# out of protocol practice



## daedalus (Dec 28, 2008)

I am having the hardest time getting this question answered. 

As a paramedic, you act within protocols as guidelines for management of acute illness and injury. I got that. When you have a patient with atypical presentations or with a acute disease you have no protocol to manage but you do have a treatment option with your medications and knowledge, can you preform advanced treatments on these patients? Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?


----------



## flhtci01 (Dec 28, 2008)

ABCs, gain IV access as needed and contact medical control.


----------



## Hastings (Dec 28, 2008)

daedalus said:


> I am having the hardest time getting this question answered.
> 
> As a paramedic, you act within protocols as guidelines for management of acute illness and injury. I got that. When you have a patient with atypical presentations or with a acute disease you have no protocol to manage but you do have a treatment option with your medications and knowledge, can you preform advanced treatments on these patients? Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?



What do you mean? Like giving ASA for a headache? No.


----------



## Epi-do (Dec 28, 2008)

Contact medical control, tell them what you have and what you would like to do.  See if you get the go ahead, or if they give you different orders all together.


----------



## daedalus (Dec 28, 2008)

Hastings said:


> What do you mean? Like giving ASA for a headache? No.



Tehe that would be a bad idea.

Contact med control. Got it. Thanks guys.


----------



## MagicTyler (Dec 29, 2008)

Wouldn't giving an intervention like that be outside scope; even if medical control told you to?


----------



## firecoins (Dec 29, 2008)

Not necessarily.  Something could be outside your protocols but inside your scope of practise.   RSI is something I have been trained in but it is not in my current protocols.


----------



## MagicTyler (Dec 29, 2008)

Ok, totally playing the what if game now. Lets say aspirin will stop hiccups.  Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?


----------



## firecoins (Dec 29, 2008)

MagicTyler said:


> Ok, totally playing the what if game now. Lets say aspirin will stop hiccups.  Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?



I don't know if that is the same situation.  They tell you to give a drug that the patient does not meet the criteria for or the patient meets the criteria for an intervention not in your protocols but in your general scope of practise?


----------



## marineman (Dec 29, 2008)

MagicTyler said:


> Ok, totally playing the what if game now. Lets say aspirin will stop hiccups.  Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?



Giving aspirin is within our scope, keep in mind that use is not within our scope so no we can't give it on our own. We contact med control and they tell us to administer ASA to relieve the hiccups (hiccoughs?), since the administration of ASA is something I'm trained to do I will administer it, repeat to medical control when receiving the order what medication, route and dose they want and give it. I think R/R will post soon but too many people get caught up in not stepping outside of that protocol book. If medical direction tells you to do anything that you've been trained in, you do it with their recommended dose unless you have a reasonable belief that it will harm the patient. With strange orders from medical direction it's often best to repeat the information to make sure that they got the correct information and are requesting an appropriate line of treatment. Remember to document exactly what you do and what med direction tells you to do. If you do something outside the protocol book if it goes to court you will have to prove that you are trained in whatever you did and you will have to prove that you did exactly what medical direction told you to do. At that point it's all on them. If you refuse to do something that medical direction told you to do you had best have a good reason as you're starting a pissing match with someone that has much more training than you. Document exactly what the patient presented with, what medical direction told you to do, and why you didn't do it. If that issue goes to court or even if it goes to your boss you will have to prove that you had a reasonable belief that it would harm the patient or you will have to prove that you are not trained in that procedure and even that's iffy as sometimes (our) medical control will walk us through a procedure we don't know how to do if it's vital for the patients outcome.


----------



## MRE (Dec 29, 2008)

The whole idea of protocols is that they are like standing orders for treatments for certain situations.  When medical control tells you to do something not in your protocols, its really the same thing as them writing you a protocol to use in this one situation.  

As far as the ASA; if med con says to do it, its in your scope and the pt doesn't have any contraindications for ASA, then go for it.


----------



## reaper (Dec 29, 2008)

You have to look at your state SOP. Some states have an SOP set up for what is allowed by a medic or EMT. Your protocols may not include everything that the state has in theirs. Most states do not allow you to go beyond what their SOP is for your license.

A lot of states I have worked allow Mag for asthma Pt's. The state I am in now does not include it in their state SOP. We had a medic give it after a MD ordered it. That medic lost his job, due to the treatment being outside the state SOP.

We are allowed a lot of freedom in our protocols, but we still must practice inside our state SOP's.

Just something else to keep in mind.


