MEDICAL AID ‑- EMERGENCY MEDICAL PERSONNEL ‑- DRUGS ‑- AUTHORITY OF EMERGENCY MOBILE HEALTH CARE PERSONNEL

MEDICAL AID ‑- EMERGENCY MEDICAL PERSONNEL ‑- DRUGS ‑- AUTHORITY OF EMERGENCY MOBILE HEALTH CARE PERSONNEL

(1) Emergency mobile health care personnel, as defined in RCW 18.71.200, need not receive a new authorization from a physician for each instance in which they perform the emergency procedures for which they are certified.

(2) The requirement of RCW 18.71.210 that services of emergency health care personnel be rendered under the responsible supervision and control of a licensed physician is satisfied when:

(a) The services are rendered at the scene of an emergency to a person who is in imminent danger of loss of life or has suffered grievous bodily injury; and

(b) A licensed physician is not present but the personnel are in telephone or radio communication with such a physician and able to report vital statistics and other pertinent information to him; and

(c) The personnel render treatment that is prescribed by the physician at the scene of the emergency.

(3) By substituting the word "imminent" for the term "immediate" in RCW 18.71.210, the legislature, by its enactment of chapter 55, Laws of 1977, has expanded the coverage of that statute to include cases where the loss of a person's life may be near, close or threatening as opposed to being restricted to cases where the event will occur without delay.

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                                                                    July 11, 1977

Honorable Richard A. King
State Representative, 38th District
309 77th Place S.W.
Everett, Washington 98203                                                                                                               Cite as:  AGLO 1977 No. 29

Dear Sir:

            By letter previously acknowledged you requested our opinion  [[Orig. Op. Page 2]] on several questions pertaining to emergency mobile health care personnel under the amendments to chapter 18.71 RCW which are contained in chapter 55, Laws of 1977.  We paraphrase your questions as follows:

            (1) Must emergency mobile health care personnel receive a new authorization from a physician for each instance in which they perform the emergency procedures for which they are certified?

            (2) Is the requirement of RCW 18.71.210 that services of emergency mobile health care personnel be rendered under "the responsible supervision and control of a licensed physician" satisfied when:

            (a) The services are rendered at the scene of an emergency to a person "who is in imminent danger of loss of life or has suffered grievous bodily injury;" and

            (b) A licensed physician is not present but the personnel are in telephone or radio communication with such a physician and able to report vital statistics and other pertinent information to him; and

            (c) The personnel render treatment that is prescribed by the physician at the scene of the emergency?

            (3) How has the meaning of RCW 18.71.210 changed by the substitution (in chapter 55,supra) of the word "imminent" in place of the word "immediate"?

            We answer question (1) in the negative and question (2) in the affirmative; question (3) is answered in the manner set forth in our analysis.

                                                                     ANALYSIS

            Question (1):

            Your first question involves the meaning of RCW 18.71.020 and RCW 18.71.200 as they have been amended by §§ 1 and 2 of chapter 55, supra.  RCW 18.71.020, as thus amended, relates to the unlicensed practice of medicine and provides that:

            "Any person who shall practice or attempt to practice or hold himself out as practicing medicine in this state, without having, at the time of so doing, a valid, unrevoked license as provided in this chapter, shall be guilty of  [[Orig. Op. Page 3]] a gross misdemeanor:  PROVIDED, That nothing in this section shall be so construed as to prohibit or penalize emergency lifesaving service renderedby a physician's trained mobile intravenous therapy technician, by a physician's trained mobile airway management technician, or by a physician's trained mobile intensive care paramedic, as defined in RCW 18.71.200 as now or hereafter amended, if such emergency lifesaving service be renderedunder the responsible supervision and control of a licensed physician.  In each such conviction the fine shall be paid when collected, to the state treasurer: . . ."  (Emphasis supplied.)

            RCW 18.71.200, as amended by § 2 of the same 1977 act, then defines the three terms used in the foregoing proviso to RCW 18.71.020 as follows:

            "(1) As used in RCW 18.71.020 as now or hereafter amended, a 'physician's trained mobile intravenous therapy technician' means a person who:

            ". . .

            "(b) Is trained by an approved licensed physician to administer intravenous solutionsunder written or oral authorization of an approved licensed physician:

            ". . .

            "(2) As used in RCW 18.71.020 as now or hereafter amended, a 'physician's trained mobile airway management technician' means a person who:

            ". . .

            "(b) Is trained by an approved licensed physician to perform endotracheal airway management and other authorized aids to ventilation under written or oral authorization of an approved licensed physician:

            ". . .

            "(3) As used in RCW 18.71.020 as now or hereafter amended, a 'physician's trained mobile intensive care paramedic' means a person who:

             [[Orig. Op. Page 4]]

            ". . .

