Medico/legal liability in EMS in regards to protocols

[PRPGfirerescuetech]

Hello.

While reading the thread in regards to PEA SVT arrests, it seems another discussion and subsequent thought process is upon us.

In regards to liability.

There was a discussion of the inclusion of calcium chloride in a particular posters protocols for cardiac arrest. I dont remember where in the protocol it fell, but i dont care, because i forwarded that knowledge with the extra 1.50 of ALS pay in my check.

Anyhoo...

If you follow a protocol to a T, regardless of medical literature being against the action you take, can you be held liable as a medical practioner? Or does the region and designer of the protocol take the hit from (insert greasy haired lawyer type here).

Thoughts?

[Punisher]

Personally I believe the medical director would probably be the primary person to pay for it, but the expectation probably exists that someone versed in ACLS and emergency care in general (i.e. a paramedic) would know better than to do it. It's one of those issues that would probably boil down to how well the plaintiff's lawyer argued his case to the jury.

I'm going to ask a friend of mine who is a lawyer to comment on this......I'll let you know what his response is.

[PRPGfirerescuetech]

Excellent. Thanks for that.

Also, lets toss in the certification vs. licensure differences in the discussion. Would someone licensed be held more liable that someone certified?

[Ace844]

Here's a General explanation as posted at the beginning of my states treatment protocols..

INTRODUCTION

INTRODUCTION TO STATEWIDE TREATMENT PROTOCOLS

The goal of any Emergency Medical Services System is to provide the finest out

of hospital medical care to all the citizens and visitors of its jurisdiction in a timely and

efficient manner. The treatment protocols found in this text are designed to immediately

and definitively manage emergent patient illnesses and injuries such that rapid

intervention by all levels of EMT personnel will alleviate patient suffering and ultimately

allow the patient to be delivered to a receiving hospital in an already improved clinical

state whenever possible.

The intent of the Statewide Treatment Protocols is to establish an acceptable

standard for managing patient injury and illness by EMTs working for ambulance

services and/or first responder agencies (whether paid or volunteer). In this regard, a

great deal of attention has been paid to the format of the protocols and the clinical

correctness of the protocols. The narrative format allows the protocols to serve as a

reference text when needed, while the algorithmic treatment sections provide guidance

in the acute situation.

STRUCTURE OF INDIVIDUAL PROTOCOL

Each protocol begins with a brief explanatory preamble that delineates the

clinically important parameters for that particular injury or illness being managed in the

out of hospital arena. The next section of the protocol emphasizes the assessment and

treatment priorities for each illness or injury being addressed. This section states the

most important treatment measures relevant to a particular illness or injury and is

considered to be part of the treatment protocols themselves.

The treatment section of each protocol is divided into three levels: BASIC

PROCEDURES, INTERMEDIATE (ALS) PROCEDURES and PARAMEDIC (ALS-P)

PROCEDURES. As with any sequentially designed treatment protocol, the higher-level

EMT is expected to have carried out the relevant parts of each lower level of clinical

management.

ROLES / RESPONSIBILITIES OF EMS PROVIDERS

Personnel and Training

Emergency Medical Technicians are trained to provide out of hospital care at

several levels of training. The untrained bystander is often the first to come to the aid of

a stricken patient and may be the first to activate the EMS System. Police officers and

firefighters, given their greater availability in most communities, usually arrive before an

ambulance, and can often provide help at the First Responder or EMT level. In

Massachusetts, EMTs may be trained to the Basic, Intermediate, or Paramedic levels.

The capabilities of each EMT level areare defined elsewhere, but are clearly included in

these protocols for each level.

A minimum Pre-Hospital

Data set for each transport should be entered on the trip record such that systems-wide

improvement can be undertaken by identifying issues important to the out of hospital

management of patients. EMTs at all levels, BASIC to PARAMEDIC, may request

Physician Medical Direction on ANY call in order to facilitate patient care. Early and

concise reporting to the Receiving Facility is strongly recommended in all EMS systems.

Variation from the protocols: The informal section at the end of this text

explains the methodology / process for variation from the protocols as written.

The need for such a process is obvious: general consensus must be achieved

before a new or controversial procedure / protocol can be adopted. The

review process will always be conducted in the best interests of quality patient

care.

Variation from the protocols: The informal section at the end of this text

explains the methodology / process for variation from the protocols as written.

The need for such a process is obvious: general consensus must be achieved

before a new or controversial procedure / protocol can be adopted. The

review process will always be conducted in the best interests of quality patient

care.

INTRODUCTION 11/01/2005 Page 12

13. General Principle of the Protocols

The Statewide Treatment Protocols represent the best efforts of the EMS

physicians and pre-hospital providers of the Commonwealth to reflect the current state

of out-of-hospital emergency medical care, and as such should serve as the basis for

such treatment.

We recognize, though, that on occasion good medical practice and the needs of

patient care may require deviations from these protocols, as no protocol can anticipate

every clinical situation. In those circumstances, EMS personnel deviating from the

protocols should only take such actions as allowed by their training, and only after

discussion with medical control.

