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Minutes 11/15/1982 _, Naples, Florida , November 15, 1982 LET IT BE REMEMBERED, that the Emergency Medical Services Advisory Council met on this date at 4 : 00 P.M. in Building " F" of the Courthouse Complex in Special Session with the following members present : CHAIRMAN: Egon Hill MEMBERS: Marvin C. Cecil William H. Comte Pavid C. Graham Chief Jim Billman • EX-OFFICIO MEMBERS: Dr. John Adams for Dr . William Cox William McNulty for C. C. Wh idden STAFF ADVISORS: Douglas Greenfield Dr . Robert Tober W. Neil Dorrill ALSO PRESENT: Elinor M. Skinner, Deputy Clerk ; Joan Hamilton; Beth Fredlund ; Andy Fredlund ; Johnny Bratley; Skip Camp, Jack Wampler ; James D. Murphy; and Billie Moyer . AGENDA Review of complaint brought by James P. Murphy against Collier County Emergency Medical Service Chairman Hill said that this is the first time That the EMSAC has had a meeting in connection with a complaint and that there is a possibility there may he conclusions to be forwarded to the Board of County Commissioners since that is the only group that can make a decision. He said that Mr . Murphy also has a dispute with the hospital but that will not Page 1 Emergency Medical Services Advisory Council ' November 15, 1982 be considered at this meeting. He said that he and Mr . Murphy have been friends for many years, and therefore , in order to avoid any questions as to his objectivity, he is turning the meeting over to Vice-Chairman Gillman. He said that he had requested Mr. Murphy to bring any documents regarding this case to the Council and that he has made the same request of the EMS administrator . Mr . Murphy said that there are some statements regarding the ambulance report that he would like to challenge. Mr . Dorrill stated , for the record , that he had formally invited Mr. Murphy to be present today and that this opportunity is being afford Mr . Murphy under Article II, Section 1B of the EMSAC By-laws as amended June 30, 1980. Mr . Murphy referred to the ambulance report which lists him as "possibly a G. I . bleeder" and he read the chief complaint : weakness , dizziness, vomiting blood . He explained that 15 minutes before his attack he had eaten watermelon, and he contended that what the EMS personnel saw in his vomit was the remains of the watermelon, which he assumed to be an honest mistake. He said he challenged the fact that he , at any time , vomited blood . Dr . Tober asked how the hospital situation related to his complaint , to which Mr. Murphy said that when he was brought in , Dr . Tober ordered a blood test and he questioned the woman who gave him the blood test. He said she showed Page 2 Emergency Medical Services Advisory Council November 15, 1982 him a stick on which the test was registered and that it did not go up like a thermometer goes up, but it was practically zero. Dr. Tober said that it has been documented that Mr. Murphy definitely had a C. T. bleed . Mr. Murphy said that one week after the episode, he went to the Veterans Bureau in Fort Myers and they went through the same procedure and found nothing and that he has those records to prove that. Mr . Dorr. ill requested that copies of the Veterans Bureau records be made for members of the Council . Mr . Murphy said that , if In the next few minutes he fainted , he did not want to be taken away in an ambulance because he has had these attacks at least six times previ- ously, always in his home, and that, within minutes, he has recovered . He said that a good samaritan called the ambu- lance when this happened on the occasion in question, and he was taken to the hospital and was administered life support system. He said it is his contention that experienced people should know the difference between a faint and a coronary heart attack . He said that he has a leaky valve in his heart • which temporarily deprived the brain of blood , causing a faint and that as soon as blood is restored to his brain, the faint is over . Mr . Murphy read his statement that his sole purpose of appearing before the EMSAC is to protest the abuse of Medi- care by the local EMS which came about due to his personal • Page 3 Emergency Medical Services Advisory Council November 15, 19P2 experience. He said that , if he is successful , the only saving to him would be 520. 00, which he is well able and willing to pay, should EMSAC so decree. He said that Medicare will pay 5154 of the total bill , whereas they should only pay S62.00, thereby saving Medicare S92.00. He said that the life support rendered to him was not needed , adding that the men and women attendants are knowledgeable enough, due to their training , to know when to administer this and when not to. He said that if ordered to administer on every possible occasion as a routine procedure, the attendants are going to do so, thus, increasing cashflow by over 100%. Mr. Murphy said that he lives In Village Green, five minutes from Naples Community Hospital , and that his illness was due to a simple faint , many of which he has had previ- ously and from which he has recovered within minutes. He said that , had a good samaritan not called the ambulance, he would never have gone to the hospital . Mr . Murphy said that abuse of Medicare must stop if the system is to be saved , adding that