Schoolcraft v. The City Of New York et al

Filing 311

FILING ERROR - DUPLICATE DOCKET ENTRY - DECLARATION of NATHANIEL B. SMITH in Support re: 305 MOTION for Summary Judgment .. Document filed by Adrian Schoolcraft. (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit, # 4 Exhibit, # 5 Exhibit)(Smith, Nathaniel) Modified on 12/24/2014 (db).

PLAINTIFF'S MOTION
EXHIBIT 36

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Emergency Medicine review In the matter of Adrian Schoolcraftv City of New York,

et al. 10-cv-6005 (RSW)
Partg&JQ
Review of services provided by emergency medical technicians in and around Mr.
Schoolcraft's home

As surmised from the EMS record (5581845), EMS was dispatched to Mr.
Schoolcraft's home at 21:06 hrs. on October 31, 2009. This was apparently in
response to a Police Department call. They arrived nine minutes later however
police were involved with obtaining access to the patient and so the EMS team
documents that they did not contact the patient until 21:40 hrs. EMS notes that
they found Mr. Schoolcraft, a "34 year old male, ambulatory, alert and oriented."
The plaintiff ~took Nyqutl" but "denied taking any other medications." He
complained of abdominal pain, nausea and dizziness. Staff 1 at 21:45 hrs.
reportedly took a set of vital signs, Including blood pressure. and is recorded as
being 160/120 with a pulse of 120 and respirations of 20. Staff 2 at 21:55 hrs.
reportedly took a second set of vital signs. and is recorded as 160/110 with a pulse
of 118 and respirations of 20. A physical exam reportedly performed by EMS
Hreveals negative shortness of breath, negative cyanosis, lung sounds clear,
bilaterally, negative chest pain, abdomen soft in all four quadrants." Further history
states that the patient had been ~~nauseous for one day, negative vomiting." My
review of a taped record of the soda) conditions in the patient's home at that time
revealed that he was under some significant duress, thereby rendering the recorded
vital signs lacking in meaningful medical significance as it is well established that
acute psychological and/or physical stress can raise blood pressure significantly. (1)
4

It would appear that the abdominal pain and nausea were of concern to EMS
however, review of the audio record reveals that the hypertension was of greater
concern. Despite this concern, it should be noted that a third blood pressure was
not obtained during the subsequent 30 minutes with the patient arriving at hospital
at 22:25 hours. The emergency medical technfctan-s failure to document a stable or
stabilizing blood pressure is unsafe. The standard of care is to repeat pressures of
this nature with some frequency, usually 10 to 15 minutes.
During my review of the audiotape, and in my conversations with the patient, there
is evidence that the patient did not want to be transferred for an evaluation at a
hospital. Such refusa) is within the patient's rights. If in fact, such a refusal has been
voiced, EMS must either respect It or carefully document why it was not respected.
Central to the action of intentionally overriding the patient stated desires is the
demonstration that the patient Is non compos mentis. That is, it must be

documented that a condition was present wherein a person of average intelligence
and reason would, given the situadon, agree that transfer to a health care facility is
an appropriate action. Alternatively, it must be demonstrated that imminent danger
to life is present Neither of these standards was met in evaluating the
appropriateness of this patient's transfer to the Jamaica Hospital. This failure to
respect and honor the patient's legitimate and appropriate desires Initiated the
chain of events that resulted in an unjustlflable hospital hospital admission.

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Emergency Medicine Review, Schoolcraft v NYC 11AUG2014

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Part two

Review services provided in the Emergency Department (ED) of the Jamaica
Hospital Medical Center, Jamaica, NY.
Time log:
EMS reported arrival:
ED triage:
EDMD:
Medical eval. Completed
Psychiatric consult called
Seen by Psyche
Report & xfer to Psyche ED
Triage in Psyche ED
Transfer to inpt Psyche

22:25
23:03
00:05
00:14

01:43
06:30

06:58
13:44
14:06

310CT2009

310CT2009
01NOV2009
01NOV2009
01NOV2009
01NOV2009
01NOV2009

01NOV2009
03NOV2009

Blood Pressure
This patien~s blood pressure (as well as abdominal pain) was of concern by the EMS
workers. Triage provided after arrival in the ED revealed a blood pressure of
139/80. Over the course of this patient's care in the medical and psychiatric EDs,
his blood pressure remained stable. It should be concluded that the hypertenstve
readings obtained by the EMT workers were due to acute stress and without
underlying pathology.
AbdomjnaJ Pain

