Beyond Protcols

EMTs learn, train, and practice by protocols. But some situations challenge us to operate beyond the guidelines.

Technicians, not diagnosticians.

Here’s a fact that, despite my best efforts, eluded the students who knocked on my dorm room door at 2:00 A.M. asking me to diagnose their stomach-ache or to differentiate a possible sprain from a potential fracture: emergency medical technicians are not diagnosticians.

It’s a fact that’s drilled into us during our training. We do not paint portraits of diagnostic clarity, but form foggy sketches of clinical approximations. Indeed, every emergency medical provider is well-trained in the art of cookbook medicine. We identify plausible signs and note visible symptoms, determine which protocol best fits the patient’s condition, then systematically implement a recipe of mandates and instructions.

There’s a protocol for chest pain. Check the ABCs—airway, breathing, and circulation. Start high-flow oxygen. Administer aspirin, 320mg. Check vital signs. Blood pressure over 110 mm Hg? Start an IV, run fluid, and give nitroglycerin, 0.4mg. Repeat dose if … …

There’s a protocol—quite a few, to be precise, for difficulty breathing. Sudden onset shortness of breath? Urticaria? Swelling? B/P depression? Treat for allergic reaction. Noisy, wheezy breathing? Accessory muscle use on inspiration? Peripheral edema? See the checklist for COPD exacerbation.

While all these protocols truly underscore the ‘technician’ in ’emergency medical technician,’ where EMTs define themselves is not in these cycles of recognition and execution, but in the moments beyond the lines—those aberrations and anomalies for which no protocol exists.

Call it in; patient DOS.

“Medic 86, you are responding to an unresponsive patient. 916 River Falls Drive,” the dispatch tones blared, the lackluster monotone of the programmed voice an ironic contrast from the emotional tragedies and urgent crises it often signaled.

I stumbled out of bed and into my medic boots, groggy and irked. 5:17 A.M. … Yechhh. We moved with a requisite urgency, but our optimism muted; at this hour, it was almost invariably a panicked caller who’d awoken to find a rigid, lifeless relative in the bed across from them. To hope for more was, as I’d come to learn, to invite frustration and failure.

On scene, our skepticism was soon enough confirmed. The patient—or what had until recently been one—lay eerily still as stone in bed, her eyes locked in an inhumanly blank gaze, mouth locked grotesquely open as if to convey horror and shock, limbs woven into the unmistakable contortions of rigor mortis and imbued with the hues of lividity.

“Call it in: patient DOS,” the supervising paramedic instructed matter-of-factly.

Our anxious pulses eased, our breaths calmed, our emotions sank; there would be no opportunity to resuscitate a life here. The darkened tints of my goggles masked fresh tears. Experience and exposure aside, even the most seasoned EMTs are rarely up to the task of remaining stoic in the face of death. Sensing the mounting tensions between my external restraint and my internal distress, I withdrew to the kitchen to collect myself. EMTs, after all, are collected.

There is no protocol for human compassion and empathy.

As I stood over the kitchen sink, the warm water reinstating a sense of calm and cohesion, I heard a nearby sniffling that was not my own. I turned to see, tucked away in the shadows of a recliner chair in the living room, the patient’s son. Unlike mine, his face showed little emotion or pain; instead, his solemn countenance and still expression inspired in me both admiration and wonder.

“I’m sorry for your loss,” I whispered to the man. The words felt stale even as I said them; they were the trite recitations of someone who didn’t know how to properly express compassion or consolation. “Is there anything I can do for you?”

“She’s gone, right?” the son asked, his composure again taking me by surprise.

“ … Uhm, well … Uhh, yes. Yes, I’m sorry to say so. Sometimes, we can try to start their heart again, but here, it doesn’t seem like there’s anything we can do. I’m sorry.”

“Actually, I don’t think that’s true,” he responded, motioning to the foot stool beside him. “If you could spare a moment, would you sit down?”

Now as confused as I was curious, I obliged. The son paused for a moment, taking a pronounced gulp and wiping his eyes for the first time.  “Please,” he said, “Would you pray with me?”

I drew back, stunned by this request. Religion, to me, was going to the temple once a year because my grandparents said so. Religion was when we would skip prayers at Diwali to swap brightly-wrapped gifts and eat rich sweets. It had no bearing on my moral compass, much less my practice as a healthcare provider. I was an EMT, not a priest or chaplain. What place did I have to engage in prayer?

For the first time in my medical career, I was at a loss for words or actions. In my EMS training, I could triage a mass-casualty incident. I could intubate a patient and breathe for her. I could stabilize a fracture of any size, location, or orientation. But I could not respond when asked to share in a gesture of faith and spirituality.

There was no protocol for human compassion and empathy.

There, caught at the intersection of reason and emotion, challenged by intuition and expression, I deferred thought to instinct. I met the son’s gaze, sat down, and put my palm in his. At that moment, there was no sense of protocols or directions, rules or expectations; there was only the circumstance before me, and what felt like the right thing to do. The man closed his eyes and wept in silence. After several minutes, he cleared his throat, loosened his grip, and nodded to me with a brief, “Thank you.”

A reflection.

When I’m asked what my most memorable call in EMS has been, people expect the multi-vehicle collision or the successful resuscitation. But there’s more to EMS than running lights and sirens, and there’s more that we can do than fulfilling checklists. That night, I wasn’t confronted by a matter of faith, but a matter of understanding and responding to a person’s needs as he navigated one of the most difficult chapters of his life. In that moment, the best care that I could offer that patient was to be emotionally present for her son.

In a discipline where it’s easy to feel the frustrations of merely checking off boxes or meeting the medical-legal obligations of cover-your-ass medicine, it’s important we remind ourselves that our most profound abilities lie not in our procedural dexterity or acute observations. As EMTs, we instead define ourselves by the moments when we go beyond the guidelines or transcend the limitations of protocol-based medicine to provide for our patients’ needs—biomedical and beyond.

In this patient encounter, names, events, and details have been altered and fictionalized to protect patient anonymity.

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