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What would you do?

October 21

Watch your thoughts, for they become words. Watch your words, for they become actions. Watch your actions, for they become habits. Watch your habits, for they become character. Watch your character, for it becomes your destiny.
— Unknown

 

It never ceases to amaze me when the classes you think you are going to get the absolute least out of, prove to be the ones that make you go home thinking. Ethics class proved to be full of  ”things that make you go hmmmm…”

I went into class fully expecting to be bored out of my gourd, which for paramedic school is not such a bad thing, easy nights are few and far between. Class opened with the instructor saying this would be one of those classes where they weren’t there to give you answers; instead they were hoping we would leave with questions, questions about our own set of values and how we exercise those values in the field.

Whatever let’s just this over with so we can go home” – none of us actually said it, but I know I wasn’t the only one thinking it.

The lecture proceeded as expected for a while, the definition of ethics, ethics vs. morals, etc.

Then an interesting “case” was presented.

A foreign “dignitary” was brought into the hospital via ambulance – the hospital was rather busy as you would expect from an urban  level 1 facility, but tonight was exceptionally busy… the dignitary was placed into one of the rooms in the old ER which is now used as the psych ER. The room was perhaps not the cleanest in the hospital, nor was it the newest, it was however fully stocked and equipped with all the necessary equipment.

The nicer rooms in the ED were all filled with “regular people”, homeless folks, the drunk that passed out in front of 7 – 11, junior who fell and broke his arm etc.

The dignitary received the top-level of care and was treated as any other person would have been.

After their release the dignitary filed a complaint about their treatment they received and about being put into the sub standard room.

Then the questions started…  Was it OK to put that dignitary into a sub optimal room instead of homeless Joe? Should that person, based on who they are or what they do receive “special treatment”? Was the complaint justified?

Of course, all of us reacted the same way you probably just did; “Damn spoiled brat politicians” Why should they have gotten a nicer room, or faster care, or any other special treatment. We were all convinced we would have done the same thing the ambulance crew in question did, and the same thing the nursing staff did when the assigned the room…

All of a sudden though what was black and white a moment ago became cloudy and grey with a single question….

What if the dignitary had instead been a police officer, a firefighter or one of your fellow paramedics who was hurt in the line of duty? What if it had been your partner? What if it had been you?

All of a sudden we all were faced with having to admit that each and every one of us (in my class) carry some level of double standard, because we all had to acknowledge that we would have expected DEMANDED better treatment if it had been one of our “brethren”

Where do we draw the line? What is the right answer? What would I have done?

Another case was presented… You are en route to the hospital with a patient suffering from symptomatic V -tach… You call the doc for a med order and to your surprise it’s your medical director who answers… You present your finding and tell the doc your plan; he denies your request to deliver an amiodarone drip and tells you instead to push 1 mg Atropine. Stunned by such an order you request confirmation, and he confirms 1 mg Atropine IV push.

What do you do?

I haven’t had my pharmacology classes yet, but even I know that if you follow the doctor’s order, you will likely kill this patient.

I pride myself on my integrity, my patient advocacy, and my absolute commitment to endeavor to do no harm… My answer was immediate and loud – I give the amiodarone drip to help my patient and I deal with the doc’s fury later…

It’s the RIGHT answer if you ask me, but then the student sitting next to me said ” I totally see what you are saying and I agree that that is probably what you SHOULD do… but how much will that help you when the medical direction gets you fired and your certification pulled, and you are standing in front of the supermarket holding out a can hoping for donations to feed your family”

I paused and considered what he had… Would that change my actions? Would the prospect of losing my chosen career after so much hard work force me to change my mind?

I like to think the answer is no… At least I will know I didn’t sell my soul to make a doc happy and potentially kill someone in the process… But it’s easy to answer that sitting here typing, much different than rolling down the road hot 3 minutes out from that very same doc, holding a patients life in the balance.

All of a sudden this stuff isn’t quite so boring, nor is it quite so cut and dry.

I’m not a huge country music fan, but Aaron Tippin sings a song called “You’ve Got To Stand For Something” there’s a line in the song that says ….

“… Whatever you do today, you’ll have to sleep with tonight…”

I guess it never really hit me much until after that class how true that was…

What would you do my friends?

 

Posted by on October 21, 2011 in EMS, EMT, Ethics, Paramedic School

4 Comments

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4 responses to “What would you do?

  1. CCC

    October 21, 2011 at 13:30

    Interesting post. I will attempt to answer your questions to the best of my ability.

    1. “Dignatary” is a matter of perception, and a higher social status does not earn one more, or better, care. I will treat a fireman, police officer, family member, and even my partner the exact same way I treat all my patients: with my best effort.

    2. Doctors, lo “Medical Directors” can be wrong. If you know the ordered medication is not in the patient’s best interest, and especially if you know it will be detrimental to the patient’s condition, I believe you have a duty not administer that drug or treatment. Imagine yourself on the witness stand, defending yourself: “I knew it was going to hurt the patient, but the doctor said to do it…”

     
    • hotlightsandcoldsteel

      October 21, 2011 at 13:57

      THANK YOU for the feedback…

      I totally agree with both of your points…

      I wasn’t trying to imply that the “dignitary” received sub optimal care… just that they didn’t get the bright shiny room right in front of the nurses station. In fact she got excellent care and made a full recovery. I would very definitely have given this patient (and all my patients) the absolute best I have to give, and I have no doubt that the hospital staff and crew involved did just that… However, my question is would we have settled for the dark, run down room in a back hallway for a fellow provider, or family member or would we have been more than a little vocal about homeless Joe being in the room across form the nurse’s station while our patient was “tucked in a closet”? Sitting here I can say with a clear conscious that homeless Joe is every bit as important a person and patient as the dignitary and he has every bit as much right to that room as anyone else. In reality, if it was my partner, a fellow provider or even a family member, I’m not so sure that my “moral high ground” would stay quite so high, it’s hard for me to say not being in the position.

      I also wholeheartedly agree that it is your DUTY to not administer that medication… No I would not be proud to defend following an order I knew was wrong, and yes I would “stake my patch” on that decision… not only because I wouldn’t want to say that on the jury stand, more because I have to look at myself in the mirror every day.

      THANKS again CCC – always great to get feedback from a respected provider.

       
  2. firetender

    October 21, 2011 at 13:59

    Welcome to the Slippery Slope!

    Ethics are not cut and dried as you pointed out.

    For the medic dependent on his/her job to support family, decisions to not rock the boat will likely be made. One of the things that is true in EMS is “You never know!” So, especially when it comes to Drs orders you disagree with your choice is to presume you know more than the Doc or just go along, since, he ultimately holds the responsibility. You can embroil yourself in conflict or make the decision to let the Doc live with his choices. You, after all, are but an underling.

    In that respect we do get to rationalize side-stepping issues that we disagree with, since we are the Lower Authority and are expected to defer. Does that excuse us? (Read on)

    In the case of placement of the Dignitary as opposed to that of a peer, it’s a very human thing to place priority on those closest to you. Would you hesitate one second in choosing to save the life of your partner over that of the Mayor if your actions could only save one?

    (…and nobody is looking! Available choices are often determined by the presence of witnesses. So in this respect, there is no guideline but the moment.)

    Often we forget we’re humans doing difficult work that OFTEN exposes us to ethical dilemmas.

    So, in the end game, I agree it truly is all about what you can live with. Our reality is that many of our patients will die no matter what and our role is to do something. Now you can choose to hide behind that and avoid taking personal responsibility, but I prefer the route of taking such ethical dilemmas seriously.

    So, in that case, what you did in class was all about exploration and tipping you off to the fact that you WILL be facing stuff like this; but you have to choose to face it and learn to make those ethical choices damned fast!

    And don’t kid yourself. The way you learn to build (and strengthen) your ethical base is precisely by trial and error in discovering what it is you CAN live with. For a lot of medics, that happens long after the choices have been made. One day they realize, “Wow, that choice rocked me and caused damage along the way!”

    Bottom line, if you are casual about your ethics in the field, it won’t be long before you discover it seeps into everything you do and critically affects who you are with others. Ultimately, you will be the one who suffers.

    I appreciate your call for us to be aware of how important it is to be a conscious medic.

     
    • hotlightsandcoldsteel

      October 21, 2011 at 14:10

      WOW – FANTASTIC commentary…

      My only point of digression would be that the presence of “witnesses” should never be what makes our decisions for us… even in the absence of others’ eyes we still have to face ourselves.

      The measure of a man’s character is what he would do if he knew he never would be found out.
      — Baron Thomas Babington Macauley, English historian and statesman (1800-1859)

      Realizing these types of decisions are part of our everyday lives as providers is exactly why I chose this topic… Hoping that MAYBE, just maybe one of those Medics whose world is rocked by a decision will have read this and chose differently, at the very least lessening the impact on their lives.

      THANK YOU for your insightful feedback. ALWAYS a pleasure to get feedback from such a respected provider!

       

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