EMS 2.0 & EMS Ethics – How far would you go?

Throughout my EMS career I’ve heard a lot of the same complaints from paramedics that seem to be endemic within the system. One of these is the quality of physician medical direction and whether or not theirs is considered “Progressive” or “Permissive” by the EMTs and Paramedics that work within the protocol system. Some systems seem almost regressive. They don’t seem to show any trust in the providers that work within the protocols and end up being putting forth “Mother-May-I” protocols that disallow aggressive field treatment and require hand holding over the radio or cell phone to a base station. Others, are fairly progressive and allow quite a bit of treatment to be provided in the field.

However, even in the more progressive of the systems out there the medics always tend to have their own personal “wish list” of things that they’d like to be permitted to do. I currently work in the most progressive protocol system I’ve ever worked in and yet there are a few things that I would like to be allowed to do further than I can do now. Toradol for pain control, and the inclusion of a paralytic to our Medication Assisted Intubation protocols would be examples.

However, there begs a question here that I haven’t seen explored before: What if this was reversed?

Say tomorrow you head on into work and get there to hear the news that your medical director up and left for Tahiti with a new love interest with whom he or she will be very happy. Incidentally, you’ve now got a new medical director that just graduated medical school after spending 10 years as a field paramedic. There’s a “Get to Know Me” meeting scheduled in a half hour,

In the meeting the new medical director, who emphatically insists that you call him “Dr. Pat”, and then changes it to “Just Pat” outlines the new protocols that you will be functioning under starting as soon as you all can get through the trainings and meetings that are scheduled. These protocols are amazing. For example, your protocols for treatment of severe asthma used to include just oxygen, nebulized albuterol, and subcutaneous epinephrine. Now you’ll be giving Albuterol mixed with atrovent for your nebulizers, Epi 1:1000 sub-q or brethine (terbutaline) sub-q, epi 1:10000 IV for severe cases, Solu-Medrol (an injectable steroid), and Magnesium Sulfate infusions for refractory cases. For pain control, you used to have to call for orders to give Morphine. Now you give Morphine in 2mg increments titrated to effect up to 20mg if the blood pressure is over 100mmhg systolic, Fentanyl 50mcg – 200mcg, Toradol 60mg IM, and/or Nitronox (Inhaled Nitrous Oxide). The protocols are really advanced and have at least twenty new medications, some of which you’ve never even heard of.

Soon after you start reading the new protocols you start noticing things that frankly, scare you a bit. Never mind the fact that you don’t know how you’re going to calculate amiodarone drips and use propofol for conscious sedation, you’re frankly scared that the protocol system directs you to perform emergent C-Sections to save a viable fetus in cases of limb presentations in pregnancy. Really?

Mannitol and induced hypothermia for head injuries? Wow. You also now have needle crics, surgical crics, Needle decompression of the chest, pericardiocentesis, retrograde intubation, and what are those words? Thoracostomy (Chest Tubes)?? Thoracotomy? Holy crap! There’s almost nothing you can’t do! 

After the meeting you head out on the streets with your partner. You’re honestly feeling a little nostalgic for the days when your Tahiti-bound regressive medical director wouldn’t let you be responsible for hardly anything. It’s completely opposite now. You’ve gone from one extreme to the other. There’s nothing that you’ve ever thought of doing in the field that you can’t do anymore.

On one hand this would be very exciting for me (and yes, I went a little overboard with plausible treatment modalities to make a point here) but on the other hand, I’d have to ask the question:

Where would be the line where progressive treatment protocols cross the line? When would be the point where paramedics are given too much responsibility for complex invasive treatments?

I’ve never seen the case I’m describing. I love working under a progressive and liberal protocol system. However, in a meeting the other day when the possibility of administering thrombolytics for refractory ventricular fibrillation in cardiac arrest came up I had a thought that I’d never had before:

“I don’t get paid enough to have that much responsibility. I take on a lot of liability and have to put in a lot of uncompensated education time for the meager wage that I get paid now… how much is that going to have to increase for no more money?”

