Date of Hearing: April 24, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 1708

Author:(Rodriguez) – As Amended Ver:April 10, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill makes requirements around the availability and use of “trauma kits.”

1. Requires certain private and local and state public buildings to make a “trauma kit,” designed and intended for treatment of emergency medical care, available on its premises. Specifically, this bill:
2. Clarifies a “Good Samaritan” who uses such a kit to administer emergency medical care and an entity that trains lay rescuers to use the kit is not liable for injuries resulting from such use.
3. Protects a person or entity that acquires a trauma kit from liability for misuse of such a kit, as long as minimum requirements regarding installation and maintenance are satisfied.
4. Requires the State Fire Marshal, the Department of Housing and Community Development and the California Building Standards Commission to jointly conduct research and collect public comments in order to determine whether mandatory or voluntary building standards should be adopted relating to the placement of trauma kits in public buildings that are constructed or renovated after January 1, 2020.

FISCAL EFFECT:

1. Likely one-time costs (GF) in the hundreds of thousands of dollars for the State Fire Marshal, Department of Housing and Community Development and California Building Standards Commission to research changing state building code standards to include placement of trauma kits in public buildings.
2. Ongoing costs (GF) possibly in the low hundreds of thousands of dollars every three years for state agencies to place or re-stock trauma kits in government and educational buildings and to notify tenants about use of the trauma kits.
3. Possible one-time and annual state reimbursable costs (local funds/GF) in excess of $150,000 to local agencies for installation and re-supply of trauma kits in local government buildings. GF costs will depend on whether the duties imposed by this bill constitute a reimbursable state mandate, as determined by the Commission on State Mandates.

COMMENTS:

1. Purpose. According to the author:

It is vital for first aid kits to be equipped with tourniquets. Steps must be taken to help injured persons while emergency medical personnel on route. By training the public to use inexpensive and easy trauma equipment, they can be empowered to help save the life of those around them during an emergency.

1. Background. This bill provides that trauma kit be placed in privately and publically-owned buildings, based on occupancy. This bill also requires that trauma kits include tourniquets, pressure dressings, chest seals, and other medical materials used by first responders. The bill provides immunity from civil liability to a person or entity that acquires and places a trauma kit for emergency care in a building that is subject to the requirements of the bill, as long as the person or entity complies with certain requirements about placement and maintenance of the kit. Existing law already exempts Good Samaritans attempting to render aid to another person from civil immunity.
   
2. Prior Legislation. AB 909 (Steinorth), of the 2017-2018 Legislative Session was substantially identical to this bill and was held on this committee’s Suspense File.

Analysis Prepared by: Kimberly Horiuchi / APPR. / (916) 319-2081

Date of Hearing: April 9, 2019

ASSEMBLY COMMITTEE ON JUDICIARY

Mark Stone, Chair

ABPCA Bill Id:AB 1708

Author:(Rodriguez) – As Introduced Ver:February 22, 2019

As Proposed to be Amended

SUBJECT: EMERGENCY RESPONSE: TRAUMA KITS; LIABILITY

KEY ISSUES:

1. SHOULD PUBLIC AND PRIVATE BUILDINGS THAT ARE REQUIRED TO INSTALL AUTOMATED EXTERNAL DEFIBRILLATORS (AEDS) ON THEIR PREMISES ALSO BE REQUIRED TO MAKE A “TRAUMA KIT” AVAILABLE FOR EMERGENCY MEDICAL CARE ON THOSE PREMISES?
2. SHOULD ENTITIES THAT OBTAIN AND INSTALL TRAUMA KITS ON THEIR PREMISES, OR TRAIN LAY RESCUERS FOR USE OF THE KITS, BE PROTECTED FROM LIABILITY FOR INJURIES CAUSED BY THE USE OF TRAUMA KITS BY LAY RESCUERS?

