Clinical Judgment and Protocols

[Just Plain Ruff]

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.

I have found in the past that if you can give a good history and physical info over the phone, tell the doctor what you are thinking adn what you are wanting to do and WHY!!! then most of the time they have no problems giving you orders or they may say, sounds good but try this first. That's why we have access to the doctors, I'm betting that they have had to take care of whatever you are calling about at least one time before and they know what they want to do and what they want you to do.

Just remember, Your lifeline in cases where there is a question is the doctor. Use them, that's what they are there for.

[BEorP]

Very interesting thread and one that I thought was worth replying to. The problem is that I've been sitting here for a while now trying to figure out what I have to say about it. My feelings are definitely mixed.

I like the general idea of the initial post, but I also know how easy it is to become jaded when working in a system that does not endorse those views and would rather just have you fit patients in protocols. In my short EMS career, I managed to get myself into trouble a number of times over doing what was best for the patient. I never went outside of my protocols, but I sometimes followed the letter of the protocols (e.g. "paramedic may" is not the same as paramedic must) rather than the interpretation that the base hospital endorsed.

The danger of this is that whenever you are tagged as someone who does not fully respect the sanctity of the protocols, you can be labelled a "cowboy medic." This is not a good label to carry with you. I guess what I am saying is that even though I am proud to say I advocated for all of my patients, sometimes at my own expense, I look back on it and sometimes wonder whether it was worth it. I wonder whether more good could have been done by trying to change the system to allow for more flexibility and to encourage better patient care by all providers rather than just improving my own care for a few patients. I also wonder whether I would have enjoyed my time in EMS more had I not been constantly going through audits and "discussions" about my actions on calls because of my patient advocacy. I do not mean to sound burnt out, but I do know how it can impact an EMS provider to seemingly constantly being up against a base hospital or EMS service and it is not fun to say the least. I guess this will really depend on the system you work in and how they view providers like this. Even with my mixed feelings though, I am proud to have advocated for and provided the best care for all of my patients.

The other important consideration or danger with this idea of "clinical judgement" and then protocols is that not all EMS providers are like the members of this forum. In fact, I would bet that most of the people who come on here to discuss things like this are probably in the top 10% of EMS providers. Do you truly believe that the bottom 10% have the clinical judgement to make decisions without simply trying to put a patient into a protocol? I certainly don't. But then this creates problems for all of us, because in the eyes of some base hospital systems, we are all treated like those bottom 10%. In some ways this seems fair, because as much as we might want some extra leeway in our protocols, we probably wouldn't want it for a bottom 10% provider treating our mother.

Taken even one step further, do you think that the average EMS provider has the clinical skills to assess a patient and then consider protocols rather than assessing a patient with protocols in mind? When you're working in an environment where you were trained to follow protocols and get in trouble if you deviate from protocols (even for the good of the patient), it is understandable that people can regress to this form of assessment.

The last comment I have on this would be that even when we consider the top 10% of EMS providers, they need to be aware of their limitations. As much as we as EMS providers may hate to admit it, the protocols are written by smart people. This by no means means that they are always right or account for every unique patient presentation. The risk though is going outside of the protocols or treating a patient based on your assessment or whatever we want to call it and then being wrong when the protocol treatment would have been more appropriate. This would be terrible for the patient and the idea that thinking paramedics are better paramedics. The obvious way to prevent this is what we're all doing right now in addition to other research, reading, and continual education.

I do not mean to sound negative about the idea of the thread. I really do think that it is great for EMS providers to be able to truly assess patients and treat them accordingly (while being in line with protocols or through a physician patch). I guess I just wonder how this could practically be something that is taken up more widely or how one provider can help to change things. And maybe the answer is that systemic change is not the goal, but rather simply the satisfaction of knowing that you have always provided the best patient care possible while accepting any flack you get for that. In that case, keep it up.

[DwayneEMTP]

Man, great responses.

I'm glad others have chimed in to defend protocols, as I have no general disrespect for protocols but find that patients often don't fit nicely into any one protocol.

Example. 80ish female, known diabetic, CVA x 2 within the last year each leaving pt with deficits, bedridden x 2 years. Called for 'unresponsive.' U/A pt is laying propped up on pillows in soaking wet bed clothes secondary to diaphoresis, arms clamped tightly to chest, a puddle of drool on her chest, very thin even when age is considered, BGL 27, unresponsive, airway patent, very obvious R sided facial droop not present when she went to bed last night and it's 'believed' that her face appeared normal when checked on two hours previous by daughter, PERRL, skin turgor very poor with significant tenting.

