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Legal Speak

Bad PR and the Good Samaritan
March 7, 2013 10:51 AM by Tony DeWitt

The recent release of a 911 tape from a non-skilled residential facility has much of the country talking about what a caregiver's obligations are to the patient. In the case making news this month, the nurse involved believed that the facility had a strict policy that forbade employees from rendering any kind of care -- including CPR -- to the residents. The facility later announced that the nurse had a "complete misunderstanding of our practice."

(if you haven't read the full story, read the AP's version here.)

Editorials like the one appearing in the Tennessean illustrate how profoundly this affected people without any knowledge of health care operations.  As the newspaper noted "how can any moral human being refuse to ask anyone nearby to help, as happened in this case, during the course of a 7-minute, 16-second 911 call."

They also illustrate why newspaper reporters should not practice law. The editorial in the Tennessee paper states that the acts of the nurse in this case should have been protected by the Good Samaritan law. That would be correct if this happened outside of a facility, and when the nurse was not on duty or not being paid to care for the resident. But if you're on duty and you're being paid to care for a resident, the failure to exercise the proper care and to discharge your duty under the standard of care subjects you to a lawsuit for malpractice, and the Good Samaritan law doesn't apply.

Reacting to an emergency in the community -- at the mall or at a softball game -- is always protected under the Good Samaritan law. A plaintiff would have to show something more than gross negligence in most cases to get a judgment in almost any state. But when you're at work -- and this is important --- you are not doing the work of a good Samaritan when you're rendering care. You're being paid for it. So that means you have to do it right.

Don't let well-meaning people explain your legal rights. If you have questions about what your state's Good Samaritan law covers, talk to a lawyer in your state.

More articles on this topic:

Documentation Keeps Nurses Out of the Courtroom

Reducing Liability Costs

Return to ADVANCE for Long-Term Care Mangement homepage

 

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The Protection of Others
February 26, 2013 8:07 AM by Tony DeWitt
It is black letter law in most jurisdictions that a hospital or SNF has a duty to protect its vulnerable patients from the criminal acts of third persons to the extent that's possible. Facilities must take reasonable security measures to protect residents from intrusion, assault, battery and sexual misadventure. 

Reasonable security measures include motion-sensitive lighting, proper door locks, and in some cases, security officers. Each location and the risks associated with that location must be assessed individually. This is one reason why SNFs and other facilities often require name badges and other means of identification among staff members.

But what about the security of visitors, suppliers and other vendors? Does a facility have a duty to protect them from the criminal acts of third persons? In most cases the answer is no. Unless an individual is uniquely vulnerable (as a senior citizen or infant would be), or is neurologically compromised (for example, under the influence of narcotics and unable to protect themselves), in most states a facility is not under a duty to protect them.

D.B. was a 22-year-old with a new car and he was visiting a large chain restaurant in Kansas City, Mo. His vehicle, a very desirable sports car, drew attention from several individuals who followed him to the restaurant parking lot with the intention of stealing the car. Workers inside the restaurant, who happened to see an altercation shaping up in the parking lot between D.B. and the men who were after his car, went to the restaurant door and locked it from the inside to prevent D.B. (and those chasing him with weapons) from entering into the restaurant. This was part of the restaurant's protocol for safety and security, even if it looked somewhat uncaring to the young man pounding on the glass for entry.

As a result, while he was trying to gain entry to the restaurant, D.B. was shot once in the back, and paralyzed from the waist down. He sued the restaurant under a theory of premises liability -- that the presence of criminal elements in the area created a dangerous condition on the property -- and he lost at trial. The jury refused to hold the restaurant owner liable based on the criminal conduct of a third party. (The plaintiff had turned down an offer of $800,000 prior to trial, making the jury verdict particularly painful for him.)

Other cases in other jurisdictions reach different results, but generally, unless a property owner knows that its property is in a dangerous or high crime area, there is no duty to warn or go to the aid of a person under criminal attack. But most innkeepers and other businesses in high-crime areas post signs warning of criminal activity and advising their customers to safeguard valuables.

Nevertheless, in a hospital or SNF environment it is important to protect patients and residents to the extent possible from criminal acts. Residents should be warned and constantly reminded to put away items of value (watches, rights, cell phones, credit cards). Identity documents and money should be placed in the facility safe. Access to residents should be carefully monitored and guests, vendors, and suppliers should be required to sign in when present on the premises.

Sensible precautions up front help prevent claims by patients later.

For more articles on legal issues see:

Managing LTC Liability Costs

Guardian Compensation

Return to ADVANCE for Long-Term Care Management Home Page

 

 

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Unauthorized Practice
February 13, 2013 11:21 AM by Tony DeWitt

If you're like most clinicians, you judge the people you work with as much by their knowledge and experience as by their results. In most cases you've worked alongside these folks for months and come to know them as competent and caring individuals. But what happens when you come to suspect that the person you've been working with doesn't have a license?

For most clinicians, who guard their license to practice with their lives and who protect that privilege by following the rules, the idea that someone would simply start providing patient care without a license is hard to swallow. After all, doing so would no doubt cause a state board to permanently bar the practitioner, and the boards of sister states would likely follow suit.

But then there is the strange case of Calvin "Tamieka" Butler in West Palm Beach, Fla. Calvin has no medical degree. Calvin has no license to practice medicine. What Calvin does have is access to a hardware store and a Walgreens. 

For the second time in a year, Calvin was recently arrested for practicing medicine without a license. According to reports, Calvin used commercially-available silicone (the kind that is presumably used to caulk windows and doors) and ordinary Krazy Glue® to add bulk and body sculpt to unwitting patients. While the media pokes fun at the rubes who went to a motel room to let a "doctor" inject them with caulking materials, the same media reports indicate that these patients are probably scarred for life as a result of Butler's unauthorized practice. Butler was a low-tech con man with high-tech aspirations.

Frank Abagnale, the real-life inspiration for the movie "Catch Me if You Can," also held himself out to be a physician. For 11 months, Abagnale impersonated the chief resident pediatrician in a Georgia hospital. The job of the chief resident was not to directly treat patients, but to supervise those who did. So Abagnale allowed residents and interns to do the bulk of the work for him. Acting the part of a physician by being at times arrogant and at other times understanding, Abagnale successfully convinced most of those he worked with that he was, in fact, a physician. After a very sick infant nearly died because he did not understand the terminology used by a nurse, Abagnale left the hospital because he realized he was putting lives at risk. Importantly, the medical establishment never caught Abagnale. Apparently no one ever bothered to check his credentials or qualifications, accepting them on faith.

