Doctors as patients

[JPINFV]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

In So Cal, there weren't really any written protocols for EMTs concerning when or when not to initiate spinal immobilization. Paramedics (who are dispatched to all 911 calls) did have a spinal immobilization protocol. That protocol, as with the rest of how OC is set up, treated paramedics like little children and isn't a system I would base any treatment decisions off of.

For Massachusetts, the protocol basically gave EMTs and paramedics as much rope as they wanted to use to hang themselves by using words such as "consider."

 

[Tigger]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

If the patient is not altered or a minor with an unaltered guardian they could have fallen 20 stories and still refused spinal motion restriction, "major trauma" or not.

If you're protocols are viewable online, post em! Very few protocols mandate anything, there's always that caveat about clinical judgement. Yours may also lack an explanation of informed consent it would appear.

 

[Sublime]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

If your protocols are for >20', then how does a ground level fall from the girl in the first scenario warrant backboarding?

I can understand why many EMS providers are so adamant about c-spine immobilization because it is DRILLED into our heads in school. However this doesn't provide an excuse for your "because I said so" reasoning to the father. Do you not feel that the father deserved a logical explanation for why you're performing a certain treatment on his daughter? If your protocols truly bind you to backboarding her than all you really needed to do was explain that to the father.

Now here are a few good links on spinal immobilization that should enlighten you on the subject. I took these from previous threads on this forum that discussed the issue.

http://www.emsworld.com/article/10322876/best-practices-myths-and-realities-of-spinal-immobilization?page=2

http://journals.lww.com/em-news/pages/articleviewer.aspx?year=2002&issue=11000&article=00024&type=fulltext

 

[Veneficus]

Patient was found unresponsive at the bottom of a tall flight of stairs leading to the ground from a hay loft. Top of stairs is approx 25' from ground. Area where she was found had several large rocks. Father "woke" her and sat her down in a chair 5' away and dialed 911.

You arrive and find the above scene. She is alert but not oriented, slurred speech, right pupil does not react. Large abrasion to left side of head, 2" above ear, moderate bleeding. Several abrasions to elbows, knees, etc consistent with fall from top of stairs. Your partner gets behind her and holds manual.

She is combative with everyone. Does not want to be touched by my crew or family. Keeps repeating that she is tired and wants to nap for the party she is going to later that day and that she only fell from 2 steps up. She can not recount the fall when asked later or remember my partners name which has been told to her several times. I don't recall her vitals other than they were unremarkable.

Are you comfortable transporting her like that?

Slow down a bit...

From the absoluteness of your position, I conclude you are very new, very scared or both.

Apparently somebody has taught you to think like this, and probably rewarded it.

I am willing to bet if the patient was "fighting you" physically, you could probably conclude there was not a spinal injury.

I would also like to point out that mechanism is a very poor indicator of injury or the severity of it.

I have personally taken some hits (including a recent fall) where somebody of basic knowledge might think I "needed" backboarding.

So long as I am in my right mind, nobody will ever put me on a backboard as a treatment option.

A competent medical provider actively listens to parents and other subject matter experts before administering a treatment.

It is the knowledge of the provider that allows them to decide if the recommendations of the subject matter expert, parent or otherwise, seem reasonable to a given situation.

If you ever transport a patient on a vent, very common in EMS, one of the first questions asked is:

"what are the vent settings."

There are times when it would be correct to change such settings, instead of simply using them, but chances are, you will be going with what was selected by somebody else who is neither onscene nor able to be contacted.

Your remark of "because I said so" is a very dangerous attitude to have.

We all make mistakes and it is just a matter of time before you do.

But I submit when you think that you hold the morally superior position, forcing your will upon others will cause far more mistakes than otherwise.

Think slow, act deliberately.

 

[DrParasite]

You're shocked that protocols aren't 100% up to date and that most protocols aren't based on evidence based practices?

Not to jump in on a sinking ship, but I'm not. Very few places have protocols that are 100% up to date, and based on evidence based practices. The reason is the old ways are the defacto standard, and until doctors get with the times, are able to review everything, have the time to realize the voodoo doesn't work, write new standards and protocols, have the legal departments review it, have them allow you to do something that is contrary to the teaching of the past 20 years, give their blessing, then have the EMS experts give their 2 cents so when a lawsuit happens, you are covered, than your agency administrators need to give their formal blessing to reeducate all your medic instructors, medics FTOs, and EMS professionals, it will take years. and there will still be salty dogs who have been doing it for 20 years who refuse to admit that the voodoo doesn't work, and they will still backboard every trauma based on mechanism of injury because thats what they have been taught to do for the past 20 years.

I will accept that your system is "100% up to date and that most protocols aren't based on evidence based practices" when you tell me your ambulances don't carry backboards for spinal immobilization, and maybe have one just to use as a carrying device.