SYNOPSIS

This bill has two main components. First, it would require certain public and private buildings—which happen to be the same types of buildings that are required by existing law to install automated external defibrillators (AEDs) on their premises--to also acquire and place a “trauma kit” on the premises. Second, the bill includes several immunity provisions that either clarify that certain people who perform certain acts, such as laypersons who provide emergency medical care and persons who provide training to lay persons in emergency medical services, are already covered by immunity provisions in existing law. The bill defines a “trauma kit” to mean a first aid response kit that contains at least two tourniquets; two pressure dressings; and four chest seals. According to the author, this bill is intended to encourage laypersons, at the scene of incidents such as mass shootings that cause traumatic injuries, to provide emergency medical care to victims who suffer serious injuries and trauma in those incidents. While mass shootings fortunately are very rare, the risk of being killed or injured at work, on the other hand, is much higher. According to the U.S. Department of Labor, two million workers are injured or killed at work every year in incidents of workplace violence. Traumatic injuries may also be caused by natural disasters, such as earthquakes, which can occur during working hours and affect workplaces. Given the possibility that some lay rescuers may have the skills and presence of mind to treat victims with traumatic injuries who are injured in the workplace, such assistance is likely to be more effective if the lay rescuer were trained and equipped with emergency first aid supplies. Therefore, the bill’s goal of encouraging the training of laypersons to provide first aid in emergencies, and making emergency first aid supplies more widely available, as proposed by this well-intentioned bill, seems like an appropriate and reasonable policy.

The author proposes minor clarifying amendments to ensure there is no confusion about which person or entity must comply with the bill’s requirements and therefore which person or entity is immune from civil liability. Those amendments are described in and incorporated into the analysis. This bill is supported by the San Diego-Imperial Chapter of the American College of Surgeons, and has no opposition on file.

SUMMARY: Requires certain private and public buildings to make a “trauma kit,” designed and intended for treatment of emergency medical care, available on their premises; clarifies that a “Good Samaritan” who uses such a kit to administer emergency medical care and an entity that trains lay rescuers to use the kit is not liable for injuries resulting from such use; and protects a person or entity that acquires a trauma kit from liability for misuse of such a kit, as long as minimum requirements regarding installation and maintenance are satisfied. Specifically, this bill:

1. Defines “trauma kit” to mean a first aid response kit that contains at least all of the following:
   1. Two tourniquets.
   2. Two pressure dressings that are inspected for replacement no less than every three years.
   3. Four chest seals that are inspected for replacement no less than every three years.
   4. Medical materials and equipment similar to those described in a), b), and c) and any additional items that are approved by local law enforcement or first responders, that adequately treat a traumatic injury, and can be stored in a readily available kit.
   5. Instructional documents developed by the First Care Provider program, the Committee for Tactical Emergency Casualty Care, or the federal Stop the Bleed campaign.
2. Clarifies that the “Good Samaritan Law” applies to any lay rescuer or person who, in good faith and not for compensation, renders emergency care or treatment by the use of a trauma kit at the scene of an emergency.
3. Clarifies that a person or entity that voluntarily and without expectation and receipt of compensation, provides training in the use of a trauma kit to provide emergency medical treatment to victims of trauma or certifies persons, other than physicians and surgeons, registered nurses, and licensed vocational nurses, in the use of a trauma kit to provide emergency medical treatment to victims of trauma, is immune from liability for injuries caused by use of the trauma kit, as provided under existing law.
4. Requires each building constructed on or after January 1, 2020 that is required to install an Automated External Defibrillator (AED) on its premises to also have a trauma kit, as defined in 1) above, on its premises. Specifically, the following buildings would be required to have a trauma kit on their premises:
5. Group A assembly buildings with an occupancy of greater than 300.
6. Group B business buildings with an occupancy of 200 or more.
7. Group E educational buildings with an occupancy of 200 or more.
8. Group F factory buildings with an occupancy of 200 or more.
9. Group I institutional buildings with an occupancy of 200 or more.
10. Group M mercantile buildings with an occupancy of 200 or more.
11. Group R residential buildings with an occupancy of 200 or more, excluding single-family and multifamily dwelling units.
12. Specifies that the trauma kit installation requirement applies to a structure listed in 4), above, that is owned or operated by a local governmental entity, but not to either of the following:
    1. A licensed health facility.
    2. A structure that is vacant or under construction or renovation.
13. Immunizes a person or entity that complies with the requirements of 7), below, from any civil damages resulting from any acts or omissions in the rendering of emergency care by use of a trauma kit.
14. In order to ensure public safety, requires the person or entity responsible for managing the building, facility, and tenants of any structure described in 4), above, that is an occupied structure to do all of the following:
    1. Acquire and place a trauma kit on the premises of the building or facility.
    2. Comply with all regulations governing the placement of a trauma kit.
    3. Inspect all trauma kits acquired and placed on the premises of a building or structure every three years from the date of installation to ensure that all materials, supplies, and equipment contained in the trauma kit are not expired, and replace any expired materials, supplies, and equipment as necessary.
    4. Restock the trauma kit after each use and replace any materials, supplies, and equipment as necessary to ensure that all materials, supplies, and equipment required to be contained in the trauma kit are contained in the kit.
    5. At least once per year, notify tenants of the building or structure of the location of the trauma kit and provide information to tenants regarding contact information for training in the use of the trauma kit.
    6. Provide tenants with instructions in the use of the trauma kit from one of three training programs specified in 1e), above.

