what happens when you deviate from protocol?

[Brandon O]

A couple random additions:

- As a somewhat little-known point in our statewide protocol, it states that if ALS is unable to make contact with medical control due to communication failures, they are authorized for all interventions that would ordinarily require such authorization. It does need to be reviewed later.

- Anytime a doc orders something, such as a med, contrary to its protocol-delineated use, he needs to fill out a form for state review, so they are understandably reluctant.

- The legal standing of orders that violate your regional protocols (state, county, service, whatever) but are directly ordered by online med control is somewhat unsettled. I like to point to this case from 1997 (a wholly true story):

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

 

[zmedic]

- The legal standing of orders that violate your regional protocols (state, county, service, whatever) but are directly ordered by online med control is somewhat unsettled. I like to point to this case from 1997 (a wholly true story):

This is reminder that you have to know who is going to be picking up the phone when you call "medical control." In some places you are talking to your companies medical director, or one of a few authorized medical control docs. Compare this to other places where a red phone rings in the ER and you are talking to whatever MD happens to be nearby. Some may be residents, some may only know what they learned in their 2 week EMS ride along during training.

So you as providers likely know much better than the person you are talking to what your protocols suggest, what the specifically forbid. That's worth remembering because you can get jammed up if you talk the medical control doc into letting you do something you know is outside of state protocols.

I think you should expect to lose your license if you have someone talk you through a procedure that you've never done before and isn't in your protocols. (Amputation, chest tubes, crics for EMTs etc). You can argue if thats right or not. But lots of state EMS boards aren't going to care that some random ER doc on the phone said you could crack the patient's chest and look for tamponade.

 

[mycrofft]

I find the discussion good because it has not lapsed into the "what I can get away with" or "what I'd do anyway because I'm RIGHT" avenues of BS.

The vollie group I have been working with has no effective medical control other than a binder four inches thicken with all the protocols and etc., and someone who retrospectively looks stuff over or might answer a consultant question. Waiting for the card house to fold. Won't be there.

 

[DrParasite]

If you're a properly educated HCP, why are you sitting in a call centre reading scripts? On the other hand if you're not, why are you questioning the script? It kind of seems like you're in some kind of grey area between the two, which begs the question as to why.

To answer your first question, because the boss's boss wants us to, and because our medical director agrees with him. I think it alleviates the liability on us if we follow the script, instead of relying on our own judgement.

to answer your second question, all of our dispatchers and call takers are EMTs, with a few paramedics who were originally cross trained as EMTs before going to paramedic school.

to answer your third questions, see answer #1.

A BS working dispatch, we must truly be in a depression. Kinda a bummer.

Not at all. I got my BS, did the corporate world for about 2 years, and was unhappy with how management treated me and by the job I was doing (as well as the pay). So I picked up a per diem job 12 hours a week doing urban 911 EMS. a year into doing that, I realized I was happier on an ambulance than in corporate america.

I switched to EMS full time, where the pay was decent (but at least if I work more than 40 hours, I get time and a half), where my job can't be outsourced. After 5 years of playing on the ambulance, I decided I wanted a change, so I accepted a job with a pension, in a bigger city, for more money. And last year I grossed about $63,000 working in EMS, and I'm only an EMT.

Can you say the same?

A couple random additions:

- As a somewhat little-known point in our statewide protocol, it states that if ALS is unable to make contact with medical control due to communication failures, they are authorized for all interventions that would ordinarily require such authorization. It does need to be reviewed later.

we have radio failure protocols, but they are ALS agency specific. some will allow every approved treatment to be given (even ones that are only to be given when MedControl says so), while some are more restrictive.

- The legal standing of orders that violate your regional protocols (state, county, service, whatever) but are directly ordered by online med control is somewhat unsettled. I like to point to this case from 1997 (a wholly true story):

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

Just for corrections, it was a Jersey City dual medic crew that did it, not North Bergen. There was a North Bergen BLS crew on the scene as well. And the hospital backed the crews actions 100%, and considered them heroes. They weren't freelancing, they weren't trying to show off, they weren't newbies, and they did it with 100% agreement with the medical control doc (who they probably knew personally). They did what they thought was right, and the hospital agreed with them.

Unfortunately, the state dept of health disagreed, but I am pretty sure they sleep well with their actions, and wouldn't be able to sleep as well if they did nothing. NY Times article on what happened

But that whole situation is off topic, since it was done with the medical control's consent and approval. I am talking about not following off line protocols, or modifying protocols to be more accurate or help treat the patient more appropriately.

Sort of like not backboarding someone who self extricates from an MVA with minor neck/back pain, despite state protocol that says all neck and back pains from MVA need to be backboarded.

 

[zmedic]

Sort of like not backboarding someone who self extricates from an MVA with minor neck/back pain, despite state protocol that says all neck and back pains from MVA need to be backboarded.

That answer to that situation is to either work with your medical control doc to implement NEXUS/Canadian C-spine protocol, or to tell the patient "hey, we recommend putting you on this board and c-collar, but you have the right to refuse."

For something as cut and dried as that, if you knowingly violate protocol you risk anything from a talking to to getting fired. Imagine the conversation with your supervisor:

"So what does the protocol say one should do with any patient with neck pain after an MVC?"

"it say to backboard them."

"Did that patient have neck pain?"

"Yes."

"So you intentionally disregarded protocol, without calling medical control?"

We spend a lot of time writing those protocols. It's one thing if someone forgets part of the protocol, or if they are in a situation that doesn't quite fit a guideline. But I'm not sure I would want someone working under my medical license who feels that they can do whatever they want.

 

[Veneficus]

We spend a lot of time writing those protocols

Maybe you do, but in my experience, most medical directors are nothing but absentee landlords who have no interest in modern science or changing what has been done for 40-50 years based on expert opinion 40-50 years ago while at the same time discounting the expert opinion of today.

Then you have the ones who simply sign off on protocols they buy from another source or refuse to be the first one to change anything for fear of litigation.

If nobody is the first to change, nothing progresses. It is even worse with state protocols.

I find little sympathy for a group of physicians who spend more effort protecting their butt than instituting modern guidlines for the treatment of patients on today's realities.

"Doctor" is far too generous a term and conveys far too much respect for people who behave such.

 

[Brandon O]

An important addendum, I think, is the human element. This is not generally like a court of law, where you can point to the word of the protocols and make a case why you think you were not technically in violation, or you were but for the right reasons, and here's what the literature says and the risk/benefit you perceived, etc etc.

There are probably twenty people above you at various levels who have the power to end your career, or your job, or at least censure you, and in most cases the only standard is their opinion. Your supervisor or CQI manager disagrees with your take on the clinical situation? You're gone. Your medical director thinks you were hotdogging rather than being smart? You don't get to argue.

As a random example, although there it nowhere states in our protocols here that suspicious mechanisms (there's a list) mandate C-spine, that is how many people read it. I suppose it behooves you to try to feel out these matters beforehand with the relevant people, but there are so many variables and so many different sources of potential trouble that you're never on entirely solid ground. So you can see why people tend to err on the conservative side.

 

[Brandon O]

Unfortunately, the state dept of health disagreed, but I am pretty sure they sleep well with their actions, and wouldn't be able to sleep as well if they did nothing. NY Times article on what happened

But that whole situation is off topic, since it was done with the medical control's consent and approval. I am talking about not following off line protocols, or modifying protocols to be more accurate or help treat the patient more appropriately.

My point, and the reason I try to keep that yarn alive, is that neither doing what seems best, nor following the orders of medical control, nor even being right is necessarily adequate armor if somebody important thinks you were wrong. Sometimes the bear eats you.