 

[Aidey]

None of us who posted claimed our systems are 100% up to date, we just said we were comfortable not putting the patient in spinal precautions. What our protocols say and what we have learned are two different things, and we know protocols are not always right. The person who posted about over ruling the guardian when the guardian said no to a back board seems to have the attitude that if it isn't in their protocols, it doesn't exist.

 

[bahnrokt]

You're shocked that protocols aren't 100% up to date and that most protocols aren't based on evidence based practices?

I'm not claiming my protocols are 100%, 75% or 50% current or close to right. But I am just an EMT B. I took a 1 semester class, passed a joke test and attend CMEs on a regular basis. Aside from that and some things you pick up on the job, my tool box is very small. Even if I work EMS for 30 years and go to medic school, the tool box is very small and the amount of information you can gather on a pt in a short window is minimal at best.

Deviation from protocols is a dangerous thing. We are not here to play doctor. You can do all the extra reading on sites like this and read the latest studies on the effectiveness of any tool. At the end of the day if you get called to the mat for playing doctor, your royally f*cked if you defense starts with "I read on the internet".

 

[Handsome Robb]

I'm curious where in the EMT curriculum/local protocols it gives you the authority to impose your will on competent patients....

Last time I checked that'd be considered battery.

As far as the little girl with the head injury, if dad doesn't wnat her boarded fine, that's his decision. He's signing a refusal of spinal motion restriction before we move any further after a thorough explanation from myself as to why I would like to place her in spinal motion restriction.

Also if she's fighting she *probably* doesn't have a spinal injury and if she does I'd bet an EMS crew fighting her onto a backboard isn't going to help her cause at all and is likely to aggravate the injury if it's present.

Per my protocols the girl in the above scenario would be boarded, she's under 12, is altered and with a presumed "significant" mechanism. Is it perfect? No, but I love where I work and I'd like to keep my job. As I said though, her father has every right to refuse treatments.

Informed consent does not equal "my way or the highway".

Edit: Another thought after reading another post, I'd personally prefer to transport this 9 yo in semi/full fowlers rather than laying her supine. Toss a collar on her and call it good. I could absolutely make a great argument to my Clinical Director and MD as to why I did what I did. A fixed pupil, AMS, combativeness and positive LOC after a fall as such that you described would put an IC bleed high on my list and if that's the case I'd like to do everything I can to keep her ICP as low as I can, hell some will even argue to forgo the collar since there has been studies stating they increase ICP by reducing venous drainage.

 

[Aidey]

I'm not claiming my protocols are 100%, 75% or 50% current or close to right. But I am just an EMT B. I took a 1 semester class, passed a joke test and attend CMEs on a regular basis. Aside from that and some things you pick up on the job, my tool box is very small. Even if I work EMS for 30 years and go to medic school, the tool box is very small and the amount of information you can gather on a pt in a short window is minimal at best.

Deviation from protocols is a dangerous thing. We are not here to play doctor. You can do all the extra reading on sites like this and read the latest studies on the effectiveness of any tool. At the end of the day if you get called to the mat for playing doctor, your royally f*cked if you defense starts with "I read on the internet".

This has NOTHING to do with playing doctor. It has to do with the attitude that the EMT and their protocols are always right and get the final say. This is wrong. The patient or their guardian get the final say. They are within their right to refuse a specific treatment, and since I know that treatment to be a bunch of voodoo, I am not going to waste everyone's time getting into a pissing match with the father in that scenario.

 

[Handsome Robb]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

Despite popular belief there are systems out there that let their providers use clinical judgement rather than "See X, do Y".

 

[DrParasite]

I'm honestly shocked by these answers. Do your local protocols back you up on this? Mine state a fall or suspected fall of >20' is a major trauma. Major trauma is automatic c spine without overwhelming evidence that MOI could not have effected spine.

It doesn't matter what your protocol says.... if a guardian wants a refuse a treatment, whether its in the patient's best interest or because the voodoo doesn't work, its still their right.

The only way protocol comes into play is if you, as the provider, are able to deviate from your protocol based on current education and research, because it doesn't work, despite the fact that protocol says you should have done it.

Bottom line, if you bring in a major trauma, and don't take c-spine because the patient or guardian refused it, as long as it's properly documented and signed as a refusal for these particular treatments, you shouldn't get in any trouble for it.

 

[heatherabel3]

As the mother of a special needs/diabetic child I am shocked and even concerned to know there are providers out there who view parents in such a poor light. I would venture to guess you dont have children of your own. Have you ever heard the phrase "a parent is their child's best advocate"? It exists for a reason. My knowledge of my child and his needs will exceed yours any day of the week. I can also promise you that if I was ever referred to as being "internet educated" I would have your job and your license by the end of the week and I am not exaggerating for dramatic effect. I would recommend you sit down with a supervisor and explain to him your position and let him tell you just how wrong you are before you end up hurting someone or your career.