he is a founding member of the Naples Senior Citizens and that they all lohbyed for the enactment of Medicare under Social Security in 1961.. He said that when Medicare was passed in 1967, the Naples Senior Citizens were invited to the White House Pose Garden to celebrate the victory and that he cannot , in good conscience, stand by and "see it all go down the drain" without protesting . Page 4 Emergency Medical Services Advisory Council November 15, 1982 Mr. Murphy said that knowledgeable people have told him that basic life support is only needed by 5% to F of all persons picked up by EMS and that examination of EMS records will review the facts of this complaint. He said that the question before the EMSAC is, " Is the local EMS abusing life support and oxygen administration when not needed"? He said that it is a matter of record that EMS was not pleased with the fee allowed when the fees were considered and that it well could be that EMS is using life support to obtain that which they wanted in the first place but was denied . Mr. David Graham asked Mr. Murphy if he requested treatment by the ambulance people to which he stated , "No" . Ms. Beth Fredlund , EMS personnel , said that when the EMS attendants walked in , Mr . Murphy was on the bathroom floor and they took his vital signs and he did not refuse treat- ment. Mr . Graham asked if it is normal procedure, when there is an lert patient, to ask him if he wishes treatment , to which Mr . Doug Greenfield said that standard procedure on a patient encounter is to advise the patient, prior to the transport phase , and that the EMS does not, normally, enact commitments to charges for actually visually inspecting a patient and assessing a patient' s condition. He said that there is a charge for what is done during the transport phase. He said that, prior to transport , the patient would have the opportunity to refuse services . Mr. Graham said that he was talking about the treatment • Page 5 Emergency Medical Services Advisory Council November 15, 1982. Mr. Murphy received in the amublance and again asked if he was asked if he wanted treatement , to which Mr. Murphy said he could definitely say "No" and that he was fully conscious all during the time. Chief Billman asked Mr . Murphy if he tried to protest the fact that they were doing the treatment, to which Mr . Murphy said , "No" . Dr. Tober said that when the EMS personnel attend someone they assume that the patient wants their help unless they specifically refuse it. He explained that when he sees someone come in, in an emergency setting , he would stop helping that person only if they said , "Don' t touch me. I don' t want treatment" . He said that it is by "Implied Consent" that he is there . Mr . Greenfield apologized that the paramedic will not he present because he is no longer in the EMS system and is ' working out of Collier County and it was not feasible to bring him to this meeting. He said that Ms. Fredlund was on the call for Mr . Murphy. Ms. Fredlund said that Mr. Murphy was quite apprehensive at the scene and that everything that the EMS personnel did was explained to him, step by step. She said that he was quite sick and that he did not refuse treatment. Mr . Murphy said that , in the state he was in he did not think he could make an intelligent decision, however , he was not unconscious. Chief Billman said that, looking from the prospective of the responding emergency people, they only have to go on Page Emergency Medical Services Advisor, Council November 15, 1402 physical evidence that they see at the scene and he said Mr . Murphy just said that he was in no position to refuse treat- ment and , therefore , the EMS personnel would operate on the presumption that he actually needed treatment . He asked for clarification regarding Mr. Murphy' s contention that this case is an assault on Medicare and Mr. Murphy said that Medicare will pay most of the bill . Mr. Greenfield asked if that was what Mr . Murphy was referring to when he made the comment regarding abusing the Medicare privileges, to which Mr . Murphy said that the nature of his complaint is the administration of the life support system and oxygen while he was in the ambulance. Dr . Robert Tober , Medical Director EMS, said that he came here today because he wanted Mr. Murphy to fully under- stand and have "his mind at rest" about what the EMS person- nel did . He said that one of Mr. Murphy' s statements was that "trained medical personnel should he able to distinguish between a simple faint and the more serious condition like a heart attack or an acute bleeding episode from the stomach" , with which Mr. Murphy concurred. Dr. Tober said that the medical term for faint is syncope and that what Mr . Murphy had is termed a syncopal episode of unknown etiology, adding that, if he had been in the ambulance and gone to Mr . Murphy's side and was under the impression that he had fainted and did not know why he had fainted , he would have to, for his safety, pursue the causes of a faint that could Page 7 Emergency Medical Services Advisory Council November 15, 1942 kill him and make sure that his heart rhythm is okay, because that is the most common cause of faint. Dr . Tober said that he was rigged to a heart monitor to make sure that his heart rhythm was pumping