Roles for providers in action medical support

18 Dec 2016 06:31
Tags

Back to list of posts

Medical providers who have not cross-trained as street medics are welcomed as an integral part of street medic mobilizations. It feels good to get out of the hospital or the clinic and work in the field, free for a moment from the encumbrances of paperwork, "cover your ass" medicine, and frustrating administrators. However, many other things are also different on the street. You don't have staff, advanced diagnostics, easy referrals, charts to give you baseline on patients, or a controlled working environment.

By working outside of medical institutions, each action medical worker becomes personally responsible for establishing and maintaining appropriate clinical boundaries in the street. How you carry your social authority may cause some people to cling to you and others to be afraid of you and refuse care. Working as part of an action medical mobilization requires an open mind, real humility, and a willingness to learn from anybody, admit what you don't know, be creative, and constantly improvise. And it can change your life.

A few roles have a particularly good "fit" with providers who have not cross-trained as street medics.

Buddy

You can plunge right into the fire and work in the field at actions, housing, or jail support as the buddy of a street medic. Don’t cheat yourself by buddying up with another medical provider; find a street medic who is not a medical provider. Your exchange with her in the street will be worth it. When choosing your buddy, get to know her and ask her questions before making a commitment. Ask when and where she was trained as a street medic, and if it was a 20 hour training. If she can't tell you, or didn't attend a 20+ hour training, she isn't a street medic. Find another buddy.

It is appropriate to ask a street medic for names and contact info of people she has worked with at past actions who can "vouch" for her as a medic. Feel free to ask, and to check in with those people and find out what they have to say about her. Ask her what actions she has worked at and what she thought of them. Ask what kind of risks she prefers to take at actions. Ask about her political philosophy. Ask if she holds any certifications or licenses in the medical field.1 Ask if she is an herbalist. You're looking for someone you can trust in the field, and someone you would like to work with. Some medics may not want to work with you if you do not have action medical-specific training. Among the many legitimate reasons for their preference might be their concern about your practical politics of informed consent or your skill in more highly fluid tactical situations. Don't be offended; be grateful your lack of affinity was discovered *before* you entered the field!

If you find someone you'd like to buddy with, encourage her to take point and to provide the majority of the care. Start practicing empowerment with your buddy! If she seems really inexperienced it's probably because she is. From your position as the "scene assessment" buddy, you can learn what your buddy knows and maintain the detachment to kindly help her grow in her confidence with assessment and care skills. Her bad health promotion judgment calls are learning opportunities for her and sometimes chances for you to kindly and respectfully help her learn. You will probably make bad tactical judgment calls, from which she can help you learn. You and your buddy can decide to switch roles in the course of care if she wants you to get hands-on with the patient or you need her to make judgment calls about your team's response to a rapidly developing environment. Debrief after every patient, and take the time to listen as well as to teach.

Clinician

Action first aid spaces and wellness centers are very different animals from most community clinics. They exist as an additional tier of care provided by action medical at an action, and do not replace existing community health services when those are needed. Patients who do not immediately need emergent care services offered by technical medicine use action wellness/first aid space to rest, get a higher level of patient care than can be provided in the street, get injuries documented, receive wellness services or nursing care, or consult with an herbalist or other clinician.

A common sight in action wellness/first aid spaces is "the drunk guy who face-planted." His friends flagged down a street medic and reported he stood up on a park bench and fell on his face. He's drunk so you can't really evaluate the cause of his altered mental status. No vomiting, no observed transient loss of consciousness, pupils equal, round and sluggish in response to light. The medics try to get the guy's friends to take him home and follow the guidelines on the head injury aftercare sheet, but they came all the way from Montreal and really want to be out in the streets. So the friends take him to the action wellness/first aid space. During his evaluation, he's meek and apologetic. Medics make him comfortable and let him sleep, herbalists brew up some tea, and a medic wakes him up every hour to check his pupils and look for late developing signs like raccoon eyes or Battle's sign. He feels better by the time his friends come back, and the medics send his friends home with clear instructions for using the head injury aftercare sheet.

