out of protocol practice

[daedalus]

I am having the hardest time getting this question answered.

As a paramedic, you act within protocols as guidelines for management of acute illness and injury. I got that. When you have a patient with atypical presentations or with a acute disease you have no protocol to manage but you do have a treatment option with your medications and knowledge, can you preform advanced treatments on these patients? Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?

 

[flhtci01]

ABCs, gain IV access as needed and contact medical control.

 

[Hastings]

I am having the hardest time getting this question answered.

As a paramedic, you act within protocols as guidelines for management of acute illness and injury. I got that. When you have a patient with atypical presentations or with a acute disease you have no protocol to manage but you do have a treatment option with your medications and knowledge, can you preform advanced treatments on these patients? Or, because you have not protocol for them, you just give O2 and monitor ecg/vitals and haul butt to the hospital?

What do you mean? Like giving ASA for a headache? No.

 

[Epi-do]

Contact medical control, tell them what you have and what you would like to do. See if you get the go ahead, or if they give you different orders all together.

 

[daedalus]

What do you mean? Like giving ASA for a headache? No.

Tehe that would be a bad idea.

Contact med control. Got it. Thanks guys.

 

[MagicTyler]

Wouldn't giving an intervention like that be outside scope; even if medical control told you to?

 

[firecoins]

Not necessarily. Something could be outside your protocols but inside your scope of practise. RSI is something I have been trained in but it is not in my current protocols.

 

[MagicTyler]

Ok, totally playing the what if game now. Lets say aspirin will stop hiccups. Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?

 

[firecoins]

Ok, totally playing the what if game now. Lets say aspirin will stop hiccups. Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?

I don't know if that is the same situation. They tell you to give a drug that the patient does not meet the criteria for or the patient meets the criteria for an intervention not in your protocols but in your general scope of practise?

 

[marineman]

Ok, totally playing the what if game now. Lets say aspirin will stop hiccups. Medical control orders aspirin to stop hiccups. but even if aspirin is within scope to give, the pt doesn't meet criteria to administer aspirin. So you can't give it, even if medical control orders it. Correct?

Giving aspirin is within our scope, keep in mind that use is not within our scope so no we can't give it on our own. We contact med control and they tell us to administer ASA to relieve the hiccups (hiccoughs?), since the administration of ASA is something I'm trained to do I will administer it, repeat to medical control when receiving the order what medication, route and dose they want and give it. I think R/R will post soon but too many people get caught up in not stepping outside of that protocol book. If medical direction tells you to do anything that you've been trained in, you do it with their recommended dose unless you have a reasonable belief that it will harm the patient. With strange orders from medical direction it's often best to repeat the information to make sure that they got the correct information and are requesting an appropriate line of treatment. Remember to document exactly what you do and what med direction tells you to do. If you do something outside the protocol book if it goes to court you will have to prove that you are trained in whatever you did and you will have to prove that you did exactly what medical direction told you to do. At that point it's all on them. If you refuse to do something that medical direction told you to do you had best have a good reason as you're starting a pissing match with someone that has much more training than you. Document exactly what the patient presented with, what medical direction told you to do, and why you didn't do it. If that issue goes to court or even if it goes to your boss you will have to prove that you had a reasonable belief that it would harm the patient or you will have to prove that you are not trained in that procedure and even that's iffy as sometimes (our) medical control will walk us through a procedure we don't know how to do if it's vital for the patients outcome.

 

[MRE]

The whole idea of protocols is that they are like standing orders for treatments for certain situations. When medical control tells you to do something not in your protocols, its really the same thing as them writing you a protocol to use in this one situation.

As far as the ASA; if med con says to do it, its in your scope and the pt doesn't have any contraindications for ASA, then go for it.

 

[reaper]

You have to look at your state SOP. Some states have an SOP set up for what is allowed by a medic or EMT. Your protocols may not include everything that the state has in theirs. Most states do not allow you to go beyond what their SOP is for your license.

A lot of states I have worked allow Mag for asthma Pt's. The state I am in now does not include it in their state SOP. We had a medic give it after a MD ordered it. That medic lost his job, due to the treatment being outside the state SOP.

We are allowed a lot of freedom in our protocols, but we still must practice inside our state SOP's.

Just something else to keep in mind.

 

[MRE]

Aren't SOP's usually set forth by the service and our scope of practice set forth by the state? Maybe we are just using different terms for the same things.

You have to look at your state SOP. Some states have an SOP set up for what is allowed by a medic or EMT. Your protocols may not include everything that the state has in theirs. Most states do not allow you to go beyond what their SOP is for your license.

