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

- Rogue Medic

50 Shades of Grey…Protocols

David Aber has some nice words to say about me in a recent post, so it is a bit of a disappointment to disagree with his main point. He writes –

I am one who believes that if protocols are well written, there should be no grey areas. I also consider myself far from a “cookbook” provider. However, I do realize that should something occur as a result of deviation from the protocols without proper authorization, that is where providers run into trouble.[1]

Well written protocols would encourage paramedic discretion. If there is a deviation from protocol that is not bizarre, why not address it at the hospital after the call?

Is there some reason that doctors cannot evaluate the appropriateness of treatment after seeing the patient?

Are medical directors really putting such dangerous medics on the street that the medics will harm patients without the magic phone call?

In the last few decades, one thing we have learned is that medical command permission requirements will be discarded as we realize admit that these requirements are not good for patients.

It is ingrained in EMS providers that should they ever have a question about deviation from a protocol, they should contact medical control.[1]

Protocols should be written for thinking paramedics, not for multiple choice from textbook patient presentations.

A thinking paramedic understands the harm of providing too much treatment, such as the 2 mg naloxone or the 25 gm 50% dextrose that David mentions.

Given the must get permission first approach, if medical command does not give permission, should the medic give an unnecessary treatment to a patient just to satisfy the protocol?

What if the medic calls command and is told to just follow the protocol?

Does the medic waste the supratherapeutic medication?

Does the medic harm the patient by giving a drug that has no possibility of providing benefit?

Is it worse to violate a protocol or to intentionally harm a patient just to protect the protocol?

I realize that David was referring to well written protocols, but well written protocols make allowances for protocol deviations and the review of these protocol deviations after the call. Are protocol violations that are expected and allowed still grey areas?

Since written protocols cannot feasibly address all patient care situations that may develop, the Department expects EMS providers to use their training and judgment regarding any protocol-driven care that in their judgment would be harmful to a patient under the circumstances.[2]

Medicine is not black and white, but grey and probabilistic.

Protocols should be written so that if a provider follows them, there should never be a question about the care they provided.[1]

 

No.

Choosing the protocol is not much different from a multiple choice exam.

If I choose the wrong protocol, is that good?

Does it matter how perfectly I follow the protocol I chose?

If I disable, or kill, a patient by perfectly following a protocol that should not have been followed, should I be immune from criticism, or from recourse?

Hell No!

But that is exactly what a lot of students say they are looking for –

What do I have to do to make sure that I will not get in trouble?

Well, you have to avoid any kind medical job.

If we want to know how to screen the bad people out of EMS, this kind of question is a clue.
 


 

How can I occasionally kill patients and not be responsible for my actions?

Why do we encourage these people in EMS? Why do we cater to them?

I am not the only one who thinks protocols should be written to encourage discretion. Kelly Grayson writes –

We are doing unnecessary things just because they’re in the protocol.[3]

We are poisoning our patients, just to avoid getting in trouble.

Yay! Aren’t we cool.

Footnotes:

[1] 50 Shades of Grey…Protocols
Posted by David Aber
The EMS Difference
June 30, 2012
Article

[2] The Two Most Important Words in an EMS Protocol
The Ambulance Driver’s Perspective
by Kelly Grayson
March 26, 2008
ems1.com
Article

.

