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Tips to prevent, manage EMS scene disagreements

You were asked to assess and treat a 22-year-old woman with an obvious leg fracture and there was a disagreement about how to proceed; did you make the right call?

While much of the care provided in EMS is governed by protocols, providers are being given more latitude when deciding how best to treat a patient. In this way, protocols are being used to define a specific scope of practice, but medical care in the mobile environment is much more of a reflection of the individual provider than it once was.

With this shift towards individual practice the chances of an on-scene disagreement between providers increases. No longer can everyone simply point to a rigid protocol for guidance.

While increasingly common, not all disagreement is a bad thing. Several skilled, well-informed providers discussing possible treatment options for a complex patient is an effective and desired approach to medical care.

The most important aspect, however, is to develop a treatment plan in a collaborative fashion with the patient's best interests in mind.

Why we do what we do
Most EMS providers have been asked during a job interview some variation of the question: "What made you choose a career in EMS?" Many answered with some variation of, "To help people."

The fact that this answer is common, though, doesn’t make it any less true. Most providers of EMS, volunteer or career, started in the industry to help people.

That pledge to your patient, however, goes beyond just "helping." More specifically, that pledge is to be an advocate for your patient.

While that often means simply providing good medical care, it may also mean ensuring that a patient is comfortable prior to transport, is being seen quickly in the emergency department or is removed from an unsafe home situation.

In the context of an on-scene disagreement about how best to treat a patient, the best approach is to start from a position of patient advocacy and to proceed from there to a resolution.

How to manage differences of opinion
It is important to realize that loud, emotional disagreements between providers does not inspire patients' and bystanders' confidence in the EMS system. Alternatively, starting from a position of patient advocacy, both parties can calmly explain why their approach is most advantageous to the patient.

It’s not about being right. It’s about doing the right thing for the patient.

Above all else, keep the conversation civil and appropriate. Additionally, realize that while providers may disagree, they are both motivated by good intentions. The two treatment options likely aren’t that far apart in most cases.

The myth of rank
Local rules vary, but generally the agency with investigative jurisdiction has ultimate authority on the scene of emergency calls. This is relatively clear cut on a vehicle crash (police jurisdiction) or a structure fire (fire jurisdiction), but becomes muddy on medical calls that may involve police or fire agencies responded with an EMS agency.

As a result, many medical directors have a protocol that states that the individual with the highest level of licensure on a medical call has command of the scene. But what if a fire captain from a BLS engine and a firefighter paramedic from an ALS ambulance disagree on patient care?

Ultimately, sorting out rank is an operational function for each department and system to determine. On scene is not an appropriate time to have a discussion about the merits of rank versus licensure level. Save the operational questions for before or after a call.

Every EMS system has the provision to speak with a physician in real time when needed. If on scene medical providers are unable to reach a consensus about patient care, involving medical direction is a great option.

Doing so brings a third, likely unbiased party into the discussion who can make a decision based on the patient's presentation and available treatment options.

Feeling strongly that Sarah, a soccer player with a leg injury, should receive pain management before splinting, you ask to speak with the paramedic for a moment while his partner goes to get the stretcher.

"Here’s the thing," you say. "We tried to apply direct pressure to the open wound before we placed her leg in the splint and she seemed like she was in incredible pain. She has obvious deformity and her vital signs certainly demonstrate her level of distress.

"Since we need to splint that leg tightly to control the bleeding and then wheel the stretcher across the field, I thought it would be better for her to be as comfortable as possible before we did that. I just don’t want to cause her anymore pain than we have to."

The paramedic thinks for a moment and says, "No, you’re absolutely right. Thanks for the suggestion. I wanted to get her to the hospital quickly knowing that she’s going to need surgery, but it’s worth taking a few minutes to make her comfortable"

He radios to his partner and asks her to bring the intravenous kit and narcotics box along with the stretcher.

Sarah receives 100 mcg of fentanyl before her leg is splinted and she is loaded on the stretcher for transport. En route she receives repeat doses of fentanyl every five minutes until her pain is well managed. 

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