            "(b) Is trained by an approved licensed physician:

            "(i) To carry out all phases of advanced cardiac life support;

            "(ii) To administer drugsunder written or oral authorization of a licensed physician; and

            "(iii) To administer intravenous solutions under written or oral authorization of an approved licensed physician; and

            "(iv) To perform endotracheal airway management and other authorized aids to ventilation;

            ". . ."  (Emphasis supplied.)

            As amended by chapter 55, supra, RCW 18.71.020 and 18.71.200 now cover three separate classes of persons who are exempt from the prohibition of the former.  They are first, as before1/ the physician's trained mobile intensive care paramedic (hereafter paramedic) and now, in addition, the physician's trained mobile intravenous therapy technician (hereafter intravenous technician) and, third, the physician's trained mobile airway management technician (hereafter airway technician).  The question presented is whether those emergency mobile health care personnel must receive a new authorization from a physician for each instance in which they perform the emergency procedures for which they are certified.

            RCW 18.71.020 is a penal statute which makes it a misdemeanor to practice medicine without a license.  As such, that statute must be strictly construed against the state and in favor of those persons on whom the penalty is to be imposed.  State v. Rinkes, 49 Wn.2d 664, 306 P.2d 205 (1957).  However, since RCW 18.71.020 is directed at protecting the public health it must, at the same time, continue to be given substantial effect in order that the legislative intent not be defeated.  70 C.J.S., Physicians and Surgeons, § 7.  Bearing both of those points in mind we turn, first, to the key language of that statute which requires that the emergency lifesaving services of all three classes of emergency medical personnel ". . . be rendered under the responsible supervision and control of a licensed physician."

             [[Orig. Op. Page 5]]

            This requirement clearly applies to all emergency lifesaving services rendered by the personnel in question.  On the other hand it will be noted that the qualifying language in RCW 18.71.200,supra, which reads ". . . under the written or oral authorization of an approved licensed physician . . ." only covers some of those services; namely,

            (a) the administration of intravenous solutions by an intravenous technician;2/

             (b) the performance of endotracheal airway management and other authorized aids to ventilation by an airway technician;3/

             (c) the administration of drugs by a paramedic;4/ and

            (d) the administration of intravenous solutions by a paramedic.5/

             Conversely, that latter qualifying language relative to written or oral authorization by an approved licensed physician is not present in the case of the following services:

            (a) The carrying out of all phases of advanced cardiac life support by a paramedic;6/ and

            (b) The performance of endotracheal airway management and other authorized aids to ventilation by a paramedic7/ - although the word "authorized" in the latter provision probably denotes some necessity for authorization by a licensed physician in the case of "other" aids to ventilation.

            Where different language is used in different parts of a statute in the same context there is a presumption that a different meaning was intended.  State v. Roth, 78 Wn.2d 711, 479 P.2d 55 (1971).  Therefore, the legislative intent must  [[Orig. Op. Page 6]] be deemed to be that paramedics be trained to proceed without specific authorization from a licensed physician to provide advanced cardiac life support and endotracheal airway management.  We also take note of the fact that in many instances a paramedic must proceed to perform those two services immediately if they are to be successful.  Thus, we conclude that a paramedic is not required to receive either a new authorization or a general authorization prior to each instance he performs those emergency services.  Even such an individual would, however, still have to be operating under the "responsible supervision and control" of a licensed physician.

            Moreover, even where such ". . . oral or written authorization of an approved licensed physician . . ." is required, it is our opinion that none of the three classes of emergency medical personnel now covered by RCW 18.71.020,supra, will be required to receive a new authorization for each instance that they render emergency services.  Statutes must be construed in a manner which is consistent with their apparent purpose and object and which avoids absurd consequences.  Blondheim v. State, 84 Wn.2d 874, 529 P.2d 1096 (1975).  Here, we are dealing with a statute which is manifestly designed to sanction the performance of certain services by trained personnel ‑ who, however, are not themselves licensed physicians ‑ at the scene of an emergency.  But since the services are to be rendered at the scene of the emergency it would be self defeating if not absurd to read RCW 18.71.200, supra, so as to require a new authorization in each case.  The only way that emergency personnel could receive a written authorization (at least) for each new case would be for a physician to be present at the scene of the emergency.  But if a physician were thus present then there would be no need for the paramedic or technician.  Therefore, we instead believe the better reading of the statute is to say that the "oral or written authorization" contemplated is such as may be given in advance ‑ prior to the emergency situation itself.  Such prior authorizations must by their nature take the form of general authorizations or standing orders.8/

             Question (2):

            Your second question involves RCW 18.71.210 which, as amended by § 4, chapter 55,supra, now reads (in pertinent part) as follows:

             [[Orig. Op. Page 7]]

            "No act or omission of any physician's trained mobile intensive care paramedic, intravenous therapy technician, or airway management technician, as defined in RCW 18.71.200 as now or hereafter amended, done or omitted in good faith while renderingemergency medical service under the responsible supervision and control of a licensed physician to a person who is in imminent danger of loss of life or has suffered grievous bodily injury shall impose any liability upon:

            "(1) The trained mobile intensive care paramedic, intravenous therapy technician, or airway management technician:

            ". . ."  (Emphasis supplied.)

