Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

EMS Needs to Be a Separate Medical Specialty – Now – Part I

Ckemtp documents one of the major problems in EMS in Every Day EMS Ethics – Self Medical Direction?

How are we supposed to deal with bad protocols, when some medical directors would rather endanger patients, than improve patient care?

Which is more ethical?

A. Follow the protocol, even though it endangers patients. I am only following orders. As long as I am following the protocol orders I am not responsible for anything that I do.

B. Violate the protocol, but document it accurately, knowing that my medical director is interested in what is best for the patient, not what is best for the protocol. My medical director makes it clear that he will support me, as long as I am acting in the best interest of the patient.

C. Violate the protocol, but document it accurately. Unlike in scenario B., knowing that my medical director thinks that a medic’s place is under the bus. Knowing that my authorization to treat patients is likely to be revoked, unless I apologize for having the arrogance to question what the medical director put in the protocol. Also, I must promise to never again protect the patient from the medical director. I may end up going to court over this, but the jury is chosen because they are unfamiliar with medicine, not because they have a clue. The medical director will be presented as the expert, while I am just the arrogant know it all.

D. I can titrate the dose of medication to the response of the patient. Stop when the desired effect appears to have been produced, realizing that things change and more may need to be given, if indicated. If my protocol does not include a rate of administration, can it really be said that I have violated protocol, by giving the medication too slowly?

E. Transport without giving the dangerous dose. Transfer care to the physician explaining that, I am incredibly clumsy and can’t imagine why I could not manage to complete a simple task, such as poisoning my patient. Mea culpa. Mea maxima culpa. Meh.

Since Ckemtp is writing about naloxone (Narcan), it is fortunate that I have written just a little bit about this – from my very first post, to one where I describe what may be the most effective way to educate a physician incompetent in the use of naloxone, to a bunch of other naloxone posts – here, here, here, here, here, here, here, here, and here. That probably is most of them, not that I have much to say on naloxone.

In answer to the inevitable comments that the medical director, even an absentee medical director, has spent years in medical school and residency. How dare I question the judgment of a physician?

First. I would hope that anyone that well educated would put the welfare of the patient above the welfare of the protocol.

Yes, protocols are important. However, if protocols are to be respected, they need to keep up with the evidence. Anything less than that just demonstrates that the physician is not acting in the best interest of the patients. The purpose of the protocol is to protect the patient. Making the protocol the weapon to hurt the patient, because the protocol is there to protect the patient, is insanely bureaucratic.

If the physician is willing to harm patients, just to make a point, or just to have his own style of control, that is not an example of patient care to be respected.

Second. Ignorance, in spite of all of that education, is nothing to brag about.

Third. This physician is advocating abusing patients. And people are defending the physician. Why are people defending the abuse of patients?

Fourth. Joseph Mengele was a physician. There is nothing about being a physician that makes one perfect, or ethical, or right. We need for good physicians to strongly oppose the bad physicians. First, both medics and other physicians should try to reason with the dangerous medical director. As I pointed out EMS is not well understood by many emergency physicians.

Fifth. The 8th Law – Half of what is taught in medical school is wrong, but nobody knows which half. Declarations of a Dinosaur – 10 Laws I’ve Learned as a Family Doctor, by Lucy E. Hornstein, MD, who writes Musings of a Dinosaur. There are links to purchase the book in her sidebar. This could explain why some medical directors do not live up to expectations.

Titration of medication is not avant-garde. Paracelsus (he lived from 1493 – 1541, so this is not exactly new) wrote –

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.

To give something in a quantity that is inappropriate is to poison the patient.

If I document good patient care that conflicts with a given protocol, I need to have a medical director, who understands good patient care. I need a medical director, who understands Emergency Medical Services. This is one of the reasons that there needs to be board certification for physicians in the medical specialty of EMS.

Separate from emergency medicine. Emergency medicine is as different from EMS as internal medicine is different from emergency medicine. One may do a good job working in the other specialty, but do you really want to be cared for by someone moonlighting in a specialty in which they are not trained?

EMS needs to be its own board certified medical specialty, because there are too many emergency physicians who just do not understand prehospital care. Too many emergency physicians who just do not understand medical direction/medical oversight.

Even those, who have worked in EMS may find that things have significantly changed since they were working the streets, or they may find that the tried and true principle of Mother may I? calls for medical command permission to provide emergency treatment are counterproductive to good patient care. Mother may I? medical command only encourages medical directors to feel comfortable allowing dangerous paramedics to work.

These medical directors claim that, I know that Medic X is dangerous, but as long as he has to call for everything, how much harm can he do? Who is more dangerous, Medic X or the medical director who sets loose a service full of Medic Xs on a defenseless population – a population in need of competent emergency care?

The medical director is there to defend the population, but the Mother may I? calls for medical command endanger the population.

Of course, I would never advocate documenting care inaccurately, because that would allow the state to pull my medic card. I must follow the protocol. I must document accurate compliance with the protocol. We must respect that when the state insists that I do something unethical, it is their position that it is unethical not to perform the unethical behavior.

Paramedic Yossarian reporting for duty.

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Trackbacks

  1. […] are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty – Now – Part I. cont still…damn restrictions… Of the 88 patients who were transported by ground, 46 […]

  2. […] wrote about the problems with bad orders/protocols in EMS Needs to Be a Separate Medical Specialty – Now – Part I. This is a little bit […]

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