While most facilities require background checks and verify credentials with state organizations, sometimes that alone is not enough. Abagnale used a fake name - Frank Conners - to practice medicine. Most background checks are conducted on the basis of name and social security number. If a person successfully steals the name and social security number of another individual, they not only have access to their name and credit, they have access to their professional qualifications, too. And one need only pick up the newspaper to know that identity theft is a real problem in this country.

While I-9 forms and other methods of identity verification are used by most employers to verify citizenship, very few actually go to the trouble to verify that the I-9 form's identity documents accurately show the person named. Instead, most employers simply assume that a driver's license and a birth certificate showing US residence is sufficient for the task. But these documents - as any 18 year old trying to get into a bar can tell you - are easily counterfeited.  And while the bouncer at a bar or night club might look very closely at such an ID, most employers, glad to have a warm body, do not.

So what does a fellow employee do when he suspects that a co-worker may not be all he seems? The short answer is to report the situation up the chain of command at the facility. If the employee is not satisfied with the response, the employee can make a further report to the regulating board (board of nursing, medicine, physical therapy, etc.)

Sometimes an employee will take matters into their own hands, investigating by using the internet or online background check companies to determine if an individual is who they say they are. This is dangerous for two reasons. First, if the individual you are investigating learns of it, he or she might take direct action against you. Second, if the individual is actually legitimate and you dig too deeply into their past, you may violate their privacy and become a target of discipline by your facility (or your state board) yourself. For this reason, the smart money is always on letting the state do the investigation.

 

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Staffing Standards with Teeth
January 30, 2013 2:00 PM by Tony DeWitt

The California Court of Appeals, and the State Supreme Court have now determined in California that nursing home residents can sue if a nursing home does not provide the required number of hours of care. California's rules require long-term skilled-nursing facilities to provide each resident with 3.2 hours of nursing care per day. A group of patients suing provider Covenant Care claims it failed to meet those standards at least 35 percent of the time over a four-year period that started in December 2006. 

Under the law of most states, when a state passes a regulation for the protection of a specific body of citizens the violation of the regulation can be considered "negligence per se" in some instances, and evidence of negligence in others. However, in federal court and in some state courts, unless the statute provides for a "private right of action" the statute can't be the basis of a lawsuit.

In California the number of enforcement actions brought by the state against facilities has been very small, owing mostly to the fact that the state has very limited resources and the state inspection program is grossly underfunded. In spite of this, the caregivers argued that because there was no private right of action, the only people who could enforce the statutes were the state regulators.

The argument was a good one, and in many states it would have been a winning one. But both the California Court of Appeals (by a unanimous opinion) and the Supreme Court (by refusing to review the Court of Appeals decision) have now spoken on the issue. In California a nursing home resident who doesn't get his full 3.2 hours can sue.

This will likely force the legislature to act because the regulations were never meant to be privately enforced, and private enforcement could create a wide range of problems for caregivers. How does a caregiver document 3.2 hours of care every day? Will each patient have a time card? 

Of course, just because the facility can be sued doesn't mean the facility will be found to have violated the law. Anyone can sue. Plaintiffs will have to demonstrate that they have been harmed by the failure to provide adequate staffing. While there is an argument that "we're not getting what we're paying for," that might apply, only about 7% of nursing home care is privately paid for. Most is paid for by Medicare and Medicaid, and states already have statutes that allow them to recover for that kind of problem.

No, each patient will have to have some kind of clinical problem that developed or worsened as a result of not getting the 3.2 hours of care, and there will be a need for expert testimony on that subject. While the plaintiffs have won a battle, they have not prevailed yet in front of a jury.

 

 

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The Full Moon & Infectious Disease
January 15, 2013 11:41 AM by Tony DeWitt

Generally speaking, I can always tell when it's a full moon.  The idea that the moon makes people crazy traces back centuries, and is the root of the word "lunacy."  Lunacy tends to afflict a lot of people who watch daytime television advertising ("Have you been hit by a meteor?  It might be someone else's fault!  Let us sue them for you....") and as a result, lawyers offices tend to get some really funny calls.

An old professor of mine once said that the difference between a fairy tale and war story is that a fairy tale starts off "once upon a time..." and a war story starts off "you're not going to believe this, but..."  So, you're not going to believe this, but this conversation really happened.

Secretary

You have a potential client on Line 1.

Me

Okay... Hello?

Client

Are you a lawyer?

Me

Yes sir.

Client

I need me some help.

Me

What kind of problem do you have?

Client

I have a problem with aliens.

Me

What kind of problem do you have with aliens, and what kind of aliens are they?

Client

They's abucturating me.

Me

Do you mean abducting?

Client

Ain't that what I just said?  Are you sure you're a lawyer?

Me

Yes. Sorry, I guess you did. And what kind of aliens are these?

Client

I don't know where they're from. I just know I wake up in my pickup truck and my pants is down around my ankles and I has all these strange bruises man. I think they're poking me with things...

Me

What kind of vehicle do these folks abduct you in?

Client

Ain't no vehicle dude, it's a spaceship or something. 

Me

Let me see if I have this right. You're being abducted by space aliens, and the space aliens are conducting experiments on you, and you want me to sue them?

Client

Yeah, that's right. You're not as dumb as you sound.

Me

Thank you so much. But we have a problem. You don't know where we can find these aliens, do you?

Client

No. I done told you, they's in some kind of spacecraft or something can't be seen with radar or nothing.

Me.

Well sir, that creates a problem, because we have to send a sheriff out to serve them, and if he can't serve them, we can't sue them.

Client

Oh God, they've gotten to you too, haven't they....

I could almost smell the ETOH on this man over the phone. He was convinced that he was being abducted; his belief was sincere. He was just having alcohol-induced hallucinations. This happened my fourth year in practice, and since that conversation, I haven't had too many conversations any stranger. But every now and then I am reminded of the conversation whenever a client calls with a potential infection case.

No place, not a home, not a SNF, and certainly not a hospital, can be made pathogen-free. You can deploy all the UV lights, disinfectants, and sterilants you want, the fact is that every hour of every day, each of us is subject to infection from bacteria and viruses unseen. Anyone who's had the flu this year probably understands that very well. 