Action wellness/first aid spaces don't see themselves as definitive care. In a pinch, they stretch their resources and pull off amazing feats with patients who absolutely refuse transfer to definitive care. But for everybody else, the clinic triages them into those who leave quick with or without a simple intervention, those who stick around for a while for assessment over time or rest, and those who leave quick in an ambulance or a car for the hospital. The action wellness/first aid space needs a good list of local low-cost and free health and social services to give patients who require definitive follow-up or services the action wellness/first aid space cannot provide.

There isn't a staff at the action wellness/first aid space to keep things running smoothly, just the volunteers scheduled during your shift, with whatever skills they have. They serve the patient, not the doctor. A street medic with experience in action wellness centers or action first aid spaces (and their buddy) should always be onsite to do clinic coordination or everything could fall apart. Jobs that need to be done include scheduling, constantly organizing and labeling supplies (and throwing out or hiding supplies that should not have been donated), cleaning up, and staffing the front desk. Some spaces include intake workers; in others, you do your own intake. People come in waves that depend on the action and mood in the street. Sometimes it's dead for three hours, then the space is suddenly swamped, right after the provider left from boredom.

Nurses and herbalists prove some of the best at intuitively understanding what is needed in action wellness/first aid spaces. The basics are two pillows and a blanket somewhere that is quiet, clean, accessible and feels friendly and safe enough for patients to relax; a box of correctly-sized exam gloves; and a caring, competent, sympathetic clinician. Everything else is extra.

Generating records for lawsuits and criminal defense

Patients sometimes want police-inflicted injuries documented for legal purposes. Common injuries include almost visibly imperceptible wrist abrasions or bruising combined with compression neuropathy of the superficial radial nerve caused by long custody in overtight handcuffs, or 30 cm wide contusions in lateral lumbar regions caused by blunt force trauma (usually from projectiles fired at fleeing protesters). Sites where requests for injury documentation are most common include at jail support (when support teams including medics, legal, and comfort maintain vigil outside holding facilities to receive released arrestees), in the action wellness/first aid space, and at housing sites. Street medics take photographic and written evidence of injuries and give these records to the patient. Reports written by anybody other than a medical provider are considered hearsay by judges, but usually a legal team can use them to build a case.

Medical providers have the authority to create official medical records which can be used as legal documents in court. The authority to create legal documentation of injuries can be a great asset to patients. In the United States, medical doctors and doctors of osteopathy are granted this right in all states. The ability of nurse practitioners to produce official medical records with the authority of legal documents in court is governed differently by each state's advanced practice nursing or advanced nursing practice laws. When producing medical records for patients, be sure to provide your business card or other contact information along with the record, so the patient can easily contact you and call you as a witness in court. Be aware that if they do initiate a lawsuit, it may be several years before you are called.

Medical records for hungerstrikers

Official medical records are also highly useful in support of hungerstrikes. Hungerstrikers use their own declining health as a bargaining chip, often when more moderate tactics have failed, and all they have left to bargain with is their own lives. Accurate, regular medical records collected every week (or more frequently during precipitous declines in health) can be given to the patient who may then share them with their support team in order to publicize their cause and their determination. Records may be used in court and you may be called as an expert witness if the court intervenes on the behalf of the hungerstrikers.

The role of a support medic during hungerstrikes is never to support the strikers' health — health support begins when strikers voluntarily break their fast and need info about a safe food reintroduction schedule, aftercare, and recovery support. Hungerstrikers' intent is to get as dangerously unhealthy as possible as quickly as possible and be as well-publicized in their campaign as possible so they can win as soon as possible. Lab reports on significant bloodwork interpreted by a sympathetic doctor on an evening news program can spark widespread concern and sway public opinion very quickly.

When hungerstrikers are incarcerated people (as they often are), you may use your social privilege to gain access to them and release the records to the support person(s) of their designation. In these situations, your special access allows you to be a valued advocate if they are being abused (ie. by forcefeeding orally or intravenously, which is rarely legal, by clandestine harassment or torture, or by inappropriate and life-threatening food reintroduction after a voluntary end to the fast).

