70Shawn Reeds FAQ on PW 35 (very long)
- Nov 29 12:01 PMThis is verbatim from the FAQ file posted on the Known World
I've taken the liberty of posting it here, as I don't know if all of
us subscribe to that *other* list.
*Concerns Raised by the Chirurgeonate concerning Pennsic 35*
The Chirurgeonate as a whole has expressed deep concern and distress over
the events that arose at Pennsic 35. Repeated requests have been made for
more information about incidents that occurred to trigger the
Chirurgeonate supervision of First Aid triage and coordination.
The Board of Directors collected and received extensive information from a
wide range of sources including the Mayor of Pennsic 35, the Principal
Kingdom Seneschals, the Society Seneschal, the Society Chirurgeon, the
Pennsic War Chirurgeon-in-Charge, Chirurgeons on staff at Pennsic 35,
parties directly involved in various incidents, and a number of interested
and concerned laypersons.
In our review, the Board has determined that poor communication and the
willful spread of rumor and misinformation, combined with highly emotional
interpretations of the words and actions of others, were responsible for
making these events far worse than they ever should have been.
Comparatively, the number of incidents that arose at Pennsic 35 to cause
concern was small, involved a very small number of Chirurgeons, and was
similar in number to issues that arose in previous years.
However, the circumstances of these incidents appeared to be serious
that the Mayor felt equally serious corrective measures needed to be
This decision was supported by the Society Seneschal, and was made in
consultation with the Society Seneschal and the three host Kingdom
Seneschals. When notified of the decision, the Pennsic War
Chirurgeon-in-Charge advised the Mayor that she understood the
ultimately supported the Mayor's authority to make the final determination
of what the Mayor believed was the best course of action for the War.
In providing this FAQ, the Board has attempted to address the major
that we have heard expressed from the Chirurgeonate, and share at
of the information that we have received. Given the sensitive nature of
information contained in the materials we have received, we will not be
releasing any of that "raw" information for public review. Due to the
of material we have received, it is not feasible to attempt to redact the
individual reports to make them available for public review.
We are aware that this report will not completely settle all of the
questions that may exist. However, we are providing in good faith as much
information as we feel is appropriate in an attempt to help all
forward. In the volume of information we received from both first hand
sources and third parties, there were different interpretations of the
situations, together with a vast quantity of anecdotal information that
cannot be verified. We have tried to distill as much fact as we can, but
there will be no way to fully resolve all of the issues that arose at
For the most part, the Board has no desire or inclination to assign
any specific individuals or groups with respect to Pennsic 35, although
there are places where we point out actions and responses that exacerbated
already tense situations. Rather, it is our intent to use the information
collected as a basis for determining what areas need to be addressed to
avoid future episodes like this from occurring. Further, we hope that the
information collected results in more options and improved methods to help
Event Staff members at other large events who may find themselves dealing
with similar issues in the future.
This information is being provided as a courtesy. We will not be
entertaining any further discussion of this information. While we have
relied upon the broad array of information we received in preparing this
document, we do not warrant the accuracy of any one instance. We have been
given this information from many sources, and this is a compilation of
corroborating source materials.
We understand that this document will engender discussion, and that people
may disagree with some or all of the findings presented. It is not the
Board's wish to stifle free speech or dissent. However, we do require that
anyone who comments on this information present their conversations on
serves and public forums in a civil, professional, and constructive
"Flames" and comments that could be construed as defamatory and/or
will do nothing but increase the hostility that already exists.
With that said, if you have constructive comments and ideas as to how
kinds of situations could be avoided in the future, please forward them to
me at *sreed@...*.
Director, SCA Inc.
*The Chirurgeonate was disbanded.*
The Chirurgeonate as a whole was not disbanded, either by the Pennsic
or any Society officer. Nor was the Board of Directors asked to
entire Chirurgeonate. No warrants were revoked, and all warranted
Chirurgeons remained officers in good standing of the SCA, Inc.
The situation at Pennsic was an event management issue, and limited solely
to the operation and coordination of first aid activities at Pennsic 35.
At the beginning of Pennsic 35, the War Chirurgeon-in-Charge (War CiC)
Viscountess Kaellyn and her staff were responsible for the
management of triage and first aid activities, with support by and
to Northwest EMS (NWEMS).
On Friday August 11 and Saturday August 12, circumstances arose that
the responsibility for coordination and management of triage and first aid
activities to be transferred to NWEMS. Because of concerns that problems
with Chirurgeonate procedures might be systemic, it was decided it
best to suspend organized Chirurgeon activities. However, individuals who
wished to volunteer as first aid staffers were invited to do so, under the
supervision of Viscountess Kaellyn and NWEMS. As such, they would be
as volunteers of the SCA.