----------



## MRE (Dec 29, 2008)

Aren't SOP's usually set forth by the service and our scope of practice set forth by the state?  Maybe we are just using different terms for the same things.




reaper said:


> You have to look at your state SOP. Some states have an SOP set up for what is allowed by a medic or EMT. Your protocols may not include everything that the state has in theirs. Most states do not allow you to go beyond what their SOP is for your license.
> 
> A lot of states I have worked allow Mag for asthma Pt's. The state I am in now does not include it in their state SOP. We had a medic give it after a MD ordered it. That medic lost his job, due to the treatment being outside the state SOP.
> 
> ...


----------



## reaper (Dec 29, 2008)

Yes, I meant Scope of practice. Just didn't feel like typing it out!


----------



## MRE (Dec 29, 2008)

reaper said:


> Yes, I meant Scope of practice. Just didn't feel like typing it out!



Oh that works.  I didn't even realize that the initials for scope of practice were SOP.  I'm in a fire dept based service and the dept has SOP's (Standard Operating Procedures) for things like what apparatus to send to certain kinds of incidents, etc.  Thats what I thought you were talking about.


----------



## FF894 (Dec 29, 2008)

I don't know how other states' protocols are written, but in MA & NH it is specifically written that the standing protocols are in place to allow the provider to perform them if he deems necessary based on education, training, and certification level.  They are not written to be followed to a T 100% of the time.  They are simply there so the provider does not have to "ask" to perform the listed skills everytime it makes sense to do so (which in most cases is more often than not).  

I know that is taking a side-step into left field, but does anyone else have that written in their protocols?


----------



## firecoins (Dec 31, 2008)

FF894 said:


> I know that is taking a side-step into left field, but does anyone else have that written in their protocols?



Yes.  Its written into NYC protocols.


----------



## mycrofft (Jan 1, 2009)

*Slicing it thin*

If you are governed by a set of prearranged orders (protocls, standardized procedures etc) and the pt meets their criteria, you use them and all is well.
If you medical control orders you to exceed them, and to your knowledge as a well trained technician it will not harm the pt, and you are technically capable of performing the procedure or act, then all is well for you (hope it works out for the pt). If they tell you to do an emergency appy, don't, has to be reasonable and you have to be capable.
If you exceed them without an order you are on your own, probably gonna get fired or repirmanded, might lose you certificate or permit or whatever, because they cannot trust you not to blow off the protcols like they could before that. If the pt does OK you might not get criminal charges, but you could get sued and lose if they come off it with chronic pain, post traumatic syndrome, nightmares, hangnails, etc. 
Good techs always think about when they may feel they _*must*_ work outside the protocols ; when the protocols aren't working or aren't enough, the usual answer is to re-examine the pt for the anomalous or missing piece of the puzzle. Poor techs are looking for the instances where they *can* work outside the protocols.


----------



## daedalus (Jan 3, 2009)

I actually have an example to further hammer out my point. There is no protocol in my county for calcium channel blocker overdose. No where does it specify in any protocols or scope of practice what can be done for this type of overdose. However, a paramedic does carry calcium. Can it be used even though there is no "protocol" for it, after consultation with med control? And take it a step further, according to Dr D Ross over at JEMS, glucagon at high doses is indicated for CCB over dose. This sure isn't in any protocols.

Our scope of practice and protocols do not define what the drugs the medic carries can be used for, they only mention required amounts. I am pretty lost.


----------



## medic5740 (Jan 3, 2009)

*Protocols are guidelines*

I have always considered the protocols to be a guideline within which critical thinking and medical control contact can modify.  I don't know about your system, but if my medical control physician orders me to give a drug or complete a procedure that I am trained to do, I am going to do it.

First case in point:  One patient had a large piece of meat stuck in his esophagus.  Medical evacuation was not possible from this location.  Medical control ordered us to mix up meat tenderizer and to have the patient sip the meat tenderizer, making sure that the airway was not compromised.  Sure enough, ten minutes later the patient was able to swallow the big chunk of meat that was stuck there.  This is certainly not within any written protocol anywhere, nor is it within any scope of practice for an EMT or paramedic, but it was necessary, it was ordered, and the order was completed.  What was the other option?  

Second case in point:  Cardiac patient needed transport via aircraft to nearest facility ASAP.  Patient was deathly afraid of flying.  Medical control ordered administration of valium and antiemetic prior to the flight.  That's not in the protocols either, but it worked very well, calmed the patient, lessened the symptoms, and prevented overworking the damaged heart by preventing the release of the adrenalin rush in the fight or flight mode due to the fear of flying.  It was definitely a valuable treatment tool for this particular patient.

Third case in point:  Dislocated shoulder patient with no means of transport available due to weather.  Patient was in a great deal of pain.  Medical control physician orders a relocation of the shoulder following specific directions provided over the cell phone after drugging the patient to a near conscious sedation state.  Physician remained on the phone with us throughout the procedure.  This is also not in our protocols.

