Do you agree with your protocols?

[Lin57EMT]

Hang in there through the hard stuff, and keep your ears open at all times (that only works well if the mouth is shut, lol!).

This reminds me of last night...

My sister, myself and two others were teaching airway station segments to an EMT-B class. At the end of the class, we were comparing notes and everyone had the same comment - good students, listened well, did good jobs on their station skills, with one exception. One very enthusiastic EMT recert was hell-bent on co-teaching every station. She interrupted the instructor, elaborating on the lesson for the benefit of all the newbies. She talked above and through the instructor, picking up pieces of equipment to illustrate, and going on to "teach" the next several steps. While I was explaining how to inflate the reservoir on a NRM, she had a nasal cannula in hand and was explaining to the students standing next to her how it was applied. She did a version of this at every station.

At my station I had to interrupt her when I heard her telling them that she prefers hooking up a cannula to using a mask, "because when you get to the ER they're going to change the patient over to a cannula anyway". New York has no protocol that calls for low-flow oxygen as an initial intervention - only as a contraindication. Every protocol we have calls for HIGH FLOW oxygen, so using a cannula is not ever a first choice - only a second choice (or third, etc). I corrected her, and she listened politely, but I think the underlying message was lost on her.

Anyway, the whole point is that the know-it-all EMT recert was the only one who didn't do my station correctly - she forgot to verbalize the tank pressure.
Lesson learned, I hope.

 

[JPINFV]

At my station I had to interrupt her when I heard her telling them that she prefers hooking up a cannula to using a mask, "because when you get to the ER they're going to change the patient over to a cannula anyway". New York has no protocol that calls for low-flow oxygen as an initial intervention - only as a contraindication. Every protocol we have calls for HIGH FLOW oxygen, so using a cannula is not ever a first choice - only a second choice (or third, etc). I corrected her, and she listened politely, but I think the underlying message was lost on her.

Just curious, because I know that instructors have to teach what is tested on not necessarily how treatment works in the field, do you agree with that protocol?

 

[Lin57EMT]

Just curious, because I know that instructors have to teach what is tested on not necessarily how treatment works in the field, do you agree with that protocol?

Here comes the proverbial can of worms....

Since you asked, as a matter of fact, I do agree with that protocol. If a patient is or may soon be suffering from lack of O2, poor perfusion, pain, nausea, etc..., giving high-flow at 12-15 LPM is what all the experts (read doctors, nurses and EMS personnel) say is the right thing to do, PREHOSPITAL. What the hospital does, the MAINTENANCE care, is the definitive course and shouldn't be confused with our small window of treatment and transport. Our job is to keep them alive until we can turn them over to definitive care. It is reasonable that the definitive care be titrated for effect - not just in the ER, but also on the floors and after the patient is released. In short, we give what the patient needs in order to help them in the emergent situation, not long-term.

Some responders have difficulty with the concept of an emergent situation vs. long-term care, especially in medical patients. I have a big issue with responders who re-write protocol based on their "years of field experience". We are given rules, guidelines, to follow that are set up specifically to address our scenarios. They are created by people who are trained higher than we are, and are intimately familiar with the long-term effects caused by our field care. Therefore, I have to trust that in the majority of situations, and for the majority of patients, my standing orders give my patient the best chance of survival.

There are hundreds, thousands, bejillions of stories that are put forth by responders as "the exception to the rule", backed up by firm belief that if the responder did everything "by the book" the patient would be dead now. I call those the "If he was wearing a seatbelt he'd be dead right now" stories. Maybe yes, maybe no. I only know that MY protocol doesn't say to do Step A, Step B, Step C OR WHATEVER YOU THINK IS BEST AT THE TIME. It says to do those steps and CALL MEDICAL CONTROL if you think it is warranted. That takes all the responsibility for error away from me and puts it squarely where it belongs - with my Medical Director, for whom I work and who trusts me to do what I'm told to do.

I signed on with all of my guidelines being laid out clearly. I am to do this, or that, or this other thing, in this manner, and if I disagree based on circumstance I have X amount of options. I agreed to this. I am bound by it, and if I adhere to it, I am protected by it.

Despite the so-called success stories of those who disregard standing orders and protocol, I disagree with the concept of it on many levels. Cowboy Medicine is not the same as making good judgement calls when it falls outside protocol or standing orders. And I think seasoned EMTs do a disservice to the newbies if they set examples based on a disregard for the very rules they agreed to abide by. As they say, without rules there is chaos. Where in EMS does it say we are to encourage chaos?

