Written Protocol vs. Common Sense

Steve Valdez only wanted to cash a check. In retrospect it seems so simple. The check was written to him from his wife’s account at Bank of America. He had two forms of ID, both with photos. The address on the drivers license was the same as the ID on the check (printed by Bank of America.) Bank of America thought differently.

Here’s the rub. B of A has a written policy that states if you don’t have an account at their bank you need to leave a thumbprint. You’ve probably seen those by now. Either you dab your thumb in an ink blotter or you use the fancy thumb scanner. But Steve Valdez doesn’t have any arms. And based on his inability to make a mark with his non-existent thumb, B of A refused to cash the check.

Clearly the bank representative thought that following the rules was the safest option. Instead of considering the needs of the customer, interjecting common sense into the matter, taking on a wee bit of personal risk on behalf of the individual being served and making a simple accommodation, the bank manager stuck to her guns. Rules are rules. And now the story has been picked up by the AP news wire and it’s everywhere.

Don’t laugh. It could happen to you. We all operate under multiple sets of rules and regulations from our written protocols to our national scope of practice to our organizations policy manual. We all are expected to apply a set of pre-established rules to our jobs in EMS. The question is how we perceive those rules. Do they trump basic common sense?

Do the prohibit us from acting in the patients best interest? When are we allowed to forgo the rules? If we decide it’s only in emergencies … well, were bound to encounter a lot of those.

  • Your patient is seizing in the basement of a building and you can’t make base contact to get your Valium order. Do you give it?
  • Your protocol says you can’t give that glucose paste to the patient without a glucometer reading but the battery is dead. Do you give it?
  • Your company policy is to splint all unstable femur fractures before moving the patient, but this dude needs a trauma surgeon yesterday. Are you willing to load and go?
  • Right now, somewhere in America there’s an EMT working in a medical tent on a wildland fire who is outside of her jurisdiction and not technically authorized to practice her skills. What should she do if one of those firefighters has a medical emergency?
  • Or perhaps your protocols contain some of those really ridiculous call-in orders for procedures like cricothyrotomy or dual-lumen airway insertion. Will you follow the rules and make the call or take a stand?

Following the rules is easy. It doesn’t require individual judgment or common sense. It doesn’t require much personal risk. “Hey, I just followed the rules” is a powerful argument. I know of at least one bank manager who’s making that argument as we speak.

       

What do you think?

   

Related Articles:

Who’s Going To Let Me? Who’s Going To Stop Me?

Get To vs Have To

Wrong Medicine

EMT Skill: Observation

      

Comments

  1. Timothy Clemans says:

    Banks are particularly strict about employees following policy. If I ever work at one I’m going follow every policy to the letter. Keeping a job is more important to me than creating a history of deciding which rules are OK to break and which aren’t. I do think the risk of termination is low in this example, but I would still want someone hire up to make the decision not to follow policy. It’s probably time for banks to have a system in place for overriding policy when clearly a situation was never considered at the time of policy formation.

    In EMS even if I were to make the right decision in the context of life or death disobeying a policy could get me into trouble. I will say however that EMS in my area began before the law allowed it. The founders of Medic One put themselves at great legal risk for the benefit of thousands of people.

  2. CKemtP had a fantastic scenario a few days back that really got my brain pan in a tizzy:

    http://proems.blogspot.com/2009/08/everyday-ethics-for-ems-providers.html

    A protocol based on what is best for the patient can solve these problems, and possibly a national standard akin to the NREMT standards couls solve the jurisdictional issues.

  3. But Timothy, you said it perfectly. They were willing to accept some personal risk to do what’s right. Sometimes, accepting your personal freedom to do the right thing involves risk. When done for the purpose of helping others it becomes noble.

    Sometimes disobedience is required for us to be free.

  4. For argument sake and good conversation: Do the “noble” thing for a single patient and maybe lose your license, or follow a rule that may mean a single death vs the career of lives you may save working by the book.

    However, I agree that follwing the rules is easy and doesnt guarantee that your giving any sort of real patient care.

  5. Loose your license seems like an extreme measure for doing the right thing. Remember we’re not talking about acting outside your scope or doing anything real crazy here.

    We’re talking about steping outside of the guidelines that are your protocols and policies when it’s the right thing to do. Even when that means you’ll have to justify yourself later.

    It took me a long time to become a paramedic and I value that certification. I consider the risk of loosing my certification a huge risk. But I’m amazed at how few people are willing to accept even a small risk on behalf of the patient.

  6. 13Zebra, is it really right to sacrifice one mans life to save multiple? It may sound noble if it is your own life, but should one human be able to determine who lives and who dies? Regardless of protocol, if my patient will not survive the short trip to the hospital because of something I could have easily fixed, even if it’s the correct thing to do in the eyes of the law, it is not the correct thing to do in my own eyes, or in the eyes of the Lord either.

    Is it acceptable to sacrifice one life to save the multitude? This question is asked in psych profiles for the government. The answer? No.

  7. It is said in fire training: risk a lot to save a lot, risk a little to save a little, risk nothing to save nothing.

  8. The county I work in (Not live in thank god) requires EMT-B’s to call for an order to give Epi by auto injector to any pt even if they are in anaphlyiss. [ This is the same county that requires you to take a class with the county before you can check a CBG, use a BIAD, apply a pressure dressing, or use a tourniquet. Not just an order but an endorsement from the medical director.] It amazes me how a medical director can lay down a set of rules that effect patient care so adversely. If you did not want the risk EMT’s practicing under your licence, Don’t be a medical director!

  9. Jimmy Futrelle says:

    A “cook book medic” follows the protocols to the letter. No risk. Mediocre patient care. A reckless medic flies by the seat of his pants. Makes every call with his “gut.” At some point his luck will run out and he will crash and burn. The exceptional medic tempers knowledge with experience, compassion with skepticism, success with the knowledge of failure. He/she knows we walk a fine line to maintain balance and quality of patient care. No call is the same. They are as random and myriad as snow flakes. Those whom remember we treat the body, mind and soul of our patient’s will find a balance in the care they give, and will never burn out, but get better with age. I’ve been in the business of saving lives for over 25 years, and I intend to continue until mine is required of me. A balance is all you need. Whether it be Protocol, experience, or that you stayed at a Holiday Inn Express, matter not. Do what’s best for the patient and you will rarely fall short. And when you do, it is usually a Mistake you can learn from and walk away from.

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