Sometimes, I think that the cookbook method of protocol-driven EMS gets in the way of patient care.  

I will say it once again.  If my medical control physician orders something that I know how to do, and if I think it will benefit my patient, I will do it every single time whether in the protocols or not.


----------



## downunderwunda (Jan 6, 2009)

daedalus said:


> I am having the hardest time getting this question answered.
> 
> As a paramedic, you act within protocols as guidelines for management of acute illness and injury. I got that. When you have a patient with atypical presentations or with a acute disease *you have no protocol to manage *but you do have a treatment option with your medications and knowledge, can you preform advanced treatments on these patients? Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?



You need to reread your protocols.

Every situation is in there. Even down to administration of O2. You have a scope of practice. You have to operate within those guidelines. To fall back on 'Medical Control' is an insult to intelligence. If the pt is atypical, do the basics, ABC, then treat what you see. If they are in pain, manage it, if their perfusion is falling, go the O2. EMS is not rocket science. 



daedalus said:


> Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?



How old are you??????? Just because you have a pt with Atypical symptoms or an acute disease, your words not mine does not mean you need to haul ***. Look at your patient, any decision to 'Haul ***' needs to be looked at with extra consideration given to 
How long has the patient been sick
Can i control their pain
How long to hospital if we haul *** Vs normal speed
How much stress will I put on the patient if we haul ***
Will their condition change that mucch in the next 10-15 minutes

The vast majority of patients, with notable exceptions for chest pain & penetrating trauma, will have little or no advantage to expidition to hospital.

Always remember, go back to basics. If a person has an acute illness, they wil tell you what they need, they will know more about t than you ever will.

Play safe


----------



## daedalus (Jan 6, 2009)

You are obviously not familiar with my local protocols nor my original question. And done right, EMS is anything but "not rocket science". And no, administration of oxygen is not covered in my protocols. There is no protocol for it, it is used PRN at the discretion of the provider and is mentioned in some specific protocols for treatment. 

My county has around 12 protocols. 12 protocols cannot possible cover the spectrum of medical emergencies that may happen to patients. For example, see above in my calcium channel blocker overdose scenario. We have no protocol in place for this particular emergency, nor does my county have a blanket protocol for procedures prior to base contact (as does LA county). So I am left wondering what the hell my county wants me to do with these patients, however I did recently find out from a local paramedic.

Also, just because I prefer to use the word butt instead of ***, does not make me twelve years old. ^_^ So I am not quite sure what your intent was here because you are anything but helpful.

EDIT: After re-reading your post, I see that you think that because a patient may have something I am not familiar with, I would run to the hospital with them. That was a figure of speech. I rarely drive code 3 back to the hospital. I used the figure of speech to convey how lost I was with the hypothetical situation.


----------



## BossyCow (Jan 6, 2009)

I've found that contacting med control is an art. If I call and say I'm clueless about a pt, they are going to be less likely to authorize me doing anything. But, if I call and give an accurate report of what's going on, suggest what I would like to try with information that shows I'm aware of the contraindications, then I'm much more likely to get permission.


----------



## Jon (Jan 6, 2009)

PA's ALS Protocols, "General Protocol Principles"


> B. Deviation from Protocols:
> 1. When providing patient care under the EMS Act, EMS personnel must follow the orders of a medical command physician or, in the absence of such orders, the applicable protocols. In addition to the Statewide ALS Protocols, ALS practitioners must follow applicable Statewide BLS Protocols and Department-approved Regional Medical Treatment Protocols. Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS personnel to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances. When the practitioner believes that following a protocol is not in the best interest of the patient, the EMS practitioner must contact a medical command physician if possible. Cases where deviation from a protocol is justified are rare. The reason for any deviation should be documented. All deviations are subject to investigation to determine whether or not they were appropriate. In all cases, EMS personnel are expected to deliver care within the scope of practice for their level of certification.
> 2. Medical command physicians are permitted to provide orders for patient care that are not consistent with the protocols when, under the circumstances, the procedures identified in a protocol are not the most appropriate care in the judgment of the physician or when there is not a specific protocol that is appropriate to the patient’s condition. Some protocols have a section of “Possible Medical Command Orders”. These are provided as a possible resource for the medical command physician and as an educational resource for the EMS personnel. These “Possible Medical Command Orders” do not substitute for the judgment of the medical command physician, and the medical command physician is under no obligation to follow the treatment options listed in this section.



A classic example of this was for crush syndrome. Prior to the November 1st rollout of the current revision of the statewide ALS protocols, there was no protocol for bicarb in a crush injury... but there was no reason a provider couldn't get orders for it.


----------

