# Physical Assessment - DCAP BTLS



## RoadZOmbie (Oct 15, 2010)

Hello everyone!!

I need a bit of help here. Can anyone help me understand exactly what to look for other than DCAP BTLS in each part of the body? Like when assessing the head I'm checking for DCAP BTLS, Battles Sign, CSF bleeding etc etc. Then what to look for in the neck, chest etc. Thanks!!


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## Aidey (Oct 15, 2010)

Um, that is an enormous amount of information. Maybe look into getting a good physical exam text book and studying that?


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## Shishkabob (Oct 15, 2010)

If it doesn't look normal, you probably found it.


Neck-- JVD, tracheal deviation
Chest-- flail segment

Crepitus, petechia, other skin things.  (Legit medical term-- "skin things")... really just way too much to put in to here.


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## LucidResq (Oct 15, 2010)

As has been said, covering such a topic is way too much for a forum. 

My one recommendation is to make the most of your time in clinicals and such and listen to breath sounds, palpate abdomens, get as much hands on time as you possibly can... in the hospital you might actually the chance to actually place your stethoscope on someone's chest and have an MD tell you "this is what rales sound like..." 

Even if you don't get to hear/see/touch abnormal... the more you start learning what's normal... the easier it is to recognize what's not normal. You may not even initially be able to understand what is going on... but at least you'll get that "hmm something's wrong here" sensation. 

Take blood pressures and listen to breath sounds and such outside of class too, as much as you can. On your grandma too... I feel like a common problem people face coming out in to the real world is they get so used to taking blood pressure and such on their healthy, young classmates they get all fumble-f***** when they have to take a BP on an older lady with skinny arms and lots of extra skin for the first time in the field.


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## JPINFV (Oct 16, 2010)

Bate's Guide to the Physical Exam and History Taking:

http://www.amazon.com/Physical-Examination-History-Taking-CD-ROM/dp/0781735114

followed by 

Rosen's Emergency Medicine
http://www.amazon.com/Rosens-Emergency-Medicine-Concepts-Clinical/dp/0323011853


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## JJR512 (Oct 16, 2010)

Doesn't the EMT-B text book explain all this?


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## RoadZOmbie (Oct 16, 2010)

Thanks for the info. The book explains most of it but just wanted to get some feedback on what if any tips you used to help you remember what to look for.


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## SanDiegoEmt7 (Oct 16, 2010)

LucidResq said:


> As has been said, covering such a topic is way too much for a forum.
> 
> My one recommendation is to make the most of your time in clinicals



All 12 hours of it!!!!


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## SanDiegoEmt7 (Oct 16, 2010)

JPINFV said:


> Bate's Guide to the Physical Exam and History Taking:
> 
> http://www.amazon.com/Physical-Examination-History-Taking-CD-ROM/dp/0781735114
> 
> ...



He skipped the DCAP-BTLS section in the physical exam chapter, but I'm sure he's going to read these two brief pamplets h34r:


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## RoadZOmbie (Oct 16, 2010)

Shoot, we have to do 30 hours of clinical. Once a week, 3 hours a session.


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## Symbolic (Oct 16, 2010)

If you have the patient trauma assessment sheet that is used for the practical NREMT, It lists the highlights that should be assessed.


Your basically just looking for DCAP-BTLS. The mnemonic is used to help identify what to look for. Your essentially just palpating the various regions of the body. Starting with the head, you palpate the scalp and facial areas, note any CSF or drainage, moving on to the neck looking for JVD/Tracheal Deviation/Subcutaneous emphysema, step offs of the spine, etc. Moving on to the chest- Auscultating/palpating, then to the abdomen, pelvis, extremities, etc.


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## MrBrown (Oct 16, 2010)

My advice is not to "look" for anything but see what is there, when you start "looking" for only certian things you run the risk of excluding what is important because it wasn't on your list of things to look for.