I don’t want to think that way, and I’d have to question the dedication of any paramedic in any of the protocol systems that I’ve examined that would say no to being able to provide potentially lifesaving treatments to their patients. I can’t imagine refusing to do something because I didn’t think that I was compensated enough to take on the responsibility of doing it. I’d be happy to sit through the required education, but I doubt that they would increase the compensation of the medics in the above example.

Could it happen? Has it happened? Will it happen as treatments progress and professional responsibility increases? I’ll firmly say that I’m nowhere near adequately compensated for the responsibility I have today. Where would I be if the above scenario happened to me tomorrow?

EMS 2.0 needs to seek out and find answers to the questions that we haven’t asked yet just as much as we need to find answers to the questions we’ve been struggling with for years.

What do you think?

  • mr618

    I can't comment specifically on your points, as I'm licensed “only” at the Basic level, but I can comment on the increased options available to us as EMTBs. When I first took the class (in 1979), we were pretty much nothing more than advanced first aiders. This was back in the days when paramedics were few and far between, at least in the farther reaches of suburban Connecticut. We were basically scoop-n-go, cranking down the highway doing CPR in the old Caddys.

    On the second go-round, in 1994 (I let my license lapse as my employment in the early 90s ruled out any EMS stuff), we could do more, but still very little in the overall scheme of things.

    This time (2008), we can do all sorts of things that had been unimaginable back then — 324 mg aspirin for cardiacs, asthma inhalers, assisting patients with (their own) nitro and epi injectors (under medical control, of course). Of course, the Red Cross now offers training in epi and asthma as part of their First Aid curriculum.

    Yes, the course has become much more complex over the years, and I'm sure it's even worse for paramedics, but on the other hand, at the Basic level, we can now do a LOT more to help keep the patient alive until we can meet up with a paramedic unit. (Here in Maine, most of the volunteer services still run EMTI at best; paramedics are usually either full-time FD/EMS staff in the larger towns or employed by the commercial services).

    A lot more complicated, a lot more responsibility, and — for the most part — little to no pay for the volunteer squads (in my town, we get $10/hr while out on calls, after attending the class on our own time).

    But, to us, it's worth it. If we can save one life that might have been lost otherwise, it's worth it.

    Starry-eyed? Naive? Maybe. But for those out here in the trenches in the boonies, we do the best we can with what we've got.

    I can understand the concerns about the extra liability, especially given how litigious our society has become. Maybe part of EMS 2.0 has to be increased legal protection, for all of us in EMS – it's insane that we still have to worry about whether or not we're covered under a Good Samaritan law.

    We basics can't do a fraction what you paramedics can do, but the more your training and responsibilities increase, there is a trickle-down to those at our level, allowing us to better assist you guys. That, in turn, leads to better patient care, and to me, that should always be the main concern.

  • http://www.999medic.com Medic999

    Chris,
    Very interesting and thought provoking post. Youve had me thinking about this for alot of the afternoon.

    I will comment on this on my blog as I feel my comment will be too long for here.

    I will try and get it out tonight mate!

  • http://www.999medic.com Medic999

    All done Chris,

    Pop over and let me know what you think:

    http://999medic.com/2009/10/19/my-thoughts-on-e

  • http://profiles.yahoo.com/u/4BVPTK4KF5HEXZNVHXLVLAECIQ JamesR

    I'd like to have tubing, basic IV therapy, and CPAP in my scope so it frees up the hands of the medic to do more important things, like get meds into the patient and pay more attention to the patient. As an EMT-B, I get relegated to the job of secretary, or airway management. Both are of value, but I wonder if things wouldn't go better for the patient if some of the things in the back of my EMT book were available to us. Jim R, NY

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  • http://www.flashingbluelights.com/ Polarbearmedic

    This line of thinking is in fact one that I've been contemplating for quite a while. Who among us hasn't had a patient that would have benefited from a relatively safe drug or procedure that wasn't available to us, and the patient subsequently had a poor outcome?