Comments

  1. Protocols IMO cater to the weakest provider. Giving them a template to treat a patient who meets certain presentations. They wont deviate from it since it is easy and safer “for them” to just follow the written word that is brought down from the medical director with the safety net of ” I am working under a doctors license and they they said this is what I should do” who am I to question the doctor’s orders and put his license in jeopardy? <– a whole notha topic.
    People would rather just go along to get along and not rock the boat, even if they know a treatment in a protocol may be over treating a patient or may be something that the patient could do without or even harm them, hiding under the protocol umbrella.
    Calling med control is an option when deviating and should be used if the provider thinks that a protocol would do harm. Of course like you mentioned you do run the risk of the doc telling you just follow the protocol and then your in a hard spot.
    I have been caught by QA/QI by calling a doc to withhold treatment on standing orders that I felt the patient didn't need, being told " You didn't have to call med control, you could just give that med" at same time told "You should have called med control because you gave that medication, just to let the doc you did it."
    I am sure many others meet this type of commentary and may be a reason why so many just follow the protocols to a tee and not have to deal with charts getting QA'd and just fly under the radar.
    The key I guess is if you deviate or question treatment in a protocol, you need to educate yourself as to why you do and present that to the powers that be. Promoting change in a guideline or at least shining light as to why it may be omitted, questioned or seeking clarification for a patients sake and not just what your paperwork says.

    • Jim,

      Protocols IMO cater to the weakest provider.

      I agree. I can get almost anyone to agree with that.

      The problem is that few people want to do anything to change that, because they see the alternatives as increasing liability.

      Does requiring a higher level of competence increase liability?

      Giving them a template to treat a patient who meets certain presentations. They wont deviate from it since it is easy and safer “for them” to just follow the written word that is brought down from the medical director with the safety net of ” I am working under a doctors license and they they said this is what I should do” who am I to question the doctor’s orders and put his license in jeopardy? <– a whole notha topic.

      Yes.

      People would rather just go along to get along and not rock the boat, even if they know a treatment in a protocol may be over treating a patient or may be something that the patient could do without or even harm them, hiding under the protocol umbrella.

      Don’t make us think or act as if we are giving treatments that are dangerous.

      Never mind that about a third of the drugs most medics carry are given for off-label indications.

      If we understood more about medications, we might be much less aggressive with some of the medications.

      If we understood more about the medical conditions we treat, we might be much more aggressive in treating with some other medications.

      Calling med control is an option when deviating and should be used if the provider thinks that a protocol would do harm. Of course like you mentioned you do run the risk of the doc telling you just follow the protocol and then your in a hard spot.

      There is also the problem of having to interrupt assessment and/or treatment to contact medical command. There may be a delay to get a doctor on the phone. And there is sometimes the problem of discussing the patient’s condition in front of the patient.

      I have been caught by QA/QI by calling a doc to withhold treatment on standing orders that I felt the patient didn’t need, being told ” You didn’t have to call med control, you could just give that med” at same time told “You should have called med control because you gave that medication, just to let the doc you did it.”

      It seems that some of the worst people in EMS end up in the quality control business.

      I have been told that I did the right thing in deviating from protocol and in disregarding the orders of the on line medical command physician, but each time I have been told not to do it again.

      They didn’t like the way I did it and would have preferred if I kept calling back until the doctor refused to take another call, or that I not treat the patient appropriately and take it up with the doctor after the call.

      In other words, it is better to harm the patient than to do what is best for the patient, if doing what is best for the patient requires deviating from protocol.

      Just more evidence of the absence of ethical standards in EMS.

      I am sure many others meet this type of commentary and may be a reason why so many just follow the protocols to a tee and not have to deal with charts getting QA’d and just fly under the radar.
      The key I guess is if you deviate or question treatment in a protocol, you need to educate yourself as to why you do and present that to the powers that be. Promoting change in a guideline or at least shining light as to why it may be omitted, questioned or seeking clarification for a patients sake and not just what your paperwork says.

      Yes.

      Better to have a bunch of protocol monkeys than to have people doing what is best for the patient seems to be the attitude in many places.

      .

  2. Humm…Well maybe my posting was not written clearly enough. Because, after reading yours I feel that we are in agreement about protocols. My comment about following protocols and then never needing to be worried about questioning maybe needs a little clarification. I am glad that I for one do not operate in a “Mother may I system.” I work under very good protocols that allow for things such as sedation of combative patients and chest decompression without medical control contact, both which don’t need the delay of using the “magic microphone.” However, we still have providers wasting time calling for approval.
    Towards the end of my post I made the point about the EMS profession being taken seriously by M.D’s. If we cannot even follow what we have written for us now, what foot do we have to stand on to make our case for less “multiple choice” vs. essay type protocols?

