Piping In or Checking Out; The Delicate Balance

[Jaymazing]

I'm posing this question in the form of a scenario. It's based on real events, but obviously I had to change some details to protect various people's privacy.

You are an EMT-A working with an EMT-Paramedic. You're relatively new to the service you're working with, and the medic is someone who's been around for quite a while. You're working in a rural community with limited resources, and it's been yet another slow tour for you and your partner, who together form the only ALS crew in the region. You are called to back up a BLS ambulance responding for a 30 year old female, 9-echo (Cardiac arrest, CPR in progress). Collapse was witnessed, and compressions were performed by family for approximately 9 minutes prior the BLS crew's arrival, at which point the monitor was attached, V-Fib was recognized, and one shock was delivered. V-fib continued, and compressions resumed, and that's when you and your "ALS" partner showed up.

Being an EMT-A, you recognize that the Paramedic is calling the shots now and assume a supportive role. Good quality CPR and ventilation is maintained, IV's are established, and coarse V-fib continues despite one round of Epi and another defibrillation attempt. It's been about 20 minutes since collapse, and the family is standing nearby watching you attempt to revive their wife/mother, and they are increasingly distraught by the events unfolding.

It is at this point where things start to unravel.

Your paramedic partner looks at the coarse, obvious V-Fib showing on the monitor, and requests you to draw up Atropine...

"Do you mean Amiodarone?", you ask quietly.

He retorts with a glare, and absolutely insists that Atropine be drawn. This is an easy task to accomplish, as the Atropine you carry is in a preload syringe. You reluctantly pass it to the medic, who proceeds to push the drug slowly into the patient.

Fibrillation persists.

5 minutes later another dose of Atropine is given. No change.

A little over 30 minutes into the arrest and the third shock is delivered, at which point the patient goes into asystole. Upon seeing this, the medic determines that no further medications are to be given, and that transport should be initiated to the closest facility (about 30 minutes away). Compressions are continued, but no further electrical activity is restored enroute, and all measures are ceased shortly after arrival at the care center.

So my question to you is this; being the EMT-A in this scenario, at which point do you interject and voice your concerns over blatantly poor decisions and errors made by your "superior" who's running the call? Bare in mind the setting of this scenario, and the fact that all communication on scene can be easily overheard by the patients family. Do you say anything on scene? Do you address the matter afterwards, or in private? Or do you just assume that your partner knows something that you don't, and move on.

And what do you do in other situations when a partner that "outranks" you makes a Tx decision on scene that you absolutely disagree with (morally or clinically)?

I'd really appreciate your thoughts on this...

[Arctickat]

Four Words....

Alberta College of Paramedics.

Report this incompetent fool before he kills anyone. It won't mean the end of his career, but it will mean he'll never screw up like that again.....You did what you should have done. You recognised his error, attempted to correct it in a manner I would find acceptable, yet he insisted. After the call, on the way back to base I would ask him why. Don't make it a form of accusation such as "Amiodarone is indicated for Vfib, not Atropine. You screwed up." Ask him as a learning experience. "I'm sorry I questioned you in there, I was told one time that Amiodarone was the appropriate medication in that instance. How does the mechanism of action for Atropine work on VFib?" It strokes his ego and hopefully gets him thinking back to the call and realising he screwed up. What does the call report say? Amiodarone or Atropine?

[chbare]

I'd refuse to administer or draw up the atropine and state on scene if need be that atropine is not indicated for refractory ventricular fibrillation according to the current 2010 AHA recommendations. Then, report as necessary if needed.

[Jaymazing]

I'd like to clear the air here and state that I was not the EMT-A on this call. I am friends with the EMT though, and since this call I have had similar instances where people who outrank me have made decisions that I felt would negatively impact my patient, and have been faced with the challenge of confronting the matter either on-scene or after the call.

I felt this scenario was black-and-white enough to keep the focus clear; when is it inappropriate to challenge the medic in charge, and at what point does the risk to the patient outweigh the risk of losing the confidence of the family or seeming unprofessional in the public eye?

[Kiwiology]

Dude is in the wrong, you have every right to tell him so and question him on being a Paramuppet

[Curiosity]

I'm anxious to hear how people respond to this. I'm now the highest authority on scene and I know if someone questioned me, I would be thinking really really heard about what I'm about to do and why. We're human, we make mistakes. To completely ignore and dismiss your partner like that irresponsible, neglectful, and may have killed this patient!

I don't know exactly how I would have handled that situation but I do know I would have pushed my partner more than that. I have to go home and sleep at night. Knowing I could have done more would kill me.

[DwayneEMTP]

Yeah, man, what a mess.

...Report this incompetent fool before he kills anyone [else]...

Fixed that for you...

...What does the call report say? Amiodarone or Atropine?

That is the $64,000 question right there. (Sorry if the reference is lost on you youngesters..) If the report says Amiodarone but there was verifiably Atropine pushed, then every effort should be made to burn this person down.

