“But it’s Protocol”

Sep 17, 2014

As the debate rages on about whether or not “cookbook medics” are the new fad, an interesting question was raised on the Paramedics on Facebook page that sparked some interesting conversation.  The question was about deviation from protocol with an elderly patient that some could have considered a priority to take c-spine precautions on.  I’ll let you read it for yourself:

You’re dispatched to the assisted living facility for a fall. You arrive to be met by staff who is escorting you deep into the bowels of the building. During the walk, she tells you that the patient is an elderly gentleman who is under comfort care only, DNR/DNI with all appropriate paperwork, for stage IV liver cancer with metastasis to just about every organ system in his body. He’s accepted it, as has his family. He just wants to die with a little peace.

But tonight he tripped on the carpet, and when he fell, he hit his ear on the night stand. There’s a laceration that bled a fair amount. Facility requires his transport for a fall, though.

You walk in the room to find the FD strapping him onto a backboard with a collar in place. The patient is alert and oriented. The only visible injury is the laceration to the ear, which has been controlled, but it looks like it needs a couple stitches. He has no signs of injury on his head, neck, or back. He has no neck pain. He had no back pain before the board.

The patient says he is in incredible pain since being on the board, and wants off. He’ll go to the hospital, but he’s in agony.

His GSC is a solid 15. He’s not stoned on narcotics, and he’s able to understand risks. No history of dementia.

Here we have a patient who is alert, oriented and refusing a portion of the care that you are trying to provide to him.  Some will argue that protocol is protocol, and others that he should be taken straight off the board, and the evidence does not support taking spinal precautions of this patient.  Congratulations, folks.  You’re all right. . . kind of.

Far too often, we treat protocols as absolutes.  We view them as a flow chart that dictates that if we are going to get to step five from step one, we need to do steps two, three, and four.  When manufacturing widgets, that might be true.  Omitting steps will create poor products and flaws, but in medicine we need to look at each individual scenario as just that, an individual scenario.

Every patient that we encounter is going to present differently than the one before who had the same differential diagnosis.  Take, for example, diabetics.  If your protocol says that you are to administer 25G of D50 to a patient with a blood sugar under 50, and you are presented with a patient with a sugar of 55 and altered mental status who is diaphoretic, are you going to withhold the medication because the patient does not fit the protocol, or are you going to at least consider administering it?

When treating patients, we need to keep in mind that protocols are better described as “recommended guidelines” and not absolutes because in medicine, there is really no such thing as an absolute.  In this case, informing the old man that “I know we are hurting you, but we are really helping you, I promise,” in this paramedics opinion is not the correct course of action.

As for the evidence side of the argument, you too are also correct, however some places are slower to adopt and buy into that evidence than other places are, and we need to keep that in mind.  The analogy that I always use for this is the implementation of CPAP in Massachusetts.  We were years behind many other systems with this mainly because the Commonwealth of Massachusetts needed to see proof that CPAP worked in Massachusetts specifically despite evidence that it worked in other parts of the country and the world, as if crossing the border from Connecticut to Massachusetts transported you into some magical world where airway pressures are regulated differently.

We need to be careful with the implementation of evidence though.  Providing a treatment outside of your protocols and telling your medical director that, “I read a study that this was a very successful treatment in a system in Oklahoma” is probably not going to keep you out of potentially landing in hot water.

So what would SBK have done?  This is a situation where care has already been initiated so there are a few steps that we need to take before we undo that.  I would have explained to the alert and oriented patient the potential risks of refusing C-Spine precautions.  If he again refused, I would ask him if he would compromise and allow me to let him sit up, and place a c-collar on his neck.  If he again refused that, I would make sure that the patient’s decision was well documented.

Prior to removing him from the board, I would perform a neruo exam looking for any tingling, loss of sensation, strength or movement in any of his extremities.  Once he was removed from the board I would repeat that exam and look for any changes.

When I called in my patch to the ER we were transporting him to I would explain to them that the patient began to experience pain that was not previously experienced when an attempt was made to take spinal precautions.  I would tell them that the patient adamantly refused to be boarded (and potently refused to be collared as well) and I would explain further upon arrival at the ER.

The best course of action for any EMT or paramedic in this situation is to first make sure that your patient is informed about what is going on, and then be ready to stand on your own two feet and justify your actions if somebody questioned it.  I used to like my old medical director’s take on situations like this.  He would tell us that if we acted in the patient’s best interest that he would be able to find a way to defend us.  And really, that is key here.  Put the patient’s best interests first.  Remember, we are here for them.