Throughout my EMS career Iíve 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 ďProgressiveĒ or ďPermissiveĒ by the EMTs and Paramedics that work within the protocol system. Some systems seem almost regressive. They donít seem to†show†any trust in the providers that work within the protocols and end up being putting forth ďMother-May-IĒ 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 ďwish listĒ of things that theyíd like to be permitted to do. I currently work in the most progressive protocol system Iíve 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 havenít 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, youíve now got a new medical director that just graduated medical school after spending 10 years as a field paramedic. Thereís a ďGet to Know MeĒ meeting scheduled in a half hour,
In the meeting the new medical director, who emphatically insists that you call him ďDr. PatĒ, and then changes it to ďJust PatĒ 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 youíll 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†Ė 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 youíve 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 donít know how youíre going to calculate amiodarone drips and use propofol for conscious sedation, youíre 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! Thereís almost nothing you canít do!†
After the meeting you head out on the streets with your partner. Youíre honestly feeling a little nostalgic for the days when your Tahiti-bound regressive medical director wouldnít let you be responsible for hardly anything. Itís completely opposite now. Youíve gone from one extreme to the other. Thereís nothing that youíve ever thought of doing in the field that you canít 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, Iíd 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?
Iíve never seen the case Iím 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 Iíd never had before:
ďI donít 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 nowÖ how much is that going to have to increase for no more money?Ē
I donít want to think that way, and Iíd have to question the dedication of any paramedic in any of the protocol systems that Iíve examined that would say no to being able to provide potentially lifesaving treatments to their patients. I canít imagine refusing to do something because I didnít think that I was compensated enough to take on the responsibility of doing it. Iíd 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? Iíll firmly say that Iím 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 havenít asked yet just as much as we need to find answers to the questions weíve been struggling with for years.
What do you think?