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## Akulahawk (Oct 16, 2010)

http://www.amazon.com/Physical-Examination-Extremities-Stanley-Hoppenfeld/dp/0838578535I'm a fan of the Hoppenfeld book myself, but it only deals with ortho stuff. It does, however, provide a good understanding about what the structures are that you're palpating during the exam. The one BIG problem with that book is that it introduces special tests that are beyond the scope of prehospital providers. I can't imagine a Paramedic needing to do a Lachman's or check for GH joint instability in the _normal_ course of work. 

DCAP-BTLS is simply a "device" to remind you about what you're looking for during that trauma exam. While I forget the specifics of the mnemonic, I check for all those things when I examine someone. I use my eyes, ears, hands...

Once you get used to doing that exam, it only takes a couple minutes at most to do it. I found that verbalizing everything I'm doing actually slows me way down. It takes me about a minute to do it that way. If I'm not verbalizing and just "doing", it only takes me about 30 seconds to do. It's not that I'm just speedy at it, it's that I've done a LOT of them over the past 18-20 years. I know what I'm "looking" for and I have a pattern that I follow EVERY time I do it. It's close to, not exactly, the same sequence you're learning. 

For purposes of testing, VERBALIZE the steps as you're doing them and verbalize during the skills test. Your proctor NEEDS to hear you say what you're checking for, otherwise your proctor won't know that...


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## Veneficus (Oct 16, 2010)

MrBrown said:


> My advice is not to "look" for anything but see what is there, when you start "looking" for only certian things you run the risk of excluding what is important because it wasn't on your list of things to look for.



That leaves too many occult findings unchecked in my not always humble opinon.

I like exam by regional anatomy or system based, depending on the complaint.


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## Melclin (Oct 16, 2010)

Had a ganda at Bates a while back. Twas alright. It definitely had some gems (I particularly liked the stuff about pulse quality), but it was in amongst what seemed like an awful lot of fairly useless chatter. 

Any other PE and Hx books I wanna look at while we've got a new thread open about the topic?


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## Medic41Mike (Oct 18, 2010)

Ok, Here ya go. Hope this helps.

D- Deformity
C- Contusions
A- Abrasions
P- Punctures

B-Burns
T-Tenderness
L-Lacerations
S-Swelling

Head and Face:

Observe and palpate skull (anterior and posterior) and face for DCAP-BTLS;
Check eyes for equality, responsiveness of pupils, movement and size of
pupils, foreign bodies, discoloration, contact lenses or prosthetic eyes;
Check nose and ears for foreign bodies, fluid or blood;
Recheck mouth for potential airway obstructions (swelling, dentures, bleeding,loose or avulsed teeth, vomit, absent or present gag reflex) and odors, altered voice or speech patterns and evidence of dehydration.

Neck:

Observe and palpate for DCAP-BTLS, jugular vein distension, use of neck
muscles for breathing, tracheal tugging, tracheal shift, stoma and medical
information medallions.

Chest:

Observe and palpate for DCAP-BTLS, scars, implanted devices such as
pacemakers and indwelling IV/arterial catheters, medication patches, chest wallmovement, asymmetry and accessory muscle use in breathing;

Have patient take a deep breath if possible and observe and palpate for signs
of discomfort, asymmetry and air leak from any wound.

Abdomen:
Observe and palpate for DCAP-BTLS, scars and distention;
Palpation should occur in all four quadrants taking special note of tenderness,
masses and rigidity.

Pelvis/Genital-Urinary:

Generally, a patient’s genital area should not be exposed and examined unless
the assessment of this body region is required due to the patient’s condition,
such as trauma to the region, active labor or suspected/knownbleeding.When
possible have an EMT of the same gender as the patient perform evaluations ofthe pelvis/genital area.

Observe and palpate for DCAP-BTLS, asymmetry, sacral edema and as
indicated for other abnormalities; Palpate and gently compress lateral pelvic rims and symphysis pubis for tenderness, crepitus or instability; Palpate for bilateral femoral masses, if warranted.

Shoulder and Upper Extremities:

Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill,
edema, medical information bracelet, and equality of distal pulses;
Assess sensory and motor function as indicated

Lower Extremities:

Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill,
edema and equality of distal pulses;
Assess sensory and motor function as indicated.

Back:

Observe and palpate for DCAP-BTLS, asymmetry and sacral edema.


