Physical Assessment - DCAP BTLS

[Medic41Mike]

In medic school our instructors worked in 4 different counties hince 4 different protocols. These protocols rarely matched what was in our textbook. Our instructors read and studied their protocols, they did not read our textbook. This made for a aggravating time in paramedic school. they could not agree on anything, and you one answer could be praised by two instructors, scorned by all the others.

this is why L4L is so mad at the world. paramedic school scarred him for life.

I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.

End the end it saves your bacon rather than reading the policy and changing it to your favor

 

[JJR512]

I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.

End the end it saves your bacon rather than reading the policy and changing it to your favor

I believe the real reason why some members here are against following the protocols like "scripture" is because it leads to blindly following the protocols. Protocols cannot account for every possible situation, and some members here have encountered providers who simply could not function if the situation did not follow the script in the protocols.

 

[usalsfyre]

I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.

End the end it saves your bacon rather than reading the policy and changing it to your favor

So you follow the policies and protocols even when they don't make sense fot that paticular patient presentation? Or do you make the patient "fit the box" instead of the "box fitting the patient"? If you think this limits your liability, your sadly, sadly mistaken.

Protocols should be treated as guidelines, nothing more. If you are not educated enough to omit or add steps to the protocol in consult with med control as needed you need to step up your game or get out of taking care of patients.

 

[MrBrown]

I understand you agrivation pertaining to your previous experience at Medic school, however I personally like to follow my Counties Policies as if they are scriptures. I like having the peace of mind that if I were ever to get called to court for some sort of descrepincy between a former Pt and my Pt care, I can resort back to my PCR showing that I exactly followed my Protocols word per word.

End the end it saves your bacon rather than reading the policy and changing it to your favor

Thats pretty bad mate I mean seriously .... that sort of attitude is probably going to do some serious harm to somebody one day.

 

[Lifeguards For Life]

I believe the real reason why some members here are against following the protocols like "scripture" is because it leads to blindly following the protocols. Protocols cannot account for every possible situation, and some members here have encountered providers who simply could not function if the situation did not follow the script in the protocols.

this too. Follow protocols when following protocols is the right thing to do. When following a protocol is not the best thing for the patient, don't follow that protocol.

I still hate when people quote protocols to prove they are right. Different medical directors will have different protocols for different situations.

 

[Aidey]

My med director flat out says the protocols are guidelines and that he expects us to use our brains. If you don't do something totally stupid, can explain your actions and you had a sound thought process you aren't likely to get in trouble with him.

 

[MrBrown]

Anybody with enough education of the basic scientific and clinical rationale underpinning whatever "protocol" is flavour of the day should be able to pick up the localised verison of the day, run with and dexteriously apply it.

 

[Veneficus]

following the protocol like scripture.

The poor creatures, they don't know any better.

 

[Lifeguards For Life]

I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)

 

[MrBrown]

I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)

It is simply because as the Ninja fellow said, they don't know any better. Whatever education they got just ain't cuttin it ....

You'd never get away with "but the guideline says" here. Obviously there is a degree of clinical and medicolegal risk mitigation built into any policy or procedure however whatever protocol or guideline you work with should not be followed blindly.

On the other hand, they say a little knowledge is dangerous

Man this whole thing makes me so angry

*Brown slams his fist on the streering wheel, blasts the air horn, guns the engine and watches his face turn the same shade of orange as his "DOCTOR" jumpsuit ...

Red base, Delta Alpha is stuck in traffic .... Oz get out and see wha the hold up is

 

[JPINFV]

It is simply because as the Ninja fellow said, they don't know any better. Whatever education they got just ain't cuttin it ....

I've taken up the helm of calling a spade a spade, which means calling 'the integration of a physical exam, history, POC testing (EKG and BGL) to form an opinion of what's going on, and then form a treatment plan off' making a diagnosis. It's amazing the absolute vitriol that some EMS providers have against the "D" word. It's so bad that one person posted about how he doesn't make a diagnosis, and then uses the term "field diagnosis" while someone else posted about how I must be advocating non-transport, since apparently the only thing that occurs at hospitals is diagnosis, but no treatment.