A lot of states I have worked allow Mag for asthma Pt's. The state I am in now does not include it in their state SOP. We had a medic give it after a MD ordered it. That medic lost his job, due to the treatment being outside the state SOP.

We are allowed a lot of freedom in our protocols, but we still must practice inside our state SOP's.

Just something else to keep in mind.

 

[reaper]

Yes, I meant Scope of practice. Just didn't feel like typing it out!

 

[MRE]

Yes, I meant Scope of practice. Just didn't feel like typing it out!

Oh that works. I didn't even realize that the initials for scope of practice were SOP. I'm in a fire dept based service and the dept has SOP's (Standard Operating Procedures) for things like what apparatus to send to certain kinds of incidents, etc. Thats what I thought you were talking about.

 

[FF894]

I don't know how other states' protocols are written, but in MA & NH it is specifically written that the standing protocols are in place to allow the provider to perform them if he deems necessary based on education, training, and certification level. They are not written to be followed to a T 100% of the time. They are simply there so the provider does not have to "ask" to perform the listed skills everytime it makes sense to do so (which in most cases is more often than not).

I know that is taking a side-step into left field, but does anyone else have that written in their protocols?

 

[firecoins]

I know that is taking a side-step into left field, but does anyone else have that written in their protocols?

Yes. Its written into NYC protocols.

 

[mycrofft]

Slicing it thin

If you are governed by a set of prearranged orders (protocls, standardized procedures etc) and the pt meets their criteria, you use them and all is well.
If you medical control orders you to exceed them, and to your knowledge as a well trained technician it will not harm the pt, and you are technically capable of performing the procedure or act, then all is well for you (hope it works out for the pt). If they tell you to do an emergency appy, don't, has to be reasonable and you have to be capable.
If you exceed them without an order you are on your own, probably gonna get fired or repirmanded, might lose you certificate or permit or whatever, because they cannot trust you not to blow off the protcols like they could before that. If the pt does OK you might not get criminal charges, but you could get sued and lose if they come off it with chronic pain, post traumatic syndrome, nightmares, hangnails, etc.
Good techs always think about when they may feel they must work outside the protocols ; when the protocols aren't working or aren't enough, the usual answer is to re-examine the pt for the anomalous or missing piece of the puzzle. Poor techs are looking for the instances where they can work outside the protocols.

 

[daedalus]

I actually have an example to further hammer out my point. There is no protocol in my county for calcium channel blocker overdose. No where does it specify in any protocols or scope of practice what can be done for this type of overdose. However, a paramedic does carry calcium. Can it be used even though there is no "protocol" for it, after consultation with med control? And take it a step further, according to Dr D Ross over at JEMS, glucagon at high doses is indicated for CCB over dose. This sure isn't in any protocols.

Our scope of practice and protocols do not define what the drugs the medic carries can be used for, they only mention required amounts. I am pretty lost.

 

[medic5740]

Protocols are guidelines

I have always considered the protocols to be a guideline within which critical thinking and medical control contact can modify. I don't know about your system, but if my medical control physician orders me to give a drug or complete a procedure that I am trained to do, I am going to do it.

First case in point: One patient had a large piece of meat stuck in his esophagus. Medical evacuation was not possible from this location. Medical control ordered us to mix up meat tenderizer and to have the patient sip the meat tenderizer, making sure that the airway was not compromised. Sure enough, ten minutes later the patient was able to swallow the big chunk of meat that was stuck there. This is certainly not within any written protocol anywhere, nor is it within any scope of practice for an EMT or paramedic, but it was necessary, it was ordered, and the order was completed. What was the other option?

Second case in point: Cardiac patient needed transport via aircraft to nearest facility ASAP. Patient was deathly afraid of flying. Medical control ordered administration of valium and antiemetic prior to the flight. That's not in the protocols either, but it worked very well, calmed the patient, lessened the symptoms, and prevented overworking the damaged heart by preventing the release of the adrenalin rush in the fight or flight mode due to the fear of flying. It was definitely a valuable treatment tool for this particular patient.

Third case in point: Dislocated shoulder patient with no means of transport available due to weather. Patient was in a great deal of pain. Medical control physician orders a relocation of the shoulder following specific directions provided over the cell phone after drugging the patient to a near conscious sedation state. Physician remained on the phone with us throughout the procedure. This is also not in our protocols.

Sometimes, I think that the cookbook method of protocol-driven EMS gets in the way of patient care.

I will say it once again. If my medical control physician orders something that I know how to do, and if I think it will benefit my patient, I will do it every single time whether in the protocols or not.