In spite of that, when patients get post-surgical or wound infections, they always conclude -- wrongly -- that it is malpractice for that to happen. Sometimes, of course, the perception of negligence is heightened when a caregiver fails to treat the infection, and in some cases when the caregiver fails to find the source of the infection. And the failure to treat an infection can indeed be negligence; but the infection itself is a normal and natural complication of life. It can (and usually does) occur in the absence of negligence. Worse, it runs into the same problem as the case of the space aliens:  no sheriff can be sent out to serve a bacteria, and it's the bacteria, not the clinician, that's at fault.

But that doesn't mean that you should not worry about being sued for infections. Anyone can sue you at any time for anything.  Your neighbor can sue you because you wore red tennis shoes. It doesn't mean he'll win, but it does mean that you'll have to hire a lawyer to defend you. And while you can't outflank crazy, you can at least minimize your risks from normal people.

Pro-active risk management dictates that as part of your teaching you should talk to residents about infections, particularly when a pressure sore or similar event occurs. Teaching should be aimed at explaining all the methods used to prevent sores, and all the methods used to prevent infection when a sore develops. Telling a resident that infections happen as a natural result of a break in the skin helps them understand that even the best of care is unlikely to have prevented it.  And of course, care should be rendered consistent with the plan of care and the standards of care too. But teaching often has the effect of educating people whose knowledge of bacteriology has been learned by watching General Hospital on television.

Keep in mind that diabetics require special attention with skin infections, and the key to surviving any lawsuit (and preventing most) is excellent documentation. Even if the policy and procedure says you don't need to document every day, when there is a wound or an infection -- and especially where the patient is diabetic or has vascular issues --  documentation every day helps prove later that attention was given to the problem. Remember, no one ever got to court and said, "Gosh, I wish I'd written less."

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The View From The Other Side of the Bed
December 5, 2012 11:00 AM by Tony DeWitt

Thanksgiving was a difficult day for me this year.  It was filled with the things I am traditionally thankful for: my wife, my family and my health. The family gathered and there was feasting and frivolity, but I didn't get to enjoy it because, in addition to being a day of Thanksgiving, it was also a day of personal tragedy.

At 6:00 a.m. on Thursday my mother-in-law woke us up unable to breathe. She quickly progressed to cardiac arrest. The cardiac arrest was caused by a spontaneous pneumothorax. Once that was treated, regular cardiac rhythm returned, but not before she was in profound coma from hypoxemia. She is currently comatose in a hospital bed in an ICU in a small town in the south. For her privacy, I won't reveal her name or the hospital. I will call her Miss Mary because that is the way the hospital staff addressed her.  And I will take a moment or two to comment about my observations about the care she received and the way that care was administered.

Generally speaking people with a health care background are the most critical of their own professions when someone they love is lying in the hospital bed. They look to make sure clinicians wash their hands. They check the charting to ensure ventilator checks are done on time. They ask direct questions. They expect to have direct answers. Let me say, from the outset, that I believe that the majority of people who go into health care go into it with the idea of helping people, and for the most part do a great job. Most do their job competently. Most do it pleasantly. But some go above and beyond.

Take the respiratory therapist who cared for Miss Mary. Every time he approached her and even though she was comatose, before he touched her, he would speak softly to her and say "Miss Mary, I'm just going to listen to your lungs for a minute." He would then do his job, get his readings, and then just as before, he would say "you're doing very well, and I'll be back to see you soon."  To him, Miss Mary was not a lump of flesh in a bed, she was a real person. She was someone who had wants and needs. She was someone with a family who loved her. She was someone who had seen and endured much in her life. And even though she was comatose, he talked to her with respect. He understood the concept of patient dignity.

The night-shift nurse, however, was not quite so pleasant even though she was technically very competent. Surely she was angry to be working Thanksgiving night instead of spending it with her family. I'm sure she was annoyed that the evening shift had let us stay in the room a little longer than the visiting policies provided. Maybe she had burnt chicken for dinner, I don't know. But while she gave Dilantin in the central line and then flushed it, she worked silently, neither talking to Miss Mary, or to us. She checked lines, gave meds, and did measurements all without saying a word. It was like she wasn't even aware that Miss Mary was there in the room with us. When she went to check blood sugar, I could bear the cone of silence no more. I told my mother-in-law "you're going to feel a poke in your finger because they're checking your sugar." 

The nurse looked at me and said, "She's in a coma!"  I nodded, and said, "Yes, but that doesn't mean she doesn't hear you." I got the standard "you don't know what you're saying" look from the nurse who wordlessly charted the numbers and left the room. Miss Mary was a clinical problem. She was the patient in 109. She was the "post-arrest coma" in bed 1. She was a constellation of symptoms, not a human living person. Whether communicated in words or wordlessly through actions, it denotes a lack of respect for the dignity of the patient.

So, today's teaching point, if there is one, is that the one thing that gets more hospitals and nursing facilities sued is treating patients without dignity. It is acting like the patient is a mass of cells laying in the bed, not a human living person. It's the view that the people in the beds are no more than potted plants, and you're delivering the Miracle Gro®. People will tolerate all kinds of errors by well-meaning staff, but they won't tolerate their loved ones being treated like they are not there.

The fact is that every one of us, whether a caregiver, a lawyer, a doctor or a plumber, will one day face the end of our lives, or be in a comatose condition through no fault of our own. If you have burnt toast for breakfast, if you have a fight with your spouse, if you are angry about the election, or your favorite college team's defeat in football, leave it at home!  The people who you care for on a daily basis have a right to expect the best of you. That means they have a right to expect that you will do what you are trained to do both with competence and compassion.  And while both are important, it is the compassion that is remembered by the patient and family long after the stay in the facility is done.

As I have said many times, people do not sue people they like.

1 comments »     
When Insurance Isn't
November 26, 2012 12:53 PM by Tony DeWitt

From time to time I have argued that insurance is something that people purchase, forget about, and never use.  That is, until something awful happens, and then they find out that the insurance policy they bought is not the policy they think they bought.

 

As a lawyer who sues big corporations from time to time for violations of the False Claims Act, it’s hard for me to feel sorry when a big company gets hit with a big lawsuit that alleges they bilked the federal government for millions of dollars.  And when that lawsuit is coupled with a claim that the company fired a whistleblowing employee, I have even less sympathy.  But there are news reports today that a Japanese drug-maker is suing its insurer because the insurer is reneging on its insurance contract.

 

The company thought it had coverage, entered into settlements, and now can’t get the insurer to step up to the plate and pay it back.