Hopefully without trying to go through the entire presentation I'm making it clear that my initial impression was likely hypoglycemia/possible CVA. Fire is on scene, has Glucagon/syringe layed out on the bed for me. When I try to straighten her arms to check for IV sites I get a nauseating grinding in the elbow/shoulder joints bilat...I've not really felt anything like it before but it concerned me that I may damage her if I apply any firm pressure to straighten them. Access very poor due to dehydration. I make one attempt on the back of her forearm and miss, my partner makes two attempts in her legs, neg x 2. We are both competent when starting IVs.

I decide to start an IO, (pissing of Fire with my 'cowboy shit'), as I don't want to wait on the Glucagon to work before deciding if I'm going to alert the stroke team secondary to the facial droop. I'm also not confident that the Glucagon will create a significant benefit for a patient in this condition that may not have sufficient glycogen stores. Also, I don't want to complicate her in hospital care by burning up any glycogen she may posses if I have an option, thus the I/O.

Now, this is where we have to think, in my opinion. Protocol says that hypoglycemia with 2 or more IV attempts and access unlikely to give Glucagon. But the protocol is unaware that my patient may also be having a stroke. Stroke protocol says that if the patient is positive for Cin stroke scale to activate stroke team (after gathering competent history of course) and transport L/S to appropriate center. But the protocol doesn't know that I am unable to do a neurological assessment secondary to hypoglycemia.

So I set my I/O, push some Lidocain and sugar, pt wakes up, straightens up, face goes back where it belongs, stroke scale negative, transport is uneventful. I believe that I have helped the patient, I am way ahead of the game had the stroke scale been positive. I feel good, the patient is doing well, I'm proud of this call.

Yet it's one of three calls that they cited when they terminated me. Their argument was that it was "too aggressive and outside of protocol. You just don't start an I/O for hypoglycemia!!" For the record, my protocol for an I/O at the time was at least two missed IV attempts with IV access unlikely but access appears necessary. For Glucagon at least two missed IV attempts when access appears "impossible." I explained that we made three attempts without the likelihood of success with future attempts. And that I didn't use the Glucagon as access wasn't impossible, as proved by my successful I/O placement." I don't believe that there was one single 'cowboy' moment here. But my employer felt differently.

So, I went on my way, now work for a really cool company, doing really cool stuff, and life goes on.

So, hopefully this shows that I have no disdain for protocols or guidelines, only that they often, maybe even rarely, address more than one condition at a time and my experience has been that medical patients rarely, and trauma patients seldom, present with a single issue. 95+% of the time these issues can be resolved without any 'cowboy' shit, but sometimes, in my opinion, you are forced to decide your loyalties...to your patient, or the powers that be?

Great thread all! Thanks for taking the time to participate..

Dwayne

Edited to correct a grammatical error only.

Edited March 23, 2011 by DwayneEMTP

[Johnboy]

I agree with fiznat 110% on this one. I, in no way, shape, or form will work outside the scope of my practice, if it means I lose my job- unless, it is for my family, and that is the only exception. We as providers did not cause this emergency to occur, nor are we sure our treatment is going to work. Someone said it before, be humble, because we only skim the surface of medicine. It is only because of the collaboration of the system as a whole, that makes modern day medicine what it is today. I am not a cowboy, nor a hero, we should be humble at the fact that we have an opportunity to learn more and more each and everyday.

I commend everyone on this board for going the extra mile for their pt's, as I do the same, or atleast try. Again, my family alone are the only people on this earth that I will lose my job for. This might seem harsh, but I am not the one who jammed the 40 cigs a day into that COPD pt's mouth, nor am I the person who held down the obese person with Metabolic Syndrome down to the sofa while he stuffs another Whopper into his mouth. We all make decisions in our life, and they are the small ones that lead to a healthy, or a not healthy life. With the exception of the things we can't control, we all have a mind, to make any decision.

Do your best, be humble, try hard, learn, and utilize the system to the fullest for the best intrest of your pt, but, most importantly- protect yourself, and your family- because WE COME FIRST.....

