General, weird question about EMS, knowledge, and protocols/standing orders

[intelli78]

Alright, so I am just wrapping up my EMT class this week, and I have been mulling a question. Keep in mind that this question is from someone with only book knowledge - it might not even make sense, because my premises could be wrong in the first place. In fact, they almost certainly are, but I just don't know in what way. I hope someone understands my line of thinking and can help.

The question is, how much "leeway" do EMTs have with regard to standing orders/protocols?

I started wondering about this after looking at my local SO/protocol documents. Just based on what I saw in the PDFs, it seems there are very rigid decision trees for various patient presentations (cardiac arrest, chest pain, seizures, etc). But, I feel like there must be more leeway than it appears, because I see people on here all the time talking about the importance of learning and keeping up with new research, etc. From my perspective, I am thinking that if EMTs really operated all the time with such simple decision trees, it would mean learning and new research would be useless or even detrimental. It wouldn't matter if you had knowledge above and beyond, because you would still be limited to performing the routine actions dictated by protocols/standing orders.

So, what's the deal? Is there more leeway than it appears, or is real-life implementation different than on paper? Does extra-curricular knowledge come into play in a way that I don't understand, like maybe in history taking which seems much more free-form than treatment?

Like I said, kind of a weird question, but I think it's a valid one. Thanks in advance for responses...

 

[leoemt]

Well how much "leeway" you get is really up to you and what your willing to risk. Standing orders / protocols have been put in place to guide you through treatment of a patient. They are in no way shape or form an "instruction manual".

What is important is your Scope of Practice. Going outside of that will get you in big trouble.

If you ever read protocols you will notice they are open ended. For example ours will say something like "initiate oxygen therapy if appropriate for presenting signs and symptoms."

Bottom line is you need to do what is best for your patient based on their signs and symptoms while remaining within your scope of practice.

 

[Clare]

I did put something here but it seems to have not come up, strange.

Clinical Practice Guidelines are guidelines only, you must use your knowledge and judgement as no written guidance can cover every situation.

 

[TheLocalMedic]

On the whole, most protocols are developed along the "if-then" format. For example; if a patient is complaining of chest pain, then gather a history, perform a 12 lead, give aspirin, nitro, morphine and O2, gain IV access and transport. (I know, your local protocols may differ in the details)

The reason they have evolved along this route is because these are the acceptable standard treatment modalities. Most cases are fairly straightforward and these "cookbook" guidelines outline the normal procedures that are expected when dealing with a particular complaint.

However, there is no substitute for good ol' common sense! Generally, most of the calls I go on aren't as simple as my protocols seem to make them. Patients may have multiple problems or there may be some ambiguity as to whether their symptoms fall into any particular category. Protocols and guidelines are exactly that: they are general guidelines for you to follow. Please bring your own assessments and understanding of treatments into play when you are caring for patients, as long as you aren't doing anything too radical or anything that may harm the patient. It is important to keep up on research and evolving treatment modalities, and if you see a trend that appears to be improving patient outcomes, they why not start implementing that into your basic patient care? Where I work we have a good rapport with our medical director and I often go to him with questions about new studies and ideas for how to improve patient care, so remember that you have people like this as a resource to turn to when you have questions about new treatments and the like.

 

[usalsfyre]

Depends entirely on the service. For my purposes here the amount of leeway you're given often has to do with the justification of your decision making.

 

[Bullets]

There is a difference between your treatment protocols and you standard of care. The standard of care is rigid, as a EMT i cant run a 12-lead, start and iv or push or carry meds. Those you have to adhere to.

You treatment protocols are set by the service to guide you through what the medical director feels are appropriate. Such as chest pain consider Oxygen, neck and back consider SMR. But most protocols ive seen use words like "consider" and "if"

Do whats best for the patient within your scope.

 

[mycrofft]

Well how much "leeway" you get is really up to you and what your willing to risk. Standing orders / protocols have been put in place to guide you through treatment of a patient. They are in no way shape or form an "instruction manual".

What is important is your Scope of Practice. Going outside of that will get you in big trouble.

If you ever read protocols you will notice they are open ended. For example ours will say something like "initiate oxygen therapy if appropriate for presenting signs and symptoms."

Bottom line is you need to do what is best for your patient based on their signs and symptoms while remaining within your scope of practice.