 

Unless you work in the legal profession where this occurs regularly, you probably don’t know that about 25% of the time insurance companies sell policies that provide coverage for several things, but then include exclusions that swallow whole the coverages offered.

 

If you have not read your homeowner’s insurance in a while, pull it out of the firebox (Yes, surely you keep your policy in a fireproof box in your house in the event of a fire, right?).  Read through the policy declaration page, that’s the one that says you’re covered for $100,000 for fire, wind, etc.  Now go back a few pages and start looking for the exclusions.  Here’s where you’ll find that your insurance policy doesn’t really offer all that much protection.

 

One of my favorite exclusions is the “intentional acts” exclusion.  Suppose some religious zealot comes to your house and attempts to push his way inside with 14 tracts explaining why you’re going to hell if you don’t convert to his particular religion.  Nicely asking him to step off your front porch doesn’t work, so when he attempts to push past you into your living room, you push him hard in the chest and he falls over your azalea bush and breaks an ankle.  He sues you for battery and negligence.

 

Battery is what is called an “intentional tort.”  You had to intend to make harmful contact with your victim.  You didn’t really intend to hurt him, you just were trying to keep him out of your house.  Nevertheless, you’re likely to receive a letter from your insurer telling you that it is defending you under a “reservation of rights.”  What this means is that it will offer up a defense but if the plaintiff wins, any judgment gets paid, if at all, by you.

 

Most people don’t read their insurance policies until after something bad happens.  But the time to change insurers is now if something in your insurance policy is not what you want it to be.  Different insurers have different policies and different interpretations.  It is a good idea to discuss any questions you have about coverage with your insurance agent, and get any answers to those questions in writing. 

 

 

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The DeWitt Endorsement
November 7, 2012 10:36 AM by Tony DeWitt
 

For hundreds of years newspapers and media organizations have been throwing their support in one form or another to various candidates. Depending on whether you lean to the left or the right, you can find a news channel on television to give you the news that fits your own political bias. But newspapers, which normally trend toward balance, often endorse one candidate over another. 

This election season, I made an endorsement. I didn't endorse any particular political candidate. I endorsed something far more important: critical thinking. If you think critically, if you evaluate all the factors and biases and predispositions, it is my view that you will ultimately vote in the right way at every level from the state to the national elections.

Let's start with something on the ballot in Missouri, where probably only a few of you are from. There are two propositions that should be considered. One is Amendment 3, and the other is Proposition B. Let's begin with the last one.

Under Proposition B the state's tobacco tax, which is the lowest in the nation, would be raised to improve education in the state.   There are two classes of voters who oppose this initiative. Those who smoke cigarettes, and those who sell them. It seems pretty obvious that smokers would not support the measure because it would require them to pay more. I support their right to object.  But the commercials on television and the signs at the gas stations, all paid for by Big Tobacco, encourage people to vote against it because it's "just another tax." 

So, here's the real issue.  When someone spends money to fight against an issue on the ballot not because they have a personal interest in things (the way smokers do), but because they have a profit motive, it should make you at least a little suspicious about the nature of their opposition to the measure. A critical thinking adult might think that the tobacco companies wouldn't spend millions opposing the tax if they weren't going to lose millions because of it. That would make me discount their message out of hand, and I will certainly be voting yes on Proposition B.

Amendment 3 is similar. Amendment 3 was pushed through by a zealous group of people who seek to change the way judges are appointed in Missouri. In all but four counties judges are elected. In the four biggest counties and at the appellate court level a commission decides on three candidates for each position, and the governor must choose one of the three. The people behind Amendment 3 would like you to vote for direct political control of the courts. Why?  Because the over-reaching legislation passed by the corporate-friendly legislature has recently been running into trouble with judges who understand the Missouri Constitution. In essence the politicians want to make the least political branch of government as political as the other two.

When judges decide based on the facts and the law, and not because they are beholden to special interests, it works in favor of the general public, and against the interests of people who would spend their money on the best legislators money can buy. Is it any wonder that these folks would fight back by trying to buy the Courts too? And if it is good for corporations and lobbyists, do you think it would be good for you?  gain, critical thinking argues against voting for this amendment.

At that national level Political Action Committees or PACs now dominate the advertising and the media generated around the election. Some of these PACs are funded by billionaires. They write multi-million dollar checks to support them. Some of these millionaires and billionaires made their money on the stock market and in banking circles and have been hurt by financial reform spearheaded over the last four years. 

One noted former presidential aide to Mr. Bush has been spent more than $100 million on television ads pushing one candidate. All of these PACs either have lofty-sounding names (The Freedom Coalition) or they have names that make no sense at all (GPS-Crossroads). But what they have in common is lots of money, and money can buy talented salespeople.

These commercials are triumphs of media glitz. The flag flies proudly in the background, eagles swoop from the sky, military men and women salute, and earnest announcers talk about freedom and liberty all while asking voters to reject these same concepts when it comes to a woman's reproductive health care. 

So the question has to be this: what makes it worth $100,000,000 to these corporate titans to advocate for a change in government? The answer has to be something worth more than $100,000,000 or it makes no sense.  Since you cannot take liberty and freedom to the bank, then the answer must be that the people who the advertisements support will throw back to these corporate sponsors something worth far more than $100,000,000 at some later point in time. 

Again, this should make the critical-thinking voter sit up and take notice. That's especially true when the average donation for the other guy's campaign has been from people giving $25 to $50 a month out of their paychecks.

PT Barnum once said there was "a sucker born every minute." 

In December, 1944, on a cold and snowy field in the Ardennes, my Uncle Victor Gower was shot in the chest and died in service to his country. He died to safeguard my right to vote.  When it came time, I put on the same uniform of the United States Army, as my son did, only a few years ago, to make sure that the right to vote was protected.  All of us swore an oath to the Constitution. 

This year, as an attorney, I was once again at the polling places to protect the right to vote. The right to vote is too precious, and has come at too high a price in human lives, to exercise without being informed, and being informed does not mean getting all your information from You Tube, a particular news station, or one publication. It does not mean being swayed in exercising the franchise by your local newspaper. Whoever you voted for, you should have because you conducted honest personal research and found the candidates that best protect your interests. Inform yourself. Don't prove Mr. Barnum right. Get the facts and make your decision from the facts.

That is what it means to be an American.