No warrants were revoked, although a very small number of Chirurgeons
directly involved in some of the incidents received counseling or
disciplinary action. All warranted Chirurgeons acting at Pennsic remained
officers of the organization with the associated insurance benefits.
*The Mayor and Seneschals did not have the authority to suspend Chirurgeon
There has been a great deal of discussion on the authority of the
the Seneschallate to suspend ongoing Chirurgeon activities during the
of an event. If nothing else has been made clear, it is this: the
Chirurgeons' Handbook and the Governing Documents are not fully in accord
with one another, and neither speaks as clearly to this type of
apparently is necessary. Throughout the reports that we have received, the
Board has seen the same sections of the Handbook used to support
diametrically opposing interpretations of who had what authority.
To this end, the Society Seneschal and the Society Chirurgeon will rework
the Handbook *and* the Governing Documents in order to clarify such
Regarding the reorganization of first aid at Pennsic, the Board of
upheld the Society Seneschal's policy interpretation that Event Stewards
have the right to hire, remove, and reorganize members of event staff, and
have the authority to re-organize first aid (see the President's Report of
the October 2006 Board meeting for the specific text of the policy
*What were the incidents that cause Chirurgeon activities to be
The Pennsic Mayor, Mistress Brise, reported three incidents that
a relatively short period of time that raised substantial concerns and
triggered the suspension of Chirurgeon supervision of first aid at Pennsic
NWEMS reported to the Pennsic Mayor than an individual went to
Point with vomiting, pale skin, dizziness, and headaches. Chirurgeons'
cared for the individual with sips of water and potato chips for 2 hours
before NWEMS became aware of the situation, at which time they treated the
individual with IV fluids due to heat-related dehydration. It was the
opinion of the NWEMS paramedics that the care provided by Chirurgeons'
put the individual at substantial risk.
*Investigation by the War CiC immediately after the incident, and
by the Society Chirurgeon's report, revealed that:*
*The length of time the individual was at Chirurgeons' Point was
misreported, and was shorter than originally thought,*
*The Chirurgeon on duty did initially refer the individual to EMS, but
the individual refused, and*
*The potato chips were given later when the individual was beginning
to feel better and requested something to eat.*
*However, the War CiC also found poor judgment and documentation errors
made by the Chirurgeon involved. Specifically, the War CiC found
discrepancies between documentation and first hand witness reports.
CiC took appropriate action to deal with the Chirurgeon involved, who was
suspended for the War and remanded for additional training in
documentation. The Pennsic Mayor was not aware of the documentation
discrepancies or any of the other findings, until after Pennsic 35 ended.*
The Mayor received a first hand account that Public Safety Dispatch
a call from an encampment requesting Chirurgeon assistance for a "medical
emergency." The Mayor was told that Dispatch notified Chirurgeons' Point
that there was a "medical emergency" call, and that Chirurgeons left the
pavilion and asked NWEMS paramedics to move off of a golf cart so that the
Chirurgeons could take it. NWEMS asked twice what was going on but did not
receive an answer. NWEMS described the Chirurgeons' expresses as "very
intense". Dispatch received a second call from the encampment, this time
requesting an ambulance. Dispatch notified NWEMS directly, who immediately
went to the encampment. NWEMS treated the individual, who was thought to
have been having a seizure.
The Mayor's concern was that Chirurgeons responded to a report of a
"medical emergency" rather than immediately notifying NWEMS of an
thus potentially endangering the life of the individual.
*Following the incident, the Mayor and the War CiC interviewed the Public
Safety Dispatcher and the Chirurgeons present at the point,
try to verify what happened and determine if Chirurgeon procedures had
followed or not. In the course of the interviews, the Mayor and the
received differing reports as to whether the initial notification to the
Chirurgeons specified a "medical emergency." As there were conflicting
results of these interviews, the War CiC intended to make further
but did not have the opportunity to do so. During the war, the
could not be resolved and the concern remained that Chirurgeon procedures
concerning a report of a "medical emergency" had not been followed
*During her subsequent investigation, the Society Chirurgeon was also
unable to verify exactly what the Chirurgeons were told on the first call,
due to the conflict in first hand accounts. *
An individual with a rapidly and visibly spreading rash went to
Point and requested referral to the doctor or to EMS. The Chirurgeon
Point was involved in conversations with two other people and asked the
individual questions such as "Are you taking any medications? Did you
medications? Did you change laundry detergents? Did you get into
When the individual again requested referral to the doctor or to EMS, the
individual was told that the doctor was unavailable, the Chirurgeons
know where EMS was, and did not know how to contact EMS. The individual,
feeling numbness in his lips, left Chirurgeons' Point without
paperwork or receiving referral to EMS. He found his wife and they
the hospital. He was immediately treated in the hospital with IV steroids.