The comments are so sad that they're slightly humorous.
http://www.emsworld.com/article/article.jsp?id=14878

 

[Veneficus]

I've never actually had any problems arise with my protocols, I just don't like when people quote them to justify their opinions. (repeated line throughout this thread)

Protocols are written to help the most number of people.

It does not mean they work for every patient you encounter. It is impossible to write a protocol for every conceivable situation. At some point clinical judgement will have to come into play.

The idea that if you harm a patient following protocol that you will not be held accountable is in error.

In medicine (and in EMS), decisions must be made on every patient. The decision not to make a decision and follow a cookbook is an option.

Can you follow the cookbook if it might harm a patient and certainly will not legally protect you?

"I was just following orders" has not been an afirmitive defense in a great many years.

Like i said with my earlier post. People believe in religion, they think if they follow it and the more literally they follow it they will be saved or get some grand reward. It remains to be seen.

If you medical director was facing suit or at risk of losing his medical license over somebody following the cookbook, I will bet dollars to doughnuts that he will defend himself by saying they were meant to be guidlines not applicable to every situation, the medics knew that, or were supposed to and it will be the medic who finds his rear hanging out in the breeze all alone.

"Ladies and gentlemen of the jury who aquitted OJ, you have heard expert testimony from an infinite number of providers that protocols are just guidlines, that clinical judgement must be excercised in the care of the sick and injured. The defendant is trying to hide behind "just following orders" in order to justify his inaction or gross negligence by performing uncalled for treatments on the deceased. You have heard the testimony of the experts saying they would not have acted that way as it would obviously not help or cause harm. You have also heard testimony from an infinite number of providers of the same level that show in the basic EMS education, it is made clear that protocols are not meant to be used as the absolute treatment decision. It is also clearly demonstrated that local protocol is not part of the national curriculum. We ask for damages in the amount of..."

(yea, following the protocol as scripture doesn't seem like a winner.)

 

[MrBrown]

The prosecution would like Dr. Brown, MBChB, PGCertHSc(AeroRetvMed), FANZCA, FJFICM, BHSc(Paramedic)(Hons), PGDipHSc(IntsvCare)(Dist) admitted as an expert witness.

Now, Dr Brown is not true that Ambulance Paramedics should have adequate knowledge and cognitive dexteriory to interpret treatment guidelines and vary them in an appropriate manner to achieve best outcome for thier patient?

In that way .... yes, oh hang on .... yes hello Delta Alpha 91 here, its a go you say, an RTA, possible RSI, Oz is on his way you say, ok have him meet me out front .... sorry Your Honour I have to go .... my standard fee will still apply however, do tell Counsel that

*Brown struggles into his orange "DOCTOR" jumpsuit and hurries to the front steps of the courthouse

 

[zmedic]

If you medical director was facing suit or at risk of losing his medical license over somebody following the cookbook, I will bet dollars to doughnuts that he will defend himself by saying they were meant to be guidlines not applicable to every situation, the medics knew that, or were supposed to and it will be the medic who finds his rear hanging out in the breeze all alone.

I'm going to flip this one around. If I was the medical director and knew that my license was on the line, I'd hope that my medics would be following the protocol that I had approved.

Most of the protocols I have seen are pretty reasonable and spell out what you can and can't do. They aren't guidelines, they are the law as far as you are concerned. If they saw "don't give nitro for a BP under 100" and you give it for a BP of 90/50 I don't care that you had an IV, that you thought it would help. You're going to get nailed to the wall.

The thing is that in almost all cases you have online medical control that you can call if the situation isn't fitting the protocol. If you call up and ask for something extra or not to do something and the doc says okay, you're protected. But I'm not going to let someone get me sued because they thought that they didn't have time to make a 3 minute phone call.

 

[abckidsmom]

I'm going to flip this one around. If I was the medical director and knew that my license was on the line, I'd hope that my medics would be following the protocol that I had approved.

Most of the protocols I have seen are pretty reasonable and spell out what you can and can't do. They aren't guidelines, they are the law as far as you are concerned. If they saw "don't give nitro for a BP under 100" and you give it for a BP of 90/50 I don't care that you had an IV, that you thought it would help. You're going to get nailed to the wall.