You know what Brother, this is a really tough question. But I absolutely love the context that it is asked in. Not only patient focused, but patient family focused as well. This is so important to their future healing...

It's difficult for several reasons. First, the fact that your correction wouldn't be welcomed by the medic is professionally pathologic. Like Curiosity said, such a comment coming from ANYONE would have given me pause and cause me to consider my current course of action. I don't know how many times my partners have steered me onto a course of action that I liked better, but it has been many, many times. Sometimes it wasn't adjusting an obvious error, though that's happened too, but just a way that they felt was better, and I could see that they were right.

Once on a cardiac arrest I instructed my basic partner to push two amps of bicarb on an extended arrest. One of the First Responders (Very lowest level of care in the U.S.) put his hand over my partners before he could push it, looked at me really intensely, help up one finger...the obvious question being, "Don't you mean one amp??" My partner, ever the professional, wasn't offended, looked to me for clarification, and I instructed him to push both amps. Afterwards the first responder came and asked why I'd made the decision, and I explained that it was the proper dose for such a large patient.

These types of interactions should be welcomed by every member of the team. I've often wondered how a medic justifies ignoring the possibility that others might have valuable input that they'd not considered when on every arrest I've ever worked to the hospital the last thing the doctor does is to turn to everyone in the room and ask, "Is there anything that anyone can think of that we've missed, or that they think that we should try before calling this?" If it's good enough for the doctors, then it should damn well be good enough for me too...

Sometimes what appears to be an obviously wrong decision, won't be. So where do you draw the line at "I've made my suggestion and it's been over ruled, so now I'll trust that my medic has a good reason and move forward with his/her plan." Or "I KNOW s/he is wrong..I am morally and ethically bound to stand up and defend this patient against this treatment!" I don't know. If you constantly work with different partners then It's difficult to get to the "I trust you even though I believe this to be wrong" stage...I've just never really been in that position. I've been really blessed that any time that I wasn't the lead person on scene, that the person that was welcomed any and all feedback that was delivered in a professional manner.

Sometimes, you just have to teach your medic how to be a grown up, and if you can't do that, then sometimes you have to report them and allow others to force the maturing process. It's truly not easy being smarter than you're supposed to be when a lower level of care...And I mean that sincerely...

[ERDoc]

I wonder if the medic thought the EMT was asking which he wanted, as if the EMT hadn't heard him. A quick sentence with what's wrong and what should be given might work. "Do you mean Amiodarone for his vfib?"

[Jaymazing]

Sometimes, you just have to teach your medic how to be a grown up, and if you can't do that, then sometimes you have to report them and allow others to force the maturing process. It's truly not easy being smarter than you're supposed to be when a lower level of care...And I mean that sincerely...

I really like how you put that!

I wonder if the medic thought the EMT was asking which he wanted, as if the EMT hadn't heard him. A quick sentence with what's wrong and what should be given might work. "Do you mean Amiodarone for his vfib?"

Maybe you're right; the problem with being shy about a treatment disagreement is that it leaves a lot of room for misinterpretation.

I, unfortunately, have been on both extremes of the spectrum, in that I've been too quiet on some occasions, while being overly assertive on others. If you're too quiet, you don't seem confident in your suggestions. But if you're too loud, people just think you're being obnoxious and try to ignore you. I guess it's a skill that develops over time...

I don't know exactly how I would have handled that situation but I do know I would have pushed my partner more than that. I have to go home and sleep at night. Knowing I could have done more would kill me.

Honestly, that was a pivotal point in my career when I figured that out; whatever I do or do not do, I have to live with my actions in the end. I'd rather be able to sleep at night than worry about an ego. The problem is that I need to remember that lesson all of the time.

[systemet]

Your paramedic partner looks at the coarse, obvious V-Fib showing on the monitor, and requests you to draw up Atropine...

"Do you mean Amiodarone?", you ask quietly.

He retorts with a glare, and absolutely insists that Atropine be drawn.

Odd. Are you sure that coarse VF is actually on the monitor, and that you're not seeing CPR artefact? This is more commonly mistaken for VT than coarse VF.

A little over 30 minutes into the arrest and the third shock is delivered, at which point the patient goes into asystole. Upon seeing this, the medic determines that no further medications are to be given, and that transport should be initiated to the closest facility (about 30 minutes away). Compressions are continued, but no further electrical activity is restored enroute, and all measures are ceased shortly after arrival at the care center.

Two more bits of weirdness here:

(1) If the patient has been pulseless for some 30 minutes or so, after an initial downtime of 20 mins, there's no reason to transport, this code should be called on-scene.

(2) If we're working a code it's epi q5 until we stop. We don't stop giving meds.

These are surprising actions for a registered paramedic.