 

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Union Dues
October 18, 2012 11:43 AM by Tony DeWitt
I grew up in a house where no one was a union member. About the time I was 14, my aunt married a guy who was a union steward, and I learned first hand about unions from him. He was very proud of his union membership and what it had done for workers at the factory where he worked. But it always amazed me that if a worker dropped a bolt or spilled something on the floor, they could not clean it up. That was a job that belonged exclusively to another group of unionized workers. It seemed to me that unions were very inefficient, at least from the perspective of someone who normally picked things up when he dropped them.

As a health care worker I never believed unions were in the patient's best interest in the hospital setting. I still hold that belief in general, although the long-term care arena is one of the few places where I believe the benefits and protections afforded workers outweigh the slight risks to patients. Much of the work force in a long-term care facility is unskilled labor (nurses aides and assistants). Many of these folks could not act as their own advocates in getting better pay or benefits, and probably require a union to get it done in situations where management is purely profit driven. In the majority of well-run nursing facilities, unions do not add much. If you treat employees fairly, in most cases you never have to worry about a union.

Today comes news of a union-related problem in California. The facility at issue was sold. The seller employed nurses and aides represented by a union. The buyer knew this, but didn't want to deal with them. When the new buyer took over, he decided he did not need union workers and proceeded to refuse to negotiate with them, firing union workers and replacing them with non-union employees. The union filed an action with the National Labor Relations Board (NLRB).

But you just can't do that. The National Labor Relations Board imposed a $1.25 million assessment, directing the rehiring of terminated workers and ordering backpay. It also issued an order mandating compliance. 

This is what happens when people who have never tried to deal with a union try to deal with one in a heavy-handed way and without legal assistance up front. The union may not win the early battles, but in the end it prevails with the NLRB. Along the way, legal costs mount, and whatever money the facility saved by trying to dislodge the union it wound up paying back twice when it was all over. And now employees who probably never would have joined a union now see that a union has a significant advantage for them.

If you have union woes, hire an expert. Don't try to go it alone. Lots of companies provide legal and professional assistance in dealing with unions. They earn their money.

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Fall Festival Brings Creative Ideas
October 9, 2012 1:44 PM by Tony DeWitt

One of the things I love about the South is that every Fall there are craft festivals. My wife's favorite of these is held in Gay, Georgia on the first weekend in October. This year I met a woman who was selling a product she designed and patented that is a modular bib.

 

I suggested she should market her products in the long-term care industry. She indicated she was already doing that. The design and functionality of this creative bib system permits a resident to wear a small, lightweight bib over which a larger washable bib is attached with Velcro. If the bib becomes soiled it is easily removed, washed, and returned to service,

 

Peggy, the owner and entrepreneur who developed the bib design is, like me, an Air Force brat who grew up all over the world. Her company is located in Columbus, Georgia and she has a Facebook page where you can get more information on Peggy's Bibs.

 

What intrigued me about the product was her statement from an elderly user who used to have a thick terry cloth towel draped over her at mealtime. It made mealtime hot and uncomfortable. "I got my dignity back," she said.

 

One of the things people often cite about nursing homes is that the residents are deprived of their dignity. They often lack control over bodily functions and are frequently at the mercy of their caregivers. And when SNFs are sued the underlying theme is often one of stolen dignity. So if using a well-designed product improves residents’ perceptions about their dignity, that's probably money well spent.

 

 

   Peggy Gay - (706) 575-4918 -  Info@peggysbibs.com

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The Trial That Wasn't
October 1, 2012 12:01 PM by Tony DeWitt

Lawyers are supposed to love going to trial.  I never have.  It's a lot of stress for a short period of time, and the courts generally don't favor plaintiffs attorneys.  But when the other side never makes an offer to settle, you have to be willing to go to court and get your case heard.

So on Sept. 17, 2012, I went to Cole County Circuit Court prepared to try my case against a local nursing facility.  The allegations were pretty serious.  The facility let a resident's weight drop from 162 to 137 over 45 days and never intervened.  For two months they had not been keeping food intake records, and at one point a period of 26 days elapsed between nurses notes.  The photographs of the resident's bruising were almost stomach-turning.  It was an awful case.

The defendant, of course, said we were full of gas.  Twenty-six days without a nurses note?  No problem.  Twenty-five pound weight loss?  No problem.  Twenty-six bruises, including bruises on the inside of the woman's thigh?  No problem.  She was old, she was going to die anyway.

The first phase of any trial is voir dire.  That is Latin for "to speak the truth" and it talks about the process where jurors are asked about their biases and prejudices.  Everyone comes to court thinking they can be fair, but some of our biases are just too much.  One juror in our panel said he had a similar experience with the same nursing home, and he clearly did not think he should sit on the jury.  But others never said a word when first I, and then my opposing counsel, asked the panel questions.  They sat with their arms folded and their faces inscrutable.  It was like picking a jury full of sphinxes.

After throwing off 20 people for bias and prejudice, the net result was a jury of 12 people and 2 alternates that we couldn't tell one way or the other whether they were fair or whether they could be fair.  But it was our jury, and we were set to live with it.

We went to lunch and came back ready to open up the case with opening statement.  And that's when the whole thing fell apart.

"Counsel, would you please approach?"

At the judge's request I went up alongside the defense attorney.  The judge said "I think I should probably tell you that I am pretty sure I've done legal work for both sides.  Ask your clients if you want me to recuse."

Neither the defendant nor our side was happy with this, but in the end the judge had to recuse.  He had a lawyer-client relationship with both parties, and that means that even though he was probably just as fair as could be, there is no way to ensure that.  The defendant was bothered that all the rulings had gone in favor of the plaintiff up to that point, and would have asked him to recuse if plaintiff had not.

So, at the end of the day, after five weeks of prep, we suffered a mistrial.

It's tempting to look at that as a set back.

But a funny thing happened when I got back to the office.  New information came to light.  That information, supplied by a family member, will make a huge difference on retrial, and that could only have happened because we suffered a mistrial here.  

Legal work is taxing work, but every now and then, even when bad things happen, they can turn out for the good.


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A Message to Candidates
August 23, 2012 8:22 AM by Tony DeWitt
This column is an open letter to candidates running for political office, from the lowly county clerk to the lofty President of the United States. It represents what I would like to see in politics this fall.

Dear Candidate:

Thanks for having an interest in public service. Public service means that you exist to serve the public, not to have the public serve you. Should you be successful in your quest for elective office, please try and remember that.

Our country's founders believed citizens should hold elected office, but should do so for short periods of time and then return to private life. Please do not try to set the record for the longest-serving politician in this role. The public as a whole really gets tired of you after about 6 years.