properly, and that it was presumed that he had possibly vomited blood and that it was the EMS personnel ' s obligation to get an intravenous line into his arm before he bled so severely so that his veins would collapse, and that those were the two advanced life support modalities that were charged against him. Responding to Mr . Murphy, Dr. Tober said that he would not ask him if he wanted that treatment . Dr . Tober said that it has been documented by himself and another specialist, who took care of Mr. Murphy, that he bled . Mr . Murphy gave Dr . Tober the specialist' s notes related to him and Dr. Toper said that they stated that he had mild antritis and duodenitis and he explained that antritis as meaning that the entrance into the stomach into the first portion of the small intestine, called the duodenum, was inflammed and that the duodenum itself was inflammed. He said that the most common cause of gastro- intestinal bleeding is not an ulcer but inflammation of mucosa of the gastrointestinal tract . He explained that blood was aspirated from Mr. Murphy's stomach that was chemically identified as massive amounts of blood and that there is no question about the fact that he bled between a half and a full quart into his stomach on that day. Mr . Page P Emergency Medical Services Advisory Council November 15, 1952 Murphy said that he did not accept that. He said that he is taking a blood thinning pill that causes him to bleed a little more easy than if he weren't taking it. Dr . Taber said that Mr . Murphy needed to bring in his own physician to look over his records. Dr. Tober said that the tests were positive for blood . Mr . Graham said that Mr . Murphy is stating that he is being charged for services that he did not request. Mr . Murphy said that the only reason he is present is to protest abuse of Medicare. He said that he is asking that the treatment for life support and oxygen be cancelled . Mr . Greenfield said that in Mr. Murphy' s statement he stated that. he was given services that he did not need . Responding to Mr. Graham, Mr. Murphy said that he did not want the services because he was fully conscious and knew what was going on. Chief Hillman asked if there is a procedure whereby the billing can be reduced if a patient is treated for something he does not need , to which Mr. Greenfield said that the ability to make a reduction or status change is built into the system and that he has done it on frequent occasions and that it always a matter of a error that has been pointed out of something improperly charged to an individual such as being billed for advanced life support when basic life support was administered . Mr. William Comte said that when there is a professional dealing with an emergency patient and that patient does not say he does not want treatment, that is Page 9 Emergency Medical Services Advisory Council November 1.5, 1Cl2 implied consent. Mr . Greenfield said that there is a double system of checks and balances on this type of thing in that the third portion of the trip ticket on any advance life support care does go to the Medical Director for his review on an individual case basis. He said that on the reverse side of the first page of the run report is a legal document that does give any patient the opportunity to refuse services and that there are places for witnesses to sign. He said that if Mr. Murphy had indicated that he did not want to be transported or treated , he could have done so at the time, and that Mr. Murphy admitted to him that he did not indicate that prior to transport . Mr . Greenfield said that it was an attorney' s opinion in Hillsborough County that a signature at an emergency accident is "not worth the paper it is written on" , adding that Implied Consent is something , in the State of Florida , that is dealt with every day and has to be recognized for the people who deliver this kind of care to the field . Mr . Hill stated that a quorum was present. Mr. Graham moved that the County reduce Mr. Murphy's bill . The motion died for lack of a second. Stating that, after hearing Dr. Tober's expert testimony there is no doubt in his mind, Mr. William McNulty moved that Mr. Murphy's bill stand as presented, seconded by Dr. Adams and carried 4/1 , with Mr. Graham opposed and Mr. Cecil and Mr. Hill abstaining. Page 10 Emergency Medical Services icivisory Council November 15, 1982 Mr. Murphy thanked the EMSAC for their attention. Mr . Greenfield noted for the record that on March 9, 1982 the Board of County Commissioners adopted a resolution ' pertaining to a new billing procedure , which was prior to Mr . Murphy' s case , and he said that one of the highlights of the resolution on ambulance billing is that Collier County EMS, by billing practice, does not directly bill any third party carrier which includes Medicare and insurance companies . He said the EMS bills only the patient directly. Be said that. , on occasion, Medicare is billed only after research techniques are done by the billing coordinator that indicate that the patient involved cannot , by normal standards , pay the bill that is encountered . * * * * There being no further business to come before the EMSAC, the meeting was adjourned at S: 02 P.M. EMERGENCY MEDICAL SERVICES COUNCIL *Chief Jim Biliman, Acting Chairman Page 11