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On Pissing Contests and Patient Advocacy

I follow a few EMS forums on various social media sites, but lately I've been commenting less frequently because the signal-to-noise ratio leaves me in despair of the future of our profession. I have to wade through far too many comments from adrenaline junkies, protocol monkeys, booger-eating cretins and fervent disciples of EMS mythology to find the comments of the few people who actually have something relevant and insightful to add to the discussion.

But recently, on the Book of Faces, I read this post on from an anonymous poster:

Recently I ran into a situation: We were to transfer a patient to a local trauma center 1 hour away from our rural hospital. Patient was a 40 year old male who tried to jump off a bucking horse, left leg stuck in stirrup. Ended up with a fractured lower Leg. Patient did not Lose Consciousness, Did not hit head, was not wearing helmet, patient did not Jar his neck, did not jar his back, did not injure his back, patient had no headache, no dizziness, Patient had NO pain or complaints other then some minor pain and unable to weight bear on his fractured left leg. Patient is able to move his neck / Full range of motion, No resistance, no pain, No Complaints.

One of the Doctors Told the local hospital he wants this patient in FULL CSpine Precautions. Our local hospital told us to do it, and the upon asking the doctor why he needs to be CSpined, the doctor said "I don't know, that's what they want"

Needless to say, I refused to put my patient through the discomfort of full Cspine Precautions when to me and my partner was completely unnecessary.

Read the whole thing. If you can, try to slog through a few of the 435 (and counting) comments without succumbing to despair and ending the pain by ritual suicide. The comment thread is divided about 4:1 between "You should have been fired! How dare you defy a doctor?" and "Good for you, intrepid patient care advocate! Spinal immobilization is harmful and unnecessary!"

Problem is, they're both right.

No matter how much science you throw at them, a sizeable portion of the EMS workforce is going to ignore best practices and cling to the dogma they were fed in class all those years ago because ZOMG! We don't have X-ray eyes! Mechanism of injury! I had a dude with an internal decapitation with absolutely no outward signs of injury and we immobilized him anyway and SAVED HIS LIFE! Eleventy!

You're never going to convince these people, and I've learned to stop trying. Twenty years from now, they'll still be practicing 1990's medicine, and still utterly convinced that they know what they're doing.

But engaging in a pissing contest with two ED physicians isn't the way to be a patient advocate, either. Being right won't pay your bills after one of the aforementioned booger-eating cretins fires you because you don't believe in Bigfoot, aliens and occult spinal injury. Many of these types also believe in the predictive value of mechanism of injury as an article of faith. And that's what it is, really – faith – because the science shows that MOI sucks great big rocks off the sea floor when it comes to predicting actual injury. We treat people, not car bumpers.

What distresses me is the sheer volume of commenters who apparently believe that protocols are immutable things, and that we absolutely must follow any orders given to us by a physician, no matter how half-assed and asinine.

Neither of these is true, people.

"I was just following orders," will not afford you one shred of protection in court if you do something obviously harmful to a patient just because a doctor told you to do it. YOu have a moral, ethical, and legal responsibility to question orders you believe are inappropriate, and if necessary, refuse to carry them out if you believe they may cause the patient serious harm.

Now, does a couple of hours of pain and discomfort qualify as serious harm? I guess that depends on whether you're the person undergoing the pain and discomfort. Certainly, outright defiance of doctor's orders was not the best option in this case, but neither is subjecting your patient to an unnecessary and painful procedure just because some trauma center's protocols require it.

I've been in this situation. Years ago, one of my medics got into an ugly pissing contest with an old country doc, and things escalated to the point that he jumped up onto the running board of the ambulance and tried to jerk the keys out of the ignition as they drove away with the patient. I had the unpleasant task of investigating the incident, and meting out whatever discipline was required.

The medic was right, and the doctor was wrong. But the  way she handled it was totally unprofessional, and she got suspended for three days as a result. Like I told her then, "You should have just smiled and said, 'Yes, sir' and drove away. Then, once you're out of sight, pull over and do what the patient needs. The doctor you were transferring to would have been much more approving of your changes in treatment than the one you were arguing with."

