Standing Orders and Consistency

A young doctor I know, who used to be a street paramedic, says the reason paramedics have standing orders is because no two doctors can agree on anything so they let the medics decide based on written guidelines. Otherwise there would be chaos.

Where I work I transport patients to any of eight hospitals, but there are four I regularly take people to. With the exception of the hospital’s EMS medical directors, hardly anyone on the medical staff are familar with our prehospital protocols. They may know the outlines (ASA for chest pain, D50 for hypoglycemia, narcan for heroin OD, albuterol for asthma wheezing, etc.) but they don’t know the particulars. I have been castigated for not RSIing a patient with trismus (We don’t carry RSI meds), for calling medical control when faced with an 68 year-old man who had a syncopal episode and was refusing to go to the hospital despite being clammy and having a heart rate of 36(I’m supposed to call so you can help persuade the patient who needs to go and not yell at me for bothering you), and questioned on the appropriateness of giving Cardizem prehospitally for rapid a-fib (it’s why we carry it).

This doesn’t happen a lot. I site it only to demonstrate people don’t know the protocols or, in many cases, the drugs we carry. Of the few things we do have to call for, I could probably go ahead and just give and have no one blink an eyelash at because they don’t know I’m not supposed to give it on standing orders.

A number of years ago, I was quite proud that I had won the right on our medical advisory committee for paramedics to now give up to 15 mg morphine(weight dependent) on standing orders for fractures (previously we had to call after 5 mg). Two medics told me, “I do that anyway.” They had been doing it and no one had questioned them.

There is not a lot of QA in our system.

But my point here is not about taking advantage of the system, it is about inconsistency.

One doctor likes Cardizem, another hates it. One doctor never gives Lasix, another gives it all the time. One doctor likes nitro paste, another says its worthless.

I recently heard about a call where a medic responded to an elderly woman who had been hit by a car at a low speed in a parking lot of a supermarket. When the medic arrived, she found the woman alert, ambulatory with only a small head lac. She said she had been brushed by the car and bumped her head against her own car. Never the less she boarded and collared the woman, and took her to the hospital, which happened to be both the woman’s choice and the closest hospital.

Many hours later, the woman developed mental status changes and it was discovered she had a broken leg. Also, additional witnesses came forward and described a different story that the medic, in her best efforts, had obtained at the scene. The family also arrived and said their relative was clearly not her usual self. That happens. You can hardly do a full investigation in your ten minutes on scene. Nor can you be expected to know the patient’s norm. The medic was later questioned on why she hadn’t taken the woman to a trauma center. Given the circumstances I probably would have done just what the medic did. An alert, ambulatory patient, a minor mechanism of injury were hardly enough to deny the patient’s choice of hospital.

Shortly thereafter I read a new study that showed that the elderly are often under-triaged when it comes to trauma. One reason sited was confusion is harder to spot in an elderly person where absent-mindedness and slowness of response are often taken for the norm. Another reason is their bones are much more brittle and prone to breaking at even the smallest mechanism. A young person acting confused and moving with a limp is easy to spot. In an elderly person it is the norm if you are unfamilar with their baseline.

Keeping this in mind, I had two patients in two days who were very similar. Each, an elderly woman who had sustained a fall, striking their head in the morning and then were not themselves afterwards, displaying serious and gradually worsening mental status changes. In both cases, the staff at their facilities waited hours to send them out.

I board and collared both of them, and gave them the full ALS workup, although niether did I transport lights and sirens. Both went to a trauma center. One patient went into the trauma room, the other was immediately taken off the board and I was questioned as to why I had collared her since she had been up and walking after the fall. I didn’t think either patient had a spinal injury, but since they had both fallen, struck their heads and had altered mental status and were elderly I was following out liberal spinal immobilization policy that as liberal as it is, still requires me to immobilize a fall head injury patient with altered mental status. Had I not immobilized the first patient, I would have had to stand there while the doctor call for a collar to be applied in the trauma room. It’s happened to me before. All trauma room patients at this one hospital get a collar if they are to have a head scan. I’m not disputing the motives of either doctor. I wouldn’t want to be on the back board. It is just that doctors view things differently. That’s why we have standing orders. We need consistency to keep us from being as unpredictable as the doctors. While our education is fairly extensive, it is not broad enough to allow us to practice beyond the norm.

6 Comments

  • TOTWTYTR says:

    In our system we get medical control, on the rare occasions we need it, from one hospital. Doesn’t matter where we are transporting, we get medical control from our resource hospital. There was a time when doing medical control radio was part of the residency for the doctors. They had a large board with our protocols on it and they could look up from the radio and look at the board to see what they were supposed to order. As we gradually moved to standing orders, the board was updated less and less frequently. At one point it was replaced by a loose leaf binder. I don’t know if that still exists or not. When we used medical control routinely it worked well to have our orders come from one place, not the receiving hospital. We had a good working relationship with the ED attendings and residents, which fostered mutual respect and trust. It did annoy some doctors at some of the other hospitals that we didn’t take orders from them, but it did give us a consistency of treatment, and that was the point. Ahh, for the good old days.

  • Anonymous says:

    All of our medical direction comes out of one hospital in the county, even if you’re going to one of the other ones. All the ED residents at that hospital are required to do a single ambulance shift as part of their training. They are also somewhat familiar with our protocols. When we call medical control, we first speak with a paramedic who gets the quick gist of it (patient age/gender/chief complaint/vitals/physical exam/history) and will page for a physician on the overhead in the ED. The ED physician goes to the medical control office and gets a report from the paramedic at the desk and either relays orders through them or gets directly on the phone with the provider. At the end of every call involving an ALS intervention (wether you call medical control during the call or not), you have to call medical control and provide the patient’s name/address, chief complaint, vitals, history, physical exam findings etc. They also record your IV and intubation success rates.Any deviation from protocol is then reported to our Chief of Education who will then decide how to handle it. Depending on the situation, he may let it slide, call you on the phone and counsel you, have you come in for re-education or begin an investigation.

  • Rogue Medic says:

    I have a much broader variety of medical command doctors to deal with. Some will insist on transport only. This is rare, but can really mess with the patient who is not stable, or make a stable patient less stable. Depending on the nature of the call, the doctor, and the facility, I may feel comfortable disregarding inappropriate orders.Most are reasonable in their orders, or are trying to be reasonable, and will listen to suggestions from me. It has been my experience that they may be hesitant at first, but if you demonstrate that you are aware of the concerns they may have about the treatment they are not comfortable ordering, they are flexible in their orders. The orders still may not be what you think is best, but you are closer to where you want to be.Some are comfortable with leaving a lot to the paramedic’s judgment. Sometimes because they are comfortable with the medic on the phone. Sometimes they just trust EMS a bit more.We get command from the receiving hospital most of the time. Any PGY 2 ED physician can give medical command orders. Only a medical command doctor is permitted to answer the phone, so of course we have to ask the person who does answer the phone to get a medical command doctor.Most doctors have good relations with EMS. Those who endanger the patient, EMS, and others are the problem. A problem without a good solution.

  • PC says:

    Thanks for all the comments. I think the ideal is to get all your medical control from one location stafed with an MD who is fully familar with the EMS system and its protocol/guidelines.We used to also get all of our control from our sponsor hospital, but then a number of years ago, when we regionalized our protocols, we switched to getting control from the recieving hospital.Our big problem is the wide variety of people who will pick up the radio to answer the request for medical control. It can range from the head EMS director to another MD on their first day at work.

  • Brandon says:

    Is anyone still reading this. I have a question regaurding protocols and standing orders. Please respond if this is still live.

  • medicscribe says:

    Hi Brandon-

    What’s your question?

    Peter

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