EXISTING LAW:

1. Provides that no local agency, entity of state or local government, private business or nonprofit organization included on the statewide registry that voluntarily and without expectation and receipt of compensation donates services, goods, labor, equipment, resources, or other public or private organization which sponsors, authorizes, supports, finances, or supervises the training of people, or certifies those people, excluding physicians and surgeons, registered nurses, and licensed vocational nurses in emergency medical services, shall be liable for any civil damages alleged to result from those training programs. (Health and Safety Code Section 1799.100. All further statutory references are to this code, unless otherwise indicated.)
2. Provides that a “Good Samaritan” who in good faith, and not for compensation, renders medical or nonmedical care at the scene of an emergency shall not be liable for any civil damages resulting from any act or omission other than an act or omission constituting gross negligence or willful or wanton misconduct. (Section 1799.102.)
3. Requires certain buildings and structures that are occupied to have an Automated External Defibrillator (AED) installed on their premises. (Section 19300.)
4. Provides that a person or entity that acquires an AED for emergency use is not liable for any civil damages resulting from any acts or omissions when the AED is used to render emergency care, provided that the person or entity has complied with all of the following specified maintenance, training, and notice requirements:
   1. Comply with all regulations governing the placement of an AED.
   2. Notify an agent of the local EMS agency of the existence, location, and type of AED acquired.
   3. Ensure that the AED is maintained and tested according to the operation and maintenance guidelines set forth by the manufacturer.
   4. Ensure that the AED is tested at least biannually and after each use.
   5. Ensure that an inspection is made of all AEDs on the premises at least every 90 days for potential issues related to operability of the device, including a blinking light or other obvious defect that may suggest tampering or that another problem has arisen with the functionality of the AED.
   6. Ensure that records of the maintenance and testing required pursuant to this paragraph are maintained. (Section 1797.196 (b)(1).)
5. Requires, when an AED is placed in a building, the building owner to do all of the following:
   1. At least once a year, notify the tenants as to the location of the AED units and provide information to tenants about who they can contact if they want to voluntarily take AED or CPR training.
   2. At least once a year, offer a demonstration to at least one person associated with the building so that the person can be walked through how to use an AED properly in an emergency. The building owner may arrange for the demonstration or partner with a nonprofit organization to do so.
   3. Next to the AED, post instructions, in no less than 14-point type, on how to use the AED. (Section 1797.196 (b)(2).)
6. Pursuant to Department of Industrial Relations (DIR) regulations, requires all employers to “ensure the ready availability of medical personnel for advice and consultation on matters of industrial health or injury.” (8 CCR section 3400 (a).)
7. Pursuant to DIR regulations, requires all employers, in the absence of an infirmary, clinic, or hospital, in near proximity to the workplace, which is used for the treatment of all injured employees, to have a person or persons adequately trained to render first aid. Training shall be equal to that of the American Red Cross or the Mine Safety and Health Administration. (8 CCR section 3400 (b).)
8. Pursuant to DIR regulations, requires all employers, to have specific medical and first aid equipment. (8 CCR section 3400 (f).)

FISCAL EFFECT: As currently in print this bill is keyed fiscal.