And after it was over with, I overhauled our protocols to reduce the likelihood of some doctor overriding our treatment decisions in the future. It is one thing to overrule a medic, but it is another thing entirely to bully a medic who is following the treatment protocols approved by the medical society to which you belong.

As I said in that comment thread, there's a simple way out of that sticky situation, and one that covers your ass as well. All it would have taken is a conversation like this:

"Sir, the doctor at the receiving hospital has requested that I strap you to a hard plastic board for the duration of this trip in order to protect your spine. The doctor who treated you is unsure of why he wants this, since he personally read the x-rays that show your neck is not broken. I am legally and ethically bound to inform you of the proposed risks and benefits of this procedure, so that you may make an informed decision on whether you will consent to it or not."

The risks of the procedure include pain and anxiety, particularly soreness to the back of the head, neck, lower back and buttocks, and in studies on healthy volunteers who have undergone this procedure, 100% of them suffered significant pain, and many of them reported that the pain lingered for days or weeks afterward. You will also be more likely to drown on your own vomit should you become nauseated during the trip and I am unable to suction you quickly enough. Since you are overweight, lying on this board may make is more difficult to breathe. Since you are overweight, it is less likely that you will develop a pressure sore from this procedure, but studies have shown that as little as fifteen minutes on a board can induce these sores, and they may require specialized wound care to heal properly.

On the benefits side, there is no scientific evidence that you will benefit in any way from the procedure, even assuming that your neck is broken and we do the procedure perfectly. Both the ED doctor here and the radiologist who read your neck film saw no evidence of fracture, and as such the procedure is not even clinically indicated. However, it will keep your receiving doctor happy if we do it. Do you consent to this procedure, knowing the facts as I have presented them to you?

No?

Sign here, Sir."

Document the hell out of the encounter, and let the receiving physician try to explain why the patient's right to informed consent was unimportant, and why you were wrong in respecting that right.

Following orders without question is what is expected of robots and protocol monkeys. EMS needs more from you than that, and our patients deserve it.
 

Comments - Add Yours

  • deezy

    That was beautiful. I am not even patronizing you. That was amazingly written.
    :D

  • PARAMEDIC70002

    Nice. Even that I’ve known of a few transfers like this where the sending facility was incorrect in clearing the spine – the receiving hospital found a fracture! But of course you’re right, emerging science shows no benefit in boarding this patient.

    • Ambulance_Driver

      X-rays miss more fractures than the NEXUS exam.

      But like you stated, even with a fracture, a cot mattress and self-splinting in position of comfort works better than a board.

    • Steve Whitehead

      This is the toughest thing for the c-spine crowd to wrap their heads around. C-spine isn’t just the wrong treatment for non-injured patients. It’s the wrong thing to do even.when.they.do.have.a.fracture.

  • Too Old To Work

    There are paramedics with 20 years of experience and then there are paramedics with 1 year of experience, repeated 20 times over.

    There are way more of the second kind than of the first.

  • Scott Kenny

    I know that I caused all sorts of panic in the docs when I walked into the ER after a fall. Turns out that landing on your butt is a good way to give yourself a burst fracture. Docs couldn’t believe that I was able to walk around pretty normally with an unstabilized (more properly, self-stabilizing) L1 burst fx.

  • Mark

    The next time I get hurt and need an ambulance ride, could you come down by Corpus to make sure I get transported right? The last time I was a patient in one I was in no condition to make an informed decision nor give consent, I will say that I was sore all over my body for over a week after a simple fall and a minor concussion because of the “Protocol” Backboard C-spine and secure X3. For someone who has had an ASF lying flat on my back was probably the worst thing they could have done to me.

  • Fritz

    Sir,

    You are a GEM!
    They did that to me..and when I was in the hospital, I woke up strapped down…..catheterized….tube down my throat. My injuries? A mugging and bruises.
    I lost the feeling in one hand for a YEAR because of their needles, and the sores took months to heal properly.
    leaperman