    If protocols can be deviated from and then discussed at the hospital then put it in black and white. I would love to see it! But we should not twist the “shades of grey” to make our job easier. We are there for the interest of the patient right?

    From reading many of your blogs and listening to pods that you have been on, I know (and sometimes agree) that you believe in EMS doing the best for the patient. I don’t think you will find a single provider that disagrees in that fact. However, how to get there, will take more time than just saying we are poisoning patients. Sad…but true!

    • David Aber,

      Humm…Well maybe my posting was not written clearly enough.

      That is one of the problems with protocols. One person reads it one way, while another reads the same words to mean something else, and a third person has third interpretation of the words.

      The typical patient may have a typical presentation, but there are many variations on that presentation. Plenty of those variations will be atypical.

      Because, after reading yours I feel that we are in agreement about protocols.

      Probably yes and no. I think that it is important to move from requirements, whether treatments or permission for treatments (or to withhold treatments), to considering a variety of treatments.

      We are going to be transferring care at the hospital, so that is a much better time for oversight of deviations, than interrupting assessment and treatment to make a phone call and explain everything to someone who cannot see the patient.

      My comment about following protocols and then never needing to be worried about questioning maybe needs a little clarification. I am glad that I for one do not operate in a “Mother may I system.” I work under very good protocols that allow for things such as sedation of combative patients and chest decompression without medical control contact, both which don’t need the delay of using the “magic microphone.” However, we still have providers wasting time calling for approval.

      But how much sedation can you give without calling for orders?

      Sedation protocols tend to be conservative, which means only one thing – inadequate for the truly combative excited delirium patients.

      How many IM shots will we need to give to adequately sedate the patient?

      How long will it take for the sedative to take effect?

      What drugs do we have available?

      This conversation among medics on EMT Life can give an idea of the diversity of protocols and just how horrible some sedation protocols are –

      http://www.emtlife.com/archive/index.php/t-24907.html

      You mention that there are still people in EMS who will call for permission. They do not seem to want to accept any responsibility for their actions.

      Every treatment we provide is our responsibility.

      Columbia Medical Center of Las Colinas v Bush
      November 20, 2003
      Case

      Essentially, a paramedic followed a doctor’s orders to give verapamil to a patient with a history of ventricular tachycardia and presenting with wide complex tachycardia.

      The medic claims that following the orders of a doctor is protection from malpractice.

      The court did not agree with this defense.

      Those who call for everything seem to expect that the orders they receive will be correct.

      Adherence to protocol was significantly less likely to occur as the acuity of the patient’s condition increased (p < 0.001). Nonadherence was more likely to be judged appropriate rather than inappropriate (p < 0.05) as the acuity level increased. When there was nonadherence to protocol, the use of OLMC did not improve the care provided.
      CONCLUSIONS: OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.

      Effects of on-line medical control in the prehospital treatment of atraumatic illness.
      Klein KR, Spillane LL, Chiumento S, Schneider SM.
      Prehosp Emerg Care. 1997 Apr-Jun;1(2):80-4.
      PMID: 9709343 [PubMed – indexed for MEDLINE]

      Towards the end of my post I made the point about the EMS profession being taken seriously by M.D’s. If we cannot even follow what we have written for us now, what foot do we have to stand on to make our case for less “multiple choice” vs. essay type protocols?

      You lost me there. If the protocol is inappropriate, then how does following it, and endangering the patient, encourage doctors to have confidence in our judgment?

      From reading many of your blogs and listening to pods that you have been on, I know (and sometimes agree) that you believe in EMS doing the best for the patient. I don’t think you will find a single provider that disagrees in that fact. However, how to get there, will take more time than just saying we are poisoning patients. Sad…but true!

      We need to get EMS to stop hiding behind protocols and start taking care of patients.

      Discouraging thinking does not encourage good patient care.