Injury prevention

One of the greatest assets medical providers can bring to action medical mobilizations is wise and strategic use of medical authority and social position.

At a large Occupy Wall Street action in New York City, a street medic buddy team was evacuating a patient with a head injury and altered mental status using a chair carry. Their goal was to get the patient clear of the crowd and outside police lines where they could transfer care to EMS. They grabbed two medical doctors in white coats who were protesting with a group of doctors and asked the doctors to help them negotiate through an otherwise impassable situation. Doctors who look like what people expect a doctor to look like can flag a cab in situations when it will not stop for anyone else.

In an unusual situation at a large anti-globalization protest in Philadelphia, a paramedic was waiting for ambulance backup, kneeling in the street and immobilizing the head of a downed patient with cervical spine crepitus and mechanism of injury for a c-spine fracture. He used his paramedic medical rank (higher than first-responder and EMT-B trained police officers) to order an advancing line of heavily-armed riot police to turn down a side street and re-form behind him. The line of police complied.

Similarly, an outraged medical doctor who looks like a medical doctor can work magic in a civil disturbance at times when a medic who looks like an outraged protester would become an additional casualty. At the Miami Republican National Convention in 1972, the police raided the truck street medics were using as a mobile staging unit. The police dumped all the supplies on the ground and were tossing lit matches on the pile. In the pile were two full O2 cylinders, and surrounding it was a dense crowd. A nurse practitioner in the crowd (who looked like a protester) found her way to a nearby hotel lobby, grabbed a bystander who had the look of medical authority about him, dragged him outside, and showed him the situation. The presumed doctor quickly went from fighting her off to full-blown outrage at the dangerous situation the officers were actively creating in the midst of a dense crowd. He took his outrage directly to the most in-charge-looking officer, who curbed his little pyromaniacs before anything exploded.

Spend enough time in the streets, and you will get your own story of a daring rescue using nothing but your posture of authority and negotiating skills, your courtroom testimony that changed the whole tone of a trial, or your neatly placed phone call or email that defused a situation before it ever happened. It is magical to be able to put your authority on to challenge illegitimate authority, and take it off to work in a horizontal organizing structure or provide care to a person who is extremely skittish after being brutalized by another authority figure. Using your authority strategically is a way of providing care.

Legal notes

This document is about roles, but most medical providers come to this work anxious about legal liabilities. Insurers want to scare doctors into thinking volunteer care is legally risky even when it isn't, because insurers benefit financially when anxious doctors give them money. Thus if you search the literature, you'll find a weird clash of strongly-worded suggestions that volunteer providers carry malpractice insurance and strongly-worded reminders that malpractice suits are vanishingly rare when it comes to volunteer doctors.

Federal protections for physician volunteers:

  • Volunteer Protection Act (VPA) of 1997.
  • Federal Tort Claims Act's (FTCA) Medical Malpractice Program, as extended by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and further extended by the Patient Protection and Affordable Care Act.

State protections for physician volunteers:

  • Good samaritan laws are on the books in all states; they generally apply to emergencies if the emergency wasn't caused by the good samaritan, care wasn't grossly neglegent or reckless, and care was given with permission if possible.
  • Some states immunize medical volunteers via the same apparatus used to immunize state employees from liability (operates similarly to federal FTCA Medical Malpractice Program, and usually includes a state-administered defense fund).
  • Some states (eg Michigan) immunize all volunteers from suit, including volunteer health practitioners (with exceptions, like surgery).
  • Some states (eg Virginia, Connecticut) immunize volunteer health practitioners by allowing them to purchase malpractice insurance with premiums paid by the state's department of health.

These laws come out of a recognition that states have abandoned their responsibility to serve the health needs of their population, and the unrealistic hope that volunteerism can somehow fill the gap.

There are still three things of which you must beware:

  • Records you generate must stay with patients — HIPAA still applies and fines start at $10,000.
  • You lose your license by forgetting to renew it, not by fulfilling your oath outside of your institution.
  • Protests are places of intense ethical conflict — you must struggle to be relentlessly ethical, not because you fear lawyers, but because your soul demands it.

Comments: 0

Add a New Comment

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License