COMMENTS: This bill, similar to last year’s AB 909 (Steinorth), seeks to require that certain private and public buildings make a “trauma kit,” designed and intended for treatment of emergency medical care, available on their premises. It also clarifies that a “Good Samaritan” who uses such a kit to administer emergency medical care, a person or entity who places a trauma kit in a building, and an entity that trains lay rescuers to use the kit is not liable for injuries resulting from the use of such a kit under specified circumstances. According to the author, the availability of trauma kits in large private and public facilities is vital to public safety, given “mass shootings occurring in public settings or facilities, such as schools, churches, and large scale public events.” The author states:

Although public mass shootings are only a fraction of deaths in California, they still occur without warning, and in the public areas. Having tourniquets available can help in these unwarranted situations. For example in the Boston Marathon, where makeshift bombs exploded, injuring over 200 people. . . [I]t is vital for first aid kits to be equipped with tourniquets. Steps must be taken to help injured persons while emergency medical personnel on route. By training the public to use inexpensive and easy trauma equipment, they can be empowered to help save the life of those around them during an emergency.

While mass shootings fortunately are very rare, the risk of being killed or injured at work, on the other hand, is much higher. According to the U.S. Department of Labor, two million workers are injured or killed at work every year in incidents of workplace violence. Traumatic injuries may also be caused by natural disasters, such as earthquakes, which certain could and may occur during working hours and affect workplaces in California. Given the possibility that some lay rescuers may have the skills and presence of mind to treat victims with traumatic injuries who are injured in the workplace, such assistance is likely to be more effective if the lay rescuer were trained and equipped with emergency first aid supplies. Therefore, the bill’s goal of encouraging the training of laypersons to provide first aid in emergencies, and making emergency first aid supplies more widely available, as proposed by this well-intentioned bill, seems like an appropriate and reasonable policy.

Is it wise to encourage laypersons to use all of the emergency first aid materials that are required to be included in the trauma kit, including tourniquets? Tourniquet use, especially by untrained Good Samaritans, has been controversial over the years because of the “fear that severe tissue ischemia [a restriction in blood supply to tissues, causing a shortage of oxygen that is needed to keep the tissue alive] could lead to amputation.” (Clinical Queries: “What’s the Stop the Bleed Campaign?,” Nursing2017, Volume 47, Number 12 (December 2017), p. 15.) In other words, if a tourniquet is left on too long or applied incorrectly, it can result in the loss of a limb. However, if the alternative is death, even the loss of a limb is a preferred outcome. For example, “in the case of massive bleeding caused by firearm or shrapnel wounds, the window of opportunity to save a life may be as little as 5 minutes.” (Ibid.) Thus, in 2015, the American Heart Association Guidelines for first aid were updated to say that “because the rate of complications is low and the rate of hemostasis [bleeding to death] is high, first aid providers may consider the use of a tourniquet when standard first aid hemorrhage control does not control sever external limb bleeding.” (Ibid.)

Buildings and structures that are subject to the trauma kit requirement are the same as those required to have AEDs on their premises. As a result of SB 287 (Hueso), Chapter 449, Statutes of 2015, certain newly constructed structures and buildings are required to have AEDs on their premises as of January 1, 2017. It followed from, and expanded on, 1999 legislation that provided, in an effort to encourage the installation and use of AEDs in commercial buildings, qualified immunity to commercial property owners who installed AEDs in their buildings. That legislation, SB 911 (Figueroa), Chapter 163, Statutes of 1999, put in place a number of requirements for property owners who installed AEDs in order to obtain qualified immunity from civil liability associated with the installation or use of the AED. This bill seeks to similarly encourage the installation of trauma kits in the same buildings that are subject to the AED requirement, specifically the following occupied structures constructed after January 1, 2020:

1. Group A assembly buildings with an occupancy of greater than 300.
2. Group B business buildings with an occupancy of 200 or more.
3. Group E educational buildings with an occupancy of 200 or more.
4. Group F factory buildings with an occupancy of 200 or more.
5. Group I institutional buildings with an occupancy of 200 or more.
6. Group M mercantile buildings with an occupancy of 200 or more.
7. Group R residential buildings with an occupancy of 200 or more, excluding single-family and multifamily dwelling units.

The bill also clarifies that its requirements apply to publically owned structures that meet the above criteria, but not to a licensed health facility, or to a structure that meets the criteria above but is vacant, under construction, or under renovation.