This won't sit well with rule-benders/breakers, I'm sure, but you asked, so that's how I feel. We agreed to follow the rules, and we are obligated to do so for the good of the patient. Egos need to be checked at the door.

I shall now duck.

 

[reaper]

I understand that you have to follow your protocols. I think he was asking if "you" agree with it.

Don't believe that you protocols were written that way "because that is what is best". They were most likely cut and pasted from a text book.

Not every pt needs a NRB @ 15 lpm. I would estimate that 90% of the Pt's you treat need no more then 4 lpm via NC. That is just something they drill into your head in EMT school, "everyone needs high flow O2". That is a myth, but it must remain in the EMT text book. Majority of EMT's are not taught how to assess a pt adequately enough to judge what O2 they need.

 

[Lin57EMT]

Reaper said:

I understand that you have to follow your protocols. I think he was asking if "you" agree with it.

I think I answered that rather directly, Reaper. I said: "Since you asked, as a matter of fact, I do agree with that protocol."


Reaper:

Don't believe that you protocols were written that way "because that is what is best". They were most likely cut and pasted from a text book.

You are familiar with the authors of the NYS protocols then, and are saying they didn't write anything - just stole the words of others and made it into our protocol without any evaluations, any qualifications, any quality assurance, any effort, any science, any attempt to evaluate it's effectiveness? The sum total of our NYS protocols is that they were swiped from a textbook?? I have a hard time buying that one.

Reaper:

Not every pt needs a NRB @ 15 lpm. I would estimate that 90% of the Pt's you treat need no more then 4 lpm via NC. That is just something they drill into your head in EMT school, "everyone needs high flow O2". That is a myth, but it must remain in the EMT text book.

An interesting slant. You have very firm opinions, which you even back up with percentages, without even needing to SEE my patients. I simply don't know how to respond to that, so I'll let your statements speak for themselves.

Reaper:

Majority of EMT's are not taught how to assess a pt adequately enough to judge what O2 they need.

Exactly why they should not be deciding how much O2 a patient should have. Follow your protocol.

That is the first thing you've said that I MIGHT be inclinded to agree with, in a very broad sense, and only because EMTs are only as good as their experience and training have made them (tempered by their own individual ability to learn, comprehend, and exercise their skills based on that comprehension).

But even still, that ability does not give them the authority to practice outside the scope of their authority or outside their protocols and standing orders.

So there are some EMTs out there who don't have very good skills yet, and other EMTs who excel right out of the gate, and still others who, no matter how much time they have under their belts, will never, EVER become trustworthy responders. They will always be rogues, they will always be dangerous, and they will always be the loose cannon.

But that's another thread....

 

[JPINFV]

This won't sit well with rule-benders/breakers, I'm sure, but you asked, so that's how I feel. We agreed to follow the rules, and we are obligated to do so for the good of the patient. Egos need to be checked at the door.

I shall now duck.

May I suggest that you start with yours? It was a serious question of not whether you follow your protocol or not, just whether you agree with it. You answered it and then went on a tirade about following protocols (which depending on where you are are either nonexistent (like where I first worked), guidelines (many places state plainly in the forward that the protocols are guidelines, and not absolute), or very liberal (where I currently work, each and every disease protocol state that EMS workers will apply oxygen as clinically indicated with no absolutes to rate or delivery method).

Now I would argue that the majority of the emergent patients (emergent being defined as being taken from someplace outside of the hospital to an emergency department) that I have transported had no real need for oxygen therapy and the majority of those that did did not need a NRB (I've seen enough of Ventmedic's posts to know not to refer to it as "high flow"). I my education tells me that

Cowboy Medicine is not the same as making good judgement calls when it falls outside protocol or standing orders.

If we follow protocols as a cook book where one misstep will ruin the product, where in a protocol does judgment come in? Let's be honest here, how many patients that are put on a NRB, or oxygen therapy in the field in general, have oxygen therapy discontinued almost immediately in the ED? Does anyone honestly think that the patient's condition has somehow magically changed by the very act of entering the emergency department and having an initial assessment done by an RN?


Of course the requirement by protocol for providers to blindly follow protocols without thought, question, or independent thought is what happens when a system fails to insure that their providers have the needed education and are forced to build their protocols around the lowest common denominator.

 

[Lin57EMT]

You answered it and then went on a tirade about following protocols...

