Deviating from Standards of Care based on EMTCity?

[captainstandup]

Protocols should be considered guidelines. There is no conceivable way that a written document could be so broadly written as to cover every patient situation.

EMT City is arguably one of the best resources I have encountered in almost 16 years in this business. With this said I may incorporate things learned here into my practice, but I would never change or alter a protocol based treatment on what I read in these threads as they are often opinion only. Just remember the folks on EMT City will not be there if the Medical Director decides to review the call.

[Dustdevil]

This topic is certainly worth revisiting.

It seems that many are still too stuck in “protocol” mode to really address your question, even though you made it quite clear that you were talking about situations outside the protocols, those grey areas that make up more than half the practice of medicine. It also seems that everybody is stuck in ALS mode instead of considering the basic practises that make up ninety percent of what we do.

I’d like to hear other examples of what you are talking about, but I think I understand you clearly. For example, your protocols say that you are to immobilise specific patients within specific criteria, but they do not spell out how you are supposed to do that in a step-by-step fashion. Although there is probably a rough consensus of how everybody does it in your area, there is no protocol or SOP addressing it. And there is a good chance that the way everybody else does it there sucks. Consequently, if you were to learn from others her a better way of doing this immobilisation, I believe it is absolutely reasonable to follow that advice. Of course, it is first important that you do a lot of serious intellectual and scientific evaluation of this plan before you implement it to determine that it is indeed medically sound, because a lot of things that sound great on the surface turn out to be absolutely wrong under the microscope. You just can’t go off half-cocked thinking, “Hey, that sounds cool! Let’s do it!” Again, I don’t think that is a problem for you.

I have definitely learned things from others on this forum that I have incorporated into my practice. There is always a better way of doing things. And it is an important prerequisite for professional growth that you remain open to different and better ways of doing things. Every idea you consider – whether you ultimately accept it or not – is an exercise in critical thinking for you, so this is a very positive thing.

[AnthonyM83]

This is more of what I was getting at. I think we can take it as a given that violating a direct protocol is not an option. A few posts did address the ideas of using meds for different purposes at the ALS level, which I appreciated, was looking for, and helped me....but I also wanted some BLS topics.

There are three main Los Angeles County medical protocol references:

EMT Scope of Practice (General List)

EMT Treatment Protocols (Adds that Pt in Distress = "Comfort, High Flow O2, Shock Position prn, VS" & Nitro/Alb/Epi Assist Criteria)

Specific Treatment Guidelines (Only 10 apply to BLS...many only restrictions like O2 maintained until transfer of care)

Note: There are a few other pages addressing transport decisions, DNRs, etc

Dust, the cspine example is great...our guidelines (though written like a rule) say:

"EMT-I's shall implement spinal immobilization on patients with suspected spinal trauma based on mechanism of injury." (Whereas paramedics use a specific algorithm)

If I read that 0% of GSW's to the head caused spinal damage and I stopped immobilizing such patients (provided no other trauma), I feel as if that would be asking for trouble. But now if patient starts having airway issues, even if mild, I would probably release cspine sooner that others might. Not sure if that's a reasonable compromise.

A hypothetical example (null, because one protocol says distress = high flow O2) would be starting to use a cannula for chest pains with no other complaint based on articles read here (and advise from a few ER physicians I've asked) even though EVERYONE gives high flow NRB. I was never technically "trained" to give NC to CP...

Another example: Not that we ever end up using oral glucose, but there was talk once about a lethargic patient getting some rubbed on gum, even though we're taught never to give orals to ALOCs (heheh, orals).

Another vague one: Our scopes says "Provide initial prehospital treatment of trauma." That's it. I can see that as actually being a good thing...not that there's too much extra I could find myself doing as an EMT....

[Dustdevil]

That was actually my second typing of that post. The first one accidentally disappeared right before I hit the "submit" button. :x

In the original one, I actually mentioned that, while it would be acceptable to find an innovative and more effective way to immobilise your patients, since that is not specifically laid out for you, but that it would not be acceptable to decide to implement SSI and not immobilise certain patients at all because you learned it here or elsewhere on the net, because that is specifically laid out for you.

