Scenario: Ethics of violating protocol

[JPINFV]

You are given this order by the physician. It is a lawful order, one that is appropriate to the patient's condition. The physician fully understands the patient's condition and diagnosis, and has given an order that represents, at least from his perspective, the standard of care. As a prehospital provider you work under the license of a physician, and technically are following orders in the form of protocol. You are now being given a direct online order by a licensed physician, one that your medical director allows to give online orders. Can you refuse it?

[Dustdevil]

You are given this order by the physician. It is a lawful order, one that is appropriate to the patient's condition. The physician fully understands the patient's condition and diagnosis, and has given an order that represents, at least from his perspective, the standard of care. As a prehospital provider you work under the license of a physician, and technically are following orders in the form of protocol. You are now being given a direct online order by a licensed physician, one that your medical director allows to give online orders. Can you refuse it?

Sure. There are several reasons why you could or would refuse the order. If you honestly believed it was beyond your capabilities, you could refuse it. After all, as Rid pointed out, apparently this isn't even touched upon in passing in many medic schools anymore. If you honestly believed it was inappropriate for the patient, you could refuse it. After all, miscommunications are a very real possibility when the doctor is not there to actually see the patient. But yeah, your legal right to refuse does not guarantee you will keep your job. It won't even guarantee that you will keep your cert.

On the other hand, following the order does not guarantee that you will keep your job either. Right and wrong are not of concern to your employer. They only care about appearances and other nebulous concepts. But, if the situation is indeed as painted in the above quote, then I don't see significant concern for licensure action.

The tough part of this scenario, for me, is putting myself into the shoes of somebody who did not have adequate education to feel comfortable with the order. Yes, if I were freaking out and my mind racing with thoughts of decertification and unemployment, trying to remember what the xiphoid process was, and didn't know what Beck's Triad or pericardialcentesis was, I would quite likely pass on this order. But, being a well educated medic who is thoroughly familiar with the anatomy and physiology involved, and having been specifically trained on this procedure in both paramedic school and ACLS class back when both classes were actually worth a darn, I would have no problem with it.

As for the differences in responses between the medics and EMTs, I think it goes back to the simple difference between education and training. EMTs (and far too many medics too) tend to be of the mind that, so long as you are trained on a procedure, that is all you need. We see this same scenario -- with varying particulars -- everyday here at The City. Everybody wants a new one-hour merit badge skill and is chomping at the bit to utilise it. They don't need more education. They just need more protocol! All that book learnin about anatomy and physiology and assessment aren't really important if you can start a 14 gauge IV upside down in a burning car, in the dark, in the rain, while being shot at (never mind that what the patient REALLY needed was to be pulled out of the car!).

Once a provider is educated, it becomes painfully obvious how absurd this popular misconception is. And then the craving for protocol is replaced by a hunger for knowledge and understanding. And once you have that knowledge and understanding, you no longer need protocol because now you know what to do.

[becksdad]

Dustdevil wrote: "Once a provider is educated, it becomes painfully obvious how absurd this popular misconception is. And then the craving for protocol is replaced by a hunger for knowledge and understanding. And once you have that knowledge and understanding, you no longer need protocol because now you know what to do."

THAT'S IT RIGHT THERE!!!!!! A MILLION WORDS TRYING TO SAY THE SAME THING, AND THERE IT IS!!!!!!

[ERDoc]

Strictly from a skills point of view, a pericardiocentesis is much easier than intubating. We are better as tubing because we practice and use the skill much more. To mess up a pericardiocentesis in these circumstances you really need to try. We know what it takes to screw up an intubation (leaves a blank for others to fill in).