      If protocols can be deviated from and then discussed at the hospital then put it in black and white. I would love to see it! But we should not twist the “shades of grey” to make our job easier. We are there for the interest of the patient right?

      Why do you assume that this is about making our job easier?

      In what way does deviating from protocols make OUR job easier?

      I need to explain to the doctor, to the medical director, and to the QA/QI/CYA people (and pretty much every officer in the company) what I did and why.

      Easier is just ignoring what is best for the patient and following the protocol.

      Deviating from protocols is entirely about doing what is best for the patient.

      .

      • So much for a relaxing Sunday..LOL!!

        Let’s take the “make our jobs easier” statement. In my blog post I talked about the Narcan administration to someone on pain medications. Let’s assume that this patient may, or many not have, take a few too many pills. They are lethargic, but are able to maintain an airway and the protocol reads that administer Narcan should be given in suspected opioid overdose to provide a patent airway and adequate respiration’s. Now if all this patient needs is an occasional “Sir stay awake” verbal conversation, then why do anything more invasive? Because for some providers, it would just be easier to push some medications and then not have to worry about anything else….Right? Too bad the patient will now have to build a therapeutic level back up.

        • David,

          So much for a relaxing Sunday..LOL!!

          I am at work, so I am not planning any relaxation. I am surprised I have not been busier, but it is not yet the hottest part of the day.

          Let’s take the “make our jobs easier” statement. In my blog post I talked about the Narcan administration to someone on pain medications. Let’s assume that this patient may, or many not have, take a few too many pills. They are lethargic, but are able to maintain an airway and the protocol reads that administer Narcan should be given in suspected opioid overdose to provide a patent airway and adequate respiration’s. Now if all this patient needs is an occasional “Sir stay awake” verbal conversation, then why do anything more invasive? Because for some providers, it would just be easier to push some medications and then not have to worry about anything else….Right? Too bad the patient will now have to build a therapeutic level back up.

          I thought you were stating that deviating from protocols makes things easier.

          I agree with you about the interpretation of the protocol, but the patient might be best off if we give enough naloxone to discourage the ED staff from giving naloxone to wake him up. Titrating in enough to rouse the patient enough to answer questions without generating the naloxone response from the ED. This depends on knowing the people working in the different EDs. Some are great. I recently brought a patient to a specialty hospital. At the sending facility, he was given a bit of opioid for the road, which is completely appropriate. The sending facility nurse had been considering a nasal cannula to make him safe for the ride, but I convinced her that I would keep him talking to keep him moving air. He required regular conversation to keep his sats OK (our protocols state at least 94%). When I transferred care, the receiving nurse stated that she worked in PACU (Post-Anesthesia Care Unit) and that she was used to this. Nobody suggested naloxone. Not the sending facility. Not the receiving facility. During transport, I was able to keep him breathing adequately by just asking him questions that required more than a Yes or No answer.

          I documented everything, including attaching a printout of vital signs (including SpO2) from the start of transport and one from the end of transport. The relevant protocol for me is Altered Mental Status. His GCS was not 15, unless I kept him talking, which is requiring stimulus. He met the criteria for the protocol, but there is no treatment indicated as long as he does not have respiratory depression. As long as I kept him talking, he did not have any respiratory depression. If he did have respiratory depression, I am supposed to give a bolus of 400 mcg naloxone, which would be horrible patient care.

          This was a patient with no signs of any drug abuse history. If he were an addict, he would have had much more tolerance to opioids.

          A bolus of naloxone would be blatant patient abuse.

          For anyone who thinks that this was wrong, remember that we are supposed to obtain informed consent for any treatment, if it is practical. There is absolutely no reason I should not ask this patient if he wants me to eliminate the effects of the pain medicine he has received, just to satisfy my protocol.

          Of course, once I start asking him about anything, the response demonstrates that he no longer meets the criteria for treatment under the protocol. Repeat as necessary – or just keep him talking and dance around the black and white parts of the protocol.

