Outdated protocols and medical director behnd the times.

[Epi-do]

If I had any doubts about stepping back in time with my current job, they were erased last night. The medical director was the ED doc, so I asked him about a run we recently had.

The run was a young, healthy, 20-something that didn't lift her foot up quite high enough when stepping out of the tub, causing her to trip and fall forward. She bumped her forehead on the edge of the sink as she fell. There was no bruising, swelling, redness, etc where she claims to have bumped her head. There was no loss of consciousness and the only complaint the girl had was mild pain on her forehead. She is also putting on quite the show for the rest of the family.

Everyone else on scene wanted to board and collar this girl. There was absolutely no reason, IMHO, to do so. However, there is not a protocol in place that allows for me to selectively c-spine someone, and the ED docs have beat into everyone's head around there that absolutely any injury to the head or neck must be c-spined, no matter what the complaint, or lack there of.

Since I am still new, rather than step on anyone's toes or unintentionally "insult" someone due to small town politics, I went along and let the girl be boarded and we headed to the ED with her, where she was immediately removed from the board and collar.

All I could think was how absolutely ridiculous it was to have to do this to this girl. There was absolutely no reason what so ever to even think about boarding her. So, I decided the first opportunity I had, I was going to as the medical director about it.

Last night was that opportunity. After explaining the run to him, as well as what was done in the ED, I told him that personally, I didn't think there was even a reason to consider boarding and collaring her, but wanted to know if, as I had been told by my co-workers, he really wanted us to do that for these sorts of runs.

His response was that as the senior medic (aka only medic 99.9% of the time) on scene it was ultimately my decision, but he would prefer I board and collar everyone. His exact words to me were "It is better to board a few people who don't need it, since we get them off the boards pretty quickly, rather than miss something and not board that one person that really does need it." He went on to say he thought it was important to board them because that gives us additional time with the patient where something else may become apparent that isn't easily detectable initially. All I could think was, "Really? Like what? That there tailbone or back now hurts from laying on the hard board?"

We are the only ALS provider in the county, and the closest provider for a handful of services in some of the surrounding counties, so we can easily have 30+ minute responses at times. I just don't see how the policy of punishing, err.....c-spining, the masses to protect a very, very select few is good practice. Of course, this is coming from the same doc that doesn't support getting 12-leads for the ambulances "because it isn't going to change what you do for them, and they take too long to do."

I guess you could say I am not too impressed with my medical director. And to think, the people I work with think they have these incredibly liberal and progressive protocols and that the medical director is the best think since sliced bread. He may be a nice guy and very intelligent, but he is way behind the times when it comes to current practices in EMS.

 

[usalsfyre]

Good luck. If he's that far behind it's not going to change without a medical director change.

 

[Shishkabob]

Since he said it's up to you, I'd take that and run :lol:



We had a patient several weeks ago AMA from an MVC, then call a few hours later complaining about head, neck, back, and pain all over. We didn't backboard. Technically, protocols say to. But I used my medical discretion and chose not to. No point, what's been done was done (which was nothing) and I was also not willing to risk my back for something of the like.


We get to the ER and the doc thanked us for not backboarding the patient. Yay me.

 

[mgr22]

Since you're the only medic most of the time, that puts you in a better position than most of us to at least suggest changes to your protocols. Why not pick two or three issues, support your recommendations with research, and present them in a private, non-threatening setting? You might be surprised by the response. Even if nothing changes, you'll establish a rapport with your medical director and show him you're capable of critical thinking.

 

[VFlutter]

Good luck. If he's that far behind it's not going to change without a medical director change.

+1

I am guessing he is very conservative in all aspects of his medical practice. That has its pros and cons but either way you most likely will not be able to change his outlook.

 

[Bullets]

Do you not follow National Registry and PHTLS?

Do your protocols specifcally state when and when not to apply SMR?

 

[Veneficus]

Several years ago there was an article in the NEJM that demonstrated physicians outside of academic hospital settings fall into a thinking and treatment rut about 10 years after they are out of residency.

From this point on they are not readily agreeable to change and often prescribe the same treatments without considering alternative dx until the treatment fails to work.

Several years ago I thought I might make a rather progressive medical director, sometime early in my medical school career, I decided not only was it not likely to get a spot as I have no interest in emergency medicine as a specialty, I decided that the whole culture of EMS medical directors was way too much BS than it is worth.

Even the most progressive ones basically have their hands tied by "the standard of care" aka the crap all the deadbeats are doing and won't change.

I also have mixed feelings about medical direction being soley in the hands of EMs. While this seems almost intuitive at first, the idea quickly begins to lose appeal when you consider that not only is Anesthesia usually the "emergency" doctor in most of the world, but they usually see the most amount of really sick patients, and often provide a similar psychomotor skill set.

I have even seen senior trauma surgeons forced from prehospital EMS simply out of politics of the Emergency Medicine specialty, not for the benefit of patients. I mean why would somebody who is interested in EMS care and advancing the level of it, as well as integration with the hospital, be unfit to be a medical director compared to somebody who doesn't handle critical as well as anesthesia, doesn't handle nonemergent medical as well as IM, and has less surgical capability than a surgeon?

In medicine politics and ego always trumps medical care.

But you will have better luck switching systems than trying to convince this medical director of anything. Judging from your comments, you are very rural, and people suffer and die out there without the benefit of modern medicine.