# Breaking protocol. Is it ever permissible?



## amonteve (Mar 2, 2008)

Ok, I've been wondering under what circumstances it might be, if ever, permissible to "break the rules".
The sort of scenario I keep thinking of would happen in a place where rapid transport and transfer to higher levels of care is not an immediate option.
Say, a transatlantic flight where someone eats the wrong thing and goes into anaphylactic shock. The only epi available is another passenger's prescription. It is not expired. I would have to think you would give it, right?

That's just the sort of example I've been wondering about. Is it even a good example?

Can anyone think of any other uncommon situations where protocol has to broken in the patient's best interest.


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## MSDeltaFlt (Mar 2, 2008)

There are no protocols for every single situation every single EMT/medic might experience.  It is physically impossible to not only come up with these scenarios, but it would also be physically impossible to carry said protocol book.  It would not fit into ANY sized vehicle or football stadium.

That being said, if you work long enough in this field, you will encounter situations that will fall outside protocol.  If you do, contact Med Control.  If you cannot contact Med Control, you better be able to back up your decisions with your documentation.  That way the powers that be will be able to understand your predicament and see why you did what you did.

My 0.02


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## Ridryder911 (Mar 2, 2008)

One has to use common sense. Is this worth potentially loosing one's license or being able to justify their action? It is all dependent. 

I "break" protocols on a daily basis, however; I use common sense enough to be able to justify my actions. I have developed a repor with my Medical Director that he understands my rationale on doing so. 

One has to be able to justify any action, even following protocols. Protocols should be only suggestions and guidelines, not set in stone. Medicine is based upon science, but practiced as an art. Each treatment individual should be based upon a standard of care. 

As MSDeltaFlt described there is never enough protocols to cover everything, nor should there be. That is why I find protocol books more than a hundred pages, foolish. In reality the medical director should use the .._upon the discretion of the medic"..._ on each guideline. Step by step type protocols only produce cookie cutter protocols and usually endorse "shake and bake" medics. Many not able to treat anything unless it is listed in the protocols. Again, the reason I am even against Statewide protocols, they should be tailor based upon your area, your services ability, and the general gestalt of the medics. 

R/r 911


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## MikeRi24 (Mar 2, 2008)

one thing that i've been hearing a lot in the classroom and seeing a lot more in the field, is you have to improvise. if you go by the book all the time, you're never going to get anywhere. you may come upon a situation where you dont have the ideal equipment or the ideal conditions to treat someone, so you use what you have and make it work the best you can. like it has been previously said, as long as you can legitimately back up your actions, you should be ok.


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## Flight-LP (Mar 2, 2008)

amonteve said:


> Ok, I've been wondering under what circumstances it might be, if ever, permissible to "break the rules".
> The sort of scenario I keep thinking of would happen in a place where rapid transport and transfer to higher levels of care is not an immediate option.
> Say, a transatlantic flight where someone eats the wrong thing and goes into anaphylactic shock. The only epi available is another passenger's prescription. It is not expired. I would have to think you would give it, right?
> 
> ...



Improvise, adapt, and overcome.....................

Utilize your best judgement and advocate the care necessary for the best interest of your patient.........

Words to live by and they will lead you down the right path young grasshopper!

BTW, the majority of your airliners will be fully ALS equipped with S.O.P.'s in place for its use.........................


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## MedicDoug (Mar 2, 2008)

Flight-LP said:


> BTW, the majority of your airliners will be fully ALS equipped with S.O.P.'s in place for its use.........................


 And most even have contract online medical control available if you get that deep in the weeds... 
There's a fine line, though, between "breaking protocols" and exceeding your level of training. Famous case of roadside c-section in CA that cost the Paramedic his license forever, regardless of the fact that the infant survived. Clearly not in the Paramedic scope anywhere.. In your example of in-date epi that belongs to another passenger... do what you think best then document what you did, why you did it, and the response from the patient to the treatment. File it with your local EMS agency if they have an "Unusual Occurence" mechanism. It's far better to get your side of the story documented first, rather than to have to defend it later.


