Why EMS should put compassion before protocols

Family members may not be allowed in the back of the rig, but when the infant you’re doing CPR on probably won’t regain a pulse, will you deny the people who love her the chance to be by her side?


“No smoking. Oxygen in use.”

“No family in the back of the rig.”

“Food or drinks allowed in cab only.”

“No pets in the rig.”

Rules abound in EMS — algorithms, protocols, policies and procedures. As a profession, we put great stock in the rules.

They’re so prevalent in EMS and health care; the accreditation process intended to be the stamp of an agency’s legitimacy focuses primarily on how many rules and policies they have in place. Everywhere you look there’s a mechanism for addressing every conceivable situation.

But often we forget that it is impossible to conceive of every possible situation, and that the only unbreakable rule is that every rule has an exception.

The messiness of human grief

Real life has a way of throwing you curveballs. That’s because we’re people, caring for other people, and people are inherently fallible creatures. We’re complex, irrational, emotional, unpredictable beings, and most of our patients haven’t read our rulebook.

It’s easy to get bogged down in the minutiae of the protocol book, and ignore the mercies we are meant to bestow.

I’m sure your rig, like mine, is festooned with little decals that say, “No smoking, oxygen in use.”

But when your patient has just watched his 17-year-old daughter get taken away in another ambulance for the intentional overdose that may very well take her life, he doesn’t care about your safety regulations. And the bleeding from the cuts on his arms he sustained when he broke her apartment window is well-controlled, but his fear isn’t.

So when he pleads with you to let him smoke a cigarette  just one, he begs – to settle his nerves before you put him in the rig, will you tell him no? How long will that cigarette take you out of service?

Is that extra couple of minutes going to cause your patient or the system to crash? Is the minutiae in the rulebook more important than the mercy?

There are plenty of reasons not to allow family members in the back of the rig. But when all your training and experience tells you the frail old man you’re transporting to another hospital two hours away isn’t likely to survive the trip, or the infant you’re doing CPR on probably won’t regain a pulse, will you deny the people who love them the chance to be by their side during their last moments?

A firm, “Sorry, no. Company policy,” is the expedient answer, the convenient lie that shields you from the messiness of human grief. But is it the merciful thing to do?

Yes, I know a hysterical family member can interfere with a resuscitation, even be a safety hazard in the back of the rig. But when the wife has signed a DNR for the trip, or the mother is emotionally devastated but still holding it together, is your comfort or the company’s policy worth their pain?

When the person on your stretcher isn’t likely to survive despite your best efforts, who is your real patient? What is best for them?

Is the rulebook more important than mercy?

OSHA has rules about food or drinks in the back of the rig, and for good reason. But when your patient has spent close to 12 hours in the ED with nothing but a limp turkey sandwich and a bag of chips to sustain him, and his wife brings him a burger before he is transferred out, do you deny him a simple meal, especially when he isn’t NPO?

Or do you delay the transport that has been holding for several hours just a few more minutes until he can wolf down his heart attack in a sack, or simply pretend you didn’t see it when he munches on it in the rig?

No doubt your agency has rules against animals in the rig. I know mine does. Maybe it includes exceptions for service animals, or maybe it doesn’t.

But all I know is that when I think my patient really needs to go to the hospital, I will pull out all stops to convince him to go. And if that requires me making friends with his psychotic little ankle biter, and detouring five blocks off my route to the hospital to drop off the dog with a friend, that’s what I do.

The cops were unsympathetic — “Not my job,” their body language quite clearly conveyed. And when the victim is a histrionic, HIV-positive gay man bleeding from multiple lacerations, they were quite happy to make him my job. The fear and revulsion were plain on their faces.

So I made friends with the dog, and I promised the man I’d see to his welfare. And I violated company policy to do it. I put the little critter in the front of my rig, where he cowered in the passenger floorboard until the man’s partner opened the door five minutes later.

But one man got to see that not everyone is like the homophobic thugs who beat him up for nothing more than their own amusement. That man saw that not all big, white rednecks are the same, and that not everyone he calls for help will treat him like a leper.

And when I told my supervisor about the encounter, he didn’t much care about my violation of company policy.

“Was the dog bloody, too?” he wanted to know.

“Yep.”

“Did you disinfect the rig thoroughly?”

“Yep, front and back.”

“Sounds like you did what was necessary, then,” he shrugged. “Good job.”

I’m not telling you to do anything that will get you fired. Don’t flaunt company policy just on my word. What I am saying is that most rules have some wiggle room, and a compassionate provider will exploit that wiggle room for the good of his patient.

If the letter or the law is more important to you than the intent, and you place more value on the minutiae than the mercy, then perhaps EMS isn’t the career for you. And if your employer puts the protocol book and the policy and procedure manual ahead of patient care, then perhaps you’re working for the wrong people.

There are a hundred little mercies we can bestow every shift we work, and believe me, those little things are more appreciated by our patients than any medical expertise we can muster.

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