Ambulance Driver

One of the main goals of this blog is to link the affect of public policy to the delivery of health care, especially as it relates to emergency medical services. An example would be how the public investment in a statewide radio network positively enhanced various public agencies’ performance during the I-35 bridge collapse and the Republican National Convention. There are many such issues that seem to be fertile ground for public discussion.

The Health Insurance Portability and Accountability Act, or HIPAA, however, was not one that had immediately come to mind.

Soon after this website’s beginnings, a reader forwarded an anonymous email voicing the concern that Ambulance Driver, in its 911 Update series, was violating HIPAA laws as it pertained to patient confidentiality. This was rather surprising given the care given not to disclose personal health information and the efforts made not to link data to a specific patient.

Since this subject has been dropped in the lap of Ambulance Driver, and it does directly relate to the goal stated above, we may as well talk about it.

The first call was made to the Ambulance Department manager requesting to have this blog’s content reviewed by the hospital’s HIPAA compliance officer.This request was made March 3rd and, in what may very well be a

bureaucratic world record, a reply was sent the very next day.

Permission has not been granted to disclose the reply but a fair synopsis would be:

• A policy on this subject is in the works
• Providing dates of service is a problem
• Providing location of service any more specific than a state is a problem.
• Blogging on the course of your work is not advisable
• Blogging on the subject of patient care is not advisable

Ambulance Driver is unconvinced that a patient’s identity could be gleaned from the information provided on its 911 Updates. However, after reviewing a legal summary of the law, one has to admit that the employer’s reasoning does have merit. HIPAA is a morass. For a health care agency to be cautious is just being prudent. The employer did not write the law, they are merely trying to comply.

HIPAA law seems to indicate that one may state, “I picked up a patient in Illinois last week with a broken leg.” On the other hand one may not say, “On March 2nd I picked up a patient in Chicago with a broken leg.” Seems silly, doesn’t it?

While not discussed in their response, the employer probably has some other thoughts on this topic. They have thousands of employees, hundreds of which may use social networks such as Twitter, Facebook and My Space. A few may be blogging. In this context, protection of patient confidentiality would be

a concern.

Ambulance Driver will do its best to alleviate the employer’s concerns over this website’s content and is confident that the situation can be worked out to the satisfaction of both parties. This has been submitted to an attorney familiar with HIPAA law and inquiries made to my Congressman in an effort to obtain a definitive answer to this question. All material will be shared with this blog’s readers and with the employer.

If any of my millions of readers have any comments, please feel free to share.

1. Since shown the door in the November 2006 elections, I haven’t spent much time at the Minnesota State Capitol but that does not mean my interest in public policy has waned.

Recently,  the Department of Public Safety was making their budget presentation in front of the House Public Safety Finance Division, the archives of which can be found online. The Department’s presentation was very good and the questions asked by committee members were on-point and probing. Representative Debra Hilstrom (pictured here)  was particularly well prepared and her questions reminded me of something that captured my attention in 2004 while a member of that same committee.

That year I stumbled upon some information that seemed to suggest that the Department was appropriated monies from 911 fees under pretenses that no longer applied. When asked privately about this, the response of Department officials was to tug at their collars, look down at their shoes and try to change the subject. At the time it was safe to conclude that I was onto something. However, after the 2004 elections, I moved off the Public Safety Committee and let the matter drop.

After listening to that committee hearing twice, and spending some time confirming that the situation had not changed since ‘04, I called Deb’s office and left a short message basically saying, “Saw the hearing – got an idea – give me a call.”

For Republicans like me, Rep. Hilstrom can be thought of as  a “Good Democrat.”  She is pleasant, thoughtful, hardworking and easy to work with.  But knowing the pressures and load she was carrying, I did not expect a prompt reply – and none was forthcoming.

Fast-forward to last week. For the third time since leaving office, I ventured to the Minnesota State Office Building. Wandering around for three hours, meeting old friends and sticking my head into places that the public does not know about was both enjoyable and fascinating.

On the Ground Floor level, heading towards a hearing room where I spent hundreds of hours, I saw Deb Hilstrom speaking with a group of people -I lingered.

Deb turned around to head back into the hearing room and saw me. It was obvious that my presence was not a pleasant surprise but she did manage to mumble, “I owe you a phone call.”  About that time Rep. Michael Paymar burst out of the room and asked for the whereabouts of a person whose name I did not catch.

Deb immediately blurted, “Sheisatthecafeteriahavinglunch,I’llgogether.” – and off she went. She did not lope, she did not trot, she wasn’t even merely running. She sprinted, and I mean SPRINTED, down the tunnel towards the MN-DOT cafeteria with her shoes slapping the marble like a drum roll by the U.S. Marine Corps Band .

With my hands in my pockets and watching her rapidly fade off into the distance, I had two thoughts -

• Look at that girl run
• Don’t waste any time sitting by the phone waiting for her to call you back

All of this only goes to prove that my close personal friend, former State Representative Ken Wolf, was right when he said, “There is nothing more useless than a former state legislator.”

A reader, who claims to be a health care professional, has anonymously declared that this blog violates the Health Insurance Portability and Accountability Act, or HIPAA,  as it relates to patient confidentiality.

Insuring that a patient’s protected health information is kept private has been my greatest concern. It is my understanding that as long as the information presented here cannot be linked to a specific individual patient, then there is no HIPAA violation.

To protect a patient’s confidentiality, I have set up some rules for myself which include:

• No ages – just a general description, such as elderly.
• No addresses – not even the city.
• If the patient does not speak English, they are described as non-English speaking. No nationalities are reported.
• Specific hospital destinations are not given
• If I am on a scene that will probably make the 6 o’clock news, I will simply say, “I was there.”