As you set about campaigning, those of us who will be forced to sit through your endless commercials have a favor to ask. Talk about one problem and your solution in every advertisement. Make several of them. Talk about what you see as the problems, and what you propose as solutions. If it is necessary to criticize the other guy, criticize his proposals or his definition of the problem; don't tell us he's a sleazy politician. Sleazy politician has become an oxymoron. Tell us why you're the right guy, not why he's the wrong guy. If you have to attack someone's character, do it in a face-to-face debate, not through some anonymous voice-over in a commercial featuring the most unflattering picture of the other guy you can find.

Here's another suggestion. Don't take a sentence out of context and try to make it say something that the other candidate never said or intended. You can fool the zealots most of the time, but those of us who actually read and who think for ourselves are not impressed by lies masquerading as fundamental truth. Get caught telling the truth - it will do wonders for your electability.

Our nation faces a fiscal crisis. We've been living on borrowed time and borrowed money. We have spent money on things we did not need to spend money on. But even though most of us are not economists, we understand mathematics. We know that 1 + 5 = 6. We also understand that 6 - 9 = -3. So, while you always try to make it sound more complex than it is, we all understand we can't spend more money than we have in our wallet and that if we do, sometime down the road we have to pay the piper.

Similarly, we all understand that income taxes on corporations and persons are what our government funds operations with, and that the amount of money coming in has to be more than the amount of money going out or we can't bring down the red ink in our budgets. So don't tell us your solution is to tax us less, spend more, and somewhere in the middle magic will happen that will solve our problems. Be honest.

Also keep in mind that we're Americans, and that while we value our freedom greatly, we also understand we have a responsibility for those who cannot make a life on their own in society. Understand that we all believe that if you can work, you should work. But also understand that we do not punish the child for the sins of the parents. Whatever changes you make in the social contract, you have to protect the elderly, the children and the working poor.

Remember that your morality is not mine. I like and respect religion, but I don't want someone else's religion telling me what I can and cannot do. I make those decisions for myself. And stop trying to regulate what the women in my life can do with their own bodies based on your narrow views of religion. If I wanted to be governed by religious law I would move to Iran.

Finally, remember that much of the electorate is like me. We started working somewhere around 8th grade (1968 in my case) and have been required by law to contribute to Social Security and Medicare with every paycheck we have ever earned in our entire life. We did not get to opt in or opt out because Congress was wise enough to know that we all thought we'd never need either retirement or health care. But we paid into these programs when we paid our taxes, and you've held our money for a really long time. Let me be clear here: That's my money, not the government's money that's in Social Security and Medicare.

So, when you start talking about "entitlement programs" my teeth clench and I get red in the face. Welfare is an entitlement program. Tax Increment Financing for businesses is corporate welfare and an entitlement program. Social Security was my investment for the future. Medicare was a promise that health insurance would be available for affordable rates when I got older. You hold my money. How dare you call it an entitlement program. The bank does not call my checking account an entitlement program, and you should not get away with calling my Social Security and Medicare money an entitlement program. The quickest way to lose my vote is to talk about what I was forced to contribute as an "entitlement."

Don't assume I'm an idiot either. Social Security and Medicare reform need to happen. The system is not currently going to remain self-funding and self-sustaining. We get that. But those of us who have invested want what we were promised. We do not want to be like those who invested with Bernie Madoff. Fix the problems - sure - but don't cheat us out of what we earned.

Finally, when you point a finger at someone else, there are three pointing right back at you. Sling all the mud you want, but remember it makes you look just as dirty. And if you sling enough of it, no one will believe anything you say. If you can't say something nice, you shouldn't say anything at all.

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Clearing Your Name
August 16, 2012 7:20 AM by Tony DeWitt
There is an old parable about a woman who sought forgiveness from a rabbi for spreading a rumor about a neighbor. The rabbi told her to be forgiven she should go to the top of her roof, rip open a pillow, and let the feathers scatter. Then she should pick up the feathers, and when she got the last feather, she would be forgiven. The parable is a grand reminder of how charges of misconduct take on a life of their own. Today across the Internet there are at least 100 different emails circulating rumors about politicians and public figures that are, in fact, mostly false. That seems to be the price of holding an elected office these days. But it should not be the price that anyone should pay for being cleared of a false charge.

My job here is to comment on the news related to long-term care. Recently I wrote a blog post that relied on and reflected about material published by the Los Angeles Times and that referenced a nurse who purportedly abused a patient. The Los Angeles Times report referenced another derivative work and I erroneously relied on in reporting that a clinician had engaged in inappropriate conduct. Once the error was pointed out to me, I removed the reference to it, and Google removed it from its search engine. I learned an important lesson about verifying information in public sources, and I also learned from the victim of my error how difficult it is to clear your name after the media reports something as fact.

Imagine this situation. You come into work tomorrow and you are asked to speak with a detective. He reads you your rights and asks if you abused the female patient in room 11. You say no, but he has already talked to the patient who says you did. You point out the patient is demented and can't be believed.

In spite of this you are arrested for abuse, fired from the facility, and left to defend yourself. The media reports that you are accused of abusing the elderly. Friends who used to call now no longer do. People who would wave to you in the grocery store now turn their heads and pretend not to see you. A ride in an elevator with an old friend seems like a 10-day trip in the cone of silence. No facility will hire you. The nursing board notifies you of an investigation. The nursing board in a distant state where you still maintain a license also starts an investigation.

Your trial is set for 6 months out, and your lawyer does a good job of getting experts who can testify about the mental status of your accuser. But then a week before you are to go to trial, the victim dies, and the state quietly drops the case. The nursing board investigation ends without any action being taken, but the nursing board in the distant state wants you to appear for a hearing. You've paid thousands for lawyers and you don't have the time or money to appear in the distant state. Because you can't afford to fight, you surrender your license there. Now, even though you never admitted any wrongdoing, your licensure surrender will haunt you forever.

The media which happily ran the photo of you in handcuffs being led into the jail on the front page 10 weeks earlier now runs a 12-sentence article on page 11 that says your case was dismissed because the victim died. The prosecutor is quoted as saying "We couldn't prove the abuse without the patient's testimony." The implication is that "the guilty go free."

How do you go about getting your life back?

There is no motion you can file in a courtroom. There is no writ any court can give you that clears your name. Your arrest record can sometimes be expunged, but rarely will the court records themselves be sealed. Because you never got to trial, you never got a chance to clear your name. While a friendly media outlet might report on your story, most will balance that report with a quote from the prosecutor where he says he stands by the allegations in the charges.