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## jetsfan925 (Mar 3, 2008)

this topic was sort of interesting to me, so i asked my mom, and dad if they were ever put in a position like that, where they needed to go against protocol in order to save a patient. my mom told me about this time where a heavily religious person came into the hospital to check on her son who was getting treatment, who had just come into the er and was now in the icu. the patients mother was not allowed in the icu due to air control (my mom tried to explain it to me but i didnt really understand because i was doing my calculus homework at the same time) but once the patient was stable he was brought into the main hospital area. anyway-long story short- the kid wanted treatment, the mother did not want him to get treatment because of her religious preferences (in general it seems like the scientific community is less religious than the general community). the child was only 14, and legally at that time could not sign for his own treatment if there was a legal guardian present. my mom (an r2 at the time), along with an intern and the chief resident on call decided to treat the patient secretly. the risk of the treatment was relatively negligible, and the patient risked having possible heart problems in the future if treatment was not done. What they actually did was cover up the iv-bag with aluminum foil, and just told the mother it was nutrients that needed to be kept at a cooler temperature.

I was wondering what other people would do in a similar situation. on one hand doing the treatment conflicts with the law, but on the other hand doing the treatment saved the patient a lifetime of problems, and the patient consented to the treatment-even though he wasnt legally able to do so.

keep in mind that this was in the day when people didnt just sue doctors on a whim- they actually respected the medical and emergency community

thanks in advance for the responses

on a side note, what do all of you think about the increase in people suing others in the medical profession (and maybe police profession as well, im not really sure)? do you think it is good because it keeps the members of the medical field doing the right thing? both my parents said that they were for people being able to sue others, but there should be some type of rule against what you can sue for-especially to members of the emergency teams, and medical teams, when decisions must be made in a matter of minutes. they said that there should be a rule that the person acted totally without respect for the patient's well being, and/or acted outside his or her training.

One major problem, my parents said, is that although people in the medical and health car professions are not getting paid more, health care, and emergency costs are increasing, because insurance against malpractice is increasing due to the increase in people suing.

they said it is somewhat ironic that many of the people who are inclined to immediately sue, are the ones complaining about health costs in the first place.

btw sorry about such a long post


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## JonathanGennick (Mar 4, 2008)

I looked up some definitions of the word "protocol". My sense from reading those definitions is that the word is not intended to describe a set of rigid rules.

Here's an interesting link to a Wikipedia entry on the term "Medical Guideline":

http://en.wikipedia.org/wiki/Medical_guideline

The very first sentence of the article reads as follows:

"A medical guideline (also called a clinical guideline, clinical protocol or ..."

Notice that last word, "protocol". The sentence equates "guideline" with "protocol".

And I do tend to believe that protocols should be looked upon more as guidelines than as rigid rules. Now, whether I know enough to know when to disregard a protocol and when not to, that's a different matter entirely. 

BTW, in a past life I worked as a database administrator, managing large, corporate databases. There are accepted ways of doing things in database administration. Call those accepted ways "protocols". A knowledgeable administrator, one who has deep architectural understanding of the system that he's managing, can accomplish tasks in ways that a someone with lesser knowledge should never attempt. Oracle Corporation used to promote this concept of a "database operator" as one who performed routine tasks by rote. But when anything goes wrong, you don't want a database operator. You want a well-educated and well-practiced database administrator, one who understands the underpinnings of the system, and with experience solving the hard problems.


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## MedicDoug (Mar 4, 2008)

JonathanGennick said:


> And I do tend to believe that protocols should be looked upon more as guidelines than as rigid rules. Now, whether I know enough to know when to disregard a protocol and when not to, that's a different matter entirely.


 Couple of things here worth noting. As others have written before, no set of treatment protocols can cover every possible situation. BUT, the Treatment Protocols in our systems were written and approved by the physician medical director, after some degree of review by the local community (providers, physicians, etc.). In California, at least, paramedics and EMTs operate under the EMS agency's physician medical director's license. The medical director expects you to follow the treatment protocols. If we deviate from protocol we'd best have a good reason, and we'd best be documenting our butts off to justify it. That said, I've never been in a system where the occasional protocol transgression (for the documented justifiable reason) was dealt with particularly harshly. Most were handled either with an on-the-spot discussion in the ED, or an "educational meeting" with the Medical Director in the agency office. On the other hand, if you become known for repeatedly disregarding protocol, things can get harsh. 

Also, most of us think of treatment protocols as limiting. Actually, they cover our butts if we follow them... Assuming you assess your patient correctly and treat according to protocol and policy your actions are pretty much covered. If you go off the reservation and there's a bad outcome you have nothing there for your protection... except perhaps the mercy of the jury.

Just my 2 or 4 cents... maybe a nickel...