The EMT workers documented complaints of abdomfna1 pain with nausea and
dizziness but without vomiting and diarrhea. In the ED; the attending physician,

apparently working from a template record, notes approximately 15 hours of midepigastric discomfort, which is sharp, intermittent and improves without
intervention. The review of systems notes as negative both psychfattic and
gastrointestinal complaints. The physical exam was essentially negative, including
the examination of the abdomen. Laboratory evaluation included a CBC, pulse
oximmetry, lipase, amylase, and a comprehensive chemistry profile. These
evaluations were all non-revealing. The ED physician concluded that the patient
was stable from a gastrointestinal point of view and cleared the patient for
psychiatric evaluation.
,PsYchiatric Bvalu;nlon
There is significant emergency medicine literature describing what medical
evaluations should be accomplished in the ED so as to be certain that a psychiatric
condition is clearly differentiated from a medical condition (2). Although it is not
common that such a condition is discovered Jn the ED there are obvious dire
consequences associated with placing a medically unstable patient on a psychiatric
ward. This standard evaluation includes the documented consideration of
conditions that may mimic a psychiatric condition but in fact be due to other causes.

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My review of the documentation present reveals only that a CT scan of the head was
ordered so as to rule out the presence of central nervous system lesions that could
produce psychiatric-like presentation. This study was unrevealing. Not addressed
was an evaluation for the presence of pharmacologic agents that could significantly
alter this patient's mental status. In my experience~ a drug screen ts a standard part
of this evaluation. These screens are commercially available and with simply a urine
specimen can detect.. among others, ethanol, hallucinogens, narcotics, sedatives and
amphetamines. In general, the psychiatric evaluation does not occur until either the
substances screened for are shown to be absent or the substances so identified as
present would be reasonably expected to dear from the patient's body.

In my conversation with the Mr Schoolcraft, I specifically asked whether he had
been able to provide a urine specimen. He answered to the affirmative. It does
occasiona1ly happen that a patient will not provide such a spedmen, but in this case,
that was not the instance. If fact; the chart documents that the toxicology screen
was cancelled.
Progressing to the psychiatric aspect of the ED physician) s duties, it is critical that
the ED physicians convince themselves that a psychiatric emergency is present
That is, there needs to be a condition where the patient presents wfth historical or
physical exam findings that would predict that the patient has a condition that rises
to the standard of a substantial, immanent life threat to the patient or other persons.
While it is true that not all psychiatric admissions need to rise to that standard, such

as a voluntary admission where the patient perceives their schizophrenia is out of
control, this standard must certainly be met for involuntary admissions. In that an
involuntary admission dearly intrudes into the patient•s civil rights, concordance by
two healthcare professionals is critical. A documented conversation between the
two heaJthcare professionals assures that details of the case are not omitted and
that all facts are fully considered by the two professionals. In fact, in my opinion,
and to a reasonable degree of medical certainty, this patient should have been
released from the ED as it was never demonstrated in the record that he was of
substantial risk of danger to self or others. In my practice, I involve not only a
mental health provider but nursing staff as well. With three . . part concordance I can
be more certain that what I am about to do is the right thing for the patient.
Documentation present in the chart fa Us to demonstrate that the ED attending had
independently evaluated this patienrs psychiatric condition or discussed that
evaluation with the psychiatric professional seeing this patient at the ED attending's
request This failure improperly deprived the patient of a complete evaluation that
was critical to avoid an action that Improperly deprived the patient of his civil
rights.

Separatelyj there is some question as to how various providers in the ED became
aware of the patients possible past psychiatric history. Not only may this have been
a violation of the patient's rights under the HIPPA legislation, but it may have
additionally tainted this patient's ED evaluation.

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Summary
Prehospital, there were concerns of hypertension and abdominal pain, which fairly
rapidly became nonissues after just a few hours in the ED. Attention was fairly
rapidly turned to psychiatric issues. The ED attending failed in his duty to
appropriately evaluate this patient on two fronts. First, usual and customary
evaluations for conditions that may mimic a psychiatric presentation did not occur.
Secondly, the ED attending failed to accomplish and communicate an adequate
psychiatric evaluation on his own. In my opinion, and to a reasonable degree of
medical certainty, there were significant failures of medical practice that led to an
action that intruded upon the patient's civil rights.

11AUG2014

References;
(1): Zimmerman RS and Frohlich ED Stress and hypertension: J Hypertens

Suppl. 1990 Sep;B(4):S103-7,

(2): www.njha.com_media_3107_Clearance ProtocolsForAcutePsyPatients.pdf

AUG-10-2014

02:21

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40 Stimson Ave

401·322-9040 (H)

Robin's EM: [e-mail]

Dan's EM: drdanhr@gmail_.com

Robin's Cell: 401-339-0769

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401-273-0822 (H)

Providence, Rl 02906-3218

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Dan's Cell: 401-339-0771

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DATE: 10 AUGUST 2014
TO:JOHN LENOIR
PHONE: [phone]

FAX: 646--417·7245
RE:SPEEDCRAFT
Number of pages including cover sheet: 5

Message

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You can call me anytime to discuss- 401 . . 339-0771

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