David Aber has some nice words to say about me in a recent post, so it is a bit of a disappointment to disagree with his main point. He writes –
I am one who believes that if protocols are well written, there should be no grey areas. I also consider myself far from a “cookbook” provider. However, I do realize that should something occur as a result of deviation from the protocols without proper authorization, that is where providers run into trouble.[1]
Well written protocols would encourage paramedic discretion. If there is a deviation from protocol that is not bizarre, why not address it at the hospital after the call?
Is there some reason that doctors cannot evaluate the appropriateness of treatment after seeing the patient?
Are medical directors really putting such dangerous medics on the street that the medics will harm patients without the magic phone call?
In the last few decades, one thing we have learned is that medical command permission requirements will be discarded as we realize admit that these requirements are not good for patients.
–
It is ingrained in EMS providers that should they ever have a question about deviation from a protocol, they should contact medical control.[1]
Protocols should be written for thinking paramedics, not for multiple choice from textbook patient presentations.
A thinking paramedic understands the harm of providing too much treatment, such as the 2 mg naloxone or the 25 gm 50% dextrose that David mentions.
Given the must get permission first approach, if medical command does not give permission, should the medic give an unnecessary treatment to a patient just to satisfy the protocol?
What if the medic calls command and is told to just follow the protocol?
Does the medic waste the supratherapeutic medication?
Does the medic harm the patient by giving a drug that has no possibility of providing benefit?
Is it worse to violate a protocol or to intentionally harm a patient just to protect the protocol?
I realize that David was referring to well written protocols, but well written protocols make allowances for protocol deviations and the review of these protocol deviations after the call. Are protocol violations that are expected and allowed still grey areas?
Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS providers to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances.[2]
Medicine is not black and white, but grey and probabilistic.
–
Protocols should be written so that if a provider follows them, there should never be a question about the care they provided.[1]
No.
Choosing the protocol is not much different from a multiple choice exam.
If I choose the wrong protocol, is that good?
Does it matter how perfectly I follow the protocol I chose?
If I disable, or kill, a patient by perfectly following a protocol that should not have been followed, should I be immune from criticism, or from recourse?
Hell No!
But that is exactly what a lot of students say they are looking for –
What do I have to do to make sure that I will not get in trouble?
Well, you have to avoid any kind medical job.
If we want to know how to screen the bad people out of EMS, this kind of question is a clue.
How can I occasionally kill patients and not be responsible for my actions?
Why do we encourage these people in EMS? Why do we cater to them?
I am not the only one who thinks protocols should be written to encourage discretion. Kelly Grayson writes –
We are doing unnecessary things just because they’re in the protocol.[3]
We are poisoning our patients, just to avoid getting in trouble.
Yay! Aren’t we cool.
–
Footnotes:
–
[1] 50 Shades of Grey…Protocols
Posted by David Aber
The EMS Difference
June 30, 2012
Article
–
[2] The Two Most Important Words in an EMS Protocol
The Ambulance Driver’s Perspective
by Kelly Grayson
March 26, 2008
ems1.com
Article
.