So my question to you is this; being the EMT-A in this scenario, at which point do you interject and voice your concerns over blatantly poor decisions and errors made by your "superior" who's running the call?

I'm a paramedic. For years, I've started every shift I've worked with an EMT I don't know with a short little speech, something along the lines of, "I like to help people, I don't get in trouble, and I don't start fights. I like to fix problems. I may spend a lot of time on scene, and I do a lot of 12-leads. If you see me doing something stupid, let me know, because there might be something I've missed. If you're in the back at any point, and the patient complains of pain or nausea, let me know, and we can pull over and take a look at it. If there's any patient, BLS or ALS, you're not comfortable with, let me know, and I can ride in. They pay me a couple of dollars an hour extra, and I can happily do a couple of extra calls. If you have a question, let me know, I love to teach.".

One of my bigger fears as a paramedic is that I'll do something stupid one day because I missed a critical piece of information, or got lazy, and no one bothered to let me know.

The guiding principle in all of this needs to be "first do what's in the perceived best interests of the patient". Sort of a modified Hippocratic oath. You should intervene when you know or believe that what is being done may potentially cause harm to the patient. This is part of what you're getting paid to do, regardless of your certification level.

Bare in mind the setting of this scenario, and the fact that all communication on scene can be easily overheard by the patients family.

Then you need to be professional. "Sure, I can grab that atropine, but isn't that coarse v.fib on the monitor? Would you like some amiodarone instead?". It sounds like that's what you (or your friend) did. You can't really get in a fistfight over this, and try and wrestle the atropine out of his/her hands, or everyone's getting fired, and the patient's family is getting horribly traumatised, but you can politely and professionally point this out in a way that the family isn't aware of. They likely have no idea what amiodarone, atropine, or VF are.

Do you say anything on scene?

Yes, but politely, and with respect to your level of practice and the possibility that you may be wrong, and in proportion to the potential harm to the patient. If the paramedic chooses to ignore this warning, then they're fair game.

Personally, I've always gone by the rule that I will never keep silent and then take an issue to management / medical direction. If it's important enough to make an issue of, then it needs to be talked about before its done. If I do my best to warn someone, and they choose to ignore that warning, then I have to protect myself, and future patients.

Do you address the matter afterwards, or in private?

As well. What are they going to do? Shout at you a bit? They can't take away Christmas, or dock your pay. If they're mean to you or rude, or threatening, it's only going to make your decision easier.

Or do you just assume that your partner knows something that you don't, and move on.

In this situation, no. In other situations, maybe. Your paramedic may have a great reason why they're not treating someone's symptom complex involving "chest pain" with ASA and NTG. Or why they're not intubating this patient. There are things that may be provider-dependent, like pain control. Some things have lesser impact for the patient.

This is not one of those situations. Granted, the patient has been dead for some time prior to your arrival, there's minimal evidence to support antiarrhythmics in general in cardiac arrest, and your patient is extremely likely to stay dead regardless of what wonder drug you push in the IV line. But, there's a clear, and bizarre med error being made here if the patient is actually in VF.

If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed. And wondering why I gave atropine to VF.

And what do you do in other situations when a partner that "outranks" you makes a Tx decision on scene that you absolutely disagree with (morally or clinically)?

There is no "outranking" in EMS. You're all responsible for the patient, and will be judged as a group. That being said, as an EMT, you're at less risk than any ALS providers on this call, as this is something out of your scope. Other decisions, particularly the problem of a partner wanting to do a refusal on a patient with potential ACS symptoms will put your job at jeopardy as well, even if a paramedic is there. In this situation where an ALS med error was made, you're less likely to get disciplined.

Of course, the point here isn't to not get disciplined -- it's to do the right thing for the patient.

As an aside, this is one of the reasons I like working with an EMT better than another paramedic. It keeps me sharper, and ultimately I'm going to be accountable for anything done wrong, and can intervene and play the paramedic card without going through the mess of arguing with another paramedic.

I'd really appreciate your thoughts on this...

This is a difficult situation. Similar situations, probably of lesser magnitude, will arise again. EMS often has a very blue collar mentality where we cover for each others mistakes, let one provider run roughshod over others, and fail to report these things when they happen. As a provider you have to decide where the line is for you personally, and what's more important, doing the right thing, or being popular with your peers?

In the situation described, I would talk to the paramedic after the call, and demand, first politely and then rudely, to know why atropine was given instead of amiodarone. Explain why you think amiodarone should be given -- specifically that the patient was in VF. See if they were aware of this. Give them a chance to admit their mistake, and sugget that they take it to medical direction or management instead. If they refuse to, then I would suggest dealing with it internally first, and considering a complaint to the college.

Ultimately, if it's a serious enough issue, you were present, and you fail to report it, your employer, the college (who can be quite unforgiving), and ultimately the police, may come after you as well. Especially if there's been any collusion on an attempt to alter or doctor documentation.

Merry Christmas.