Clinical Judgment and Protocols

[Bieber]

Hey, everyone.

So I just finished day two of a five day stint today, and I had a couple of interesting calls and a good learning experience from one that I'd like to share with you guys.

Patient number one was a female in her early twenties complaining of abdominal pain and difficulty breathing. Shortly after arriving on scene, I determined she was in diabetic ketoacidosis (blood sugar of 346, Kussmaul respirations present, abdominal pain and polydipsia) and I got her packaged and ready to go with an IV line running wide open. Unfortunately, I'm not (or wasn't) that familiar with just how quickly an open line should flow in, and while I checked it periodically to make sure that it wasn't flowing in more than I wanted to, it didn't occur to me that in my ten minute transport time I should have gotten the full liter in, and it also didn't occur to me until when we got to the hospital that she had had her arm bent and had kinked the line--which is why only about 150 made it in.

My other mistake on that call was to let my uncertainty about our clinical guidelines and protocols get the better of me. I should have given the patient pain relief, but I didn't due to the fact that I was more concerned with what admin would say about mixing protocols. As it turns out, I would have been fine, but the real lesson learned here was that I need to be developing my treatment plans FIRST, and worrying about how it fits into my protocols second. I know what treatments I want to give, but I oftentimes get too wrapped up in worrying about what my protocols let me do that I start thinking only in the form of protocols as opposed to sound treatment. I spoke with Dwayne about this call afterwards, and he really helped to set my head on straight. He told me that I need to be putting the patient--not protocol--first, and he's absolutely right. Treatment plan first, how I'm going to make it work within my protocols second. It's about performing sound clinical judgment, and either finding a way to make your protocols agree with what you know the correct treatment is or getting on the radio and getting the doctor involved so you CAN perform the right treatment. And I know this sounds like common knowledge, but it really is a hard balance to get right, especially for a new paramedic. And even though I later found out that I COULD have treated the patient's pain no problem, it's the simple fact that when I'm assessing my patients, I'm not thinking of how I need to treat them, I'm thinking of what protocol I'm going to work under.

So Dwayne's message to me was a good wake up call, and one I'm not going to forget. I'm not out to blatantly violate protocol, but my primary focus needs to be on how I can make this patient better or at least prevent them from getting worse and on how to at least treat them appropriately. And thankfully I got the chance to redeem myself in a way on my last call today, where I forced myself to take a step back and think about what TREATMENT I wanted to give, and then later found the protocol that made that possible.

I'm not too proud to admit I messed up today. I had a chance to positively impact a patient and I let it slip by me due to my incompetence (not double, triple, quadruple and quintuple checking my IV line) and due to my preoccupation with protocol over correct treatment. And I'm sure I'm not the only one who's ever made this mistake, and if you work under pretty rigid protocols like I do, you've probably found that it can be hard to do what's right and still be within your protocol.

Dwayne, you're the bravest paramedic I know, I've gotta say it, man. You are the epitome of what our mentality towards patients should be. You lost your last job doing what's right, and though it can be hard for us to stand on principle over practicality, you've proven that if any one of us want to be half the medic you are, we have ABSOLUTELY got to put the patient first. I wasn't doing that before, I knew the lines, could recite the mantra back and forth, but it takes more than just being able to read the script to really be that kind of paramedic. I know I get a lot of praise here for being "such a promising newbie", but the truth is, I'm not half the paramedic you guys are. If you guys could see me in action, you'd see just how green I am and how much, for all my words and strong beliefs about what EMS is, I haven't lived up to the message I've tried to deliver.

But I'm going to do better. Because I want to be THAT paramedic who never compromises, who never puts anything but the patient first. I messed up today, and I messed up before today. And to be honest, I'll probably mess up again. But I'm going to try not to, I'm going to try and follow through with that I say, to act in accordance to my very strong beliefs about medicine and EMS. And maybe, just maybe, some day I'll really be worthy of all the kind things you guys say about me. But that day isn't today, and it isn't tomorrow. But every patient I see, I am going to remember what you said, Dwayne. I'm going to keep your words in the back of my mind and I'm going to try my damnedest to do what I claim to believe in.

So thank you, Dwayne. You forced me to take all my philosophical bullshit and really prove that I mean what I say. And every day, I'm going to consider it a challenge to live up to the things I say and the beliefs I hold about medicine.