The doctors at the hospital ER told the individual's wife that a longer
delay would have most likely resulted in the individual's death.
The details of the incident above were relayed to the Mayor by the
individual's campmates (who were in contact with the individual's
the time), shortly after they went to the hospital. The Board of Directors
has since received direct confirmation of these details from the
The Mayor additionally notes that at the time the incident occurred, NWEMS
was available 24/7 by radio, and were in fact on site, wearing bright
"EMS" shirts, in their camp approximately 150 feet from Chirurgeons'
*The War CiC did not have an opportunity to review this incident.*
*The Society Chirurgeon attempted to review the details of this incident
during her investigation but, despite her best efforts, was unable to
definitively identify the incident. Due to the urgency of the
individual left without completing any paperwork and as such there is no
documentation to pinpoint the incident for sure.*
*Couldn't other steps have been taken to deal with these individual
incidents, rather than changing the organization of Chirurgeons' Point
These three incidents occurred in a relatively short span of time, and
involved different Chirurgeons. There was a very real concern that the
procedures the Chirurgeons were using were breaking down or not being
followed correctly. The War CiC and the Mayor initially attempted to work
out solutions following steps that had been used in the past for dealing
with procedural problems and quality control issues. However, as problems
continued to arise, the Mayor's observation and concern was that the
Chirurgeonate at Pennsic was not functioning in a safe and effective
and the processes in place were not working properly.
Based on the information available *at that time*, the Mayor felt that
having the Chirurgeonate remain in charge of coordination and
first aid activities at Pennsic posed a potential danger to the safety and
wellbeing of the populace of the event. It was the Mayor's
make a decision that she felt was in the best interests of the entire
populace. She consulted with the Society and host Kingdom Seneschals about
this decision. She also consulted NWEMS before taking this action to
that they were capable of taking over responsibility for all event triage.
The Mayor did work with the War CiC to some extent to try to find less
extreme methods of dealing with the issues as they arose, but ultimately
felt that those methods were not effective. The War CiC was not
the meeting at which the actual decision was made.
Many people disagree with the decision that Mistress Brise made.
has been agreed from both the Operations side and by the War CiC that the
responsibility for making this decision rested with the Mayor, and that
Mistress Brise was acting in what she felt was the best interests of the
*The populace was placed in danger because first aid was suspended,
ability of Chirurgeons to provide care to the populace was disrupted.*
At no point was first aid or medical care suspended. The management and
coordination of care was changed, but emergency medical care was always
available, and Chirurgeons were asked to continue providing first aid
Some concerns have been raised that NWEMS did not have sufficient staff to
fully accommodate the attendance at Pennsic War. It was determined in the
course of the investigations that NWEMS was advised of the situation and,
prior to the final decision, they did confirm that they felt they were
capable of managing the first aid at Pennsic.
Many Chirurgeons (particularly those holding modern advance
were hesitant to assist as first aid providers because they were unclear
about their liability protection under the Volunteer Protection Act in the
new organizational structure.
Both of these are valid questions that will be more fully explored in
by a committee to help lay out better policies and procedures for dealing
with first aid and medical care at major interkingdom Wars.
*No information about the Mayor's decision was presented during the War.*
It is true that there was a substantial void in providing detailed
information about the circumstances that led to the reorganization of
aid care at the War.
Concerning the incidents themselves, the Mayor felt that it would be
inappropriate to discuss specific details, in order to protect the privacy
of those individuals who were directly involved in the incidents.
Additionally, the Mayor adds, "I did not print my reasons for the change
because I did not want the Pennsic Community to lose trust in the
Chirurgeonate. I felt that stating that there were grave concerns,
disciplinary actions taken, or that an individual's life was put at
risk would cause further consternation than was necessary. It was my
to simply state the change and move on."
In retrospect, had more information been provided in a more timely manner
and with some additional detail, it is likely that things would not have
become as unpleasant as they did. Additionally, the way that
communicated by the Operations staff *AND *within the Chirurgeonate was
However, once it became clear that the information void was more damaging
than originally realized, attempts were made to reopen communications and
improve the situation. The Pennsic Mayor and East Kingdom Seneschal
question and answer session to try to address questions and rumors.
of the Board of Directors who were present at the War and had a general
"Town Hall" meeting scheduled, entertained a great many questions even
though they were not involved in the management of the War and were not
involved in the decision making process. Information was published in the
In all of these instances, attempts were made to provide clarifying
information without releasing sensitive information. Attempts were made to
deal with rumors.
