Deviating from Standards of Care based on EMTCity?

[AnthonyM83]

So, at EMTCity, we often bring up new studies or protocols from certain areas regarding new and progressive ways of treating the ill and injured...

A lot of times, it won't really change how we treat our patients, because we're bound by specific protocols. Other times, we may have leeway, simply because protocols don't address the topic or are vague. But there is still a standard way of treating those patients in your EMS community.

Assuming you're not violating a protocol, is it appropriate to change your treatment plans based on something you read here or a study you read in a respected journal? Do protocols forbid you to do certain things simply by failing to mention a certain skill or treatment or failing to order an approved skill/tx for a different situation? What if they tell you how to tx a situation, but you'd like to add to it?

I don't think it's clear cut, because there's probably very specific things that are never mentioned in protocols, but you're still expected to do based on your EMT training. So, should you wait until you take a class that tells you to do something, so in a review board, you could back up why you did something and liability calls on the class?

I'm not talking perfect EMS system scenario...I'm talking actual reality of how EMS and legal world is now.

A concern I have is I think we sometimes forget a study isn't proof of the new way things should be done, but simply results of a one trial. Studies usually have to be replicated several times in order to gain mainstream credibility and taken more as fact. Unless you're getting consistent stats from another system who test trialed a tx/skill/method showing improved survival or pt condition, shouldn't you wait off?

[mrmeaner]

Some protocols are written with enough rope to hang yourself with. If you question the need to talk to someone about a new idea, you should. Not only to CYA, aut also to keep tx's standard. Tx's should also be acceptable based on your training. See the dilation assessment thread. That said, training needs to be standard, which doesn't seem to happen.

[mrmeaner]

Some protocols are written with enough rope to hang yourself with. If you question the need to talk to someone about a new idea, you should. Not only to CYA, aut also to keep tx's standard. Tx's should also be acceptable based on your training. See the dilation assessment thread. That said, training needs to be standard, which doesn't seem to happen.

[vs-eh?]

I'm not entirely getting what you're asking here. I certainly would not deviate from a recognized "standard of care" that is currently recommended by your service by what people on this forum suggest. Same goes for reading about a "new standard" in a journal that may differ from your current treatment modality.

While there are generalized global standards of care regarding most situations, in the end the physician that dictates your practice can "do whatever they want". If you have a concern regarding your "protocols" then bring them to the attention of your service and medical director. I would recommend not "doing what you want, just because it doesn't actually go against 'protocol'".

Some examples -

My service started doing the "up-front" chest compressions (and new compression ratio's) for unwitnessed arrests quite a while prior to them being "standards of care". I (and others) found that it lead to a significant increase in prehospital ROSC. I would not expect people on this forum to institute that modality until it is recognized by their service/physician.

I don't have any standing orders regarding treatment of a hyperkalemic patient. So, should I come across a renal patient in a wide complex bradycardia say, I can't simply administer sodium bicarbonate and salbutamol (the only medications we carry that are in the standard treatment) without calling a doctor first. Even though they are "standards" and I'm not going against "protocol" (because there isn't one), I still have to have a chat with the doctor.

Same goes for the oral administration of D50W that was talked about on this forum. Just because it can be administered by that route, I doubt that very many people have this option spelled out in their orders. Therefore you are giving a medication by a route not specified and must call for administration. A similar example is midazolam. Initially we didn't have IN as a route available, and even though it is an accepted route, you cannot simply do it. Unless you have something in your orders to the effect of "administration may proceed by all acceptable routes per drug insert" (or something), you can't simply do it.

I can give morphine to a ischemic chest pain patient, but I don't have to. I have read some journal articles questioning morphines efficacy in this setting and personally refrain from it. People do administer it though, but I find most patients prefer not to have it. Same goes for the subjective nature of treating a chest pain patient in itself, you may treat, where I wouldn't. That is the beauty of having guidelines rather than have-to-do's.

Again, if you are questioning certain treatment guidelines that your service does, based on new information, approach your service/physician first before you take things into your own hands.

[Richard B the EMT]

While I keep chanting my mantra, if you have a good rapport with your on line medical control, mention possible new protocols to them, or to those at the county, state/province, or national levels, to see if, on a county, state/province, or national level, such protocols, either as new protocols, or "pilot" try-out programs, can or might be implemented.