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## JPINFV (Mar 4, 2008)

*System by system problem*

This really is a system by system issue though, even as much as things should be done based on a patient's presentation instead of pigeon holeing a presentation into a protocol. Example (California has county wide protocols):

Riverside County EMS (911=mostly AMR)


> It is important to note that these policies are intended as a thought process or decision tree, not as an absolute plan. Every situation is unique; a policy could not possibly be written to cover every circumstance. We expect paramedics to use their training and good judgment when treating patients in the field and to document situations that vary from the norm. In the policies, the treatments that appear in the non-shaded areas tend to be the treatments of choice for that set of symptoms. Therefore, it made sense to include those treatments in the “prior to contact” realm. Paramedics *have the option* to perform procedures or administer drugs in the non-shaded areas on their own counsel, or to contact the base hospital for consultation. Not all treatments need to be done prior to base hospital contact.



First paragraph. No emphasis added.
On the other hand, neighboring Orange County's (paramedics only with the fire department) protocols state:


> These treatment guidelines define advanced life support (ALS) treatment and patient destination standards:
> 1. The treatment guidelines are clinical recommendations; the base hospital (BH) physician may determine appropriate care based on the patient’s condition.
> 
> 2. Some patients may require care not specified in the treatment guidelines; when clinically indicated, BH physician deviation is appropriate.


http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/i05.pdf

Not necessarily as clear cut for Orange County medics in terms of "deviating" from protocol. 

As with other issues (DNR procedures being my favorite example), nothing beats knowing your treatment options, your protocols (note: you (generic "you") actually seeing them, not being told about them), and having a strong background in physiology, anatomy, pharmacology, and pathophysiology.


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## Ops Paramedic (Mar 5, 2008)

*Breakin protocol.  Is t ever permssible??*

From reading all the posts it would appear as if there is a commenality amungst them all and that is: Although you have a published protocol, it should be used as a guideline.  Protocols have two functions, the first being to safe gaurd the patient (treatment wise) and the second is to be used as a tool to regulate the profession or practitioners practising these protocols ensuring they don't perform open heart surgery roadside!!

In order to break the rules, one has to know the rules, inside out.  When consedring to work a step above your protocol, be sure that you know what the next step is.  The "reasonable man act" asks the question of what someone with the same training and exposure would do when faced with your circumstances, if the answer is consistant with your actions, you should be in clear.  Bearing in mind that you never know is looking at what you are doing.   

A lot of people open the protocol book first and see where the patients falls in.  You as the practitioner should treat the patient by using your skils, knowledge and resources available to you.  Your protocol is a resource and should be used as a quick reference on scene, should the need arise.

Going back to the original scenerio of the patient in the aircraft...  The Captain of the aircraft is the one who ultimately carries the responibilty all the passengers on board.  Be carefull though to use the epipen (or anything else for that matter) should you not have knowledge to do so.  One can maybe assist the persons who's epipen it is to administer it.


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## firetender (Mar 12, 2008)

Theoretically, ALL ALS offered in the field is under the direction of a physician, or a set protocol designed by physicians. That means, as has been emphasized, it's important to document when you do otherwise. If you are breathing, you will do otherwise.


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## paramedix (Apr 4, 2008)

Ridryder911 said:
			
		

> One has to use common sense. Is this worth potentially loosing one's license or being able to justify their action? It is all dependent.
> 
> I "break" protocols on a daily basis, however; I use common sense enough to be able to justify my actions. I have developed a repor with my Medical Director that he understands my rationale on doing so.



If you don't know ask... I have done the same in many cases where my ALS or doctor "allowed" me to practice the skill needed. Exactly what Rid said, the MD understands the rationale and therefore he knows what he is capable of doing. If in doubt, you have to ask and you will receive guidance.

Be careful what you do though... you ultimately take that patient's life in your hands.


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## aussieemt1980 (Apr 9, 2008)

An interesting scenario, and does pose some very interesting issues for the medic.

Here is Aussie Land, we have a little thing called duty of care, that pretty much applies anywhere in the world I think.

I did ask my supervisor about activities at an accident scene while off duty, not quite the same but a very similar scenario.

I was told that the patient's life is paramount, and to render all available assistance (actually, it is enshrined in law in NSW that we must render assistance to the injured - or we can be sued for breach of duty of care...)

But the administration of medications is a grey area. Had the argument with a Registered Nurse the other day that I can administer some high level medications, such as pain relief medications (penthrane) while off duty, but my authority to practice only covers me while I am on duty (used the example that an RN cannot take morphine home just in case of a car accident), and I only carry basic equipment whilst off duty.

The Authority to Practice is an important area as it allows some of the grey area questions to be answered, but as the scenario would technically be a remote area exercise, the grey areas keep coming back.

