A number of academic institutions mandate mastery of specific skills before graduation.

For years, universities required students to learn how to swim and demonstrate they would not sink. Cornell accepted 75 yards as the bare minimum.

In 1975 the school standardized the test required that students “jump into deep water and swim 3 lengths (75 yds) continuously. 25 yds on the front, 25 yds on the back, and 25 yds choice.

Columbia put the requirement on pause during COVID. In summer 2022, the test was put back on the list of to-do’s.

The school says that the test was established “in order to ensure that every student has the opportunity to learn and practice this important life — and life-saving — skill.”

In the 1970s, just under half of US colleges had such a requirement. Today, the number that still mandate the requirement can be counted on less than two hands and include:

Bryn Mawr, Columbia, Cornell, Dartmouth, MIT, Swarthmore, and service academies such as West Point.

It’s hard to argue that learning how to swim is not useful. It is.

Moving on from swimming…one surgical residency program mandated CPR as a skill that must be mastered to complete its program.

It’s hard to argue that learning CPR is not useful. It is.

A new resident in that program has a lifelong disability. She is unable to safely perform manual chest compressions for CPR without potentially causing permanent injury to her arms. Presumably, she is otherwise able to perform all requirements technically required to safely perform surgery. It’s only CPR manual compressions that pose the challenge.

Normally, when a code is called at an inpatient facility, many people show up. There’s at least one person who can perform chest compressions. This resident is just not one of them, though she is fully able to perform the range of skills to complement the ongoing compressions.

In an early analysis, the institution concluded that this resident posed a “direct threat” to the safety of its patients. Even if she was provided a “reasonable accommodation.” She was voted off the island.

“Direct threat” and “reasonable accommodations” are buzzwords for the Americans with Disabilities Act.

If an employee has a disability that lasts longer than a specific period of time, their employer must provide reasonable accommodation which allows them to do their job. A disability is:

an impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment.

As to whether something interferes with a major life activity is a hotbed of litigation.

Onward to “reasonable accommodation.”

Under Title I of the Americans with Disabilities Act (ADA), a reasonable accommodation is a modification or adjustment to a job, the work environment, or the way things are usually done during the hiring process. These modifications enable an individual with a disability to have an equal opportunity not only to get a job, but successfully perform their job tasks to the same extent as people without disabilities. The ADA requires reasonable accommodations as they relate to three aspects of employment: 1) ensuring equal opportunity in the application process; 2) enabling a qualified individual with a disability to perform the essential functions of a job; and 3) making it possible for an employee with a disability to enjoy equal benefits and privileges of employment.

OK, if a job requires someone be able to hear on a telephone, and that person can hear reasonably well with a hearing aid, that employer must provide a hearing-aid compatible telephone headset or adapter.

The analysis does not end there. Does that employee pose a “direct threat?”

However, even an employee who has a disability as defined by the ADA, and can perform the essential functions of the job, may be fired based on his or her disability if the employee poses a “direct threat.” Under the direct threat defense, an employer may fire or refuse to hire an employee who poses a significant safety risk.

The ADA creates an exception for employers who fire or refuse to hire an employee who poses a direct threat. A direct threat is defined as a significant risk of substantial harm to the health or safety of that employee or others, which cannot be eliminated or reduced by a reasonable accommodation.

Whether someone is a direct threat (even with a reasonable accommodation) must be determined using objective criteria. It cannot be a hunch or an intuition.

Back to our vignette.

The resident who could not perform manual compressions during CPR first argued many other institutions make no such requirement. And CPR is still successfully performed at those institutions via the team approach. She argued the requirement was not necessary for patient safety. That argument fell on deaf ears.

Then she located this academic study. Leg-heel chest compression as an alternative for medical professionals in times of COVID-19. Am J Emerg Med. 2021 Dec; 50: 575–581.

No need to do manual chest compressions. One can use a leg/heel to get the job done.

 Our data indicates no credible difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method.

https://www.sca-aware.org/sca-news/heel-only-cpr-a-giant-step-for-resuscitation

But wait, there’s more. A study performed in Savannah, GA:

revealed that 49 people—each acting as his or her own control by attempting 10 minutes of manual compressions before attempting 10 minutes of heel compressions—showed that four times as many people were able to hit 10 minutes using their heels, compared with using their hands (65 percent vs. 16 percent). This was in the context of using a CPR manikin with chest stiffness that is one-third less than the average adult chest.

“Stamina gets a boost with heel compressions,” said Trenkamp [the author]. “Because one cannot use his or her total weight—just the upper body weight—when performing manual compressions, the use of heel compressions increases the percentage of the adult population that can deliver guideline-compliant chest compressions.” Many people in the age group tested cannot perform guideline-compliant chest compressions manually, he added. Some cannot get down on the floor and some have arthritis issues with their hands or wrists that interfere with performance of manual chest compressions.

Meaning there may even be advantages to doing chest compressions using one’s legs.

There are many high performers who have mastered arm-based skills with their legs.

Stunning photos from the Paralympics.

https://fstoppers.com/pictures/inspiring-photos-athletes-paralympics-5297

https://www.foxsports.com.au/olympics/paralympics/nothing-is-impossible-table-tennis-player-with-no-arms-stuns-paralympics-using-mouth-to-play/news-story/c85bf09989d9bdab4f9cd43bf087bee3

Back to the resident who offered a plan B for performing CPR compressions. She might just prevail.

What do you think?

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Jeffrey Segal, MD, JD

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Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.