To make it easier to find a job, you move 100 miles away. The Internet makes much of the information about your case easy to find. All a prospective employer needs to do is Google your name and your life history is now an open book. For the next 10 or so years you will be explaining to everyone what happened and how it was all a big mistake.

Eventually in this distant city you find an employer who is willing to trust you. Your work is excellent and you are well regarded at your new job for 13 months before a visitor from your old home town spots you. She goes home and searches the Internet. She finds that your license was surrendered in a distant state. She misses the article where the case was dismissed, and so she reports to the administrator that you are a felon who was convicted of patient abuse. She shows the copy of the agency action from the distant state where you surrendered your license.

Nearly everything she said is wrong, but you are still out of a job. Not because you did anything wrong, but because nurses on your shift don't want to work with you anymore. They don't trust you. They worry that you'll abuse a patient. They understand guilt by association. And of course, so does the nursing home. So again you're unemployed.

The fact is you can do everything in your power to clear your name, and in spite of this, you could still wind up being unemployable in health care even though you were never convicted. In some ways it would be easier to get a job if you had been convicted and later pardoned. But without a jury passing on the facts, you can never show you were innocent.

This is why it is so important to document patient interactions, document adverse outcomes, and where a patient is prone to making abuse accusations, to always have a second or third person in the room when dealing with such an individual. Once charges are filed it is difficult to reclaim your life. That's why prevention focuses on having witnesses who can attest that you did nothing wrong.

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Minimalist Charting -- And the Problems It Can Cause
July 20, 2012 9:33 AM by Tony DeWitt
From time to time I speak to nurses and they often tell me they are told to chart only by exception in the record, and this somehow "protects" them from liability. Frankly, being familiar with both hospitals and nursing facilities, I find this difficult to understand. But it deserves some dissection because there are really two theories about charting.

One is the rigid formula method adherent of SOAP (subjective, objective, analysis, plan) and PIE (problem, intervention, evaluation). The clinician adopts an organized approach to listing the subjective and objective signs and symptoms, defining the problem, and planning the care. The other method is the more unstructured "charting by exception" process where a practitioner charts only when there is a problem, and only things that document that problem. Normative data are rarely recorded.

Most skilled practitioners are taught if you adopt a rigid approach to your documentation early in your career it will eventually save your bacon down the road. No one ever got into a courtroom and said, "Gee, I wish I hadn't charted so much." But many have said, "If only I had written that down!"

When you adopt a formula like SOAP that encourages you to identify subjective and objective data, analyze the data, and plan for the resolution of the problem, you are in effect teaching yourself to chronicle the information you obtained and the analysis you performed. For the skilled practitioner this normally means you write down the information you use in planning and delivering care. Similarly, when you take the PIE approach, you put in place a rigid formula for both documenting and evalutating the progress of the patient.

In 95% of the cases this is great because the practitioner is a good observer, familiar with the patient, careful with the doctor, and patient care is enhanced.

Where both PIE and SOAP charting break down is with the lazy or unskilled practitioner. People who don't like to write, or who do a slipshod job of performing patient care frequently have holes in their charting, and these holes are where lawsuits come into play.

Consider the case of VB, a patient at a nursing home who, when assessed by the LPN on the morning shift was found to be short of breath. She did a pulse oximetry reading and found a value of 79%, which she believed to be "close to the 80 number we were taught in nursing school." She did no other diagnostics (no breath sounds, no heart sounds, no record of the patient's color, sensorium or position). She charted "O2 Sat 79%; started oxygen."

The nurse had been taught to chart by exception, so her cross examination in her deposition went as follows:

-Had you done prior saturations on VB?

-Not that I see here

-So you didn't know what her normal value was?

-Everyone's normal value is about 80.

-Did you record her pulse?

-No, it was probably normal. We only record it if it's not normal.

-Did you record her respiratory rate?

-No, again, we only chart stuff that's abnormal, so it was probably normal.

-What about her color, did you make note of that?

-No, it was ...

-Probably normal, yes, I know. So did you document or check her orientation? Did she know who she was, or where she was?

-I didn't document it. So I assume it was normal.

-But you've already testified you don't have an independent recollection of the events of March 21, isn't that right?

-Yes.

-So, other than your assumptions, there is no data in this medical record that anyone can see, and know for sure that all these things were normal, because you didn't check them and write down a value or say they were normal, you just didn't record them.

-I sometimes go four or five days without charting on a patient's chart if they are normal.

The problem with the colloquy above is that everyone knows that's not really how things are done. And indeed, this nurse was later impeached at her deposition as follows:

-Look at this record from February 9. You indicated her pulse was 120, and her respirations were 110? Do you see that?

-Yes.

-Was this part of one of those comprehensive assessments you talked about?

-No. I just had some extra time, so I wrote down this stuff.

-But these are normal values for her, right?

-Yes.

-And you previously testified you only write down abnormal values.

-When we're dealing with a problem, yeah.

-So why would you write down more information when things are normal then when you were dealing with a problem?

-It's just the way we do things.

Later in the deposition the lawyer explained that a saturation of 79% equated to a PO2 in the upper 40s. The nurse, who was a second-career nurse who was not familiar with how oximeters worked, was horrified. She essentially backtracked in her deposition and testified she was very busy that day without much help, and she just neglected to look up the panic values. The case ultimately settled.

While it is likely that nothing could have saved this nurse from the failure to understand the oximeter readings, good charting would have at least made her look reasonably competent. Before a jury, a jury that expects things like pulses and respirations to matter to health care providers, her testimony would have been a disaster.

Clinicians who do use documentation by exception should be exceptional documentarians. They should document what's abnormal, and why it is abnormal.

Heart rate is 67. This patient always runs a heart rate in the upper 90s, so patient is borderline bradycardic.

They should illustrate for a later reader what they found and why it is significant.

Patient has crackles in both bases of her lungs, and JV distension. Patient has never had JV distension previously. She is struggling to breach and coughing up pink frothy sputum. She is mildly disoriented. This is not normal for this patient.

They should provide any history that is omitted from the main part of the medical record, because only when you provide this additional information does a jury have the information necessary to determine if you acted reasonably under the circumst
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On Being American
July 2, 2012 12:55 PM by Tony DeWitt
 I'm a Yankee Doodle Dandy,

Yankee Doodle do or die,

A real live version of my Uncle Sam,

Born on the 4th of July...

