New Jersey High Court Upholds Immunity for Paramedics in Infant’s Brain Injury Case

In a unanimous opinion, the New Jersey Supreme Court has upheld lower court rulings that paramedics who attempted to intubate an infant following the orders of a doctor in two phone calls are entitled to immunity under the state’s Emergency Medical Services Act (EMSA).

The paramedics failed twice before succeeding on their third incubation attempt right before transferring the infant to the hospital. The boy suffered a brain injury and other effects.

The EEMSA, as updated in 1984, immunizes persons who provide medical assistance in emergency situations, including paramedics who perform advanced life support services (ALS) “in good faith” and “in accordance with the EMSA.” Under the 1984 legislation, mobile intensive care paramedics, like those who treated 21-month old Jeremy Almonte, may perform ALS services provided that they “maintain direct voice communication with and are taking orders from a licensed physician.”

The phrase “maintain direct voice communication” is not defined in the EMSA and appears only in a provision that specifically states: “No mobile intensive care paramedic . . . shall be liable for any civil damages as the result of an act or the omission of an act committed while in training for or in the rendering of advanced life support services in good faith and in accordance with this act.”

The family of the infant argued that the paramedics did not maintain the necessary direct communication with the doctor that is called for under the law because there were gaps in the communications.

The high court noted that under the provision, a paramedic may act “negligently” yet still be immune from civil liability.

First, the high court found that the interventions of the paramedics attending to Almonte fell squarely within the definition of ALS services set forth in the law. They intravenously administered doses of muscle relaxant and sedative medications, monitored his heart rate through an electrocardiogram, and utilized endotracheal intubation, an adjunctive ventilation device.

Also, as required by the law, the medical care orders to the paramedics were conveyed during “direct voice communications” with a doctor.

Almonte’s mother called 9-1-1 immediately after observing her son fall and strike his head on a hardwood floor while running and playing in their home. After the fall, Almonte’s face and neck began “twitching,” which rapidly progressed into full body convulsions. Atlantic Ambulance responded to her call and the paramedics immediately attended to the boy. They twice callied Dr. Niti Sharma, M.D., a licensed physician from Overlook Medical Center.

During the first call, Dr. Sharma instructed the emergency medical technicians (EMTs) to administer valium. As Almonte’s heart rate continued to drop, the EMTs called Dr. Sharma again and she instructed them to administer additional medications and to intubate Almonte. Following an unsuccessful intubation attempt, the ambulance arrived at University Hospital. The EMTs made a second and then a third intubation attempt, with the latter deemed successful, before Almonte was transported into the hospital.

When he arrived at the trauma center, Almonte was in cardiac arrest. He was reintubated and resuscitated; his breathing returned. Almonte was discharged from the hospital on September 25, 2012. Almonte was diagnosed with anoxic brain injury, along with a number of significant physiological repercussions.

The boy’s parents filed a complaint against Atlantic Ambulance Corp., the paramedics, and others, alleging that their “negligent, careless, reckless, willful, and wanton” acts caused the boy’s injuries.

The paramedics and other defendants moved for summary judgment, maintaining that the paramedic immunity statute shields the paramedics from liability because they rendered ALS services “in accordance with the EMSA.” The trial court granted the motion and dismissed plaintiffs’ complaint. The Appellate Division affirmed. The Supreme Court granted certification limited to weighing whether the paramedics should be granted “immunity, which depends upon whether they acted in accordance with the EMSA.

The Almontes asserted that the paramedics’ “silence” for 17 minutes while attempting to intubate after their second call to Dr. Sharma was inconsistent with “maintaining direct voice communication,” and they further argued that a significant change in a patient’s circumstances such as a decline in heart rate or the ambulance’s arrival at the hospital, mandates reestablishing contact with the medical command physician.

The high court dismissed those arguments, noting noted that the Legislature did not specify a cadence for “direct communication” with the physician, nor did it impose criteria for intervening events that require recontact. The court explained why:

“Such a requirement would undermine the Legislature’s intent to enable paramedics to act in high-stakes situations without fear of tort liability. The discretion paramedics are afforded and the time constraints under which they operate counsel against interpreting ‘maintaining direct communication’ to require paramedics to divert from the crisis at hand and to contact the physician at set intervals or upon specific undesignated, intervening events.”

In addition, the high court found that the contents of the paramedics’ phone calls with Dr. Sharma clearly establish that they were “taking orders from a licensed physician” within the meaning of the law and that that Dr. Sharma’s initial authorization to intubate Almonte was sufficient to span the seven-minute timeframe during which multiple intubation attempts were made.

The court further noted that a statement accompanying the 1984 law explains that paramedics may perform duties that are “necessary to assume the orderly transfer of advanced life support care . . . to hospital staff upon arrival at an emergency room.” Here, the paramedics testified that transporting Almonte to the emergency room staff before establishing an open airway would have been “reckless.”

The high court affirmed the appeals court: “Here, the paramedics who rendered advanced life support services to Almonte acted under Dr. Sharma’s order to intubate, which she conveyed during two mobile telephone calls with the paramedics. Accordingly, we find that the paramedics ‘maintained direct voice communication with’ and “took orders from a licensed physician,’ such that defendants are entitled to the immunity provided by the EMSA.”

The court acknowledged “the profound tragedy presented by this matter and the significant impact it has had on all parties involved.”

Topics New Jersey