This is where your clinical director and MD is supposed to be doing the job for you. They are supposed to be staying on top of the current literature and best practices in order to keep the practice of your agency current. If your MD is allowing the old skool conventional wisdom of "what we've always done" substitute for an intelligent analysis of the data and constantly updated protocols, then he sucks, and is putting you and himself in legal jeopardy, and your patients in physical jeopardy.

Of course, a problem I frequently ran into in EMS was that I found the better or even best way to do something, backed up by practice and the literature, but the powers that be (and the preponderance of lazy medics) still wouldn't go for it. SSI is an excellent example of that kind of thing. Yes, there is an overwhelming amount of scientifically sound literature espousing SSI as the state-of-the art in EMS practice. But a lot of agencies don't want to get on board because of fears of legal repercussions. The problem is, as much as SSI can be validated, nobody has yet shown that it does significant harm. Consequently, people will hold on to it out of legal fear because of the "no harm done" theory. And I can totally understand that.

That would differ completely from a situation like MAST pants where we the literature now tells us not to do it not because it's not necessary, but because it is critically harmful to the patient. In that case, it is nothing short of criminal to continue with a practice just because you aren't current or can't/won't understand the science behind it all.

lolz@orals

[AnthonyM83]

Out of curiosity, how would you guys interpret: "EMT-I's shall implement spinal immobilization on patients with suspected spinal trauma based on mechanism of injury." There's no accompanying list of MOI's or types of injuries. So, it could be a bad thing as in cspine anything that could be conceived as causing spinal injury or good as in you can use reasonable suspicions of injury (this whole topic was covered very poorly in EMT school).

[Dustdevil]

Out of curiosity, how would you guys interpret: "EMT-I's shall implement spinal immobilization on patients with suspected spinal trauma based on mechanism of injury."

Yikes! That's a sticky situation. Sounds like they're giving you just enough rope to hang yourself with. That's a total set-up for a reason to fire you, should they want to. With my luck, all the guys that routinely walk accident victims to the ambulance before boarding them will enjoy long and lucrative careers, but I'd get sacked the first time I didn't board somebody who was clearly eliminated by the Canadian and NEXUS criteria.

There was a time about 25 years ago when this didn't require clarification. Before the mid 80's, MOI ruled. And just about every MVA involving damage qualified as MOI. We were -- as we still are today -- arguing about the best way to do it, but it was pretty well agreed in professional EMS (not including urban firemonkeys) that if the possibility of spinal injury even crossed either medic's mind, then immobilisation was in order. But then something weird happened; PHTLS changed everything. Having been in on the ground floor of PHTLS, I was amazed by how it transpired. But when we introduced the concept of "rapid extrication," it seemed as if half of our students totally disregarded the rest of the course, and leeched only onto the rapid extrication thing. Within a couple of years, all of a sudden half of the medics in the country are yanking people out of crumpled cars, a la 1969, and tossing them onto boards without proper immobilisation, invoking the "rapid extrication" clause, even though PHTLS never taught it as a standard protocol to be used in every case. Amazingly to me, that attitude still persists heavily in many areas of the U.S., and we are right back to where we were before PHTLS because of PHTLS. :?

Now SSI comes along and actually lightens our load for us, but I really fear it will have the same effect that PHTLS did. It's just going to give lazy arse medics more encouragement to be lazier.

Taking all this into account, it becomes obvious that you just can't make any assumptions or take anything for granted with your protocols, because you really don't know where the heads of those who wrote them are at. But then, when you take the safe route like that, you face another problem. How do you go to your management and ask for clarification of the protocols without them concluding you are either stupid (for not reading their minds), or poorly trained (for not knowing what their crappy school taught them), or just a troublemaker for nitpicking everything? It is a tough dilemma, but you can't just interpret the protocols as you see fit without clarification. If you had no suspicion, but they do just by reading your chart, you're sacked.

I think this topic segues well into another topic, which is how to get clarification -- and possibly even progressive change -- of your protocols without incurring the stink-eye from your management. If I ever figure that one out, I'll be glad to share the secret with everybody, but for now, I'm still getting fired everytime I try. :roll: