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Back It Up: What Good are Protocols Without Guidance?

Dear Sirenhead,

I_m a firefighter/paramedic for a department that provides both fire and ALS transport services. Lately, our officers have begun to blow off or make fun of EMS training or advances in prehospital care, responding with comments like, "That_s geek crap." Many of the officers think we need to do things the way they did them in the _70s and _80s by putting our patient in the back of the truck and driving as fast as we can to the ED. Hard to believe, but they don_t understand that high-quality prehospital patient care can make a difference in the outcome of a call.

Three months ago, we received new protocol books, which read like a paramedic textbook, often describing the etiology of the condition but skipping treatment guidance. Also, we don_t have some of the medications or equipment called for in the protocols. For example, CPAP treatment protocols but no CPAP machines. Protocols to perform 12-lead ECGs and communicate to the ED but no 12-lead capable machines. Fentanyl as an analgesic but no fentanyl.„

Surrounding departments provide their patients with a much higher standard of care. Don_t get me wrongƒwe provide adequate care with response times that average less than four minutes for ALS. But we could be providing so much more.„

In addition to better care, my concern is that we need to be able to rely on our officers to back us up if a problem should arise. But because of the officers_ lack of concern and lack of continuing education, I don_t feel we would have sufficient backup if needed.

What can we do as field medics to change this downward spiral?

Without Backup

DEAR WITHOUT BACKUP,

You have got to be kidding me. It_s 2009, right? I thought all the dinosaurs died when the asteroid hit. My gut response is to tell you to do a Johnny Paycheck on them and find a department that wants to deliver 21st century care to patients and equip crews appropriately. But it sounds like you_d rather fix things, so let_s go down that road.

Your protocol book was written by someone. Find out who it was and talk with them. Ask them what you asked me.„

Before you get that far, determine whether the protocols you mentioned are required or jurisdictional options. Some systems make programs optional so jurisdictions can pick the ones that best meet their patients_ needs, take into account transport times and don_t unduly burden operational budgets. I bet that last one stings, right? Well, nice as 12-lead monitors may be, they ain_t free. Costs are up, and tax revenues are down.„

Lest you think I_ve gone soft on the admin guys, let_s say that I_m off the mark and your department_s got money falling out of its pockets. Your bosses need to communicate with you. Seems like some chiefs just haven_t listened to their successful peers. So, advocate„opencommunication. Managers need to realize that when they don_t tell their crews something, crews will make up the answer and pass it along as Gospel.

Other than talking with the protocol writer, here are some options, in order of least to most invasive.

Send your question up the chain of command. It may take a while and you might not get an answer, but when used properly, the chain of command is a great way to ensure that each level of supervision shares information and issues are handled at the lowest level. You have to be aware that it_s also a great (and legal) bureaucratic way to delay answers and action to the point that you just give up. Do you really believe that an officer who has been riding you about too much patient care is going to send your complaint up the chain?„

Call your medical director. Most of these physicians are contracted by a jurisdiction or assigned by a local hospital. Is your medical director aware that you can_t deliver protocol-required care because you don_t have the stuff to do it? Do they know company officers are impairing patient care? I_d bet most docs aren_t crazy about anyone practicing marginal medicine in their system. But when you call, be sure to listen, not whine.

Do you have a union? Your union can bypass the chain of command and go directly to the top. As a labor organization, the union can also go directly to the media, elected officials and the citizens. I_d use the latter contacts as a last resort, and it has to be well planned. Just because you_re a member of the union doesn_t mean you can spew your concerns. Check your contract and bylaws.„

Your final option is to leave. Are your pay, benefits and location so great that you_re willing to put up with the deficiencies you described? If so, ride it out and hope it passes. If not, it might be time to move on.„

None of these options are easy to initiate. Hit the pause button before you take any action. Regardless of the path you take, expect some unhappy people. Let me know how it works out.JEMS

Tell Someone Who Cares

Got a question or complaint? Let Sirenhead hear all about it. He_ll answer you with 124 dB of traffic-stopping noise. E-mail„sirenhead@elsevier.com, and then brace yourself!

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