The thing is that in almost all cases you have online medical control that you can call if the situation isn't fitting the protocol. If you call up and ask for something extra or not to do something and the doc says okay, you're protected. But I'm not going to let someone get me sued because they thought that they didn't have time to make a 3 minute phone call.

Sued? This eternal fear of lawsuits in EMS is inflated, in my opinion. 15 years now, and I have once been involved in potential litigation, which was resolved outside of court. Our eggregious error? Dropping the patient. Pretty easy to find out who was in error there.

I think you're missing the point. It's not whether you should administer the nitro with the systolic BP less than 100 mmHg, it's whether you should even be in the ACS protocol to begin with. "Oh, but she was complaining of chest pain! We needed to be following the chest pain protocol!"

There's not usually a pneumonia protocol, or a spontaneous pneumothorax protocol. In fact, in our 200 page protocol book with far too many words, I'd be surprised if "chest pain" "nitro" and "spontaneous pneumothorax" were even on the same page.

So how's a protocol-based provider going to get from a complaint to a protocol that doesn't exist, and if your method of practicing is to use the protocols as scripture, what do you do when you don't have a chapter and verse to go to?

This is when educated clinical decision making comes into play. If, prospectively, you plan to provide healthcare using the protocols as your prime source of litigitation avoidance, how do you expect to deal with the nearly 40% of situations you'll encounter that will not be addressed specifically by the protocols?

Let's don't get caught shoehorning patients into protocol scenarios. Please, let's get educated and use scientific rationales for our decisions. It's so much more effective, and useful in closer to 100% of interactions than protocol-based medicine.

 

[reaper]

I have never seen a set protocols that did not list that they were "Guidelines for treatment". Nothing is cut and dry in medicine and any service that tries to keep their medics at protocols only, will certainly suffer.

 

[zmedic]

I guess it comes down to what you mean by following a protocol. It is one thing to say "this patient doesn't fit neatly into a protocol so I had to use some judgement on how to treat them." I have no problem with that. My problem is when the protocol is explicit about something, you know that protocol applies, and you decide to violate it anyway. The medical director put down those explicit rules for a reason. If it says you only get 2 attempts at intubation before you BLS the airway, you only get 2 trys. There is no real place for judgement to come into play. Or if the protocols say transport to the closest hospital unless you get medical control approval, and you drive an extra half an hour without calling, you are in trouble.

Some things in the protocol are cut and dried. Max doses of medication. Limits on intubation. Criteria for cath lab activations. Etc.

EMS is a agreement worked out where physicians say "you can practice under my license, but there are some rules. If you want to do something else you have to call and get approval." The reason we have this system is because the good from the very few cases where blatant protocol violation helped a patient are far outweighed from the harm if everyone could just decide for themselves when to follow those rules.

This can go round and round in the abstract. Let's hear some examples. For those who say they are just guidelines, give an example of when you (or someone else) felt the protocol was putting a patient in danger you violated them without calling medical control. Similarly I'd like to hear some examples of when someone got sued for following a protocols that directly lead to a bad outcome.

 

[abckidsmom]

This can go round and round in the abstract. Let's hear some examples. For those who say they are just guidelines, give an example of when you (or someone else) felt the protocol was putting a patient in danger you violated them without calling medical control. Similarly I'd like to hear some examples of when someone got sued for following a protocols that directly lead to a bad outcome.

That's the thing: I don't have any knowledge of a paramedic being sued for care, one way or another. I see regulatory boards investigating paramedics, medical directors calling them in for counseling/review, but NEVER have I heard of a medic sued for wrongful death, malpractice or whatever. The ONLY times I have heard of settlements have been when medics dropped a patient.

These lawsuits are myths! There is not. that. much. risk of litigation! Surely, there have been lawsuits, but in reality they are rare beyond calculation given the number of patient interactions we have each day.

The factor that should motivate us here is the desire to provide the best care possible, not the desire to avoid an astronomical risk of litigation.