--Yankee Doodle Dandy, by George M. Cohan

 

On March 23, 1775, after a series of "intolerable Acts" by Britian, Patrick Henry stood before the Virginia Convention and told those assembled that he didn't much care what course others might take, but "as for me, give me liberty, or give me death."

The speech was widely reported (which in the 1700s, before the Internet and blogs, meant it took weeks to make it outside Virginia). Only a few months later, on April 19, 1775, the first shots of the Revolutionary War were fired in Concord and Lexington. Yet, it was not until July 4, 1776, that the United States declared its independence from Britain. In a few days we'll celebrate that historic date, and it seems a proper time to reflect on what it means to be an American.

In 1775, battlefield medicine was pretty much limited to bandaging wounds and hoping against hope they were not infected. A wounded soldier might not die immediately, but disease and infection claimed three times more lives than did bullets and bombs.

Weapons were single-shot muskets fired at exceptionally close range, sometimes less than 100 yards. The injuries inflicted by the large, soft, .50 caliber lead shot were large, bled profusely, and were routinely mortal. Still, only roughly 8,000 combat deaths (and 17,000 non-combat deaths) occurred during the Revolutionary War.

Less than 100 years later, in 1865, another war was fought on U.S. soil, this time pitting brother against brother. The union was preserved, but the cost again was terrible in terms of lives. Historians say more than 625,000 Americans died, 364,000 on the Union side, and 260,000 on the confederate side. Battlefield medicine had advanced somewhat, with wounds being treated with amputations and antiseptics, but there are still small southern towns where the stories of that horrible time in American history are told as though they happened yesterday. This because there is a lesson there: the union we celebrate on July 4th is something precious. We cannot forget the sacrifices that bound it together.

To be an American is to know your history. It is to know the names like Antietam and Gettysburg, where American soldiers on both sides died for something they believed in: freedom.

It is to know like Bastogne, Inchon, and Operation Iraqi Freedom. Because freedom and American know-how prevailed and great victories were obtained.

It is also to know places like the Chosun Reservoir, Bataan, and Corregidor, where Americans made awful sacrifices for their country. Being an American means being conscious of the fact that the blessings of liberty have been protected and preserved by the sacrifices of ordinary people.

It is to recognize that we are not a "melting pot" as is so often claimed, because we do not all meld together into one homogenous whole. Rather, we're a stew pot, with bits of brown and black and white, and red, and seasoned with eccentrics, charlatans and billionaires. Being American means respecting the sacrifices others have made to see to it that you got a high school education, and individual freedom, as birthrights. It is passing along the teachings of the last generation to the next one. As a nation we are one, but we retain our individual character. We are free to pursue our individual passions so long as in doing so we do not tread upon the rights and privileges of others.

And there are men and women who make sure that if we step over that line, or harm others, that we're held accountable.

Being American means understanding that the law is there to help you, and that while our political process is far from perfect, and at times seems broken, good men and good women still live within that system and good things can still be accomplished. Being American means understanding the checks and balances. If the will of the people is such, Congress can pass legislation, and if the President is opposed, he can veto. But his veto is not permanent - it can be overridden in Congress. Similarly, if Congress oversteps, the judicial branch is there to curb Congress if it exceeds the structural protections of the Constitution. And if Congress or the people feel that the Supreme Court has been wrong, then there are procedures to amend the Constitution. And this same process exists at every state level.

Do we have problems? Sure! Politics is infected with money and with corruption. Yet, meet this challenge: find a political system - any political system - that is not similarly infected. As a nation we've overcome presidential plots, congressional inaction, and outright criminality in government and come out wiser and stronger for it. Because, in our hearts, we believe in our system. It may not be perfect, but then again, neither are we.

We fight amongst ourselves for sure. We have a long history of it. Many of our ethnic and religious minorities have been badly mistreated. We work within our system to fix those inequalities, but even then we are sometimes violent. Our civil discourse, which should foster rational debate, often fosters ad hominem personal attacks and often involves less listening and more shouting. We rarely agree as a nation on any one thing. We spend billions to convince others our views are the right ones. Others spend money to counter us. We fuss, and we fight, and we lament our losses. Yet, what happens when, as a nation, we are attacked?

Those same mistreated ethnic minorities become our greatest strengths. The Navajo Indians used their nearly incomprehensible language to frustrate Japanese code breakers during World War II. The Tuskeegee Airmen, who couldn't drink in the same bars with their white comrades, fought savagely alongside those aviators over the skies of France and Germany. The Japanese-Americans who fought in the European theater did so while many of their families were interned in camps in the Northwest. An attack on one of us is an attack on all of us. I may disagree with those who hold different political views, but when we're attacked we come together. That is how it is when you're an American.

On September 11, 2001, two aircraft flew into the World Trade Center, an act singer Toby Keith described as "a mighty sucker punch." Thousands perished in the blink of an eye, and others suffered horrible deaths from fire or falls. But there were Americans there that day, and their fellow Americans came to their aid. Fire battalions responded and were wiped out to a man when the buildings fell. Over 600,000 people were stranded on Manhattan and sought refuge at the water's edge. And in a feat far more impressive than the evacuation of Dunkirk, ordinary American citizens with boats - some that were tugs, some that were fishing vessels, and some that were just pleasure craft - descended on Manhattan and carried those 600,000 to safety. No civil defense drill prepared these men and women to carry out this feat. No training had been given. No practice had been done. This was common men and common women with uncommon valor who simply stood up and went to work rescuing their fellow citizens.

The story of this boat lift is told here. I encourage you to watch the video and remind yourself of what it is to be an American. And if your eyes are dry at the end of that video, then Sir Walter Scott wrote a poem for you:

 

Breathes there the man with soul so dead 


Who never to himself hath said, 


This is my own, my native land! 


Whose heart hath ne'er within him burned, 


As home his footsteps he hath turned 


From wandering on a foreign strand! 


If such there breathe, go, mark him well; 


For him no minstrel raptures swell; 


High though his titles, proud his name, 


Boundless his wealth as wish can claim 


Despite those titles, power, and pelf, 


The wretch, concentered all in self, 


Living, shall forfeit fair renown, 


And, doubly dying, shall go down 


To the vile dust from whence he sprung, 


Unwept, unhonored , and unsung.

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    A.L. "Tony" DeWitt, RRT, CRT, JD, FAARC
    Occupation: Attorney
    Setting: Jefferson City, Mo.
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