While there were problems with the delay in providing information by the
Pennsic staff and the host Kingdoms, while many believe that the
that was eventually provided was insufficient, and while the manner in
some Operations staff presented information was uncalled for, some members
of the War Chirurgeonate significantly contributed to the escalation of
rumor, misinformation, hearsay and hostility. In meetings where the
staff and the Board attempted in good faith to share information and
they knew them*, some Chirurgeons repeatedly challenged and disputed
comments and statements, and behaved in a thoroughly unprofessional
Rumors and third hand anecdotes were repeated at will for the duration of
the War and continue to be repeated to this day. Such behavior was not and
is not of any assistance in this situation.
Additionally, public statements were made at the War, on line and in the
Pennsic Independent, by the Society Chirurgeon and some senior Chirurgeons
in her chain of command that were based on incomplete or incorrect
information. Those Chirurgeons should have referred questions to and/or
fully discussed responses to questions with Viscountess Kaellyn, as the
Chirurgeon in Charge for the War and the responsible party handling the
various situations. While the Society Chirurgeon and her staff had good
intentions and were attempting to share what they believed they knew and
answer questions and concerns, the result of some of their statements
increase, rather than alleviate, confusion.
*Chirurgeons were told they must wear modern garb if providing first aid,
were prohibited from wearing Chirurgeon insignia, and were threatened with
expulsion from site if they did so.*
As has been reported by senior Chirurgeons who were present at information
meetings, as well as commentary from the Mayor, it was never the Mayor's
intent that individuals be prohibited from wearing Chirurgeon regalia or
ejected from site for doing so. Modern clothing was not required of anyone
volunteering to provide first aid after Chirurgeons' Point was closed.
It appeared that some individuals on site may have gotten carried away and
misrepresented the Mayor's intent. It should be noted that such
not on the Mayor's staff and were not speaking in any authority for the
Mayor's office. This was addressed by the Mayor in a public meeting at
*Communication between NWEMS and the Pennsic War CiC was prevented until
the beginning of the War.*
Viscountess Kaellyn was not prevented from contacting NWEMS prior to the
War. In fact, she made several attempts to contact NWEMS, starting as
as March 2006, with the Mayor's knowledge and approval. Unfortunately,
despite her best efforts, Viscountess Kaellyn and the owner of NWEMS
connect with one another until the opening of the War.
This year's Operations staff did choose different methods of interacting
with the EMS vendor than had been used in previous years, but this did NOT
include preventing contact between the War CiC and the EMS service. It is
certainly acknowledged that communication between the War CiC and NWEMS
could have been conducted in a more efficient and effective fashion.
However, this does not appear to be the fault of any member of the
will be another issue that will be addressed for future major Wars.
*NWEMS did not have realistic expectations of what they were going to deal
with, were understaffed, and did not perform well.*
NWEMS was in contact with the Pennsic Mayor's staff well in advance of the
War and was given information on the specifics of Pennsic War. NWEMS has
substantial experience with a wide variety of large events of a similar
scope to Pennsic.
NWEMS works under the direction of Dr. Stein, who is also the
oversees and directs Portersville EMS, the previous EMS provider at
War. Some of the paramedics working with NWEMS did have prior first hand
experience with Pennsic War. The owner of NWEMS met with members of
Portersville EMS, Slippery Rock Ambulance Service, the local Volunteer
Department, the Homeland Security Planner, Butler County Emergency
Dr. Stein, and local hospitals prior to Pennsic in order to review
rates, type of injuries to expect, transportation volume, and other
During the early days of the War, NWEMS staff members were given
introductory instruction on some of the issues unique to SCA battles,
including an armor extrication class. [NOTE: NWEMS did not remove armor at
any time during the event.]
For the most part, reports are that NWEMS did a good job of responding to
the needs of Pennsic War and enjoyed the experience. There were some
of problems, which would have been expected with any new vendor, but we
found those to be exceptions, not the norm.
It would be completely inappropriate to categorize NWEMS as being
for the demands of Pennsic 35.