And this is my challenge to the rest of you guys. If you've been letting protocol dictate your treatment, if you've been thinking protocol first and correct treatment second, if you've been saying the words but not living up to them, I want you to change that. I'm not asking you to violate your protocols, I'm asking you to think about what is the BEST treatment for your patient, and either finding the protocol that lets you deliver that care, or getting on the horn and asking your physician to give you orders that provide that treatment. Practice what you preach if you're not doing it already, and if you already are, make sure your partner is as well. Because that partner could be just like me, waiting to here the same words Dwayne told me, to break them out of their "what protocol do I use?" shell and back into thinking like a paramedic.

[DwayneEMTP]

You know what man, I couldn't have been prouder than when I talked to you today. You took responsibility for what you did and didn't do, and I'm very flattered by your comments.

But there is a flip side. And many here are about to explain that to you. I've been fired twice now for doing what I believe was top shelf medicine. (Another time for just being an asshole..heh..but that's another story.)

And each time I left my family without an income so that I could follow my morals and ethics as I understand them. The vast majority of the medics/nurses/basics that post here on a regular basis make me look like a monkey fucking a football when it comes to knowledge and practice. That's just simply the truth.

You know why I focus on patients first and protocols second? Because I'm not smart enough to do what I believe to be the very best medicine that I can and at the same time constantly be comparing it to my protocols to make sure that I never get jammed up. I tried in the beginning and found that I could paralize myself with second guessing care vs covering my ass. I'm just not that smart. There are many here that can, and do, do both.

So I had to make a choice. When I was in Afghanistan, I called my wife Babs once when it appeared obvious that I was going to get fired if I followed my conscience instead of my supervisors orders..she said, "If you choose to hurt your heart so that you don't get fired, I won't ever thank you for that. If you choose to damage your paramedic spirit so that you can keep earning that paycheck..don't come home expecting me to call you a hero, because I won't. Do what you always do...do the right thing. If that gets you fired then fuck em...come home and we'll get naked..." And I have followed her rules every day, on every patient, since that time.

That works for me brother. Some people that I respect trememdously have shown me respect in return because they are confident that they won't ever have to question my direction. But if you're not prepared to get fired, not prepared for people to call your medicine bullshit simply because they are afraid to do what they think is best...then follow you protocols only. People rarely live or die based on our care. Some times they suffer more or less, and yeah, sometimes they live or die. But you have to make the decisions that are right for you, and the beautiful young woman of yours.

Billygoatpete told me after I got fired last..."You know, I've never known a good paramedic that hasn't been fired.." And I believe EVERYTHING he tells me...

You had a couple of good calls my friend. The lesson here is to find the happy medium. Don't become a "Screw the protocols" cowboy, but don't be afraid of every intervention because someone else may have been afraid of it...

Protect your patient...from illness, and death, from pain, both physical and mental, and do so to the very best of your abilities within your guidelines and you should be coming up roses. But someday when you get your ass canned because your supervisor wants you to be a protocol monkey? Call me, or any of about 100 other decent medics on this forum, and we'll get you hooked up... :-)

Dwayne

[Lone Star]

I got 'blackballed' because I did 'the right thing'...Not only did I get fired over it, but I also stood by my actions based on the protocols at the time. Because I didnt just slink quietly into the shadows and lick my wounds, I was labeled a 'renegade' by that company.

I can't prove what the company did after I was fired and had to list them as 'previous employment', but it seems VERY suspicious that a company who is dying to get manpower, wouldn't touch me with a 10 foot pole.

I did what was right for the patient and by protocol and STILL got shafted because I wouldn't back down to a nurse at an ECF (Extended Care Facility). Would I do it the same way again? You bet your ass I would!

No harm came to the patient, protocol was followed. The nurse wouldn't listen to the limitations I was under, and called the company saying that I was 'argumentative and unprofessional'(among other things). My hands were tied by protocols, and there was no other way of dealing with the situation.

Keep in mind, if I HAD violated ANY state protocols, local protocols or somehow brought harm to the patient, the company was required by law to report it to the state licensing board, who would have investigated the formal complaint and taken the appropriate action.

My license from the date of issue to the date of expiration (12 years later) was 'clear' with no charges or investigations. My concience is clear on this matter, and because no charges COULD be filed, I stand vindicated in my actions.

[Bieber]

None of us got into this job thinking planning to compromise patient care for the sake of keeping our bosses happy, but many of us, myself included, somehow ended up doing just that. And that's a shame, because there's something extremely and intrinsically noble about medicine and paramedicine as well. But in this world of paperwork, administration, and protocol, somehow we became removed from our patients. It stopped becoming about them, and started to become about making sure all the paperwork was just right. I realized that the first time when I first saw a respiratory therapist with not a stethoscope to be found on his person, but damned if he didn't have his little mobile computer.