The "Good Samaritan" law and unintended consequences of express immunities. Under existing common law tort rules, a person who voluntarily comes to the aid of another person suffering a medical emergency is immune from liability for injuries and even death, so long as that person acts in a reasonably prudent manner under the circumstances. In addition, in 2009, California adopted a so-called "Good Samaritan" statute. (The term refers to the parable in the Gospel of Luke about the "lowly" Samaritan who came to the aid of a stranger left for dead while supposedly more upstanding citizens ignored the cries of the dying man.) California's Good Samaritan statute (Section 1799.102) grants qualified immunity to any person who renders medical or non-medical aid in an emergency, so long as that person acts in good faith and not for compensation, and so long as that person's conduct is not grossly negligent or willful or wanton.

In recent years this Committee has heard, and the Legislature has enacted, bills seeking express immunity from liability for lay people (as well as off-duty professionals) who voluntarily render medical aid in a specific emergency situation, such as administering cardiopulmonary resuscitation (CPR), applying an AED, or giving an opioid antidote, among other voluntary actions. These provisions, granting immunity to persons performing CPR or administering AED devices or epinephrine auto-injectors, may be unnecessary given that any of these methods of administering medical or non-medical care by a lay rescuer at the scene of an emergency would most certainly qualify as rendering medical aid in an emergency by a Good Samaritan, regardless of the mechanism by which the care is administered.

For example, it is difficult to imagine a situation in which a person who rendered emergency trauma care with the contents of a trauma kit installed pursuant to the requirements of this bill, or even an untrained lay person who voluntarily rendered aid to a victim of trauma by providing care or assistance to a victim with materials or equipment found in a trauma kit (or even with other materials, such as a t-shirt, scarf, or tie used as a tourniquet) would not be protected from liability for injuries caused by such assistance under the Good Samaritan statute. While providing express immunity for specific medical emergencies may be unnecessary in light of the Good Samaritan statute, one could argue that this bill – and prior bills like it – is a harmless and potentially useful clarification of existing law.

Immunity for persons and entities that provide training in the use of trauma kits. Existing law, in order to encourage and facilitate more widespread training in emergency medical services, provides immunity to entities that provide such training. (Section 1799.100.) But the immunity in Section 1799.100 is limited by two important factors. It only applies to training provided under the following circumstances: (1) “voluntarily and without expectation and receipt of compensation;” and (2) to persons who are not physicians and surgeons, registered nurses, and licensed vocational nurses.

This bill seeks to provide immunity to entities that provide training in the use of trauma kits by cross-referencing Section 1799.100. The two important limitations on immunity in Section 1799.100—training provided without expectation of payment and training and certification of lay rescuers—are explicitly incorporated into the bill. Therefore, this cross-reference appears to be appropriate and consistent with existing law.

Immunity for an entity that “acquires and places” a trauma kit on the premises of a building. The bill provides immunity from civil liability to a person or entity that acquires and places a trauma kit for emergency care in a building that is subject to the requirements of the bill, as long as the entity complies with certain requirements about placement and maintenance of the kit. Given the complete protection from immunity from liability that a Good Samaritan has in rendering emergency medical care, regardless of the mechanism by which the care is rendered, it is hard to imagine a scenario under which the person who acquires and places a trauma kit for the use by a Good Samaritan would incur any liability. However, there is precedent for the Legislature to provide building managers, owners, and operators with arguably unnecessary immunity from liability (as long as they comply with a number of installation and maintenance requirements) in order to encourage them to provide emergency medical supplies, such as an AED, on their premises.

In the case of this bill, it would be the responsibility of the “entity responsible for managing the building, facility, and tenants” of any occupied structure that meets the specifications set forth in the bill to obtain a trauma kit, as well as to satisfy all of the inspection and maintenance requirements of the bill. As a result, that entity would have immunity from liability for any injuries caused by lay rescuers who use the trauma kit.

Potentially overlapping or conflicting requirements for “employers” to provide medical treatment and supplies to employees. There is a “general industry” regulation (meaning it applies to all industries) about maintaining a first aid kit at every worksite. The Department of Industrial Relations regulation, 8 C.C.R. Section 3400, means that every employer must have a mechanism to provide emergency medical care to employees whenever there are multiple employers in a building.  The regulation is tied to the employer and the worksite, rather than a building (as provided in this bill). Some businesses may occupy a building but not have any “employees” (a small office suite of some professionals that are independent contractors) and therefore would not be required by the regulation, but the vast majority of employers, both public and private, must, in the absence of an infirmary, clinic, or hospital, in near proximity to the workplace that is used for the treatment of all injured employees, have a person or persons adequately trained to render first aid whose training must be equal to that of the American Red Cross or the Mine Safety and Health Administration. (8 CCR section 3400 (b).) Employers are also required to have “[a]dequate first-aid materials, approved by the consulting physician, readily available for employees on every job” that are “kept in a sanitary and usable condition” and required to be inspected frequently and “replenished as necessary.” (8 CCR section 3400 (c).)