THERE's your "money shot"

The protocols may not be a how-to, but they may serve as company guidelines outside which your arse is grarse.
Protocols which say " "initiate oxygen therapy if appropriate for presenting signs and symptoms." must list any signs or symptoms they want addressed, beyond those taught as part of the standardized curriculum which your certificate says YOU KNOW.

The open end of any protocol is to allow you to do something when the situation as you know and see it is not responding to the protocol. This ignorance can be due to a problem past your training, or something you can't se in the field or don't know about the pt's history or main complaint (or secondary or tertiary). Do it without wanton recklessness or negligence yet within your scope and training, and pray it works.

There is at EMTLIFE and elsewhere an overweening sense that protocols are there to keep you and me from doing stuff for the patient. Answer is, damned right. I cannot imagine how many times a medical person of any level of education has "done something" for a patient and watched them die or become invalid due to that "something"...and as a tech, you are not qualified to start trying to use something a doctor told you once, or a journal article you read somewhere. You are qualified to discover information, apply it to models (protocols) and follow treatment orders written by a doctor in those protocols.

Every set of standardized procedures and protocols ought to be entitled "What I Would Have You Do If I Can't Be There" and signed boldly by your medical director.

 

[mycrofft]

Uh, little much?

 

[intelli78]

Heh, not at all, in fact all of the replies are very helpful. Makes a lot of sense - the protocols and standing orders are guidelines and allow for flexibility depending on judgment. The scope of practice is what's rigid, but it only describes permissible treatments/interventions generally, not specific actions depending on patient presentation. The AAOS book could have been clearer on these points.

But at the same time, it sounds like you, mycrofft, are cautioning that some providers take TOO many liberties and irresponsibly apply knowledge from self-study.

 

[Veneficus]

Heh, not at all, in fact all of the replies are very helpful. Makes a lot of sense - the protocols and standing orders are guidelines and allow for flexibility depending on judgment. The scope of practice is what's rigid, but it only describes permissible treatments/interventions generally, not specific actions depending on patient presentation. The AAOS book could have been clearer on these points.

But at the same time, it sounds like you, mycrofft, are cautioning that some providers take TOO many liberties and irresponsibly apply knowledge from self-study.

I wouldn't say they take too many liberties.

I think it is just a question of realizing your limitations.

One of the biggest pitfalls in any branch of healthcare is learning on the job without the appropriate background knowledge.

A single published study or hearsay is not really good enough.

What I usually see is a provider learns to do something a certain way and thinks that way is always applicable or anyone not doing it that way is wrong.

It is also quite impossible to see the thought processes of providers. Consequently the uninitiated or overzealous often try to replicate the action they see only.

At the EMT level, medicine is basically "if you see x then you do y, anything outside of that you call for help."

Contrast that with medicine at the doctoral level. "This is what we know today, best of luck."

It is not advisable to go off the decision or sole advice from one physician when treating your patients.

That is the opinion of a highly educated provider. Others may not share that opinion. If you try to apply it outside of protocol, you can make a mistake in when it should be applied as well as how.

Also, the opinion that matters most to you is your medical director.

As for leeway, it is service dependant. There is no single answer. But the best leeway is to call and get permission.

 

[mycrofft]

Heh, not at all, in fact all of the replies are very helpful. Makes a lot of sense - the protocols and standing orders are guidelines and allow for flexibility depending on judgment. The scope of practice is what's rigid, but it only describes permissible treatments/interventions generally, not specific actions depending on patient presentation. The AAOS book could have been clearer on these points.

But at the same time, it sounds like you, mycrofft, are cautioning that some providers take TOO many liberties and irresponsibly apply knowledge from self-study.

A protocol or standing order is a medical order from your medical director. You diverge from it at your own and the patient's risk.

Since medicine is an art, you might find at times that you need to do something besides what's written, either due to wierd circumstances, or ignorance (just means something you don't know, for whatever reason). If you go off protocol, you had better have a good solid reason to do it, and another to support what you either did, or what you stopped doing.

Rule of thumb: if protocol isn't working, you need to think fast and get the pt to the receiving facility, or you will be rapidly caught in a "coffin corner" of cascading problems (aka The "Single Combat With Death" Syndrome).

 

[mycrofft]

PS: from personal experience, I can tell you there can be some pisspoor protocols out there, at many levels of care. Know your stuff and use that as the base from which you judge all else in your scope.