Just because it’s right…

…doesn’t mean you can do it.

We’ve had some confusion around the yard as to just what we’re supposed to be doing when it comes to assessing the car rather than the patient.
We all know to assess the patient, not the car, the patient, not the monitor etc etc.

At a recent training evidence was presented that contradicts our current protocols as set forth by our regulators.
It seems a number of folks took that training to heart and are trying to apply it to the patients they encounter in the field.

Problem is, the treatment, or omission of treatment in this case, is causing trouble for me in the CQI office since I now have to talk to folks about doing the right thing and breaking the rules.

First a note on one of our favorite terms: mechanism.

Motor vehicles today are designed to crumple, absorb energy and disperse it around the passenger compartment. This design allows for a great deal of damage to be incurred prior to the passenger, if properly restrained, is injured. This is the reason that recent CDC wording of field trauma triage criteria specifically mentions intrusion into the passenger compartment. Your protocols and policies likely have a similar clause.
The problem is when the protocols and policies start making assumptions about the possible damage to the car and how it relates to possible damage on the patient, then prescribes treatment based on the car, not the patient.

Rollovers used to be a big deal. If everyone is belted chances are they’re self extricating before you get there and strap their curved spine to a flat board. You know…just in case.

Even more frustrating is when you finally convince the patient that the hospital will take careful care of them in case they have a back and neck injury only to arrive to a triage nurse removing the collar, performing the same assessment you did, then removing the board if your treatment was based only on mechanism.

Even worse is when you convince them to be seen at the trauma center based on damage to their car, only to see them moved to the hallway prior to your chart being completed…no board, no collar.

I asked a few of my crews to think of the worst Paramedic they had ever seen and if they would want that person “clearing” C-spine injury in the field on them. The point set in that most of us can barely get our noses out of the cookbook long enough to do a complete assessment now. Those folks have no future in EMS if I have anything to say about it.

So what to do?

Attend the meetings of the groups that make the rules. Get on the agenda and speak. Bring research, evidence, examples from other systems already doing what you want to do.
You get a lot more attention when you bring in a multiple page presentation on Community Paramedics rather than complaining in the yard that we need more training to be able to do more.

Follow the policies. If they aren’t what your patient needs, lobby to change them. Don’t ignore them in the field or your next patient may suffer when you’re on suspension and that medic you despise has to treat them.

Which is worse?

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5 thoughts on “Just because it’s right…”

  1. Hard for anyone to advance when the trauma center is triaging based on mechanism, in many cases even worse than EMS did with the same patient.  

  2. How about consulting medical control every time the protocols tell you to do something you know is stupid?  As a medic, I find the “mother may I” approach irritating; but I imagine that getting constant nagging calls when the protocols say to treat the vehicle rather than the patient is even more irritating to the MDs who have to field the calls.  Annoy the doctors with enough obvious calls and saying, “sorry, but I needed to call you before deviating from protocol” might get the MDs to force changes on the county.

    1. mptak, calling to Mother to deviate from policy is rarely successful, especially in a Base Hospital System where the MD making the decision is not always the MD who will be assuming patient care when we arrive at the hospital.  In the case of trauma, yes, but the system assumes the MDs at one hospital can make decisions for the others.  Its an outdated method, but the only one we have.
      Another problem we face is the ability for an overcrowded and understaffed ED to get a base Doc to the phone or radio in an acceptable time frame. If they have to wait 15, 20, 30 minutes in some cases to get “permission” to deviate that’s a waste.
      Falling back on medical control is an option but a poor one.  The Docs at the base hospital can influence the County to change the policy, but they sit at the same table I  do at those meetings.
      And besides, will the Doc really allow spinal motion restriction via self splinting on the passenger of an SUV rollover with 12 inches intrusion simply because I say she’s uninjured?  Unlikely.

      1. It isn’tt about whether we end up getting permission at the end of the magic phone call.

        It is about getting the doctors on record requiring a treatment with no evidence of benefit and a lot of evidence of harm, based on the assessment of the car.

        It is also about causing this to be almost as much of an inconvenience for the doctors as it is for the patients. Contra Costa ended up getting permission to start IVs on chest pain patients because the MICNs were swamped with calls. If we tie up the doctors on this nonsense, maybe things will change.

        Some of the doctors should be reasonable. After all, they have completed medical school and the phone call should cure the patient. That is the way magic works.

        Spinal clearance does not depend on the competence of the people applying it, since spinal immobilization is not a treatment that can be shown to provide any benefit to the patient.

        If it takes half an hour to get the doctor on the phone, this should be an excellent way of demonstrating the ridiculous nature of the magic phone call and the use of the backboard as a treatment.

        Your last paragraph doesn’t make any sense. What does the mechanism have to do with whether the magic backboard works? Where is there any evidence that a backboard improves outcomes for patients with unstable spinal injuries?

        .

  3. When dealing with spinal precautions my newest standing orders make a LSB a tool of extrication and not for spinal immobilization.  I have always had the ability to clear c-spine but this is an amazing tool for patient comfort since the new studies are showing the LSBs do not help and in fact can harm a patient.  We are also beginning to use the soft collars for some patients to avoid hyperextending necks.
     
    As far as calling, I call when I need to exceed SOs or for something outside the box.  If I feel withholding something from a patient is warranted I do not call and feel Paramedics should not call for that.  You can assess and make a decision based on that assessment and our docs do not want you to call them because, it makes them think you are questioning yourself so they will not allow you to deviate.  If you are unsure then you should not be withholding a treatment.

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