A lot of information to read over however do not skip any of these as most proctors will deduct a point on you examif you do.


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## MrBrown (Oct 18, 2010)

What textbook did you get that out of


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## Medic41Mike (Oct 18, 2010)

MrBrown said:


> What textbook did you get that out of



Straight out of our counties policy book


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## Lifeguards For Life (Oct 18, 2010)

MrBrown said:


> What textbook did you get that out of



I hate when people quote protocol books like scripture. Protocol books are not textbooks or even really books at all


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## Lifeguards For Life (Oct 18, 2010)

Lifeguards For Life said:


> I hate when people quote protocol books like scripture. Protocol books are not textbooks or even really books at all



In medic school our instructors worked in 4 different counties hince 4 different protocols. These protocols rarely matched what was in our textbook. Our instructors read and studied their protocols, they did not read our textbook. This made for a aggravating time in paramedic school. they could not agree on anything, and you one answer could be praised by two instructors, scorned by all the others.

this is why L4L is so mad at the world. paramedic school scarred him for life.


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## Medic41Mike (Oct 18, 2010)

Lifeguards For Life said:


> In medic school our instructors worked in 4 different counties hince 4 different protocols. These protocols rarely matched what was in our textbook. Our instructors read and studied their protocols, they did not read our textbook. This made for a aggravating time in paramedic school. they could not agree on anything, and you one answer could be praised by two instructors, scorned by all the others.
> 
> this is why L4L is so mad at the world. paramedic school scarred him for life.



I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.

End the end it saves your bacon rather than reading the policy and changing it to your favor


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## JJR512 (Oct 18, 2010)

Medic41Mike said:


> I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.
> 
> End the end it saves your bacon rather than reading the policy and changing it to your favor



I believe the real reason why some members here are against following the protocols like "scripture" is because it leads to _blindly_ following the protocols. Protocols cannot account for every possible situation, and some members here have encountered providers who simply could not function if the situation did not follow the script in the protocols.


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## usalsfyre (Oct 18, 2010)

Medic41Mike said:


> I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.
> 
> End the end it saves your bacon rather than reading the policy and changing it to your favor



So you follow the policies and protocols even when they don't make sense fot that paticular patient presentation? Or do you make the patient "fit the box" instead of the "box fitting the patient"? If you think this limits your liability, your sadly, sadly mistaken. 

Protocols should be treated as guidelines, nothing more. If you are not educated enough to omit or add steps to the protocol in consult with med control as needed you need to step up your game or get out of taking care of patients.


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## MrBrown (Oct 18, 2010)

Medic41Mike said:


> I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.
> 
> End the end it saves your bacon rather than reading the policy and changing it to your favor



Thats pretty bad mate I mean seriously .... that sort of attitude is probably going to do some serious harm to somebody one day.


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## Lifeguards For Life (Oct 18, 2010)

JJR512 said:


> I believe the real reason why some members here are against following the protocols like "scripture" is because it leads to _blindly_ following the protocols. Protocols cannot account for every possible situation, and some members here have encountered providers who simply could not function if the situation did not follow the script in the protocols.



this too. Follow protocols when following protocols is the right thing to do. When following a protocol is not the best thing for the patient, don't follow that protocol. 

I still hate when people quote protocols to prove they are right. Different medical directors will have different protocols for different situations.


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## Aidey (Oct 18, 2010)

My med director flat out says the protocols are guidelines and that he expects us to use our brains. If you don't do something totally stupid, can explain your actions and you had a sound thought process you aren't likely to get in trouble with him.


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## MrBrown (Oct 18, 2010)

Anybody with enough education of the basic scientific and clinical rationale underpinning whatever "protocol" is flavour of the day should be able to pick up the localised verison of the day, run with and dexteriously apply it.


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## Veneficus (Oct 18, 2010)

following the protocol like scripture.

The poor creatures, they don't know any better.


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## Lifeguards For Life (Oct 18, 2010)

I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)


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## MrBrown (Oct 18, 2010)

Lifeguards For Life said:


> I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)



It is simply because as the Ninja fellow said, they don't know any better.  Whatever education they got  just ain't cuttin it ....

