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They’re Protocols, Not Suicide Pacts

Brandon Oto over at EMS Basics shares a story where monkey-see monkey-do medicine went wrong.

Go read the whole thing, and then come back.

If you learn nothing else in EMS, learn this: protocols are no substitute for common sense and clinical decision-making.

In fact, they’re often the antithesis of critical thinking and clinical decision making. Protocols, with very few exceptions, are written to keep the dumbest medic in your system from being too dangerous to satisfy a risk manager. They are testament to the fact that your medical director only places limited trust in your knowledge and skills, and the more restrictive they are, the more they say that your medical director thinks you are a barely competent idiot.

And if you apply them blindly, without thinking of why, like the medics in this story, you are indeed a barely competent idiot.

Don’t be that guy. Don’t be a protocol monkey.

Think. Question. Protest. Advocate for more clinical freedom and better protocols. Do your research, and make your argument count.

And if you fail, and you still find yourself in a system built around the lowest common denominator, get the hell out.

Better systems exist. Find some place that challenges you and expects much of you, and work your ass off to be worthy of that trust.

And if you’re satisfied with being a protocol monkey, don’t bitch because you continue to be paid in bananas.

Comments - Add Yours

  • VinceD

    My argument here is that the crew actually got into trouble because they didn’t follow the protocol correctly, not because the protocol was flawed.

    Any trauma algorithm worth its salt will lead off with the ABC’s (or CAB’s) and immediate life-threats. In this case ‘C’ was handled by external aortic compression. While it’s not standard or even well known, this pressure point was providing hemorrhage control none-the-less. With ‘C’ addressed, the providers attempted to move on down their algorithm. What went wrong, however, is that when the patient decompensated after removal of the pressure point they didn’t perform that basic step of returning to ABC’s – which would have resulted in them re-instituting external aortic compression.

    What happened instead is that they incorrectly continued moving down the algorithm, not up, performing more procedures they were comfortable with. Rather than being a failure of the protocol or checklist, this is a study in human factors and what affects the decisions we make.

    While I agree that we should be aggressively questioning the practice of fully packaging every patient we transport, I just want to be clear that in this case it isn’t the fault of the protocol but rather influenced by the people who implement and enforce the protocol and the critiques received by providers who don’t “finish” the checklist.

    As Brandon discusses, hopefully it is covered as part of EMT-Basic training that sometimes we’ll never make it past the ABC’s on certain patients and that’s okay. Any protocol I’ve seen doesn’t force you to, but rather it’s the expectations of receiving staff, co-workers, and supervisors that influence that flawed behavior of working the list to the end.

    • http://www.ambulancedriverfiles.com/ Ambulance driver

      And in further reply, you’re right about the people who QA and enforce compliance. All too often, the reviewers are more interested in enforcing lockstep protocol compliance instead of sound clinical decision-making.
      This was the case with my current employer. No one ever said, “Gig people for not completing protocol steps 1-10.” In fact, we were told just the opposite. The problem is, the people they select to be on that team were chosen based on their ability to zealously apply protocol steps 1-10.
      Whether they were necessary or not.

      It got very lonely being on that team, being the only one who placed more importance on documentation and sound clinical decision-making than protocol compliance.
      Kelly Grayson

  • skidmark

    Question from a non-EMS type: a) could the physician (I’m guessing acting under Good Samaritan laws) have given the crew a medical order to maintain compression and b) would the crew have been under any obligation to follow that medical order?

    Yes, I fully understand the idiots probably would have done what they did in spite of the doctor’s order unless he went with them and could slap them up side the head when they decided getting vitals was so almighty necessary.

    stay safe.

    • http://www.ambulancedriverfiles.com/ Ambulance driver

      He could have done that, but they’d likely be under no obligation to comply. Usually in those situations, if an on-scene physician gives orders contrary to protocols (or common sense), we’re under no obligation to comply.
      If he presses the issue, we usually politely invite them to ride in with us and assume all responsibility for patient care. They usually decline.
      Thing is, such an order shouldn’t have even been necessary. You shouldn’t have to tell two trained medical professionals to keep doing what’s keeping the patient alive, and stop doing unnecessary stuff that gets in the way of that.