[medic001918]

I'm thinking I wouldn't try the procedure. There's too much grey area that would open me up to litigation and liability. While I understand that the procedure could potentially save the patient's life, it's also not in my protocol anywhere and I haven't been educated on how to perform the procedure. The procedure seems easy enough, but how is this whole thing going to play out in court (where a case like this has a high potential to end up)? I believe there have been cases of paramedics performing other procedures at medical directions request and still losing their licenses over the events and being held legally responsible. If you pass on the procedure, at least you can say that you stayed within your education and did the best that you could with what you had. In a litigation free society, I would be more likely to try the procedure. It's sad that legalities and litigation come into play in making a medical decision, but that's the society we live in presently.

Shane

NREMT-P

[Asysin2leads]

There right answer to this scenario is that there is no right answer. In a political philosophy course I once took, we discussed different ethical models for priniciples of government. One model that should be familiar to anyone who has participated in MCI planning is "The most good for the most people." That is, whatever decision provides the greatest amount of good for the greatest amount of people is the correct one. An example of this would be what the pilot of New Jersey's Northstar Medevac once told me about take off clearance: Just because they may get a critical call does not mean they get immediate take off clearance out of Newark. Just because someone somewhere in the Garden State needs to get to a trauma center doesn't mean that you can jam up the take off and landing schedules of all the flights on the eastern seaboard. The needs of the many outweigh the needs of the few.

In this case, even if say we were succesful and didn't get fired after doing our pericaridialcentesis doesn't mean we are not going to at least knock our unit out of service for a good long time while the paperwork storm clears. As EMS providers we not only have a duty to our immediate patient but to all of our patients, and potential patients, to keep our units in service and running. The needs of the one (pericardialcentesis) cannot always outweigh the needs of the many (access to ALS services).

The flip side to that is that you can't always justify everything that way. If you did, it would be perfectly ethical to execute an innocent man if it brought a sense of justice to the masses, the needs of the one (the innocent man) would be outweighed by the needs of the many (justice for the masses). Sometimes everyone else will have to just wait so that one person can get the treatment they deserve. Heck, I pride myself on causing some major traffic jams on that principle. This is why rules are so important, if rules were in place allowing access to pericardialcentesis in the field, then we could address the needs of the one without hanging ourselves and our unit out to dry.

So, like I said before, there is no right answer, its someplace in that grey area in the middle. If you always follow the rules you'll end up sharing a seat at our next version of the Nuremburg trials, and if you break the rules and go with your heart whenever you feel like it, I'll see you shirtless and sporting a mullet on the next episode of Cops. Life is complicated, do your best.

[Dustdevil]

The procedure seems easy enough, but how is this whole thing going to play out in court (where a case like this has a high potential to end up)?

On what information are you basing this assumption upon?

Remember day 1 of CPR class? You can't kill a dead person.

And, as already pointed out, you are less likely to cause "harm" with this procedure than with CPR.

No harm = no foul.

[tniuqs]

Hell no.

I love my job, thank you.

HELL YES!

I love my job thank you and I don't do this job to feel politically "comfortable" and so many folks hide behind this excuse.

In a new york heartbeat I would follow this M.D.s advice as the picture is painted so clearly, and in theory I have provided the "facts" to lead him to make this diagnosis..... can you imagine just what HE/SHE is thinking, can I trust this medic? He did, so its a no brainer, period........but......... is that the end of the story?

You have medical backing and this is a very simple procedure, (it is taught here in theory but no formal practice) In fact in every ACLS course I have attended in the last 20 years this is an option to be "considered'.......isn't yours? Besides the fact that I truely hate "THE WOLF" and could this very patient be the one that makes the difference in how we treat this ugly disease and you failed to do your part?

I would be even "more comfortable" in preforming this procedure in a trauma call, it is Christmas and I bet my bottom dollar that some childs Mother or Father would be VERY pleased that "I would dare to make a difference in an outcome" so that they would have another Christmas with their Family or at least give that patient every chance. I in fact joined this board to give Kevkie a rough time and vehemetly opposed his views in a very similar thread. How can we advance the profession by sitting on our humps and quote some paper regulations, they can be changed. WE are the forefathers of the future.....so just how does one think we got here in the first place ? Advancement of medical practice everywhere has always been by individuals that have been willing to take some risks.