You'd never get away with "but the guideline says" here.  Obviously there is a degree of clinical and medicolegal risk mitigation built into any policy or procedure however whatever protocol or guideline you work with should not be followed blindly.

On the other hand, they say a little knowledge is dangerous

Man this whole thing makes me so angry

*Brown slams his fist on the streering wheel, blasts the air horn, guns the engine and watches his face turn the same shade of orange as his "DOCTOR" jumpsuit ...

Red base, Delta Alpha is stuck in traffic .... Oz get out and see wha the hold up is


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## JPINFV (Oct 18, 2010)

MrBrown said:


> It is simply because as the Ninja fellow said, they don't know any better.  Whatever education they got  just ain't cuttin it ....



I've taken up the helm of calling a spade a spade, which means calling 'the integration of a physical exam, history, POC testing (EKG and BGL) to form an opinion of what's going on, and then form a treatment plan off' making a diagnosis. It's amazing the absolute vitriol that some EMS providers have against the "D" word. It's so bad that one person posted about how he doesn't make a diagnosis, and then uses the term "field diagnosis" while someone else posted about how I must be advocating non-transport, since apparently the only thing that occurs at hospitals is diagnosis, but no treatment. 

The comments are so sad that they're slightly humorous. 
http://www.emsworld.com/article/article.jsp?id=14878


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## Veneficus (Oct 18, 2010)

Lifeguards For Life said:


> I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)



Protocols are written to help the most number of people.

It does not mean they work for every patient you encounter. It is impossible to write a protocol for every conceivable situation. At some point clinical judgement will have to come into play. 

The idea that if you harm a patient following protocol that you will not be held accountable is in error. 

In medicine (and in EMS), decisions must be made on every patient. The decision not to make a decision and follow a cookbook is an option. 

Can you follow the cookbook if it might harm a patient and certainly will not legally protect you?

"I was just following orders" has not been an afirmitive defense in a great many years.

Like i said with my earlier post. People believe in religion, they think if they follow it and the more literally they follow it they will be saved or get some grand reward. It remains to be seen. 

If you medical director was facing suit or at risk of losing his medical license over somebody following the cookbook, I will bet dollars to doughnuts that he will defend himself by saying they were meant to be guidlines not applicable to every situation, the medics knew that, or were supposed to and it will be the medic who finds his rear hanging out in the breeze all alone.

"Ladies and gentlemen of the jury who aquitted OJ, you have heard expert testimony from an infinite number of providers that protocols are just guidlines, that clinical judgement must be excercised in the care of the sick and injured. The defendant is trying to hide behind "just following orders" in order to justify his inaction or gross negligence by performing uncalled for treatments on the deceased. You have heard the testimony of the experts saying they would not have acted that way as it would obviously not help or cause harm. You have also heard testimony from an infinite number of providers of the same level that show in the basic EMS education, it is made clear that protocols are not meant to be used as the absolute treatment decision. It is also clearly demonstrated that local protocol is not part of the national curriculum. We ask for damages in the amount of..."

(yea, following the protocol as scripture doesn't seem like a winner.)


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## MrBrown (Oct 18, 2010)

The prosecution would like Dr. Brown, MBChB, PGCertHSc(AeroRetvMed), FANZCA, FJFICM, BHSc(Paramedic)(Hons), PGDipHSc(IntsvCare)(Dist) admitted as an expert witness.

Now, Dr Brown is not true that Ambulance Paramedics should have adequate knowledge and cognitive dexteriory to interpret treatment guidelines and vary them in an appropriate manner to achieve best outcome for thier patient?

In that way .... yes, oh hang on .... yes hello Delta Alpha 91 here, its a go you say, an RTA, possible RSI, Oz is on his way you say, ok have him meet me out front .... sorry Your Honour I have to go .... my standard fee will still apply however, do tell Counsel that 

*Brown struggles into his orange "DOCTOR" jumpsuit and hurries to the front steps of the courthouse


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## zmedic (Oct 18, 2010)

Veneficus said:


> If you medical director was facing suit or at risk of losing his medical license over somebody following the cookbook, I will bet dollars to doughnuts that he will defend himself by saying they were meant to be guidlines not applicable to every situation, the medics knew that, or were supposed to and it will be the medic who finds his rear hanging out in the breeze all alone.



