Mike left a comment on the last post I wrote “EMS Politics, Medical Ethics, and… What would you do?” with a good quote that I’d like to bring the forefront of discussion: “Your next call could be your last call”.
That sentence sums up something that I’ve always said about EMS quite nicely. Bravo to you and your old partner, Mike.
I firmly believe that EMS professionals face “No Win” scenarios several times in their careers. There are things that come up and situations we face that would test the most knowledgeable medical ethicist. Often times we have to make terrifyingly difficult split second decisions using woefully inadequate information that will not only affect the very life of a patient but also our careers and our livelihoods. It’s not fair, and it’s not fun. Paramedics are entrusted with huge responsibility for clinical judgment but can be quickly chastised and sanctioned for even stepping a little bit outside of the box. No, we’re not physicians and No, we’re not licensed to perform everything that a patient may need. I understand that there are some things that are just too dangerous to do in the field, and that yes, patients sometimes die in front of us and we are powerless to stop it.
However, in the scenario presented in the abovementioned post, that was not the case. In the case presented, the patient needed a surgical cricothyrotomy and needed it NOW. The paramedic described in the scenario had been trained in the procedure, had the tools available to him to perform the procedure, and the patient was going to die quickly without the procedure. The catch was that the protocol system he was working in did not allow him to perform the procedure.
The scenario gives two choices:
Don’t perform the cric. Use your full airway bag o’ tricks such as first trying BLS techniques (Heimlich Maneuver, abdominal thrusts) attempting to remove the object with Magill forceps under direct laryngoscopy, attempting to intubate the patient with an ET tube and push the blockage into the right main stem bronchus with the tube allowing the left lung to be ventilated (It’s better than nothing), and scooping the patient up and running really fast to the hospital. If all that takes more than 5 minutes from the time the airway got blocked, including the time from incident to the 911 call, the dispatch time, and your travel time, expect brain damage at the very least. If it’s much longer than that, expect the patient to die.
- Perform the cric. You’ve got the knowledge, you’ve been trained on the procedure, and you have the equipment available to perform the procedure. The procedure is in the standard scope of practice for paramedics all across the country. Unfortunately, even if the patient makes a full recovery, you’re in deep trouble. The Medical Director in the scenario has not authorized the procedure for paramedics under his/her direction and therefore you’re practicing medicine without a license which is a violation of the letter of the law. It may very well be the only thing that will save the patient’s life, but you’re likely to face severe penalties for violating your protocols.
So what do you do?
I firmly believe that medical direction should not hold paramedics back and that there has to be some leeway in the standard operating procedures that paramedics function under to allow for these situations. Every protocol system and EMS service that disallows such procedures that are allowed under national accepted scope of practice can have situations where patients have poor outcomes up to and including death. In these systems, the EMS provider bears the brunt of the negative result. If he allows the patient to die, it could be argued that he withheld lifesaving care and violated a duty to act. If he was protected legally by the letter of his protocols and the fact that he followed them, he at least could be committing a moral and ethical violation that will haunt him for the rest of his life. I would suspect that the medical director and/or the authorizing body would not be sanctioned in this case… if they were even aware of it. By performing the procedure and saving the patient, the paramedic will be punished quite severely. Even if the patient survives but has residual morbidity resulting from the prolonged anoxia, the medic could be sued for and be held liable for the damages.
In any case, the paramedic carries the burden. It’s a no-win situation.
For the record, I didn’t actually have this happen to me, but I have worked in two systems simultaneously where one is more progressive than the other. In fact, I do right now. Fortunately, both of these systems allow surgical cricothyrotomies, but they carry different medications and have different dosages. One of my services uses CCR (Cardiocerebral Resuscitation – http://www.callandpump.org/) and the other follows an older version of the AHA guidelines. While both are acceptable and I follow the protocols for the system that I am working at when I am working there, I can see the potential for ethical conflict. I’ve been a full-time paramedic for a long time and I’ve flexed the rules occasionally when it was in the best interest of the patient. Luckily (and yes, I know I’ve been lucky) the patient has always had a good outcome when I’ve had to do this.
Here are my rules for “bending” the rules:
- Above all, always act in the best interest of the patient – If you can show that you acted in the best interest of the patient, disregarding any other potential motives, you’re well on your way to vindication. However, remember that ‘rule bending’ must be for the patient’s best interest, not your own. Something like not placing the shoulder straps on the patient during transport because it makes it more comfortable to care for them is in your own best interest, not necessarily in the best interest of the patient. Taking a patient to a hospital closest to your next errand and not to the most medically appropriate is also in your best interest and not in the patient’s. The cric scenario regards whether the patient will live or die at great peril to the paramedic.
- Know what your protocols are and why they are the way they are – Knowing your protocols inside and out is essential to being a good professional provider. Knowing WHY they are the way they are, i.e. the reasoning behind them is essential as well. Be able to show that you know them inside out when you’re questioned, to show that you’re not negligently ignorant of the rules you have to function under.
- Be able to prove what information you had available for you to consider – In these situations, you’re working with incomplete information. However it is your professional obligation to gather as much information as possible as quickly as you can gather it. Do a thorough assessment, and talk to the patient and any bystanders, if possible. When questioned about the incident later, you need to be able to present the information that you were presented with to the people who are going to play armchair quarterback. Be able to put them inside of your shoes.
- Be able to prove what options you had available to you, how you considered them, and why they did not or would not have
worked – In the previous airway control scenario, I laid out possible options that the paramedic in the scenario considered. I also laid out why they would not work as the situation unfolded. Be able to show your thought process and how you ruled out options that were within the letter of the rule book.
- Be able to prove why you thought that the option you chose was absolutely necessary – If it was a “do or die” call, be able to prove it as best you can. You should be
able to show why it was necessary that you chose the option you did. In the cric scenario, transporting the patient to the hospital so that a physician could perform the procedure would most likely have resulted in the death of the patient. In that case, the best interest of the patient, obviously, would be to continue living… which he would not have done without the paramedic violating the rules. BE THAT SURE of yourself.
I would love for people to jump in and offer their takes on this topic. Please comment away. If you haven’t read the great comments on the previous post, left by such people as Medic999, HappyMedic, and TOTWTYTR you can find it here.
I use scenarios like the one that I wrote out in the previous post as a teaching tool for new EMS people and students that I precept. I think that scenario-based teaching is a great way to promote critical thinking skills and to evaluate what a person would do when faced with the situation presented. In the future, I’m going to be featuring scenarios that challenge ethical standards as a way to educate ‘Everyday EMS Ethics’. Look for the “Featured Areas” to showcase these and other interesting articles.
And thank you for reading.