JB-

Dwayne- Sorry, but I am going to call you on this. I would have tried Glucagon IN. Family stated that this pt was left with deficites from the last CVA, at this point, with a BGL of 27, Stroke would not have entered my mind unless the trial of Glucagon with unsuccessful. Correction of blood sugar is diagnostic. Even if she was having a stroke, the BGL should have been correction first and foremost, also, if she was having an ischemic stroke, boluses of D 50 are associated with a worse outcome, and we unfortunately do not have a CT scanner. And if she was left with deficites, how did she return to normal? Just wondering....

JB-

If you hear hooves, dont go looking for zebras...

[Johnboy]

Also, you said that you did not want to wait for the Glucagon to work before alerting the stroke team. That treatment would have given you your answer as to alert them or not. There are two things that medics only do once in their career, 1) calling an MI alert, when the st segments are raised by a LBBB, and 2) Calling a stroke alert before correcting the BGL.......Don't take it personally, it is just constructive critisism.

[DwayneEMTP]

Welcome to the City! I mean that sincerely despite my at least partial, and possibly complete disagreement with your post. I am flattered that it is intelligent, uses whole sentences and supports your points. Again, not at all tongue in cheek...

..but I am not the one who jammed the 40 cigs a day into that COPD pt's mouth, nor am I the person who held down the obese person with Metabolic Syndrome down to the sofa while he stuffs another Whopper into his mouth. (Let me help you out. Following by Dwayne) And I'm not the one that put the black on the nigger shot in the street, nor the one that put the 'old' on the lizard in the nursing home, or the one that put the booze in the mouth of the fucktard vetran, or the one that made the premature bastard falling out of the crack whores twat, or, or, or,.....

Yeah man, I can see why you don't look for zebras, everyone that needs EMS assistance appears to be a lame horse in your opinion. I wouldn't risk my job over a bunch of losers either. But then again, our practice seems to be different, as mine is full of ill or injured patients. Yours seems to be filled with one type or another of people slowly, purposely, committing suicide.

..- Sorry, but I am going to call you on this.

Awesome!

... I would have tried Glucagon IN.

Fair enough. What is the mean onset via that delivery? I've not heard of giving it IN, but my guess would be that in this patient, with the presentation as described, her glycogen stores were so minimal that it would have been near useless anyway. What is your optimum window for pharmacological stroke intervention? We have two hours gone now, a min of 60-90 mins to a stroke center, perhaps 50 minutes if I activate Flight for Life now. How long do you want to wait to see if the stroke symptoms resolve with the Glucagon? You are truly going to let this window close so that you can stick to protocol? Also, as you might have seen above, I did not violate protocol to treat this patient.

...Family stated that this pt was left with deficites from the last CVA, at this point, with a BGL of 27, Stroke would not have entered my mind unless the trial of Glucagon with unsuccessful...

As above.

...Correction of blood sugar is diagnostic.

My thought exactly.

..Even if she was having a stroke, the BGL should have been correction first and foremost...

I thought I did that.

...also, if she was having an ischemic stroke, boluses of D 50 are associated with a worse outcome...

You're going to need to back that statement up with current science brother. I've heard that oft repeated, but can't find any current research that supports this except in the near extreme.

.. And if she was left with deficites, how did she return to normal? Just wondering....

My mistake. I should have said baseline. Though you already knew that.

..If you hear hooves, dont go looking for zebras...

Yeah man, if I follow your advice then a drunk is a drunk, a warm seizing baby is a febrile seizure, and the window for optimum treatment of a possible stroke closes while I sit on my hands. I'd rather burn my medic ticket and wash cars for a living.

Thanks for participating JB...I look forward to your thoughts...

Dwayne

Also, you said that you did not want to wait for the Glucagon to work before alerting the stroke team. That treatment would have given you your answer as to alert them or not. There are two things that medics only do once in their career, 1) calling an MI alert, when the st segments are raised by a LBBB, and 2) Calling a stroke alert before correcting the BGL.......Don't take it personally, it is just constructive critisism.

Not taking it personally at all, in fact, just the opposite. I love that you've jumped right in a decided to debate. There is not one thing so special about me that it should be assumed that I will be right about....well...anything really.

I'm grateful to be challenged, though I'm confident that I countered this argument before it was made, in my original post. I'm not sure what is new here? It MIGHT have given me my answers, and it would likely have given them long after I needed/wanted them.

Dwayne

Edited to correct some clumsier than usual grammar. Not significant changes made.

Edited April 4, 2011 by DwayneEMTP

[fiznat]

Also, you said that you did not want to wait for the Glucagon to work before alerting the stroke team. That treatment would have given you your answer as to alert them or not.

