to act? Of course he did. He was summoned to the scene of an emergency to perform the duties for which he was hired. His duty was not excused by impossibility, impracticability or frustration of purpose.³ Moreover, his absolute duty demanded that he not rely solely on the statements or non-statements of others, including the patient himself.
The next question for the jury was: did the paramedic breach his duty? The answer is “yes.” Where one owes a duty and fails to perform, is an act of breach. When you walk away from a call, you will most likely know whether or not you did everything you could and should have.
And the last questions included: were there damages? If so, were they caused by the paramedic’s breach of duty? Determination of cause essentially boils down to the “but for …” statement. But for the paramedic failing to fulfill his duty by not conducting a complete assessment, would Wright have died in the same circumstances in which he did? The truth is there’s no way of knowing for certain, although we can surmise that the likelihood of the patient’s likelihood of survival would have drastically improved if the paramedic fully completed an assessment.
All too often, paramedics develop preconceived notions and generate conclusions before they even arrive on scene. Granted, this sometimes works due to past experience in the field. However, each patient and every situation is unique, even those that you’ve seen a thousand times before. And determining the best treatment possible can only be done after a comprehensive and thorough assessment. Would you do a 12-lead EKG on a 34-year-old female with abdominal pain? Not usually, but I recall a situation when my partner and I did — mostly because we could — and we discovered she was having an MI.
I will never understand how some providers continue to find a disadvantage in doing a full and complete assessment. In all my years of studying, practicing and teaching in EMS, I have never seen a “partial assessment” as a matter of practice in the curriculum. Quick assessments, initial assessments, triage assessments are all followed at some point by a full and complete assessment. Nevertheless, they rationalize circumstances where it’s just too burdensome to check vital signs and ask all of the necessary and appropriate questions. However, as Wright v. City of Los Angeles proves, complacency to take shortcuts when responding to a call can result in not only the patient’s death, but also the longevity of your career.
Next time you find yourself on scene thinking “this is nothing,” I suggest you do what it takes to prove it.
¹Wright v. City of Los Angeles: 219 Cal.App.3d 318, 268 Cal.Rptr. 309 Cal.App. 2 Dist.,1990.
Zepeda v. City of Los Angeles: 223 Cal.App.3d 232, 272 Cal.Rptr. 635 Cal.App. 2 Dist.,1990.
³Torts-Cases and Materials: Prosser, Wade and Schwartz, 10th (2000)