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70Shawn Reeds FAQ on PW 35 (very long)

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  • Streonwold Wulfesbana (mka Steve Benetti)
    Nov 29 12:01 PM
      This is verbatim from the FAQ file posted on the Known World
      Chirurgeon's List.

      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
      suspension of
      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
      decision and
      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
      least some
      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
      parties move
      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
      Pennsic 35.

      For the most part, the Board has no desire or inclination to assign
      blame to
      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@...*.


      Shawn Reed

      Director, SCA Inc.

      Ombudsman, Chirurgeonate

      *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
      disband the
      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
      coordination and
      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
      led to
      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
      would be
      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
      Mayor and
      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
      situation as
      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
      occurred in
      a relatively short period of time that raised substantial concerns and
      triggered the suspension of Chirurgeon supervision of first aid at Pennsic

      *Incident One*

      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.
      The War
      CiC took appropriate action to deal with the Chirurgeon involved, who was
      suspended for the War and remanded for additional training in
      procedure and
      documentation. The Pennsic Mayor was not aware of the documentation
      discrepancies or any of the other findings, until after Pennsic 35 ended.*

      *Incident Two*

      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,
      respectively, to
      try to verify what happened and determine if Chirurgeon procedures had
      followed or not. In the course of the interviews, the Mayor and the
      War CiC
      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. *

      *Incident Three*

      An individual with a rapidly and visibly spreading rash went to
      Point and requested referral to the doctor or to EMS. The Chirurgeon
      at the
      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
      did not
      know where EMS was, and did not know how to contact EMS. The individual,
      feeling numbness in his lips, left Chirurgeons' Point without
      completing any
      paperwork or receiving referral to EMS. He found his wife and they
      drove to
      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
      spouse at
      the time), shortly after they went to the hospital. The Board of Directors
      has since received direct confirmation of these details from the
      individual's wife.

      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
      situation, 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
      as a

      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
      management of
      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
      responsibility to
      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
      included in
      the meeting at which the actual decision was made.

      Many people disagree with the decision that Mistress Brise made.
      However, it
      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
      Pennsic populace.

      *The populace was placed in danger because first aid was suspended,
      and the
      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
      information was
      communicated by the Operations staff *AND *within the Chirurgeonate was
      severely flawed.

      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
      hosted a
      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
      Pennsic Independent.

      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
      facts *as
      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
      was to
      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
      persons were
      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
      did not
      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
      SCA. This
      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
      physician who
      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
      preparatory information.

      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
      attempted to
      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
      the Chirurgeons.*

      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
      and her
      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
      of the
      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
      easily and
      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
      the Chirurgeonate.

      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
      into the
      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
      storage of
      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
      throughout the
      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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