 

[usalsfyre]

Deviation from protocols is a dangerous thing. We are not here to play doctor. You can do all the extra reading on sites like this and read the latest studies on the effectiveness of any tool. At the end of the day if you get called to the mat for playing doctor, your royally f*cked if you defense starts with "I read on the internet".

What about when the protocol is outdated or doesn't fit? From the Basic level it looks very simple to jam the patient in a protocol. The more knowledge you gain about risk/benefit, specific medical conditions, and the efficacy of certain treatments the more protocols start to look like "starting points" and less like "gospel". It's also why if your going to deviate you better darn well do the research. "I gave high dose NTG based on its efficacy in treating CHF and established use in other EMS systems" is a lot better than "some jack wagon named usalsfyre told me it was safe".

If you have a reason, most OMDs I've had have been open to deviation. I've had more problems out of ED nurses and QI people. What will get you slammed is "cowboying"...deviating without food reason.

 

[JPINFV]

Deviation from protocols is a dangerous thing. We are not here to play doctor. You can do all the extra reading on sites like this and read the latest studies on the effectiveness of any tool. At the end of the day if you get called to the mat for playing doctor, your royally f*cked if you defense starts with "I read on the internet".

Question, if protocols are designed for the least common denominator, and any deviation from the cook book is bad, what's the point of CMEs since you can't implement what you actually learn in them?

Also, I personally agree that "I read it on the intertubes" is a bad defense. Of course there's always other ways to verify that information (e.g. journal articles/PubMed, etc). There's always also opening up a dialogue with your medical director or, if need be, online medical control. I know of one case where a paramedic caught a dystonic reaction based on a forum scenario, but ran it through online medical control before treating.

 

[bahnrokt]

Up until this thread I felt pretty strongly that I made good decisions on that call and followed a course of action that I could justify and defend. Clearly the EMS community here has an alternate opinion. I don't think I did anything to endanger the pt, but perhaps my attitude toward some protocols and my willingness to deviate from them need a realignment.

I'm going to pull a copy of this pcr and bring it to our next QA meeting. Thank you all for correcting me and smashing all of my arguments.

 

[the_negro_puppy]

Head injured and combative child?

Nothing Midazolam won't fix.

Some for Mum/Dad as well

 

[medicdan]

Up until this thread I felt pretty strongly that I made good decisions on that call and followed a course of action that I could justify and defend. Clearly the EMS community here has an alternate opinion. I don't think I did anything to endanger the pt, but perhaps my attitude toward some protocols and my willingness to deviate from them need a realignment.

I'm going to pull a copy of this pcr and bring it to our next QA meeting. Thank you all for correcting me and smashing all of my arguments.

Did you consider getting Medical Control involved in your on-scene decision making? I think it's great you're willing to bring this to your QA meetings, and open dialogue with colleagues and your medical director...

 

[usalsfyre]

Up until this thread I felt pretty strongly that I made good decisions on that call and followed a course of action that I could justify and defend. Clearly the EMS community here has an alternate opinion. I don't think I did anything to endanger the pt, but perhaps my attitude toward some protocols and my willingness to deviate from them need a realignment.

I'm going to pull a copy of this pcr and bring it to our next QA meeting. Thank you all for correcting me and smashing all of my arguments.

Hey, the first part of learning is being able to put your decision making process out there to be examined. If your willing to admit things can be done differently and learn from that your ahead of the majority of people. I look back on some of the things I did early in my career and cringe...

 

[CANDawg]

I can also promise you that if I was ever referred to as being "internet educated" I would have your job and your license by the end of the week and I am not exaggerating for dramatic effect.

Wait. Accidentally insulting a patient is enough to revoke a license where you live? How do you even have any professionals left? I'm sure calling for a lift assist gets people fired on a regular basis for implying the patient is fat.

Thank God not every system is not itching to pull out the gallows because of a disagreement.

 

[bahnrokt]

Did you consider getting Medical Control involved in your on-scene decision making? I think it's great you're willing to bring this to your QA meetings, and open dialogue with colleagues and your medical director...

I'm a Vol EMT, in my day job I do sales, representing several large chemical companies to engineers and architects. I'm pretty good at getting people on board with my ideas and give them reasons to feel good about it. The father didn't want her boarded, not out of medical concern but for ease of getting her out of there. He's was placating her. I explained what the state protocols classify a major trauma as and what they say about boarding and ultimately he ended up agreeing to her going on a board. We then worked together to let her calmly get a collar on her and move her to a board.

I have in the past had pts talk to med control before signing an RMA form where I believed their choice was not in their best interest.