I'm going to flip this one around. If I was the medical director and knew that my license was on the line, I'd hope that my medics would be following the protocol that I had approved. 

Most of the protocols I have seen are pretty reasonable and spell out what you can and can't do.  They aren't guidelines, they are the law as far as you are concerned. If they saw "don't give nitro for a BP under 100" and you give it for a BP of 90/50 I don't care that you had an IV, that you thought it would help. You're going to get nailed to the wall. 

The thing is that in almost all cases you have online medical control that you can call if the situation isn't fitting the protocol. If you call up and ask for something extra or not to do something and the doc says okay, you're protected. But I'm not going to let someone get me sued because they thought that they didn't have time to make a 3 minute phone call.


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## abckidsmom (Oct 18, 2010)

zmedic said:


> I'm going to flip this one around. If I was the medical director and knew that my license was on the line, I'd hope that my medics would be following the protocol that I had approved.
> 
> Most of the protocols I have seen are pretty reasonable and spell out what you can and can't do.  They aren't guidelines, they are the law as far as you are concerned. If they saw "don't give nitro for a BP under 100" and you give it for a BP of 90/50 I don't care that you had an IV, that you thought it would help. You're going to get nailed to the wall.
> 
> The thing is that in almost all cases you have online medical control that you can call if the situation isn't fitting the protocol. If you call up and ask for something extra or not to do something and the doc says okay, you're protected. But I'm not going to let someone get me sued because they thought that they didn't have time to make a 3 minute phone call.



Sued?  This eternal fear of lawsuits in EMS is inflated, in my opinion.  15 years now, and I have once been involved in potential litigation, which was resolved outside of court.  Our eggregious error?  Dropping the patient.  Pretty easy to find out who was in error there.

I think you're missing the point.  It's not whether you should administer the nitro with the systolic BP less than 100 mmHg, it's whether you should even be in the ACS protocol to begin with.  "Oh, but she was complaining of chest pain!  We needed to be following the chest pain protocol!"

There's not usually a pneumonia protocol, or a spontaneous pneumothorax protocol.  In fact, in our 200 page protocol book with far too many words, I'd be surprised if "chest pain" "nitro" and "spontaneous pneumothorax" were even on the same page.

So how's a protocol-based provider going to get from a complaint to a protocol that doesn't exist, and if your method of practicing is to use the protocols as scripture, what do you do when you don't have a chapter and verse to go to?  

This is when educated clinical decision making comes into play.  If, prospectively, you plan to provide healthcare using the protocols as your prime source of litigitation avoidance, how do you expect to deal with the nearly 40% of situations you'll encounter that will not be addressed specifically by the protocols?

Let's don't get caught shoehorning patients into protocol scenarios.  Please, let's get educated and use scientific rationales for our decisions.  It's so much more effective, and useful in closer to 100% of interactions than protocol-based medicine.


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## reaper (Oct 19, 2010)

I have never seen a set protocols that did not list that they were "Guidelines for treatment". Nothing is cut and dry in medicine and any service that tries to keep their medics at protocols only, will certainly suffer.


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## zmedic (Oct 19, 2010)

I guess it comes down to what you mean by following a protocol. It is one thing to say "this patient doesn't fit neatly into a protocol so I had to use some judgement on how to treat them." I have no problem with that. My problem is when the protocol is explicit about something, you know that protocol applies, and you decide to violate it anyway. The medical director put down those explicit rules for a reason. If it says you only get 2 attempts at intubation before you BLS the airway, you only get 2 trys. There is no real place for judgement to come into play. Or if the protocols say transport to the closest hospital unless you get medical control approval, and you drive an extra half an hour without calling, you are in trouble. 

Some things in the protocol are cut and dried. Max doses of medication. Limits on intubation. Criteria for cath lab activations. Etc. 

EMS is a agreement worked out where physicians say "you can practice under my license, but there are some rules. If you want to do something else you have to call and get approval." The reason we have this system is because the good from the very few cases where blatant protocol violation helped a patient are far outweighed from the harm if everyone could just decide for themselves when to follow those rules. 

This can go round and round in the abstract. Let's hear some examples. For those who say they are just guidelines, give an example of when you (or someone else) felt the protocol was putting a patient in danger you violated them without calling medical control.  Similarly I'd like to hear some examples of when someone got sued for following a protocols that directly lead to a bad outcome.


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## abckidsmom (Oct 19, 2010)

zmedic said:


> This can go round and round in the abstract. Let's hear some examples. For those who say they are just guidelines, give an example of when you (or someone else) felt the protocol was putting a patient in danger you violated them without calling medical control.  Similarly I'd like to hear some examples of when someone got sued for following a protocols that directly lead to a bad outcome.



That's the thing:  I don't have any knowledge of a paramedic being sued for care, one way or another.  I see regulatory boards investigating paramedics, medical directors calling them in for counseling/review, but NEVER have I heard of a medic sued for wrongful death, malpractice or whatever.  The ONLY times I have heard of settlements have been when medics dropped a patient.

These lawsuits are myths!  There is not. that. much. risk of litigation!  Surely, there have been lawsuits, but in reality they are rare beyond calculation given the number of patient interactions we have each day.

The factor that should motivate us here is the desire to provide the best care possible, not the desire to avoid an astronomical risk of litigation.


Now, for your specific examples...I would say that they really can't be generalized because the decision to not follow a protocol that may or may not apply is a negative one and it is tough to track down a negative, statistically speaking.  Similarly, deciding that a patient fits a specific protocol that may or may not apply and following it to the end is tough to police or track because so few of our treamtents have truly long-term implications.  

Discussing hypothetical anecdotes is fun, but not really productive.


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## zmedic (Oct 19, 2010)

You make a good point, and it brings up the difference between deciding not to implement a given protocol because you don't feel that it applies to the given patient, and deciding that you want to do something that your protocols specifically say you aren't allowed to do. 

From what I've seen when people violate protocol it usually isn't a matter of them knowing all the protocols, knowing which ones apply to the patient and making a choice to violate them. It is much more often an education issue such as they were thinking abdominal pain and didn't recognize that in this female diabetic it may be atypical chest pain.

I'm thinking strongly about being a medical director and I don't mind doing education. But if someone tells me the knowingly violated a protocol, they knew they should have called in and didn't but thought that they knew better than I did when I wrote those protocols, we're going to have a problem. And I don't think that is someone who I'd let work under my license because I'd have a hard time trusting them.


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## Veneficus (Oct 19, 2010)

zmedic said:


> I guess it comes down to what you mean by following a protocol. It is one thing to say "this patient doesn't fit neatly into a protocol so I had to use some judgement on how to treat them." I have no problem with that. My problem is when the protocol is explicit about something, you know that protocol applies, and you decide to violate it anyway. The medical director put down those explicit rules for a reason. If it says you only get 2 attempts at intubation before you BLS the airway, you only get 2 trys. There is no real place for judgement to come into play. Or if the protocols say transport to the closest hospital unless you get medical control approval, and you drive an extra half an hour without calling, you are in trouble.
> 
> Some things in the protocol are cut and dried. Max doses of medication. Limits on intubation. Criteria for cath lab activations. Etc.
> 
> ...



I understand your point and it is not that I disagree, but if I could just offer what I have seen.

Patient calls for difficulty breathing. Arrive to find elderly patient with roughly stage 3 CHF. Warm to the touch. Lead medic decides this is CHF exacerbation. Effortlessly follows the CHF protocol. As it gets further down the list the lady is progressively worsening. Medic administers a total of 120mg lasix by standing order. Patient is admitted to the ICU and follow up leads to a dx of pneumonia. 

Based on presumptive dx, i watched a single classification of CHF in this case and the blind following of the CHF protocol to the maximum allowed without calling. As treatment progressed the patient worsened. Perhaps not totally because of the treatment. But at what point do you s a provider decide and at what point of following the orders that you need to stop what you are doing and reevaluate you approach? 

I am not suggested making up doses or treatments beyond the norm w/o permission. 

I watched the same medic refuse to assist a patient in taking their duoneb treatment, because as he explained "our protocol states we administer only albuterol." which it did clearly state for suspected COPD we would administer albuterol because it was all we had on the truck. But we also had a protocol that stated a provider could assist in taking prescribed meds. So despite the fact a doc prescribed it, it was albuterol and atrovent (better than albuterol alone) in the name of following the COPD protocol, we gave a lesser medication than was indicated, available, and prescribed by somebody with far more knowledge than we had. We even had a protocol that permitted us to do it.

But based on presentation, sometimes it helps to mix and match protocols, not select one and follow it until you can do no more without calling and then not call. 

I can't find it (google failed me) but i do remember reading several years ago on JEMS i believe about a Michigan medical director testifying in court his protocols were guidlines. Maybe some of our Michigan collegues are more familiar with it and can point us in the right direction?


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## Veneficus (Oct 19, 2010)

zmedic said:


> I'm thinking strongly about being a medical director and I don't mind doing education. But if someone tells me the knowingly violated a protocol, they knew they should have called in and didn't but thought that they knew better than I did when I wrote those protocols, we're going to have a problem. And I don't think that is someone who I'd let work under my license because I'd have a hard time trusting them.



I will never be an EMS medical director unless something majorly changes. But If I could just point out that in many agencies, not naming any in particular, when the medical director makes waves, the medical director is replaced. 

Just something to consider.


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## emtJR86 (Oct 19, 2010)

RoadZOmbie said:


> Shoot, we have to do 30 hours of clinical. Once a week, 3 hours a session.



We have 60...36 in the rig and 24 in the ER


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## Aidey (Oct 19, 2010)

Veneficus said:


> But based on presentation, sometimes it helps to mix and match protocols, not select one and follow it until you can do no more without calling and then not call.



Yeah, it's not like patient's ever present with more than one problem at once.


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## reaper (Oct 19, 2010)

zmedic said:


> I guess it comes down to what you mean by following a protocol. It is one thing to say "this patient doesn't fit neatly into a protocol so I had to use some judgement on how to treat them." I have no problem with that. My problem is when the protocol is explicit about something, you know that protocol applies, and you decide to violate it anyway. The medical director put down those explicit rules for a reason. If it says you only get 2 attempts at intubation before you BLS the airway, you only get 2 trys. There is no real place for judgement to come into play. Or if the protocols say transport to the closest hospital unless you get medical control approval, and you drive an extra half an hour without calling, you are in trouble.
> 
> Some things in the protocol are cut and dried. Max doses of medication. Limits on intubation. Criteria for cath lab activations. Etc.
> 
> ...



Here is the statement on the first page of our protocol book. My last service had almost the same thing:

"While treatment and transport decisions in the field vary, these guidelines can assist the pre-hospital provider by standardizing procedures for the most common and routine emergencies encountered and will be considered the minimum standard. It is expected that the pre-hospital provider preforming these skills will use good judgement. Please understand that these standards are to be used together with the standing orders, and with consideration of the level of training and certification of the provider."

As I stated before, I have never seen a set of protocols that did not list them as guidelines.


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## JPINFV (Oct 19, 2010)

One of the counties in So Cal have a similar introduction for the ALS protocols.

"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."

No emphasis added.

http://www.rivcoems.org/downloads/downloads_documents/Protocol102904/7000.pdf


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## zmedic (Oct 20, 2010)

Veneficus; said:
			
		

> I will never be an EMS medical director unless something majorly changes. But If I could just point out that in many agencies, not naming any in particular, when the medical director makes waves, the medical director is replaced.
> 
> Just something to consider.



True, but I think if someone went outside of their protocols in a big way it wouldn't take much effort for the medical director to have action taken against that employee, especially if it wasn't the first time. 