Like I said, I'm not advocating for anyone to disregard their protocols, but I'm asking for anyone who's ended up in the same state I've been in, where you're more concerned with how your care will look on paper than what's right for the patient, to change that mentality. Because in the end, good patient care will justify itself; and for every employer that will compromise care for picture perfect paperwork, there is an ever increasing number of paramedics and services that will see that and know that that is the true mark of a great paramedic.

We can't be cowards any longer. We can't compromise what we know is right for the sake of paperwork. Every time we do, we drift farther and farther away fromt he dream that is the future of EMS; one where we are true providers, true clinicians, and true professionals. We relegate ourselves to appealing admin instead of doing what is right by the patient. It is our first and foremost obligation to protect our patients, like you said, Dwayne; from themselves, and from other people--all other people. Their lives come before us, their care comes before us. And until we can all embrace that mentality, we will always be struggling against the forces that be to do the right thing.

Lonestar, I admire you. You have shown your true colors, and those colors are good and pure and noble. Never compromise, never surrender. Never fall into the deadly trap of ever thinking that you mustn't protect your patient even against the forces that be. Because in the end, admin is there to cover themselves and the service; and like any business, if that means screwing one customer for the sake of obtaining and keeping others, then so be it. Our integrity as paramedics and providers is challenged every day, and every day is an opportunity for us to grow farther away from the noble ideals we had when we first started paramedic school, and every day is an opportunity for us to live up to them and be the paramedics we always envisioned we would be. Unconditional caretakers, unconditional wardens against all the dangers our patients face.

It's not about you, or me, or admin, or paperwork, or anything or anyone else--it's about the patient. Let's never lose sight of that again, let's never compromise what is right for our patients again. Because that trap is a deadly sinkhole, and there's not enough Dwayne's in the world to keep us all in check and to kick our asses back into order when we mess up. Like I said, I know I'm not the only one who's ever slipped up, so if you have too, it's okay. Like my preceptors would tell me, that call is over, it's done. Focus on the next one.

[usalsfyre]

Have you ever sat down with your medical director and asked him how he felt about protocol deviations with sound reasoning? Reason being I've found it's not usually the medical director that has an issue with protocol deviations, it's the "can't think out of the box" supervisors who do.

[DwayneEMTP]

I think usalsfyre has it exactly right. My good medical directors expected medics to do top shelf paramedic medicine, within protocol when possible, with MD help when not, and to do what's necessary when out of contact. Supervisors often freak out over aggressive medicine, but that's not always a bad thing. The service that you work for does have to be protected from yahoos and cowboys, and those are the folks that do it. They sometimes walk a fine line. I was told when I was fired from my last job, "You don't do bad medicine, it's just not paramedic medicine. You try to make everyone better, and that's not your job. It's our job to save them if they're dying, but transport them otherwise." I won't ever be that kind of medic.

But it's important to me that our younger and/or newer medics understand that though the balance between aggressive medicine and management may at times be adversarial, it doesn't need to be negative, if both sides see the value of the other. Is there a chance that my outside of the box medicine created a positive outcome for my patient? Sure. Does that make me feel like a rockstar medic? Absolutely. Is there also a chance that my outside of the box medicine will get my service sued into extinction should I get too far outside of the box? Very much so. But if I have good, intelligent QA/QI then I don't have to spend a lot of time worrying about that. As a team we'll monitor that line and do the best that we can for both entities.

As dumb as it sounds, we just need to stay withing the positive energy. If you do good, kind, competent medicine while thinking, "Fuck those guys! I'm going to do what's right whether they like it or not!" then you're going off into the ditch and looking for trouble..and you'll find it..trust me. :-) If you do aggressive, competent, brave medicine while thinking, "though I know 90% of my coworkers wouldn't do this, I'm confident that my medical director would want me to be super aggressive here...." I can't think of a time that you would be wrong. 3 or 4 times an ER doc complained about my decisions at my last job. Each time my medical director said, "Their thinking is a little bit archaic. You don't do less medicine to make them comfortable, you do good medicine and educate them if necessary. If that upsets them then they can continue calling me."

Stay in the positive energy brother, where you seem to live anyway, and you won't go wrong most times. Just keep in mind that EMS is notorious for wanting to bump you over into a lazy, unhappy place if you let it. I choose not to participate in that nonsense..I'm confident that you will too.

Dwayne

Edit. It occurred to me when I noticed that akflightmedic was watching this forum....If you think that I was being modest before, about not being able to constantly compare my best care to cover my ass medicine while others can, well, he's a good example. When I worked with him I discovered that he can assess, develop a treatment plan, figure how it compares to protocols, what is worth risking, what's not, who needs to go to lunch, when it's time to tune up the ambulance, remember that his anniversary is tommorow, all while intubating and managing the monitor. (Friggin' pisses me off...) So it can be done. I truly tried to emulate him but nearly gave myself a stroke/MI combo so gave up and went back to doing it my way. :-) Just sayin'...