Any such deviations must be reviewed by the appropriate local medical director, but

for regulatory purposes are considered to be appropriate actions, and therefore within

the scope of the protocols, unless determined otherwise on OEMS review by the State

OEMS Medical Director.

CONCLUSION

The protocols established in this text are designed to provide a solid

framework for out of hospital treatment modalities in the Commonwealth. They are

not a substitute for a textbook or a training curriculum. As new treatment and

patient management modalities are developed, they will be reviewed and placed in

the Protocols Manual as they are identified.

In essence, and in my anecdotal expeience it has been explained that the protocols are 'GUIDELINES' as to what the 'MINIMALLY ACCEPTABLE STANDARD OF CARE' is for a particular D/O. It was further explained that due to bureaucracy, and such that the 'protocols' may not be always 'up to date'. Hence one of the many reasons we are all required to do con-ed. In situations where you have a question about the efficacy, as noted above you are suppossed to initiate OLMC. If you FAIL to and things go wrong, (i.e.: admin cacl to a patient and they have a poor out come) you stand a more than fair chnace of being the only one left standing when the music stops! You made the decision and you are responsible. Yes, your med director will take a hit, but ultimately YOU take the big fall for doing something you shoudl have known better than to do. remember ignorance is no defence in this case!!!

Hope this helps,

ACE844

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[PRPGfirerescuetech]

So, education seems to supercede protocols? Am I reading that right? *gasp*

[Ace844]

So, education seems to supercede protocols? Am I reading that right? *gasp*

"PRPG,"

I was probably 'explaining' my post while you were posting this. In a word, YES!! IMHLO, and thats how it was explained to me. As a further point of refrence See M.G.L. c.90, § 7AA &** U.S. District Court of Rhode Island, C.A. #92-0705 P.

Hope this helps,

ACE

[AZCEP]

This is one of the medical/legal/ethics scenarios that is run through in every medic class I've ever seen.

Dr. X gives you a medication order that you know is wrong. You repeat the order back to said doctor, and he repeats it without changing what he initially told you. What do you do?

I've been witness to those providers that are not confident in their own knowledge follow an obviously bad order (Bicarb down the tube anyone? :shock: ) I've witnessed the same issues with drug doses (Epi 1:1 000, 1 mg SQ for asthma :shock: ) Then you have the more confident providers not willing to cause harm by doing something so blatantly ignorant get written up for not wanting to toe this insane line.

My stand, and mine alone. If a licensed provider is willing to give me a bad order, and I make it very clear that I disagree with this order, then they had better be able to defend their position in a reasonable manner, and not just because they told me to do it.

I refuse to put my career, my children's next meal, or my next house payment on the line for someone that only thinks they know what they are talking about.

[emt-b_wa]

While I am a lowly EMT-B I aspire to join your ranks as a medic after more experience. I must agree with you and say that if your education and training tells you something with an order or protocol I would not follow said protocol.

[Ridryder 911]

IMHO, protocols are recommended guidelines and should be written and directed as such. Having a breadth of knowledge of where to place those guidelines when and if applicable to your patient becomes the key point.

Being able to make a sound clinical judgement and treat accordingly.

Yes, the medical director will definitely will be held responsible, even if the medics acted ignorant and upon their own.. again, the role of the medical director is more than a protocol machine, which many do not understand. This will not excuse the Paramedics as well. They will be held accountable for their actions. There are more and more cases where the medical director is being excused from litigation, and the Paramedics are the only plaintiffs, if it is shown that the Paramedic totally deviated away from guidelines/protocols or acted upon one self.

Now, does this mean that Paramedics are allowed to practice medicine and administer medications to situations and problems without protocols and practice medicine on his/her license certification. This is not only foolish but illegal.

Again, it resorts to education. Knowing and performing a detailed H & P , what medication(s) if any is needed and applying accordingly either by protocol or verbal orders.

As far as the scenario of wrong order, you are supposed to be educated in the areas you work in. The Paramedic is held responsible for knowing the logistics of pharmacology, use of equipment, and proper application and administering of such. Just following orders is not enough. The Paramedic will be held responsible as much as the physician giving the wrong order. If you receive an obvious wrong order, repeat it, clarify and then describe that is a deviation of protocol.. if you know it is dangerous, err on the patients side. I rather have an ass chewing for not following order than to explain why I performed a dangerous task. That is why being fully educated is so essential.. one has to know the right and wrong and not rely upon another decision(s).

Be safe,

R/r 911

[whit72]

Actually people with asthma are at greater risk of severe allergic reactions. Most asthma attacks are due to some contact with an allergen. Therefore in severe cases the treatment of asthma and allergic reactions are treated the same pre hospital. EPI injection or IV is the optimal treatment for severe acute asthma/allergic reactions. WE also have albuterol and epi by neb in are protocols for asthma treatment. Albuterol for the most part, EPi in more severe attacks.