*NWEMS abandoned an injured fighter on the battlefield, and in another
instance exacerbated an injury sustained by a fighter when they
extract the fighter from armor.*
These reports have been investigated, and neither has been found to have
merit. At no time did NWEMS paramedics abandon any patient. As stated
NWEMS did not remove armor at any time during the event. In the specific
incident that has been mentioned on several occasions, the fighter was
already out of her armor when the NWEMS medic and doctor arrived on the
*There were agreements well in advance with NWEMS that they would be in
full control of medical provision management at the War.*
The contract with NWEMS was the same one that was used in previous years
between Pennsic War and Portersville EMS. There is no evidence that any
advance arrangements were made with the intent of giving NWEMS authority
over the SCA's basic first aid volunteers/Chirurgeons.
*Paperwork was changed unexpectedly during the War, causing confusion
Although this is not directly related to the suspension of Chirurgeon
activities at Pennsic, there has been discussion off and on between the
Board of Directors, the Legal Committee, and the Society Chirurgeon
staff concerning the kind and amount of information that is appropriate to
collect and maintain, given that the SCA covers the provision of first aid
At the beginning of the War, the Society Seneschal had the opportunity to
review a copy of the incident report form that was being used at
Chirurgeons' Point. In consultation with the Society President, this form
was edited at that time to remove information fields that were felt to be
associated with the needs of advanced certification providers rather than
those of first aid volunteers, which is the mandate of the Chirurgeonate.
Chirurgeons' Point was given instructions to use the edited form.
After reviewing the changes, the Pennsic War CiC requested that some
fields that were removed be added back. The Society Seneschal and
agreed with her reasoning and the forms were changed again. This was the
final format that was used for the majority of the War.
The timing for making these changes was unfortunate and contributed to the
confusion that was prevalent at Pennsic 35. What went before cannot be
changed. For the future, the Society Seneschal and Society Chirurgeon, in
consultation with legal counsel, will develop an acceptable Society-wide
standard for information on incident report forms.
*Chirurgeons were accused of stealing medical records documents.*
Pennsic War provides a voluntary form that all attendees may complete when
they attend the War. These forms include basic information about medical
conditions, allergies, etc. The idea is that this information is
immediately available to emergency medical personnel, if needed.
Following the reorganization of first aid coordination and management,
concerns were raised that these forms, as well as other items (including
site maps necessary for prompt and efficient location of incident and
patient locations) had been removed from the Point. While the SCA is not
required to comply with HIPAA, we do take seriously the protection of
sensitive information. There were serious concerns when the voluntary
medical documents and other items could not be located in the Point, not
just because of privacy but also because these documents would not be
available for their intended purpose, providing potentially helpful
information to NWEMS if needed.
There were allegations that the Mayor had the medical information in her
possession under lock and key; however, at no time did she have these
documents. Other allegations were that the records were in the control of
the Society Seneschal, or that they had been "stolen" by individuals
Eventually the records were determined to be in the possession of the
Society Chirurgeon. He reported that he secured them when the Point was
"shut down" so that they could be included with end-of-event reports. When
concerns were raised about their location, the records were passed
custody of the War CiC, who maintained them in accordance with standard
Chirurgeon policy and procedure.
In this case, standard event management procedure would be that it was the
War CiC's purview to secure these records, as she was the Event CiC and
would be responsible for making all reports and dealing with the
any and all reports and records. Circumventing accepted event standards,
even with the best of intentions, helped to exacerbate the growing
surrounding Operations staff and Chirurgeon staff interactions.
*A final note from the Board of Directors.*
It is our opinion that the vast majority of the Chirurgeons are honorable
and generous people who work hard to provide a valuable service to the SCA
as a whole. It is also our opinion that the vast majority of the Pennsic
staff and all Operations personnel throughout the SCA are likewise
and generous people. We believe that most Chirurgeons and Operations staff
would agree with this.
We would like to acknowledge the hard work and dedication of all of those
who put in long hours at Pennsic 35. We know that many people
SCA were distressed by the events that arose at Pennsic. So were we. We
deeply appreciate the time and efforts of those who shared their
with us, and took the time to investigate what happened and report their
We would like to reiterate that the best use of this information is to
correct errors and omissions in policy and procedure, improve methods and
manners of communication throughout the SCA, and attempt to find ways to
better handle (if not avoid entirely) such situations in the future.
We found in the course of our investigation that difficult and
decisions were made, and that some individuals (both from the
and from Operations) reacted badly to those decisions and subsequent
and responses. We have pointed out in various places in this document
we believe certain individuals may have erred or could have taken other
actions to defuse the situation.
Beyond those comments, however, we have no wish to dissect this matter
further. What is done is done and we wish to view Pennsic 35 as a learning
experience. In particular, we expect the offices of the Seneschal and the
Chirurgeon, at all levels, to work together in a professional manner, and
learn from recent events.
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