[AnthonyM83]

I'm not entirely getting what you're asking here. I certainly would not deviate from a recognized "standard of care" that is currently recommended by your service by what people on this forum suggest. Same goes for reading about a "new standard" in a journal that may differ from your current treatment modality.

You pretty much did address my question. By standards of care in my community, I mean the way things are usually done just based on convention, but not written anywhere.

I guess my vague protocols can actually be a good thing (allow discretion), but also a bad thing (you don't know how far that discretion goes...is it only based on training? on new studies? on what doctors in ER tell me? on what I learn from coworkers/EMTCity?)

For example...pt has significant hemorrhaging. Closest protocol says: "Provide initial prehospital care of trauma" (that's it). So, I see some room for discretion: Try packing 4x4s until they soak through or just put pressure & tourniquet right away. I can back that up with my PHTLS class...but what if I hadn't taken the class, but read how tourniquets don't have to be a last resort.

[AnthonyM83]

As far as communicating with medical control or medical director, EMTs don't really get to do that. BLS doesn't do base contact for anything (I ONCE did it on my cellphone, because we had someone drive a critical stabbing victim up to us and we wanted to transport without medics and wanted notify receiving non-trauma ER). But we'll never get to chat with them, see them, and medical director has yet to answer an email about my questions.

Protocols that apply to us:

http://ladhs.org/ems/manuals/policies/Ref800/802.pdf (Text form of expanded scope)

ttp://ladhs.org/ems/manuals/policies/Ref800/802-1.pdf (Text for of regular scope...same thing)

http://ladhs.org/ems/Manuals/policies/ref800/802-2.pdf (In table form, which is different from text form...notice any person in distress gets high flow O2...and the spelling error)

and general guidelines, some of which apply to BLS only:

http://ladhs.org/ems/Manuals/Medprotocols/...lguidelines.htm

[spenac]

As far as communicating with medical control or medical director, EMTs don't really get to do that. BLS doesn't do base contact for anything (I ONCE did it on my cellphone, because we had someone drive a critical stabbing victim up to us and we wanted to transport without medics and wanted notify receiving non-trauma ER). But we'll never get to chat with them, see them, and medical director has yet to answer an email about my questions.

Wow, that sucks. Even as a first responder I could discuss things with our medical director. As a basic I was able to get many things improved. Our director does not care who you are, she will listen. Answer maybe no but she will listen.

[Richard B the EMT]

Must be a local thing. Within my locality, the FDNY EMS, if an EMT has a question, they can call OLMC for an answer.

If an RMA request is made that is for someone under age 5, or over age 65, the EMTs are actually required to contact the OLMC, who, after being asked what the recorded vitals (two times, from times at least 10 minutes apart), and some observations are, then talk to the patient (parent or guardian if the patient is under 5) before advising the EMTs if they can accept the RMA or not. The Doctor's ID number will be included on the call report, so there is the official record that the OLMC was contacted. I am sure they have paper trails on their end, too, as well as the audio tape of the conversation.

As a mention, I have contacted my OLMC with questions that immediately thereafter appeared on this web site. I did advise the OLMC I was doing so off duty, and that I was going to do the posting.

I am aware, from previous strings, that some area's OLMCs don't automatically put a Doctor on the wire, that a lesser trained person will attempt to answer either an EMT or Paramedic's question, even if the person calling is insistent on talking to the MD. There is actually a possible change in the NYS DoH rules that would allow it, but more on that in another posting.

[JakeEMTP]

The one word that is a constant in our protocols is " consider ". " Consider this" or "Consider that " Yes, there are standards of care that we should follow. When we are presented with a " different " pt, one that doesn't respond to treatments that are the " standard ", we have the option of calling Medical control and explaining what is happening and how the patient is presenting. It is not unheard of for us to do something that isn't in the cookbook after explaining what we want to try to the MD on the other end of the phone.

We have a good relationship with the Medical Director. He in fact, has lectured some of my classes. He is always willing to listen to something new, or a question one might have.

All in all, I'm proud of my job. Oh wait, wrong thread. :oops: