Protocol-Based Medicine

[RocketMedic]

I'm not a fan of protocol-based medicine. How can we move away from this?

 

[RocketMedic]

EDIT: I personally feel that protocol-based medicine allows us to be poor providers. We need more training, but we also need to stop justifying poor decisions with "protocol".

 

[Wheel]

More education and providers committed to clinical competence. This gets thrown around every day, but there aren't any good answers to fixing it.

 

[Frozennoodle]

I'm not a fan of protocol-based medicine. How can we move away from this?

Be a doctor? Even ER nurses work under written medical direction. It's the law. If you want to practice medicine independently go to medical school.

 

[medicsb]

Be a doctor? Even ER nurses work under written medical direction. It's the law. If you want to practice medicine independently go to medical school.

This, really. But, in many places certain physicians must operate under certain protocols (typically institution based).

 

[Rialaigh]

This, really. But, in many places certain physicians must operate under certain protocols (typically institution based).

I believe that this is the larger problem. Institutions write medical protocols now and even ER physicians have their hands tied when it comes to many things. For example I think it is absolutely absurd to have an EKG taken every time for a frequent flier 55 year old psych patient at the hospital I work at (when he/she comes into the ER). But ER protocol states that anyone over X age gets an EKG upon arrival regardless of what they are there for. Could be a toothache, they still get an EKG. It is wasteful and time consuming.

The current legal system and the precedents that have been set for malpractice lawsuits means that in most areas physicians (and hospitals) are economically unable to stand up for what they believe is proper medical care. Instead they must administer medical care based upon covering their tail against each and every possible lawsuit. As a result tens of thousands of dollars of unnecessary tests are run every day in the ER I work in, Not because the physician is an idiot. But because the hospital wrote a protocol that even the physician cannot override.

This system has worked its way from the top to the bottom of medical care. Frankly no one other than diagnostic medical specialist, those who work outside a hospital setting, and maybe critical care doctors really have the freedom to practice medicine as they see fit (as they were trained to do).

Fixing the protocol-based medicine issue is not an EMS issue. It is a issue that is system wide from the field all the way to hospice care. It cannot be fixed in EMS before it is fixed in the hospital setting.

 

[Jon]

I think to compare EMS protocols and hospital clinical requirements we are talking apples and oranges.

We have protocol based medicine because it's built around the lowest common denominator provider in your system. Face it - there are a LOT of crappy providers in EMS. Many EMS providers have minimal, if any, college-level A&P, and don't actually UNDERSTAND why we do some things. Many don't follow the latest research, or even bother to read the spoon-fed medical writing of JEMS and other trade journals. How many Paramedics do you know that regularly read any peer-reviewed EMS or EM journals?

So long as there is a large group within our profession that need a set of marching orders to do anything, we're going to continue to have protocol-driven medicine.

There are quite a few services that have moved forward with "clinical guidelines" to start weaning providers from the protocol mentality. It's a positive step.

 

[mycrofft]

Protocols enable people to act safely as technicians away from direct supervision.

Even MD's have protocols in hospitals and clinics, answerable to their peers.

 

[Frozennoodle]

I think to compare EMS protocols and hospital clinical requirements we are talking apples and oranges.

We have protocol based medicine because it's built around the lowest common denominator provider in your system.

Now I'm all for more education but degrees are not going to replace standing orders. Unless you become a mid-level provider or physician you're going to have a bad time with that argument. It's this, "EMS is special we should be hot dogging it out there," attitude that holds us back. If you want the system to respect you you have to start by understanding the system.

 

[Handsome Robb]

I'd like to hear from some of our foreign members. Paging meclin or negro_puppy or medic Tim....

Do y'all have standing orders? IIRC Canadian ACPs are licensed providers, not sure about the Aussies or Kiwis though...

 

[Jon]

Now I'm all for more education but degrees are not going to replace standing orders. Unless you become a mid-level provider or physician you're going to have a bad time with that argument. It's this, "EMS is special we should be hot dogging it out there," attitude that holds us back. If you want the system to respect you you have to start by understanding the system.

I think you are misinterpreting me.
Let me ask you - what is a "mid-level provider". I'm going to assume you're talking about a PA or CRNP. Look at some other countries. They have 4 year degree paramedicine programs and are much closer to what I was suggesting than an American PA or CRNP really is.

NVRob already mentioned a couple of folks that would be great to weigh in. I'd love to hear some folks from the Commonwealth Countries weigh in.