    My feeling is that it all comes down to education and training. In the US, a high school graduate takes between 1-2 years to become a licensed Paramedic. This is really nearly the same amount of time as a Registered Nurse spends in training when it comes down to it. However, nurses have the opportunity to further their education and training and thus have the ability to practice medicine at a higher level of care than their colleagues – this taking the form of completing a Master's Degree and becoming licensed as an Advanced Practice Nurse: such as a Nurse Practitioner, Nurse Anesthetist, or Nurse Midwife, etc. Paramedicine should have such similar opportunities for advanced training, and instead of simply attending inservices or seminars, the completion of graduate education should open up a broader scope of practice for paramedics. Whether this scope increases the primary care aspect of the profession, or perhaps includes additional surgical capabilities paramedics would be granted to perform in the field.

    Several years ago, two Paramedics, while working in an ambulance for the hospital which is currently my own employer, were presented with a pregnant patient in cardiac arrest. After all interventions failed to resuscitate the patient, in direct consultation with a physician over a mobile phone, the paramedics were directed to and instructed how to perform an emergency C-section on the patient, and the paramedics extracted a viable baby from the womb of the mother. After resuscitating the baby, she was successfully transported to the hospital (where she lived in NICU for 3-5 days, but unfortunately died). These paramedics were regarded as heroes by their colleagues and the media. However, their paramedic certifications were subsequently suspended then revoked by the state Department of Health for operating outside of their scope of practice.

    EMS 2.0 really is the next evolution of our profession. However, standards of education and scope of practice really need to be in place across the country so that all providers at various levels are on parity.

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  • firemark

    France uses a system along the lines of what you are talking. They perform as many procedures in the field as they can. The thought is: why wait to transport when we can do it here. The person in the back of the ambulance, a real MICU, is a doctor.

    In America the systems with the lowest mortality rates (as accounted for…yada yada) have the shortest transport times. Get 'em to the hospital where real definitive medical care is provided. A load and go system staffed with Basics has a higher survival rate than a system loaded with Para's and progressive protocols. Hmmmm

    Our balancing act is to provide the care the patient needs while we get them to the hospital where the long term fixes can be made.

  • firemark

    France uses a system along the lines of what you are talking. They perform as many procedures in the field as they can. The thought is: why wait to transport when we can do it here. The person in the back of the ambulance, a real MICU, is a doctor.

    In America the systems with the lowest mortality rates (as accounted for…yada yada) have the shortest transport times. Get 'em to the hospital where real definitive medical care is provided. A load and go system staffed with Basics has a higher survival rate than a system loaded with Para's and progressive protocols. Hmmmm

    Our balancing act is to provide the care the patient needs while we get them to the hospital where the long term fixes can be made.

  • firemark

    France uses a system along the lines of what you are talking. They perform as many procedures in the field as they can. The thought is: why wait to transport when we can do it here. The person in the back of the ambulance, a real MICU, is a doctor.

    In America the systems with the lowest mortality rates (as accounted for…yada yada) have the shortest transport times. Get 'em to the hospital where real definitive medical care is provided. A load and go system staffed with Basics has a higher survival rate than a system loaded with Para's and progressive protocols. Hmmmm

    Our balancing act is to provide the care the patient needs while we get them to the hospital where the long term fixes can be made.

  • firemark

    France uses a system along the lines of what you are talking. They perform as many procedures in the field as they can. The thought is: why wait to transport when we can do it here. The person in the back of the ambulance, a real MICU, is a doctor.

    In America the systems with the lowest mortality rates (as accounted for…yada yada) have the shortest transport times. Get 'em to the hospital where real definitive medical care is provided. A load and go system staffed with Basics has a higher survival rate than a system loaded with Para's and progressive protocols. Hmmmm

    Our balancing act is to provide the care the patient needs while we get them to the hospital where the long term fixes can be made.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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