Edited March 22, 2011 by DwayneEMTP

[Just Plain Ruff]

rockstar post +20

I also believe that you take the patient first.

But it's a fine line.

Luckily, I used to work with the doctors who received my patients. They trusted nearly all the medics we had and we rarely had to call for anything. I would only call if I needed a 2nd opinion such as having two drugs and each were good but one was better for this condition and I wanted to make sure that my thinking was right.

I had a case where we had a lady who fell outside her house. Ankle was really badly fractured, open and hanging by a couple of strips of skin only.

She was allergic to almost every medication out there but she needed pain control to allow me to splint her.

She said she had a slight rash when given fentanyl but was deathly allergic to morphine. I discussed this with the doctor and I suggested the treatment plan of dosing her with 50mg of benadryl first and then give 25mcg of fentanyl iv slow. The doctor agreed.

This was the right course of treatment because she ended up not getting a rash and we were able to give her the other 25mcg of fentanyl on the way into the er.

This was collaboration at it's best and WAY WAY WAY outside our protocols. Was it the right thing for this patient? You bet. She was able to tolerate the splinting of her ankle and did not suffer from any ill effects of the fentanyl allergy.

Her doctor was none to pleased at the administratoin of the fentanyl but once he saw her fracture he said "Wow, good call guys" and fixed her ankle. Do I think that we could have killed her, yep, if her allergy was any more significant but it all worked out.

Thinking outside the box is something that we do not do well in EMS.

[fiznat]

Not to be a killjoy or anything, but with all of this talk about "aggressive medicine" and taking care of patients outside of protocol I feel it needs to be said: our protocols are our lifeline to the world of science-based, real medicine, and ought to be respected as such. The best paramedics I know are acutely aware of how little they really know. They are humble people, respectful of the opportunity we are given to practice a little bit of medicine despite our short training and limited experience.

I am all for taking care of your patient, of treating injury and illness as thoroughly as we know how. But don't think for one second that your judgement is a substitute for the system. I don't mean to suggest that there isn't room for some clinical flexibility in the field (there is!), I'm just saying: don't get carried away under this "patient comes first" emotional gush stuff. Good medicine comes first, always, and respect the fact that individual paramedics don't always necessarily know exactly what that may be.

Bieber, I applaud you for coming on here and telling us about your mistake(s). I think it is an excellent way to learn, and reveals a part of your character that I think will serve you well in the future.

[Just Plain Ruff]

Not to be a killjoy or anything, but with all of this talk about "aggressive medicine" and taking care of patients outside of protocol I feel it needs to be said: our protocols are our lifeline to the world of science-based, real medicine, and ought to be respected as such. The best paramedics I know are acutely aware of how little they really know. They are humble people, respectful of the opportunity we are given to practice a little bit of medicine despite our short training and limited experience.

Fiz I absolutely agree. That was the reason why I contacted the doctor about the pain medicine issue.

It was beyond my scope to do that so I relied on the doctor. For any other patient I would have followed protocols.

I also believe that our protocols are what save a lot of us from having to go through a lawsuit. If you follow your protocols and the plaintiff's attorney see's that you did then you are more than likely not going to be named. Deviate from the protocol and patient suffers, your ass is theirs.

When in doubt follow the protocols, if that fails then call medical control.

[Bieber]

Thanks for all the replies, everyone! It's great to hear your own stories where you had to work outside the box in conjunction with medical control to make sure that your patients got the best treatment possible. You guys are all right, EMS NEEDS medical oversight, and while protocols may not be the best way to go, they're the current system and we have to work within those boundaries if we want to be not only good clinicians but lawsuit-free providers.

I'm at work right now, but I'll just say that today has been a very good day and I feel like I've really been putting treatment first. Called the docs twice so far to get authorization to provide the best treatment to my patients, and I was granted my orders both times to the benefit of my patients. It feels like a weight has been lifted off my chest, and like I am free to quit fretting over protocols and figure out what's wrong with my patients and what I should do. There's a time for protocols, but like I've said, you've got to be thinking what is the best treatment for those patients first, and THEN find the protocol that will allow you to deliver that treatment or, if there is none, call the doc and make it happen.

Oh, and I finally gave dextrose for the first time today. Checked, double checked, and then triple checked to make sure my line was good. I've heard enough horror stories about people pumping dextrose into blown veins that I was NOT going to have one of my own to tell.