            Repeated for ease of reference your question asks:

            Is the requirement of RCW 18.71.210 that services of emergency mobile health care personnel be rendered under "the responsible supervision and control of a licensed physician" satisfied when:

            (a) The services are rendered at the scene of an emergency to a person "who is in imminent danger of loss of life or has suffered grievous bodily injury;" and

            (b) A licensed physician is not present but the personnel are in telephone or radio communication with such a physician and report vital statistics and other pertinent information to him; and

            (c) The personnel render treatment that is prescribed by the physician at the scene of the emergency?

            In short, your second question again boils down to whether a licensed physician must be physically present at the scene of the emergency ‑ this time in terms of RCW 18.71.210, supra.

            RCW 18.71.210 was designed to insulate certain persons from liability for rendering emergency medical services.  Specifically, that section concerns itself with the medical services rendered bymobile technicians and paramedics.  Three factors point toward the correct construction to be given to the statute.  First, neither RCW 18.71.210 nor anything in RCW 18.71.020 or RCW 18.71.200, which are inparimateria with RCW 18.71.210, requires that the supervising physician be at the scene of the emergency.  Second, the fact that the statutory names given to the paramedic and technician contain the adjective "mobile" also implies that their services are  [[Orig. Op. Page 8]] to be performed outside the physical presence of a physician.  And third, to read RCW 18.71.210 as requiring the physical presence of a physician would, again, be absurd as negating the need for the technician or paramedic in the first place.

            Conversely, although the supervising physician is not physically present your question, in fact, has the emergency personnel performing services under the direct supervision of a physician ‑ by radio or telephone communication.  Accordingly, construing RCW 18.71.210 sensibly and in a manner consistent with its apparent purpose and object, it is our opinion that they would thus be performing those services under the "responsible supervision and control" of a physician within the meaning of that statute.  We therefore answer your second question in the affirmative.

            Question (3):

            Your final question also relates to RCW 18.71.210, supra, as amended by § 4, chapter 55, Laws of 1977, and asks how the meaning of that statute has been changed by the substitution of "imminent" in place of "immediate."

            In order to place this question in proper focus we must look again at the statute involved ‑ this time in bill form as follows:

            "No act or omission of any physician's trained mobile intensive care paramedic,intravenous therapy technician, or airway management technician, as defined in RCW 18.71.200 as now or hereafter amended, done or omitted in good faith while rendering emergency ((lifesaving)) medical service under the responsible supervision and control of a licensed physician to a person who is in ((immediate)) imminent danger of loss of life or has suffered grievous bodily injury shall impose any liability upon: . . ."

            It is a well-recognized rule of construction that where the legislature has substituted one word for another in a statute there is a presumption that it intended to change the law.  Home Indem. Co. v. McClellan Motors, 77 Wn.2d 1, 459 P.2d 389 (1969).  "Imminent" and "immediate" have significantly different meanings and we must also presume that the legislature was aware of that fact.  See,State v. Dixon, 78 Wn.2d 796, 479 P.2d 931 (1971).  Black's Law Dictionary defines "immediate" as:

             [[Orig. Op. Page 9]]

            "Present; at once; without delay; not deferred by any interval of time.  In this sense, the word, without any very precise signification, denotes that action is or must be taken either instantly or without any considerable loss of time . . . [citing cases] ‑ Not separated in respect to place; not separated by the intervention of any intermediate object, cause, relation, or right. . . ."9/

             On the other hand Black defines "imminent" as:

            "Near at hand; mediate rather than immediate; close rather than touching; impending; on the point of happening; threatening; menacing; perilous.  [Citing cases]"10/

             Therefore, it is our opinion that the substitution of "imminent" for "immediate" has expanded the coverage of RCW 18.71.210 to include cases where the loss of a person's life may be near, close, or threatening as opposed to being restricted to cases where that event will occur without delay.11/

             We trust that the foregoing will be of some assistance to you.

Very truly yours,

SLADE GORTON
Attorney General

PETER SCOTT
Assistant Attorney General

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