Continuing from the first two 50 Shades of Grey parts, David adds Part 3.
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And that same medical director is usually the ones whose license paramedics work under.[1]
Paramedics do not work under a doctor’s license.
If I authorize you to drive my car, you are not operating the car on my license.
I could do street-side surgery and not endanger the doctor’s license.
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However, when a system puts something in black and white, then this is what is to be followed. No Grey.[1]
Anything written in black and white has shades of grey. If not, there would not be much reason for a Supreme Court and all decisions by the court would be unanimous. They are working with black and white.
The question is whether our highest priority is the patient or the protocol.
Patients often do not present as black and white, but as grey.
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The requirement for a Mother-May-I phone call is based on mythology and has never been shown to protect patients. On the contrary, these magic phone call requirements endanger patients.
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Epinephrine is not required in ACLS (Advanced Cardiac Life Support), but generally is required in EMS protocols in the US.
In the next revision of ACLS, don’t be surprised if the AHA (American Heart Association) changes their wording from consider to something that is less likely to produce the reflexive everybody dead gets epi that is in so many EMS protocols.
It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).[2]
Black and white. (OK, it is orange and white.)
ACLS does not provide us with any ALS (Advanced Life Support) treatment that improves outcomes, but we convince ourselves that ALS treatments improve outcomes based on wishful thinking and seeing it in black and white.
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It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of out-of-hospital cardiac arrest.[2]
For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.128,–,133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.31,33,134,–,138 [2]
Understanding the importance of diagnosing and treating the underlying cause is fundamental to management of all cardiac arrest rhythms.[2]
It is important to understand that the routine ALS treatments probably harm patients, but our protocols tend to prevent us from following the ACLS guidelines.
We are only required to consider epinephrine. Unfortunately, the people writing the protocols do not seem to understand black and white, so the protocols tend to make epinephrine mandatory.
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In the example David cites (the pdf does not open), the medic clearly should have called medical command to ask if he should have brought his gear on a call for a patient with difficulty breathing. He also should have called medical command to ask if he should have checked vital signs on the difficulty breathing patient, who apparently was not having difficult breathing due to death.
Magic phone calls encourage medical directors to keep these medics working, because they have to call to do anything dangerous.
That is the idea. That is not the reality, as this example makes clear.
Walking a patient to the ambulance is also something that should only have been done after a Mother-May-I phone call. The same for the IV medication – giving it or withholding it. We can’t be too careful.
It is not at all clear that either the walking or the lack of however much IV medication (probably just saline solution) contributed to the death of the patient.
It is also not clear that the death would have been prevented or that a lawsuit over the death would have been prevented.
The apparent mandatory nature of protocol makes this a protocol violation and therefore grounds for a law suit.
The failure to bring equipment on a difficulty breathing (or cardiac arrest) call and the failure to assess for vital signs are signs of horrible judgment that were not addressed by Mother-May-I phone call requirements. The failure is the dependence on the Mother-May-I phone call, rather than a requirement to assess the competence of the care delivered to patients by the paramedic.
Poorly written, inflexible protocols are not oversight. A magic phone call requirement is not oversight.
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Footnotes:
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[1] 50 Shades of Grey…Protocols (Part 3)
David Aber
The EMS Difference
July 13, 2012
Article
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[2] Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Free Full Text from Circulation
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