Protocol V. On-Scene Judgement Calls

[thatJeffguy]

I'll preface this by saying I have no training yet, what so ever. Realizing that having no training and opening my mouth leaves a gigantic vacuum in which a foot can fit in, I'm going to jump in here and see what happens.

The BLS ambulance where I ride as an observer was called to the scene of a 47yo male vomiting blood and "feeling poorly". Our driver knows the man is HIV+ and HEP+, unsure which specific HEP he's got. We arrive, he's mobile, smells of alcohol and, despite his claims of vomiting blood, he's just basically retching and spitting up (brace yourself for the most unscientific term ever here) "snotty spit". The EMT-B's get the man on the stretcher and load into the ambulance. Hospital is about 7 minutes away. Patient says he's going to hurl so I grab the e. basin for him, again, just some snotty spit, no traces of blood. EMT-B takes history, pt states he's HIV+, has "severe" anxiety, past history of suicide attempts. EMT-B asks if he's been drinking, patient answers yes, a "few drinks" in the past few hours. Patient states that usually he sees his grand kids every day and they keep him "normal" but they're out of town today. The EMT-B uses a finger pulse oximeter, guy shows at about 93% so he gets oxygen. The EMT-B doesn't do anything else, no pulse, no blood pressure, nothing.

We stage on-scene at the high school football game and I ask him why he didn't take any vitals and what the patient could have presented with that would have caused him to take vitals. He said that he was using his judgment that the guy was just intoxicated, emotional and having a bit of an anxiety attack. I'm not in any way, shape, or form trying to call out the EMT-B on this, he's been doing it for 13 years so I'm aware his experience dwarfs my "experience" (or complete lack there-of). However, our protocol is that patients get their vitals taken.

I'm more specifically concerned with the abstract issue here; protocol versus the on-ground judgment call of a trained professional. How frequently is that an issue and how should a neophyte deal with such things?

 

[JPINFV]

Screw protocol. How about just doing a proper assessment in the first place? I can think of only a handful of cases where I can justify not getting a full set of V/S, and those either fall into when the patient requests not to have a BP taken or load and go situations with extremely short transport times (like less than a minute transport times).

 

[reaper]

Pt should have had vitals taken, no matter what his complaint is. That sounds like a lazy EMT!

 

[VentMedic]

Has this EMT ever heard of universal precautions?

The only vacuum I hear is the state sucking up this guy's license.

Oxygen has been applied without anything other than a spot check with a pulse oximeter? The patient was treated without any further assessment. It seems this EMT couldn't get past the HIV+ part to provide adequate care.

He also doesn't understand enough disease processes to know what is associated with alcohol and hepatitis.

FAIL!

 

[Dwindlin]

Screw protocol. How about just doing a proper assessment in the first place? I can think of only a handful of cases where I can justify not getting a full set of V/S, and those either fall into when the patient requests not to have a BP taken or load and go situations with extremely short transport times (like less than a minute transport times).

Only other situation I wouldn't get vitals on is uncooperative patients.

 

[JPINFV]

^
Good point. Forgot to think about that one. I will add the caveat that, all things being equal, I'll try harder to get a BP on a patient who I believe is uncooperative/combative due to metabolic or neurological issues that psychatric issues.

 

[daedalus]

I second the above. Vital signs, are, vital. They need to be taken on all patients if possible, and it sounds like it was possible in this case.

Uncooperative patients are another story.

 

[VentMedic]

Since this patient gave his hx willingly, including his HIV status, he was probably cooperative and even cared enough about the EMTs to tell them about his diseases. It is too bad the EMT didn't care.

 

[thatJeffguy]

Thanks for the great information and timely replies. I'll admit, when I was told he was HIV+ I was nervous, the HEP scared me more though. When I was younger I worked in Central Processing, the department of the hospital tasked with decontamination, inspection, packaging, sterilization and inventory management for the surgical tools for our ER. I've dealt with some of the nastiest, cruddiest, bloodiest, feces-caked instruments available and I'm sure that in my year there, quite a few AIDS patients were operated upon. I'd be ashamed if I allowed a patients HIV+ status to affect my patient care, frankly.

 

[DV_EMT]

Vitals.... ALWAYS!

thats my two cents

 

[zaboomafoozarg]

Jeff, I think am *kind* of in your shoes . I'm halfway through my EMT class with no actual experience yet

But let me warn you, by and large the response that I got when I made a post slightly similar to yours here is that, those of us with no field experience or training are complete idiots for even daring to question the field practices of a real EMT. I'm not saying this myself, just warning you that you will probably get responses like this.Some people on this forum completely toss any amount of book learning ("protocol" in your case) out the window.