I think your above examples are good ones, and ones that I would have no problem with someone doing. Note that the first is a problem of diagnosis, not protocol. If you said "this is a shortness of breath call, r/o sepsis", then you don't have to start on the CHF protocol at all. This example is also why Lasix is no longer a standing order in NYC for CHF, because it kept being given in patients who had pneumonia. 

The second case there was a protocol that said he could give the duoneb, so he would have been covered. 

I don't deny that protocols are generally guidelines, and do not force you to do things that don't make sense. But they also tend to set limits on certain treatments. I just don't want some rookie medic reading this thread who then thinks "I can do whatever I feel like, because these are just guidelines." 

Clearly the more reasonable the reason and the smaller the violation the less of a big deal it is. But for the rookies out there:

1: You must know what your protocols say.
2: If you think about giving a treatment that is not justified by a protocol, or want to withhold something considered a standard of care, your first instinct should be to call medical control. 
3: You should be ready to call your supervisor/medical control immediately after the call and explain what you did and why. If you are on the call and think "i'll do this and it'll be fine as long as no one finds out" you already know it's the wrong thing to do.


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## Veneficus (Oct 20, 2010)

.





zmedic said:


> If you are on the call and think "i'll do this and it'll be fine as long as no one finds out" you already know it's the wrong thing to do.



This is great

I am going to add this to the line of:

"Always ask yourself how this is going to look on the evening news."


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## RoadZOmbie (Oct 20, 2010)

Alot of good info here gentlemen! Re-read the textbook and got a better understanding of it.


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## Veneficus (Oct 20, 2010)

zmedic said:


> True, but I think if someone went outside of their protocols in a big way it wouldn't take much effort for the medical director to have action taken against that employee, especially if it wasn't the first time.



This assumes the medical director actually cares. In my EMS career I can count on one hand the ones I met who actually do.

In many agencies, everything from QA to remedial training is handled by non physician providers in a position of "leadership."

It also assumes that the medical director actually hears about it. In all forms of EMS not only is the good old boy network alive and strong, but the very nature of EMS permits many mistakes and poor practices to never be noticed.

When I worked for an FD, in order to terminate an employee, the employee had to be written up 3 times for the same infraction. Unions protect the most undeserving, I know of no medical director who is willing to take on a local IAFF. 



zmedic said:


> Note that the first is a problem of diagnosis, not protocol. If you said "this is a shortness of breath call, r/o sepsis", then you don't have to start on the CHF protocol at all. This example is also why Lasix is no longer a standing order in NYC for CHF, because it kept being given in patients who had pneumonia.



This is the great dilemma of our time. Do we taake things away from poor providers or do we raise the level of the providers?

I am of the mind we should raise the provider level, stop taking tools out of the box, and start teaching people to use the ones they have. I have said this many times: How many field medics actually take a temperature on every patient? It is a vital sign. SPo2 is not a vital sign. Every patient in the hospital gets their temperature taken. Why is EMS excused from even taking a full set of vitals?

One of the reasons  I am reducing my involvement in EMS (except for this board it seems) is because they need to be raised up to put more tools in the box to fulfill the eventual role of being out of hospital providers as opposed to prehospital providers. Otherwise, they have no hope of being anything more than overpaid taxi drivers. With the impending collapse of the US healthcare system, I would not want to be considered overpaid, over used, or under educated. But most in EMS don't want to look any farther in the future than their next bathroom break.




zmedic said:


> The second case there was a protocol that said he could give the duoneb, so he would have been covered.



That was my point, but many providers who strictly interpret protocols only ever pick one and follow it to the point where they have to call. It is impossible to properly treat patients by picking a single protocol from a single dx. That is my whole issue with strict interpretation of protocol. 



zmedic said:


> I don't deny that protocols are generally guidelines, and do not force you to do things that don't make sense. But they also tend to set limits on certain treatments. I just don't want some rookie medic reading this thread who then thinks "I can do whatever I feel like, because these are just guidelines."



Some of the more senior medics are just as dangerous. However usually not because they were making something up, but because they always do things the way they were done 10 or more years ago.


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## Lucy212 (Oct 21, 2010)

Mike, I was thinking the same thing. Doesn't each county have a protocol book with detailed information in it? Your information was great.

~ L


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