“It is easier to get forgiveness than permission.” For so many in EMS, this unspoken motto has led to countless situations just like the one in which Powell County Judge Executive — and also Paramedic — Eddie Barnes found himself when a local zookeeper met the wrong end of a breeding mamba snake.
In the patient compartment of a rescue helicopter, Paramedic Barnes knew what to do and how to do it, but was missing the piece of paper allowing him to save the life he had been entrusted with. He did it anyway, and he was called to task ... as he should be ... sort of.
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EMS training vs. EMS reality
Anyone who has ever done EMS at any level knows the reality: in school, the rules are black and white — the policies, protocols and procedures are black and white. We study them, we take the test, we get out and we get the privilege of practicing.
What they almost never tell us is that absolutely nothing in the real world of EMS is black and white; everything happens in the murkiness of a very gray area that providers must navigate in real time. They also never tell us that within that gray area, there comes a series of ever-changing and unimaginable X-factor variables providers must also respond and react to in real time ... and be correct, if not at least reasonably wrong.
Therein lies the dilemma that any provider can face on any call: what would you do if ... ? Sometimes the decisions are obvious, but other times, the decisions EMS providers have to make in the heat of a fraction of a moment make Sophie’s choice look easy. Such is the life we have chosen.
When EMS protocols meets human judgment
Training, policy, protocol and procedure are intended to take as much of the guess work as possible out of the practice of EMS. Ideally, they serve as a practice guide and a set of legal protections for providers. EMS boards and medical directors decide who can do what. If we follow the rules, we avoid the consequences — usually, and if we don’t, then we face what we face.
But still, what would you do if ... ?
“Sometimes being reasonable means blurring the lines.”
One of the most central legal rules of effectively navigating the perils and pitfalls of EMS is to always act reasonably in the execution of the duties. That is what the law says; to always act as would a reasonably prudent provider with the same level of training and experience in the same area and under similar circumstances.
If you are reading this, you already know that sometimes being reasonable means blurring the lines.
I am definitely not saying that blurring the lines of approved and not is acceptable, and violating policy is not my advice to anyone, ever.
However ...
Impossible EMS choices
Let’s consider difficult choices you may be faced with in the field based on three real-life cases I have successfully defended.
Scenario 1: Pediatric vital signs
For the sake of this discussion, let’s look at a common scenario: pediatric vital signs.
Policy, protocol and procedure require that we check vital signs on every patient without exception.
Now, imagine a toddler who was in the car seat at the time of the traffic collision. She is in dad’s arms when you arrive. She does not appear to be injured, but it was a pretty good crash, and she is going to the hospital in your ambulance. Her skin is normal, warm and dry, her eyes are tracking appropriately, and the cap refill you were able to get was fine.
However, when you reach in to attempt to get vital signs, she kicks and screams and turns red. You know the vital signs are going to be falsely elevated, and you are taking her to the ED anyway.
➡️ The impossible question: Is it reasonable, in that moment and based on those facts, to hold off on vitals for now?
Any experienced and reasonable provider would say “yes;” hold off for the moment and get them if the opportunity presents itself. Policy, protocol, and procedure require that we acquire vital signs, but in this limited scenario — for the moment — it may be reasonable to hold off for a moment.
Scenario 2: Inserting the OG tube
Now, let’s crank it up a notch. Imagine that you are just about to finish paramedic training, your internship will be over in less than a week and you will be licensed. On a day between internship shifts, you are at your regular BLS job, and you respond to a cardiac arrest. There is only one paramedic on scene, and he is flailing. He asks you to insert the OG tube for the iGel because he doesn’t know how. Do you?
You have been trained and tested; in a few weeks, you will be licensed to perform that skill. You know that if you do it before you are licensed, you will be investigated and may be in serious licensure trouble.
➡️ The impossible question: Do you perform the procedure that, in your area, is limited to ALS providers only?
Scenario 3: Life-or-death RSI
Now, extrapolating to the extreme end, imagine you are a Paramedic who has been trained and licensed in two different jurisdictions to perform RSI, and that you have done RSI 6 times in the field. You move and acquire licensure as a paramedic in a third jurisdiction where RSI is prohibited.
One day, while the entire western United States is on fire, the station where you are working as a paramedic on the ambulance is being backfilled by a paramedic engine company from out of state, a state where you are still licensed to perform RSI. Your ambulance and the out-of-state paramedic engine company are called to the scene of a traffic collision where the only patient is an off-duty fire captain from your station and he is unconscious, posturing, clenching his jaws and vomiting from the head injury he sustained in the crash.
You already know that RSI is the only viable option to protect and maintain his airway — that without it, he will die — but you don’t have the drugs or protocol authority to perform one.
“Would you do it anyway to save the life of your friend?”
The out-of-state paramedic engine company does, so they perform the RSI, but they need your help, so you push two of the drugs that are prohibited for you. The procedure is executed flawlessly, and the patient makes a full recovery.
You can bet that you will be called to task for practicing so far out of your available scope, and you should be.
➡️ The impossible question: Would you do it anyway to save the life of your friend?
Should saving a life be punishable?
This brings us back to where we started: should the EMS Board have investigated Barnes for violating the written protocol?
Yes. EMS boards have tremendous responsibility to ensure the safety of the public; to ensure that providers are competent and fully able to perform accordingly. They should ask all the questions and get to the bottom of every issue for the sole purpose of protecting the public. That is their job. That is what keeps us all safe. That is what keeps providers from going rogue and playing doctor ... or God. We need that.
In this case, the investigation found that a skilled provider with the necessary training and available tools did what needed to be done; he made a decision in a fraction of a second and that decision saved a life. That decision delivered the kind of care and skill and competence that the EMS Board should have applauded.
Barnes was not playing doctor or God; Barnes was playing the role of the good, diligent, competent paramedic and, within his skill and ability, he did the only thing that was asked of him: he afforded his patient every opportunity to make a full recovery.
When I was practicing in the field as a paramedic, I would have done exactly what he did ... and I would do it every time. I would expect the same from any paramedic treating me or my family.
While the Board was certainly justified in investigating the incident, this seems like a case in which a complaint should never have been filed, and Barnes’ character should never have been called into question. It is the age-old letter of the law versus the spirit of the law. If anything, the Board should have, first and foremost, used this incident as an opportunity to reflect on the value of the policy that was violated; to examine whether the policy itself is appropriate or whether it ties the hands of providers and could cost a life.
Maybe more than any other level of provider, paramedics need to have and maintain the discretion to reasonably function within their training and scope, even when it may not match the ink on the pages in the book. Otherwise, the only collateral effect of blind adherence to policy and failing to account for the gray nature of providing EMS is to create cookbook providers who only do what the book says because the book says so; providers who are afraid of being punished more than they are willing to do what they know they can; to drag EMS woefully backward.
The real question we should be asking
The EMS Board did the right thing in investigating the incident and Barnes did the objectively right thing in providing the appropriate life-saving care. The only remaining question should be: how can we do better next time?
The grey areas
When have you ever had to make a call in the field that went against policy — but felt like the right thing to do?