 

[abckidsmom]

I would venture that a strong medic, clinically minded, with college level A&P and a strong understanding of disease processes functions with protocols as clinical guidelines. Sure, they might get called in to talk about deviations, but those chat sessions don't tend to be punative for the medic, as much as educational for everyone involved.

 

[Veneficus]

I'm not a fan of protocol-based medicine. How can we move away from this?

You can't and it will get worse before it gets better.

Some of my colleagues and I were having this discussion last tuesday in fact.

We decided most protocols are put in place at all levels for a couple of reasons.

1. Most providers have mastered the medical education system, not the practice of medicine. Consequently they come out of medical school absolutely reliant on crutches like protocols, charts, scores, etc. to make up for lack of clinical experience, ability, etc.

2. Most "evidence based" medicine is really only studied to justify reimbursement. "look studies show it works" so you should pay for it. (you see where that can go wrong?)

3. Fear of litigation. This is perhaps the worst part of it. People believe they will be free from litigation if they can demonstrate no matter what the outcome, the rules were followed. (It is sort of like offering a sacrifice to gods) "I was just following rules/orders" is not an affirmative defense as the legal minds say. It has failed in some very big ways in history. Even in EMS.

Of note we were having this conversation in regards to hemofiltration in neonates, where the guidlines state a trial of peritoneal dialysis is indicated prior to and preferable to hemodialysis because of the independant mortality factor of exchange transfusion in the population.

However, we know that peritoneal dialysis doesn't work clinically in the same patients suffering from abdominal distension in sepsis because there is not only reduced blood flow to the peritoneum, which limits effectiveness, but also the possibility of infective gut organism migrated from the now permiable GI tract.

We are unanimously convinced if you try the peritoneal dialysis, the patient will likely die. But if you perform hemo, the patient has a statistically increased chance of dying.

The guidline sucks and the solution is not easy.

 

[Frozennoodle]

I think you are misinterpreting me.
Let me ask you - what is a "mid-level provider". I'm going to assume you're talking about a PA or CRNP. Look at some other countries. They have 4 year degree paramedicine programs and are much closer to what I was suggesting than an American PA or CRNP really is.

NVRob already mentioned a couple of folks that would be great to weigh in. I'd love to hear some folks from the Commonwealth Countries weigh in.

I'm working on my 4 year paramedic degree however its got an administration concentration and there isn't an option for an expanded clinician education. Hopefully more programs start offering them. There's only something like 12 in the US.

 

[Frozennoodle]

You can't and it will get worse before it gets better.

Some of my colleagues and I were having this discussion last tuesday in fact.

We decided most protocols are put in place at all levels for a couple of reasons.

I always enjoy reading your comments. They are always thoughtful and add to the conversation.

Where do physicians get their guidelines from?

 

[Veneficus]

I always enjoy reading your comments. They are always thoughtful and add to the conversation.

Where do physicians get their guidelines from?

Generally it is a consensus from various specialty organizations or associations.

But sometimes there is actually overwhelming evidence or on the down side, people who opine they do not want to change what is always done.

Many institutions also have SOPs, which are basically guidlines that are enforced by the agency. Usually put in place by a practice committee or medical director.

 

[ExpatMedic0]

I'm working on my 4 year paramedic degree . Hopefully more programs start offering them. There's only something like 12 in the US.

Me to man, together we will rule the world! :rofl:

 

[Frozennoodle]

Me to man, together we will rule the world! :rofl:

I don't even rule my house lol

 

[tsktsk]

Under my medical director, we operate under guidelines rather than protocols. It gives us the flexibility to determine what the appropriate treatment is and our medical director has always said that we are free to veer from this course as long as we have rationale as to why we did. He will defend us so long as we don't present him with a situation that isn't defendable....in other words, there needs to be evidence to show why you pick a specific treatment modality. I've attached a sheet from our protocol where he explains some of this.

 

[Handsome Robb]

Under my medical director, we operate under guidelines rather than protocols. It gives us the flexibility to determine what the appropriate treatment is and our medical director has always said that we are free to veer from this course as long as we have rationale as to why we did. He will defend us so long as we don't present him with a situation that isn't defendable....in other words, there needs to be evidence to show why you pick a specific treatment modality. I've attached a sheet from our protocol where he explains some of this.

Still sounds like medicine-by-protocol. For what it's worth we have a similar clause in our SOPs.

"Protocols provide process, people provide care."