It seems to me that if any personal information is to be linked to a specific patient,  it would have to be released by my employer. There is no way it can be gleaned from the stories told on Ambulance Driver.

It must be said, however, that the rules are arcane and can be interpreted in some very odd-sounding ways. Two examples come to mind.

1. At the scene of an auto accident, I can tell the police that the patient has a broken leg but I cannot tell them that I suspect the patient has been drinking. They have to figure it out themselves.
2. Cell phone cameras are great for bringing visual images from the scene to the hospital. Vehicle damage from wrecks, height of a fall, or the length of a knife that the patient was stabbed with are just some examples of information that is valuable to hospital staff. Our medical director will not allow this use due to HIPAA concerns.

I am asking several individuals and entities, whose job includes HIPAA concerns, to review this blog’s content. Unless there are good reasons to stop, I am going to carry on with my 911 Updates.

There are some days where one is almost embarrassed to accept payment for the day’s work. Today was such a day.

• Call #1 A man called 911 complaining of shortness of breath. He met us at the curb, loudly insulted the female first responders and hopped into the back of the ambulance. After making the suggestion that he might want to tone it down a bit, our exam indicated that he was not the least bit dyspnic. However, further questioning did reveal that he had been drinking (BAC .156% at the hospital), suffered from bipolar disorder and had not been taking his medications. He got a rather expensive taxi ride to the hospital.
• Call #2…..there was no Call #2  -  or Call #3 for that matter.

The Department was quiet during my 8 hour shift. We fielded only 35 calls during this period.

As I read through my first blog posts, it seems to me that some explanation is in order. While it may appear that The Ambulance Driver is doing all this work himself, nothing could be further from the truth.

On many calls we have dual responses; either police or the fire department and sometimes both show up. Who responds to a 911 call is determined by the call takers and the various department’s dispatchers. Much of the determination for who responds to EMS calls is determined by the Medical Director for the system.

On medicals, the paramedic/attendant is in charge of patient care. The medic directs the actions of the other first responders at the scene. Having said this, we do work as a team and the work could not be done in a efficient manner without them. Even though they do have less training than the medics, the first responders we work with are experienced and very capable.

In our ambulance department each medic generally works with two regular partners – one on one day, the other the next. The day is split up in a manner agreeable to both medics but the most common practice is to trade driver/attendant positions after every transport.

I have the pleasure of working with 2 very seasoned paramedics. Between the three of us we have well over 100 years of ambulance experience. Yes, we are old. But despite our failing eyes and minds, we still have strong backs and an enduring enthusiasm for the work we do. Well… most of the time anyway.

Busier day today. The Department had 82 911 calls during my 5a-5p shift. Things were slow until around 11am when everyone decided to call at once. The entire system was out of available ambulances for a time with dispatchers holding runs and waiting for rigs to clear the hospitals. I’m told that St Paul Fire handled one of our runs and I don’t remember the last time that has happened.

• Call #1 was for an elderly gentleman who had two syncopal episodes after getting out of bed. Had a significant heart history but generally in good health. Our exam did not reveal any obvious problems – which seems to be the case most of the time in this type of situation.
• Call #2 involved a very elderly male who did not speak English and whose family’s English was poor. He was having abdominal pain that seemed to be associated with his urinary catheter. Due to the language barrier, we really couldn’t figure much out – including his past medical history.
• Call #3 was for a lady who had burnt food on her stove that produced an impressive amount of smoke. She consequently developed difficulty breathing as she put the fire out and attempted to ventilate her apartment. She did not have soot in her throat or nose and her lungs were clear. She was not obviously dyspnic but did have a mild, persistent cough and a feeling of “congestion.”
• Call #4 was for a wheelchair bound elderly gentleman with a barrel full of medical problems. He had been getting progressively weaker over a long period of time and for the past 4 days has not been able to get out of his chair. Needless to say, he was quite a mess. The upshot of sitting in urine and feces soaked clothes for all this time was some rather serious pressure ulcers. “Bed sores,” as they are sometimes called, are a potentially serious medical malady. One of these days I’ll have to do a separate post on this ailment.
• Call #5 has the distinction of being my most interesting run of the week. We responded to an non-English speaking male that was “ill.” We entered a room full of people and immediately knew who the sick person was – he was obviously weak, holding his chest and had sweat pouring off of him. We quickly took him to the ambulance where a 12 lead EKG was very suggestive of a inferior MI. However it was not diagnostic enough for us to activate a catheterization lab (more on STEMI’s in an upcoming post).  My partner and I were pretty certain that the patient was having a heart attack. Nitro and aspirin were given and we sped off to a nearby hospital. When we arrived, a second EKG was obtained that was unmistakable, the guy was having an ST Elevation Myocardial Infarction (STEMI) that appeared to have inferior and anterior involvement. We took him into the Emergency Room where a third EKG showed the situation getting even worse. The Cath Lab was activated. It will be interesting to see how he makes out and what the door to balloon time was for a Sunday afternoon. But the real lesson here is this – 911 was called within minutes of onset of symptoms and if they would have waited much longer we would have been dealing with a cardiac arrest in the field.
• Call #6 was a nursing home patient that took a fall from a standing position. He had blunt trauma to the head (but no loss of consciousness) with a main complaint of neck pain. Given the mechanism of injury and his age, I was very suspicious of a neck fracture even though he had no neuro deficits. He was handled and transported carefully.
• Call #7 was for a group of intoxicated homeless folks that had just exited from a church where they were given a meal. They kept falling down. We arrived with the police and were able to determine that, with the proper amount of encouragement, all were able to stumble off on their own power.

That’s it for this update.