I think the EMT was wrong though.

 

[HCEMS]

I would like to see the PCR form that your B wrote out after the run. I would have to think that your Medical Director would be pretty upset if he the B didn't right down any vitals at all. The B did not perform good pt care nor does the hospital have any trending to go by with the vitals. I wouldn't be surprised if your B didn't write down false vitals on your PCR form unless you have a really relaxed Medical Director.

My advice to you is even if they have 13 yrs of experience doesn't mean anything if they have been doing improper pt assessments for 13 years. The only you can do is learn from his mistakes and don't replicate bad pt care. I'm glad you were paying attention though! Good luck!

 

[reaper]

Jeff, I think am *kind* of in your shoes . I'm halfway through my EMT class with no actual experience yet

But let me warn you, by and large the response that I got when I made a post slightly similar to yours here is that, those of us with no field experience or training are complete idiots for even daring to question the field practices of a real EMT. I'm not saying this myself, just warning you that you will probably get responses like this.Some people on this forum completely toss any amount of book learning ("protocol" in your case) out the window.

I think the EMT was wrong though.

I have not seen one person stand up for the EMT yet? It is one thing to question a treatment and it get defended. It is another to question the laziness of a provider. There is no excuses for that!

 

[CollegeBoy]

I have not seen one person stand up for the EMT yet? It is one thing to question a treatment and it get defended. It is another to question the laziness of a provider. There is no excuses for that!

Okay maybee someone does need to stand up for the EMT:
1...2...3 NOT IT!!

 

[mycrofft]

thatJeffguy, good post!

3 issues I see.
SHOULD VITALS HAVE BEEN TAKEN? Yes.

UNIVERSAL PRECAUTIONS (which by the way is no longer P-C, but I thnink it's the best phrase): you learn it, you practice it, gets to be second nature, you may screw up once in a while (hello, human) but fear shold never be part of your reaction unless the pt is assaultive or otherwise exceptionally risky.

On-Scene Judgment versus Protocols: this judgement thing is cited by some as a reason to skirt protocols, and by adminitrators as a means to cover theri butt for cruddy protocols by blaming the line person. The little decision tree your brain is clicking along subconsiously or consciously has a branch that says "Whoops, don't recall a protocol for THAT!". This can be due to forgetfulness, poor training, the inevitable gaps in protocols versus real life, and the appearanc of common stuff to be exotic stuff due to combinations of causes, or just funny stuff happening. The completeness of the mental database some of our forum-mates are harping about is proven right there: when the cookbook fails and you have to decide whether to act, and if so, then perform, you will need that database so your judgement is not guessment.

Good protocols are "the law", wisdom from may years of incidents and experience. Abandoning them invites problems.

PS: blood from mouth: check the mouth for the origin, be it sinuses ("post nasal drip"), teeth, oral tissues, or unapparent (which can be bad). Smell breath and you may smell bad breath like bad teeth, bad breath like infection, bad breath like blood. "Blood in snot" could be trace bloeeding in esophageal, not nasal or nasopahryngeal, mucus, sign of an incipient esphageal bleed and cause for frequent vitals and getting thee to an emergency room toute suite.
Maybe. (

 

[JPINFV]

Good protocols are "the law", wisdom from may years of incidents and experience. Abandoning them invites problems.

Good protocols also generally recognizes that, while they are the ideal treatment plan for a specific chief complaint, that not all patients will fit inside the nice little boxes created and that the paramedic should use judgment to know when to deviate from those protocols.

Also, the treatment plans developed by good prehosptial providers should independently match the protocols anyways.

 

[Shishkabob]

Which is why many MD's are changing "protocols" to "guidelines" and letting their medics make the decision at what will work best in the given situation.

 

[firetender]

There is no substitute for good judgment but that also includes good sense: Like if you're going to administer a drug (O2 is a drug) it's a really good idea to have documented vital signs along the way.

There are protocols you must do because they're designed to work, there are protocols you follow because they CYA, and there are protocols that you're "expected" to follow, but few do. Some services are choking with protocols and the medics figure out what they can get away with. The local culture kind of decides that, until someone makes a stink about it and gets "by the book".

All in all, there's no pat answer except ALWAYS weigh written protocols against the needs and safety of the patient in the moment. Sometimes, they really don't synchronize. Just be prepared to document.

 

[bunkie]

Vitals are your window into the patient. They should have been done absolutely. If he's squeamish about HIV and HEP, he needs a new job.

 

[Seaglass]

Okay maybee someone does need to stand up for the EMT:
1...2...3 NOT IT!!

Me neither. Vitals are vital...