Now, for your specific examples...I would say that they really can't be generalized because the decision to not follow a protocol that may or may not apply is a negative one and it is tough to track down a negative, statistically speaking. Similarly, deciding that a patient fits a specific protocol that may or may not apply and following it to the end is tough to police or track because so few of our treamtents have truly long-term implications.

Discussing hypothetical anecdotes is fun, but not really productive.

 

[zmedic]

You make a good point, and it brings up the difference between deciding not to implement a given protocol because you don't feel that it applies to the given patient, and deciding that you want to do something that your protocols specifically say you aren't allowed to do.

From what I've seen when people violate protocol it usually isn't a matter of them knowing all the protocols, knowing which ones apply to the patient and making a choice to violate them. It is much more often an education issue such as they were thinking abdominal pain and didn't recognize that in this female diabetic it may be atypical chest pain.

I'm thinking strongly about being a medical director and I don't mind doing education. But if someone tells me the knowingly violated a protocol, they knew they should have called in and didn't but thought that they knew better than I did when I wrote those protocols, we're going to have a problem. And I don't think that is someone who I'd let work under my license because I'd have a hard time trusting them.

 

[Veneficus]

I guess it comes down to what you mean by following a protocol. It is one thing to say "this patient doesn't fit neatly into a protocol so I had to use some judgement on how to treat them." I have no problem with that. My problem is when the protocol is explicit about something, you know that protocol applies, and you decide to violate it anyway. The medical director put down those explicit rules for a reason. If it says you only get 2 attempts at intubation before you BLS the airway, you only get 2 trys. There is no real place for judgement to come into play. Or if the protocols say transport to the closest hospital unless you get medical control approval, and you drive an extra half an hour without calling, you are in trouble.

Some things in the protocol are cut and dried. Max doses of medication. Limits on intubation. Criteria for cath lab activations. Etc.

EMS is a agreement worked out where physicians say "you can practice under my license, but there are some rules. If you want to do something else you have to call and get approval." The reason we have this system is because the good from the very few cases where blatant protocol violation helped a patient are far outweighed from the harm if everyone could just decide for themselves when to follow those rules.

This can go round and round in the abstract. Let's hear some examples. For those who say they are just guidelines, give an example of when you (or someone else) felt the protocol was putting a patient in danger you violated them without calling medical control. Similarly I'd like to hear some examples of when someone got sued for following a protocols that directly lead to a bad outcome.

I understand your point and it is not that I disagree, but if I could just offer what I have seen.

Patient calls for difficulty breathing. Arrive to find elderly patient with roughly stage 3 CHF. Warm to the touch. Lead medic decides this is CHF exacerbation. Effortlessly follows the CHF protocol. As it gets further down the list the lady is progressively worsening. Medic administers a total of 120mg lasix by standing order. Patient is admitted to the ICU and follow up leads to a dx of pneumonia.

Based on presumptive dx, i watched a single classification of CHF in this case and the blind following of the CHF protocol to the maximum allowed without calling. As treatment progressed the patient worsened. Perhaps not totally because of the treatment. But at what point do you s a provider decide and at what point of following the orders that you need to stop what you are doing and reevaluate you approach?

I am not suggested making up doses or treatments beyond the norm w/o permission.

I watched the same medic refuse to assist a patient in taking their duoneb treatment, because as he explained "our protocol states we administer only albuterol." which it did clearly state for suspected COPD we would administer albuterol because it was all we had on the truck. But we also had a protocol that stated a provider could assist in taking prescribed meds. So despite the fact a doc prescribed it, it was albuterol and atrovent (better than albuterol alone) in the name of following the COPD protocol, we gave a lesser medication than was indicated, available, and prescribed by somebody with far more knowledge than we had. We even had a protocol that permitted us to do it.

But based on presentation, sometimes it helps to mix and match protocols, not select one and follow it until you can do no more without calling and then not call.

I can't find it (google failed me) but i do remember reading several years ago on JEMS i believe about a Michigan medical director testifying in court his protocols were guidlines. Maybe some of our Michigan collegues are more familiar with it and can point us in the right direction?