BTW: Kevkie was morally correct, I was wrong!

A recent ruling in my "hood" stated that this procedure (Emergency Pericardioscentisis) is "inconsistent" with the on paper regulations for ACP level, the HDA also stated that PCP can't deliver Ventolin or shoot a Combi-tube either....sheesh! This may be the exact scenario to open up that door and dialog....or perhaps kick the damn door down! The overly conservative legal/legislative crowd really needs to put these concepts into personal perspective as we are dealing with life and death situations here and not a around a table discussion.

In fact could criminal charges could "in theory be laid" ???? That in regard: NOT PREFORMING TO THE LEVEL OF ONES TRAINING..... this could be a very viable argument in a court of law, if I am looking at flipping burgers for my retirement package I would rather consider that, than looking into some childs eyes and lying that I did my best for their Mother/Father. When I did not because I felt "uncomfortable" or explain to that child that I could have made a difference but some words on a useless piece of paper stopped me. That I could NOT do! The Law can be an ass, (to quote my OZ friends), but we do live in democratic societies don't we?

So call me renegade, call me **** disturber, call me anything you wish but you can never call me "afraid" to try to make a difference in a life, fear of not doing the right thing this is my greatest fear.

I do love my job, thank you.

cheers

[dzmohr]

This same question was asked of me when I was helping Sacramento start their ALS system in the early 80s. This was one of our skills as a paramedic and I had done several over the years but in Sacramento, till the clock it the right mark, even those certified as medics in other counties could only work as Is in Sacramento ... so we, who would precept the first medics, were grilled heavily on if we would violate I scope of practice if it came down to it.

They did not like my answer but I got the job anyway.... this was my thinking process to answer...

1. Could the patient survive to the ER, in this case the answer was no

2. Would the patient likely live if I did the procedure .. in this case the answer is yes

3. Would the patient likely die without it ... again, as in one the answer is yes

4. Is it worth my career?

We all put our LIVES on the line for patients or even POSSIBLE patients on a near daily basis. It surprises me how many would not put a JOB on the line... I am not referring to ANY of the previous posts in this thread, just the feeling in general ... those that most boldly will risk their lives will often take the easy way out if their job is on the line.

That being said ....there are so many variables and just as we may reason it is too dangerous to do a rescue we ay decide the risk/benefit of doing this procedure is too high. If we are not familiar with the procedure and do not have the equipment to do it ( in this case most of us would) I can see refusing the order.

I did throw them one curve they did not count on, when I asked where the call was they told me and I said I would reroute so we hit the tip of Butte County where I was paramedic and could legally do the skill then continue to Sac as it would not significantly change the ETA.

We have to consider many of us have families that depend on us keeping our source of income ... In any event I would not be critical of one who refused the order but I would totally have the back of anyone who complied with it and had to go to the wall.

[ERDoc]

Being the one on the other end of the phone, I can tell you that it is not a decision that the doc is taking very lightly. They probably don't the person on the other end and have no idea what their ability/intelligence is. To make a call like that and not know who you are talking to really would scare the hell out of me. It is a relatively easy procedure to do and to explain over the phone. I would rather describe how to do it to a medic over the phone than describe how to intubate or put in an IV. I would also totally understand if the medic on the other end refused to do it. I would not make a big deal out of it. Someone had mentioned that a case like this has a high likelyhood of ending up in court. I disagree, I would say that it has very little chance of ending up in court. This person is suffering from a know side effect of a known condition. It would not be an unexpected or suspicious death. It would probably never even be accepted by an ME as a case. If the medic did perform the procedure and the pt died, the family would more than likely never find out about it because they would be wrapped up in too much other stuff to worry. If the medic did it and the pt survived, the family probably wouldn't care because their loved one was still alive. The only exception I would add would be that if this happened in NY. Everyone is looking to sue someone, so who knows how it would play out there.