What would happen if you administered the epipen to the patient that needed it, and the owner then had a anaphylactic reaction and needed the medication that had been used?

I personally would not know what to do in that situation, as the major truama that I have had to deal with has been while on duty, it is very rare that I do anything off duty (only because the opportunity does not arise).

Best bet would be to make the decision at the time, be sure that you are comfortable with it, DOCUMENT, DOCUMENT and again, DOCUMENT.

After all, no medic has ever been successfully sued for saving a life.

But as for breaking protocol, in Australia you can be found as negligent, and any insurance coverage that you have will not cover you for it. In other words, you become personally liable for the outcomes.


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## YouthCorps1 (Nov 13, 2008)

um...i dont know because you are only supposed to administer it to the prescribed patient and only with a dr's consent,  also if maybe you give an OD of that med. then your a**is getting sued lol


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## KEVD18 (Nov 13, 2008)

dude..... back away from the shovel............................


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## JPINFV (Nov 13, 2008)




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## stmoffatt (Nov 14, 2008)

*Comparing Riverside EMS to Orange County EMS*

I worked in Riverside for a lot of years and I always highly valued the "guidelines" statement as it made it possible to do the job the way I think it should be done. That's saying that your quote is true in the individual paramedic's case:



JPINFV said:


> As with other issues, nothing beats knowing your treatment options, your protocols, and having a strong background in physiology, anatomy, pharmacology, and pathophysiology.



There were a few paramedics that I've seen over the years that wanted/needed to be told each and every detail. And it's easy to blame that problem on fire based EMS like Orange County (acknowledging that in California a lot of paramedics are paramedics simply because that was the only way that they could get hired by a fire department, which was their career goal), but it's not always accurate. In Riverside several of the fire departments have put emphasis on hiring paramedics with an extensive EMS background, for example Riverside City and County/Cal Fire, with good results. Another Riverside County fire department has concentrated on sending their own firefighters to paramedic school with predictable results. What I'm trying to say is that fire based EMS can work well given the right people, education, and experience.

One of the missing pieces to understand when comparing Riverside County and Orange County is that Orange County is highly developed and populated with a lot more fire stations and hospitals, while Riverside County is much more spread out and has fewer resources. Although I've never worked in Orange County it's been my impression that almost every fire apparatus has at least one paramedic staff, that there's a fire station on every third corner, that there is a hospital on every fifth corner, and that there's a private ambulance parked in every gas station. With those kind of resources who needs guidelines? 

A little off track, but of note, is that over the years every new paramedic that I FTO'd that had been schooled in Orange County had no idea how to tamponade a vein when starting an IV. Evidently the standard practice in Orange County is to place a towel under the patient's arm and move fast. I guess you could conduct a study on bloodletting there . . . 

Your quote said it all, with emphasis on the strong background.
_______________________________________________
stmoffatt - former Riverside medic


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## BossyCow (Nov 14, 2008)

YouthCorps1 said:


> um...i dont know because you are only supposed to administer it to the prescribed patient and only with a dr's consent,  also if maybe you give an OD of that med. then your a**is getting sued lol



Hon, by your name I'm assuming you aren't as long in the tooth as some of us here. I'm also assuming that your experience and education are not on a par with the average poster here. I applaud your desire to learn more, but I would recommend, that for now, you not post judgements, assessments or evaluations of those with more experience and describe treatment options, or argue in the gray areas. Instead try asking questions about things you don't understand. 

While technically its true that for a lay person, using an epi pen on someone requires that there be a current prescription for the pen for the pt, it is not the only protocol. In my state, we are not only allowed but required to carry both adult and jr. epi pens. The dosage of an epi pen is metered and appropriate for the pt. (search the forum for posts on epi). 

And, you're only going to get sued if it doesn't work!


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## mycrofft (Nov 14, 2008)

*Flip it...are you ever obligated to ignore a protocol?*

I've seen protocols (or "standardizerd procedures" or whatnot) which are bad and need revamping and people are able to work by circumventing them. The answer is not to go around but to repair. If they will not repair them, get out, you're in an ambush.

Usually a protocol seems to need circumventing because you've missed something, sometimes the intent of the protocol, sometimes part of the pt eval, scene eval, or hx.

Worse than risking getting fired is risking doing something wrong and causing the pt harm. Blowing off protocol can and probably is putting you in danger of just that. If protocols don't fit, then get the best answer you can (gotta radio or cell?), step up, remember the basics, and go down swinging if need be, but be swinging for the pt.


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