I'm not sure that would be such a great idea. Glucagon takes about 20-30 minutes before it really starts to work well, which for a lot of services (like mine) far exceeds transport time to the hospital. I don't think it is a good idea to sit and wait if you are really concerned about a CVA.

[emtannie]

I was thinking the same as Fixnat... Glucagon generally takes at least 20 minutes to take effect, and my concern with this patient is that given her current situation, are we prepared to wait that 20 minutes, as that window for thrombolytic treatment closes if she is in fact having a CVA?

Was Dwayne's treatment aggressive? Absolutely. Did he think outside the box? Absolutely! Did he do more harm to the patient? Absolutely not! This was a rare situation, which most of us will never encounter. Would I have done the same thing? I don't know, because I am not as smart as Dwayne is, and I may not have considered that option. In our protocols, thatg is a bit of a grey area, where using the IO would have been an option as long as I could have explained it to my medical director.

Johnboy, I have never heard of using Glucagon IN (which I am assuming means intranasdally). So, tonight at work, I thought I would research it a bit. I looked in the 2010 CPS, and there is no mention of using Glucagon IN. The only recommendations are IM and in lower doses, IV. A direct quote from the CPS is "It is important that the patient be aroused as quickly as possible, because prolonged hypoglycemic reactions may result in cortical damage." I believe that in Dwayne's situation, he did exactly that.

Could you tell me a little more about using Glucagon IN, and what your protocol dosages and recommendations are? Thanks!

[Johnboy]

EMT Anne, continue your research, it is the standard now, and the onset is much faster then IM. In Dwayne's defense, I will assume that wherever you are, you are not using Glucagon in your protocols IN. Still, This pt deserved to have a trial of Glucagon IM, or IN prior to your IO insertion, you had NO IDEA wether or not she had addequate glycogen stores, and it deserved attention.. BGL of 27 with a response to an antihypoglycemic agent is again diagnostic (Whipple, look it up) You have fixed her, and we all know that you would have,however now, she has a big needle in her leg. You pushed lidocaine in an older, lighter pt. Probably 40 or at the most 50 kgs, and the dose you probably used was 40 mgs. Lidocaine, a proarrhythmic, (generally considered now in modern literature) was pushed in an unresponsive pt. (NOT NEEDED, and dangerous), and now she can look forward to the possibility of osteomyelitis. Good job.

Good for you for thinking outside of the box, but this was a diagnosis of exclusion, you should have excluded it in your DDx in the field, with the intention of "do no harm" This was cowboy medicine. I believe you did not get fired because of your rx, but because of your cowboy attitude, and not knowing how to take a bit of advise from people that possibly could have done something less invasive while producing the same results, while alleviating dangerous sequelae. I would have fired you also.....

JB-

And fixnat, I never said to sit and wait...

[DwayneEMTP]

Johnboy, your holier than thou argument only works if you, as you continue to do, ignore the time frames.

You attempt to present yourself as so far above me that you can't possibly grasp the ignorance of my actions, and yet you are unable to address the simple mathematical problems that a 6 or 7 year old child would solve easily. What's up with that?

If it makes you feel really smart to continue to ignore the questions addressed to you, to ignore the most pertinent aspects of the differential and treatment, to continue to regurgitate the simple minded protocol monkey crap that you've given us over and over already...then good for you brother.

But fair warning. We aren't the basics that you seem to hang out with that are snowed by your narrow minded cookbook medicine. This is a forum of medical professionals. They, nor I, are fooled by your rah rah bullshit.

I would love to debate this with you, and will get right back to doing so just as soon as you address the logical questions that you MUST ignore to continue to make your foolish argument.

This patient didn't deserve a trial of Glucagon, this patient deserved to be thoroughly assessed and her current and future possible medical needs addressed most to least critical. You have not even made an EMTB attempt at arguing that so far.

You would have fired me? The sad thing, in my opinion, is that in the chickenshit world of cover your ass protocol medicine...there is every chance you will someday rise to a position to be able to do so.

Dwayne

Edit. For the record, "Continue your research" and "Look it up" is pussy debate tactics. It's not my place to make your argument. If you can't site your sources like an adult then don't use them. It really is that simple. You say that IN Glucagon is the standard of care? I call you a liar. Or perhaps you don't know the definition of "Standard of care." Prove it.

Edited April 4, 2011 by DwayneEMTP