The DIR regulations do not specifically require the type of materials in a “trauma kit” that are designed to treat trauma and which are required by this bill to be placed in specific occupied buildings. It is unclear from the bill how an employer who complied with the DIR regulation could be impacted by the new requirements of this bill. If the employer did not own or manage the building where employees were located, the bill would likely have no impact on them because the requirement to acquire and place a trauma kit only applies to a “person or entity responsible for managing the building, facility, and tenants.” For an employer who owned a building where employees were located and was therefore responsible for the building and its tenants, the employer would merely have to obtain the additional relatively inexpensive supplies mandated in a trauma kit, if those were not already in the first aid materials kept at the workplace, in order to comply with the requirements of the bill.

ARGUMENTS IN SUPPORT: The San Diego-Imperial Chapter of the American College of Surgeons writes to express its “strong support” for the bill:

As California’s surgeons we know too well that the only tragedy greater than a trauma patient bleeding to death is a trauma patient bleeding to death that could have been prevented with simple measures. The concept of rapid bleeding control by immediate citizen responders is well proven. We have seen several successful tourniquet and advanced dressing “saves” already in San Diego.

We are very pleased that AB 1708 includes use of national standard educational programs for bleeding control by lay civilians such as promoted in the national “Stop the Bleed” program. “Stop the Bleed” has been endorsed by the White House, the Hartford Consensus, the U.S. Department of Homeland Security, the US Department of Defense, the American College of Surgeons and leading healthcare, fire, law enforcement and EMS agencies, including the National Association of Emergency Medical Technicians (NAEMT - creators of the PHTLS program) and the Committee for Tactical Combat Casualty Care (TCCC).

The combination of Public Access Trauma Kits with increased public awareness and

“Stop the Bleed” based training is a powerful combination to save injured citizens whether bleeding after an accident or attack at home, school, work, shopping or on the road.

Author’s clarifying amendments: As currently in print, subdivision (b) and subdivision (d) of 19310 seem to be duplicative because they both require the entity responsible for managing the building to do things. It seems sensible to combine those requirements into one subdivision. Also, the current wording of subdivision (d) refers to a “person or entity that acquires and places” a trauma kit in a building [who complies with the requirement of subdivision (e)], but subdivision (e) applies specifically to the person or entity responsible for managing the building. The author proposes to harmonize the language so that there is no confusion about which person or entity must comply with the requirements and therefore which person or entity is immune from civil liability. Therefore, the author proposes the following minor clarifying amendments, beginning on Page 4, at line 25 of the bill:

(b) The entity responsible for managing the building, facility, and tenants of a structure described in subdivision (a) that is an occupied structure shall acquire and place a trauma kit on the premises.

(c) (1) This chapter applies to a structure listed in subdivision (a) that is owned or operated by a local governmental entity.

(2) This chapter does not apply to a health facility licensed under subdivision (a), (b), (c), or (f) of Section 1250.

(3) This chapter does not apply to a structure that is vacant or under construction or renovation.

(d) (c) A person or entity that acquires and places a trauma kit for emergency care pursuant to this section complies with subdivision (d) is not liable for any civil damages resulting from any acts or omissions in the rendering of emergency care by use of a trauma kit if that person or entity has complied with subdivision (e) .

(e) (d) In order to ensure public safety, the person or entity responsible for managing the building, facility, and tenants of any structure described in subdivision (a) that is an occupied structure shall do all of the following:

(1) Acquire and place a trauma kit on the premises of the building or facility.

(2) Comply with all regulations governing the placement of a trauma kit.

[Renumber the remaining paragraphs, without any substantive changes.]

REGISTERED SUPPORT / OPPOSITION:

Support

San Diego-Imperial Chapter of the American College of Surgeons

Opposition

None on file

Analysis Prepared by: Alison Merrilees / JUD. / (916) 319-2334