I didn't consider it a tirade. I simply backed up my response with my supporting statements. It seemed reasonable at the time. Had I simply said "yes", I suspect the response to that would have brought us to this point anyway. Sigh. It is hard to be new on these types of lists - one mistake of list etiquette and somebody is sure to call you on the carpet.

If you (or anyone else) consider it a "tirade" and as such, found my supporting statements to be egotistical or otherwise offensive, then I heartily and cheerfully clarify that they were not intended to be. I offer anyone who is offended my sincere apology. I assumed I was free to elaborate without needing an invitation. I was wrong, and I will be much more careful in what I say from now on.

Now that you have posted your "supporting statements" (notice I didn't call them a tirade?) I would only say that I am not familiar with your protocols and would not offer any opinion on the quality of them whatsover. My comments were in reference to me and my own area. I do, however, welcome the opportunity to hear your opinion, and am grateful to be able to learn how things are done in other parts of the country.

Regarding this statement: Cowboy Medicine is not the same as making good judgement calls when it falls outside protocol or standing orders.
I can see where my meaning is unclear. I should have worded it this way: "What some people call 'making good judgement calls that fall outside of protocol or standing orders' I would probably label 'Cowboy Medicine'."

Thank you for your comments.

 

[reaper]

This taken directly from the NYS protocols!



These protocols are not intended to be absolute and ultimate treatment doctrines, but rather
standards which are flexible to accommodate the complexity of the problems in patient management
presented to Emergency Medical Technicians (EMTs) and Advanced Emergency Medical Technicians
(AEMTs) in the field. These protocols should be considered as a model or standard by which all patients
should be treated. Since patients do not always fit into a "cook book" approach, these protocols are not a
substitute for GOOD CLINICAL JUDGMENT, especially when a situation occurs which does not fit
these standards.


This all the protocols state. I see no where that says a NRB @ 15 lpm.
II. Administer high concentration oxygen.

Again, it is fine to follow protocols, but they are not absolute.

I doubt highly that they did studies and research before making each protocol. More likely pulled from text books and other state protocols. The same way most MD's come up with their service protocols.

Read the part of "GOOD CLINICAL JUDGMENT"! Not all Pt's require high flow
O2. Will it hurt them? NO. Do they all need it? NO. We do not give Narcan to all Pt's, even though it won't hurt them. We have learned that it is not needed and should not be used as a cookbook coma cocktail. Same applies to O2. It is a drug and should be used with clinical judgment!

 

[Lin57EMT]

This taken directly from the NYS protocols!

Thank you for your post, reaper.

I can see you feel strongly about your ability to make judgement calls.

 

[reaper]

This is not about my judgment. This is about making EMT's further their education and experience.

A lot of people are working hard to get people away from the cookbook medicine.

I did not post any of this to put you down. I was just pointing out that there are decisions to be made on every pt. I enjoy a lot of your posts and hope you keep them going.

 

[JPINFV]

Actually, this thread reminded me of a website I saw posted about a few years ago and forgot. Now, granted, the state of research for prehospital interventions is poor at best, Dalhousie University Division of EMS is working to tract what evidence there is for prehospital treatments and move EMS from emotional based medicine to evidence based medicine. One interesting thing is, even for respiratory complaints, they are characterizing the state of evidence for supplemental oxygen as "poor." Mind you, a lack of supporting evidence is not the same as evidence against a practice.

http://emergency.medicine.dal.ca/ehsprotocols/protocols/index.cfm

 

[ffemt8978]

Split from original thread...

 

[marineman]

I must say I'm siding with reaper on this particular issue. Like was said you won't hurt your patient by giving them high concentrations of o2 but many patients don't need it and in my service they try to steer us away from unnecessary interventions. You most certainly will have patients that require aggressive o2 therapy and at that time please don't delay in providing it for them but using it on all patients is just not sound clinical judgment.

Do EMT's in NY have pulse ox available? Not having it and going for the better safe than sorry option is the only line of logic I can come up with for these protocols. If you have a pulse ox and you are able to look at your patient you should be able to decide what concentration of oxygen if any is indicated for the patient. While the pulse ox isn't known for it's dead on accuracy a simple look at your patient can give you plenty of info, maybe ask them about their breathing and if they feel like their getting enough oxygen, look at their breathing rate and depth.

Simple cook book medicine is preventing the field of EMS from becoming the profession that many on this board are hoping it will become so while we all appreciate your input and hope that you will continue to do so please realize that many here will disagree and voice that disagreement.