          Being able to work with the grey areas of the protocol allowed me to avoid having to interrupt on of the doctors in the ED to explain what I wanted to do, since they were very busy and had patients that required the attention of the doctors. My protocols have improved a lot, but still have a long way to go.

          • Be safe out there. Hot day all over the country!
            I’m guessing in your example above that your protocols say something about GCS and Sp02 for consideration of Narcan administration. I am glad we moved away from that and deleted the Sa02 as this number varies so much in patient populations.

            So much room for improvement…So little support

            • David,

              Be safe out there. Hot day all over the country!

              The heat is not pleasant, but the humidity is not too high. It could be a lot worse.

              I’m guessing in your example above that your protocols say something about GCS and Sp02 for consideration of Narcan administration. I am glad we moved away from that and deleted the Sa02 as this number varies so much in patient populations.

              The protocol is not specific about what altered level of consciousness means, but does state to assess GCS. This suggests that anything not 15 qualifies, unless it is normal for the patient. The notes do state that the naloxone Dose should be titrated to improved respirations, which I had forgotten was in the protocol. It is only mentioned in the footnotes and what I wrote in italics is all that is in there about possibly decreasing the dose to what is appropriate. The intention may be to titrate up from 0.4 mg.

              So much room for improvement…So little support

              They are getting better. The problem is that there does not appear to be pressure to get rid of the absentee medical directors. Many services have volunteer medical direction, which is not going to work with aggressive medical oversight except in unusual circumstances.

              There are several obstacles:

              Medical directors who don’t trust medics to make decisions, but think that a phone call for permission prevents medics from doing anything dangerous.

              Medical directors who think that their responsibility for patient care begins only after the patient is in a hospital bed.

              Medical directors who do not keep up with the research and do not network with other medical directors to learn what works.

              Medical directors who do not get any experience on an ambulance. EMS experience from 10 years ago is not the same as current EMS experience, unless the system fails to change.

              Medical directors who think that chart review is the same as oversight.

              Anything that discourages paramedics and EMTs from talking with medical directors.

              All of these require that medical directors be adequately paid. Services that do not have the money for this need to accept that they cannot afford paramedics.

              An intermediate can do a lot of what a medic can do. If we convince communities that ALS is not cheap and that putting a medic in every seat on every vehicle is just a pathetic imitation of ALS (unless a lot of time and money is spent on continual training), we can improve to where we should have been long ago.

              Some places are doing things well, while others are still working under protocols similar to what Johnny and Roy used.

              Even in the ED, there are similar problems. Some doctors will not discharge low risk chest pain, or r/o PE, patients home. Liability-wise admitting the patient seems to offer protection against being sued for what could not be foreseen. Until we change the legal environment to one that only punishes bad patient care, rather than finding the most medically naive people, and have them decide about things that experts do not agree on, we should not expect the patient to come first.

              .

  3. Protocols are thing of the past in nations such as the UK, Australia, New Zealand and South Africa where they have either never existed or been replaced with guidelines permitting a flexible autonomous approach to patient care and disposition.

    Sadly without greatly increased education and acceptance for professional responsibility such a system will not work in the US.

    • Yes Ben…
      I love when some friends of mine come over from the Gold Coast of Australia and the Netherlands so we can talk about how much further along they are than us. Dispatch, safety, and treatments are all areas they are far ahead of us in. I have had my one friend speak at our local conference and everyone leaves saying “I wish we were doing that,”

    • Ben,

      Protocols are thing of the past in nations such as the UK, Australia, New Zealand and South Africa where they have either never existed or been replaced with guidelines permitting a flexible autonomous approach to patient care and disposition.

      There are various levels of permitted flexibility in the US.

      Read Kelly Grayson’s article on the topic.

      The Two Most Important Words in an EMS Protocol
      The Ambulance Driver’s Perspective
      by Kelly Grayson
      March 26, 2008
      ems1.com
      Article

      Sadly without greatly increased education and acceptance for professional responsibility such a system will not work in the US.

