First and foremost, you are always responsible for knowing and following your protocols. Deviations, even if there is possibly a better way to care for a patient, are not acceptable. Not following protocols, can be legally devastating to you and your department/service.

I agree that as medics we are resonsible for knowing our protocols like the back of our hand. That standard should never be compromised. But we should demand ...more. 

This is a paradox in our profession, we preach patient advocacy, and we deliberately cultivate a personality trait in our paramedics to stand up when we see something wrong (like bad patient care, blindly following protocols that dont fit the patient well) and yet we immediately bring down the hammer on any new medic that dares to do so?

There must be a better way. We used to teach healthcare providers to never admit a mistake, now progressive organizations actually have a reward system for when a provider comes foward with one. The days of the protocol being handed down like the ten commandments , and "call medical control" being the standard cop-out when ever there is an odd situation...should end.  We cant claim to cultivate critical thinkers, and restrict them to cook books. 

I am fortunate enough to be a part of an organization that actually has a deviation procedure built into its protocols. To put it simply, there is a protocol to deviate from protocols. Of course this is a sentinel event, and the parameters are limited to " where the delay in contacting medical control would result in increase morbidity and mortality" , and there are mandatory reporting requirements, but the point remains... PROTOCOLS SHOULD NOT BE SET IN STONE.

Eventually, inflexibility of the protocol, and the fear of stepping out of line by the medic, will kill a patient. It has happened before, and it will happen again. 

So, as a training officer, you are obligated to teach the protocols as written.

However, you certainly can present new, current, or “cutting edge” treatments to the employees. Just be careful not to criticize your protocols. It has been my experience that if you present new things (drugs, skills, equipment, treatment modalities), there is usually one or two people who become curious about these things and do more research into it. This is how protocols, many times, get changed. 

Again, this is where the professional organizations differ from the rest. A professional organization actually has a formal process where ANY medic, 1 day on the job (though this is not advisable) to a 20 year medic can submit changes. Now many organizations have some sort of protocol committee.

The truly great organizations make it a permanent function with mandated field representation (instead of the REMFS deciding how the field practices) , and where the medics and the doctors can discuss topics freely.  In my organization, this is called the "Standards of Care Committee" and it is considered an honor to serve.

So by all means , criticize the protocols (respectfully of course). Critical formal review of all aspects of our practice as paramedics is what will set us apart as professionals.  Its also one of our most important personality traits.

Respectfully submitted, 

Croaker

RE: The Protocol:  

Here is the exact text of the protocol that deals with the diviations. 

EXCEPTION:  If attempts to establish communication with medical control fail, and a patient is at high risk for mortality or increased morbidity, or if the delay anticipated in establishing communication with medical control may result in mortality or increased morbidity, procedures and/or medications normally restricted to direct medical order may be performed or administered without the direct order of a medical control physician.  Communications with medical control shall be established as soon as possible.  The reasons for the decision to institute treatment shall be clearly documented both in the chart and on the SWO deviation form.

The reality is that this clause is very seldom enacted Our orders are pretty liberal, and comprehensive, so they work pretty well.  That doesnt mean that these clauses are useless , however. Often , if the physician is reviewing a bunch of diviation forms over the same set of issues, perhaps the protocol needs revising. Such was the case at my service. 

Many years ago, we were seeing a lot of diviation forms for narcotic adminsitration. No, not giving more than needed, but giving less. Our critically minded medics were actually giving smaller doses than the protocol allowed, when they were faced with elderly patients. Most of these were hip fractures and the like. 

The result was a new caviat to all the protocols with sedative medications. 

"...ALS providers may decrease the dosage or prolong the administration intervals of any medication with sedative properties when doing so would decrease adverse effects and still likely obtain the clinical goal. " 

Therefore, the diviation protocol forced a review that might have not otherwise occured in another system. This resulted in a positive, common sense change for the whole department. 

Re: the scenario

Wow, that is a tough one, I can tell you I have been faced with similar problems. Many years ago I was involved with an agency that actually advocated..in writing...to run "hot" to and from every call, regardless of complaint or patient stability. The fire Chiefs reasoning is "that what the public is paying for, an emergency ambulance service!" (Yes that is almost an exact quote)

In another situation, the first ALS service I worked at had a specific warning stating that the paramedic will not ever deviate from those  protocols, ever. Obviously neither of these situations are conducive to good patient care. I am sure we have all seen care that was technically "by the book" (protocol) but was still very bad care.  

Obviously, when the situation is against common sense, common clinical practice,  as well as well established expert opinion and evidence, what can you do? In the example given, I am betting the author of the protocol had a "bad experience" once shocking an afib, or witnessed a bad experience,  and has let it color his/her practice ever since.

This is a hard thing to overcome, especially when it involves a doctor. Placing the discussion in the "safe" setting of a committee with healthy debate and healthy moderation, will often remedy these problems over time. 

In the short term, as instructors, we should certainly acknowledge that there is more than one was to skin the clinical "cat". My own service has several points that differ significantly from ACLS, but in each of the cases they are well reasoned and evidence based. Therefore asking for the "reasons" behind the protocol is important to understand the true issues at hand. Then pointing out the differences, as well as the similarities, is a good approach  to seizing the teachable moment. without causing conflict that disrupts the class or loses the student.

Sometimes the protocol is so out of wack that it is not justifiable. In those cases we must recognize the reality the providers in that system are stuck with, but we must also enlighten them to the alternatives.

In the end, we must always let good patient care be our ultimate goal. As instructors, we must be clear on that. As providers, when the choice between doing what is right and what is written is clear, and the patient's life is truly on the line, and you have exhausted all of your resources to resolve the problem...then your compelled to do the right thing. And after the storm clears, be honest, well reasoned, and true. And let the chips fall where they may.

 For me it depends on the setting. If I have been asked to teach for a specific agency, such as a monthly inservice, I will address the current standards and compare that to their protocol. This often leads to discussions of the dynamic nature of medicine, importance of keeping current, how to initiate protocol changes, "what if" discussions, etc.

On the other hand, if I am doing a session that is not for a specific agency my view is that I discuss the practice of medicine, not specific protocols. Although in an ideal world there should be very few differences between the current standard of care and protocols, each person will have to refer to their local governing authority for agency specific issues. If they find discrepancies, such as protocols that lag behind the standard, they should work within their local system to initiate changes.

I have to agree with others though, protocols act as a guide for care, but there is no way they can be written for every situation. We must use sound clinical judgement, our education, and so on to provide the best care for our patients. There are of course agencies and states that do take the view "the protocol says and you may not think beyond that", but I hope those are becoming less common.

WHat is the linked in link?

I'm not sure that I understand what you're pondering.  In the short answer for me, when you are teaching you tell the students what they are going to be learning and what the source materials or "standard of care" that you will be teaching to them.  If it is a Standard of Care and not just your opinion or your experience then the standard of care must be taught.  Why would there be 2 differing objectives that you're having to deal with?