    • Garrett Kajmowicz

      I’d be more interested in having the doctor come along as a qualified spare set of hands. I would assume that at some point in time fatigue would set in – being able to trade off every few minutes like CPR would be great. This would allow one person to maintain occlusion while the other did other management tasks like airway management and administer any other medications required to keep this guy alive.

  • Expatriate Owl

    Never mind the ambulance! The same type of mentality is bound to proliferate in ALL aspects of medical care, now that Obamacare has proceeded to attenuate the locus of control for all of America’s healthcare systems to some bureaucrat’s office in Washington.

  • Divemedic

    Interesting, but increasingly harder to do here in the Sunshine State. State law says that I MUST have two sets of vitals, to include blood pressure. To fail to do so invites the loss of one’s paramedic license.
    More and more EMS systems here are demanding that medics rigidly follow protocols or face termination and reports to the state medical review board, even if it results in poor patient outcomes.

    • http://emsbasics.com/ Brandon Oto

      This is deeply disturbing.

      • http://www.ambulancedriverfiles.com/ Ambulance driver

        An unjust law is no law at all, and a protocol that invites non-compliance is no protocol at all.
        How many medics do you think fudge or falsify one or both those sets of vitals because they were busy doing more important things?
        I’ll bet it’s a lot.

        Kelly Grayson

  • Kris

    People seem to think that everything in life can be reduced to an app on a cell phone. The best protocols will necessarily weigh the sensitivity and specificity of investigations and interventions to try to prevent over or under treatment. Great if your patient inhabits the fat part of the bell shaped curve. For those in the asymptotes however….. I calculated that at the medical center where I work, if all employees strictly adhered to the rules/regulations/ protocols 100% of the time, even assuming these were all brilliantly constructed (ahem), about 30 patients a day would be ill served.
    As others have noted, these guidelines should be considered a starting point and a minimum standard. If you are content with maintenance of a minimum standard, oh well. If not, dare to be blamed for doing the right thing. Sadly, one is often judged by those who lack adequate standing to do the judging. What did Lincoln say? Those who know nothing stand closer to the truth than those who believe that which is wrong.

  • Sara

    It’s situations like this that makes my squad counting down the days until we switch protocols!

    Our current protocols were last updated in 2009 and heaven forbid we skip something because we didn’t have time. Recently we had a ROSC run and were found at fault by our EMS coordinator/Nazi because we didn’t get a blood sugar. In the run described in the article I have no doubt every member would hold compression, but I also know for certain the coordinator would have found fault that we didn’t get to or do XYZ in the protocols due to time/amount of personnel available/what’s best for the patient.

    The protocol we are switching to is a thing of beauty. Updated yearly (if not more often), evidence based, and backed by research! Everyone’s favorite paragraph thus far basically says that the protocols are not meant to be followed step-by-step, but to use our professional judgement!

  • m harris

    This has nothing to do with the current post, but is instead a question I’d like to ask EMS people. Is that OK? I have a pacemaker, am allergic to sulfa drugs, and have migraines with aura, so I wear a Medic Alert necklace. When I added the “migraines with aura” part, the company refused to word it like that, insisting on putting “aural migraines”, which, to me, is not a common term. Their reasoning was that the tag is for emergency professionals. Is that correct? Just wondering. By the way, I enjoy your blog, I found it by way of Home on the Range. Thanks for any answers, or just ignore if not appropriate.

    • Kris

      They screwed up. To a medical professional ther term aural migraine would suggest auditory symptoms as a manifestation of migraine. Tell them to correct it.

    • http://www.ambulancedriverfiles.com/ Ambulance driver

      Kris is correct. The Medic Alert company screwed up, and made you list a condition you do not have.

      • m harris

        Thank ya’ll so much! Now I get to do battle with them! :)