      You know that I think that (in most places) EMS education in the US is something that should be dismantled and rebuilt using an entirely different model.

      We teach a bunch of mythology and discourage questioning of that mythology.

      .

  4. As the QI Officer in a system locked into a decades old mother may I mindset, I recently fielded a complaint from a local hospital upset that an unconscious patient had been brought in after being allowed to refuse earlier in the day. I pulled the chart and talked to the crew.
    The first encounter was a 4th party report of a possible fall. Patient met the crew standing on the sidewalk smoking a cigarette. She stated no complaint of illness or injury and that a relative thinks she should be seen by a psychiatrist. She did not request EMS and walked away from the ambulance prior to a complete assessment.
    According to the protocols the crew is required to make Base Hospital Physician Contact to allow for an AMA.
    The crew’s response to me: “The protocol isn’t wrong, and neither are we, but she didn’t fit what they wrote it for.”
    Protocols need to be a clear explanation of the tools and services available to he practitioner, not a check list of treatments for conditions, especially in systems that refuse to acknowledge that we diagnose.
    Give them a quality formulary, training on what to expect when administering it, and how to assess what their patient is suffering from.
    Don’t tell them how to treat stroke, but how to manage a patient with the signs and symptoms of one. It is rare in my experience that patient’s fit cleanly into just one protocol.
    Then in some cases when we do make base contact for advice it goes outside protocols. Go figure.
    “35 minutes of asystole, Doc, can we call it?”
    “Give 2 amps Bicarb and transport.”
    wha?

    We are working to move to physician reporting for our crews to get feedback on their differential diagnosis to better reinforce this kind of thinking. It will hopefully greatly decrease the amount of anecdotal street medicine and allow for better protocols down the line.

    • Justin,

      I am definitely not in favor of anecdotal street medicine.

      I have always talked with the doctors about any unusual cases – and deviations from protocol should always be considered unusual cases.

      I started out in San Francisco, so I am surprised that things have not progressed more there. The doctors did not discourage conversation, unless they were busy, and were always willing to teach.

      While there are some doctors who will revert to the just follow protocol approach, I have found that convincing them that I know what I am doing encourages them to give me a lot more latitude in treating patients.

      Our assessment of mental status and our knowledge of pharmacology are horrible and that does not appear to be changing very quickly.

      Maybe it is reflected in the way we assess our own competence – with a black and white multiple choice test.

      .

  5. I would say that of all the patients I have treated, at least half of them — and probably way more than that — don’t neatly fit under any one protocol. There may be multiple protocols that address different elements of the patient’s illness, or none at all.

    More complex protocols with specific guidelines for the use of every treatment aren’t the answer. That just determines who is able to memorize a protocol. And if we need specific, written, black-and-white rules stating when we are and are not allowed to use a particular treatment, should we be using it in the first place?

    Also, getting “permission” from medical command isn’t the answer either, nor does it absolve us from liability if we do something stupid. If we are allowed to implement a treatment, possibly an hour or more before the patient will arrive at the hospital, we should know whether or not it is appropriate, or we shouldn’t be using it at all. The required call to medical command only further delays treatment.

    Catering to the lowest common denominator isn’t unique to EMS, either. I also work as a critical care RN in a hospital, and the majority of our protocols and order sets seem to be written on the assumption that the nurses are borderline incompetent at best.

  6. This discussion speaks to a nascent project of mine. I’ve been thinking of different sorts of training exercises I could do with our paramedics, beyond the standard ACLS/megacode stuff. Instead, we would aim to prepare the students to discuss & justify deviations or modifications of protocols. I’m thinking this would be scenario-based, with a medic student simulating a call to med-control, or a direct report in he resuscitation room.

    I don’t picture these as graded, “pass/fail’ exercises, but rather as pushing them gently to venture “beyond” the protocols when a patient doesn’t plop nicely onto, say page 137 of the handbook.

    Anybody have any thoughts on how such exercises could be best constructed?

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