My five-year-old son is fond of telling me on occasion (like just after he's had Lego privileges revoked for poor behavior) that he doesn't like me anymore. He informs me that I've hurt his feelings because I didn't do what he told me to do and follows this pronouncement with a request for a new Daddy. My response, as a compassionate and caring father, is to note that he's welcome to it, but all his toys stay at my house. A few minutes later, we're renegotiating our kinship over cookies and juice.
Much of the feedback I receive regarding my columns espouses the theme of "Why doesn't my medical director let me ?" It's a legitimate question that deserves an attempt at an answer.
I truly do not believe that the vast majority of EMS medical directors have any interest whatsoever in restraining progress. I think that, to a person, they'd like to see the prehospital envelope expand in a patient-centered way. I won't deny that sometimes the physicians themselves are the problem. There is undoubtedly a certain element of pigheadedness in some medical directors (our Founding Father John Adams freely noted that he himself was "obnoxious and disliked"). Other physicians who aspire to do a good job are overmatched by a lack of time, a deficit in training or extraordinary political or economic circumstances. But as a medical director, and one who considers himself an advocate for EMS care, I've got to be honest with you. There are times when we simply don't trust our folks in the field enough to answer their demands, and there are times when both EMS administrators and field crews have done little to earn our trust.
I suspect that much of why we have reservations about releasing the reins of prehospital care has to do with approach. As with most issues, there is a little fact and a lot of emotion riding sidesaddle to the problem. It's true that doctors (other than those regularly beat upon by ED nurses, techs and clerical staff) generally don't listen to anyone except other doctors. What you may not realize is that we don't listen to each other all that well, either. Our willingness to hear a message is compromised further if it's couched in terms of must, should or ought to. We're licensed as independent practitioners, by golly, and I'll be a _______ (fill in your favorite epithet) if someone else tells me what to do.
(It goes without saying that this attitude is not unique to physicians. Anybody out there know a fire chief, a supervisor, an administrator with the same belief? Hands up. One, two, three hmmm. Didn't know any vote in EMS could be truly unanimous.)
Too often, the approach to the medical director is adversarial. Paramedics and service administrators have been known to fling demands at the physician. "You've got to do this. ... It's the standard of care. ... The folks in the next county are doing it."
But that's not how professionals communicate, and the physician's response to these arguments is likely to be similar to the one Mom gave you when she asked if you'd follow your friends in plunging off a cliff. Forget for a moment that there are perfectly logical ways for the physician to blast these arguments out of the sky (50 different states defining 50 different levels of EMS care makes most "standard of care" arguments an easy target). A professional expects to be treated as one. A contrast of ideas is fine as long as the concepts are presented in a non-confrontational manner and backed by evidence. That's how science works. Medicine likes to think of itself as a science, and its practitioners wear lab coats for a reason.
This is not to say one should kowtow to the physician, nor accept any dictate without pause for thought. If a policy or protocol can be shown to be detrimental to patient care, or a new drug or technique has been demonstrated as advantageous, it is incumbent upon the medic to use whatever evidence is at hand to persuade the physician of the rightness of his course. But the more you confront the physician with demands, the more he or will she will interpret your actions as hostile and be less open to your legitimate concerns.
There are other, more concrete factors that influence the perception of trust. One of them is the actual performance of the paramedics.
We'll use field clearance of the cervical spine as an example. I truly like the idea of early clearance of the cervical spine. I think it's miserable that we force little old people with hip fractures and frightened children to lie restrained on a rigid surface for hours on end. I would love to get rid of its uniform application; I really would. But what stopped me from doing so during my EMS tenure were the actions of the paramedics themselves.
Before you use an advanced tool, I think you should first know how to use the basic device. I would not give someone a power saw without them having used a hand saw first, to have some idea of what the tool is and exactly how it works. Similarly, you tend not to place a thermonuclear device in the hands of the student in Physics 101 (or North Korea), but in the protective grasp of someone like Stephen Hawking. So I would not want to give paramedics a new tool for field use without ensuring that they were correctly using the old tools first.
As I examined the issue in my area, I found to my chagrin that the old tools had fallen into disrepair. Patients who clearly qualified for spinal immobilizations were not being supported and packaged. The KED boards were rarely, if ever, used for automobile extrications regardless of the patient's complaint of neck pain (several EMT students said they had never seen one used). Further, a review of patient refusals demonstrated that EMS providers did not always fully assess the patient's level of consciousness and orientation, crucial factors in any field c-spine clearance protocol. These were uncommon, to be sure, but when dealing with a hair-trigger issue like spinal injuries, the margin of error shrinks rapidly.
We worked hard on these issues through a CQI program and recorded progress of which I think the whole system could be proud. But until we had consistent application of the old principles, there was no way I could allow a new paradigm to be used. In contrast, I was happy to authorize the use of drug-assisted intubation in the field once our system had attained a high unassisted success rate. I considered our numbers of unsuccessful intubations to be within the margin or error and approved protocols for the use of etomidate to facilitate the remainder as I felt our crews exhibited good understanding and proficiency with the basic technique.If you want to move forward, it's all in the approach. Line up your ducks, your evidence, your support and your performance. Making certain your own house is in order is what professionals do.