I've been a paramedic for fifteen years. I've been an instructor for six months longer than that.

Once upon a time, the Little Ambulance Service That Could sent me, a brand new EMT-B, to EMS Instructor School. We were competing with a much larger service in the area, and they were shutting us out of most of the available slots in the EMT courses. So when an opportunity arose for them to have their very own in-house instructor, I was drafted for the job. I assisted with my first EMT course six months before I earned my paramedic patch. With time and teaching experience, I became one of the cadre of senior instructors tasked with training and mentoring new EMS instructors in Louisiana. I did that for close to ten years.

I still get e-mails and phone calls from instructors I trained or mentored back then, seeking advice on one classroom issue or another. Through my blog, I get e-mails from instructors and students alike, seeking my opinion on a variety of subjects. Instructors ask how to deal with clueless administrators or problem students, students seek advice on dealing with problem instructors, and some who haven't even begun their education seek counsel on how to prepare for the rigors of paramedic school. Sometimes I have good advice to offer, and for others I have no answers, able only to commiserate and say, "I feel your pain, brother."

I have been a student forced to sit through a boring lecture, and I have been the instructor struggling to make esoteric medical trivia relevant to a classroom of disinterested people who would likely never use the information. I have worked for companies –as a medic and an instructor - who didn't give a rat's ass about education, and I've worked for others who considered it a cornerstone of good patient care. Some of the poorest companies, like the Little Ambulance Service That Could, invested far more time, money and effort in education than other companies with a hundred times their resources.

I have juggled school, work and family commitments. I have felt the frustration when the company that is paying for your education refuses to give you the time and support to actually learn something from it. I have paid money from my own pocket to hire a subject matter expert to lecture my class, and I have sat through a class when one of those subject matter experts – a PharmD – put everyone to sleep with a lecture that would have made a research biochemist slit his wrists to put an end to the boredom. To this day, I remember nothing of the chemical structures of the drugs he was supposed to cover, but I'm reasonably sure that if you could synthesize his voice, it would be a chemical analogue to Diprivan.

All this is to say that I have been there, done that, and currently own a closet full of EMS tee shirts emblazoned with witty sayings like "Just tube it!" or "EMS: Our day begins when yours is about to end." I consider myself well qualified to speak to the issues faced by paramedic instructors and students alike.

Therefore, let there be no pretense between us when I offer a few observations about you, the paramedic student:

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You don't know shit.

I'm not calling you stupid, just ignorant. Ignorance, if not curable, is at least treatable with education. Stupid, however, is utterly incurable and untreatable, as you will soon discover from many of your patients. Unfortunately, stupidity is not uniformly fatal. Instead of killing off its host rapidly, thus chlorinating the gene pool a bit, the stupidity virus often becomes latent, lying in wait for a moment of weakness. Then, like an attack of shingles, it blooms forth in an epic display of "Hey y'all, watch this!" splendor. This outbreak is what transforms the latently stupid into EMS patients.

Back in my freshman year of college, I had a professor who called this little truism "man's capsule of knowledge." Simply put, there is what man knows, and what man does not know. And the more man learns, the more he realizes how truly ignorant he really is. It is humanly impossible to ever make our knowledge outpace our ignorance, and there is no shame in admitting that. Unwillingness to recognize and acknowledge your ignorance, however, is just stupid.

And make no mistake, most of your more experienced or educated peers are operating from a position of ignorance, too. Lucy Hornstein, MD, explores this unfortunate fact in Declarations of A Dinosaur: Ten Laws I've Learned As a Family Doctor. In her book, Law #8 states, "Half of what is taught in medical school is wrong, but no one knows which half."

Change "medical" to "paramedic," and there you have the state of current EMS education. The only constant in this profession is the certainty that things will change. In five or ten years, you're going to discover that half of what you learned in class is wrong… but you won't know which half until then.

So, got that? You're ignorant, your partners are ignorant, and your instructors are ignorant. For that matter, so am I.

After all, I taught all sorts of wrong information over the years, just like your paramedic instructors and the professors at Dr. Hornstein's medical school. We taught students that spinal immobilization was beneficial and rarely harmful, that volume resuscitation in trauma patients saved lives, that the Golden Hour was based on scientific research, and PASG could auto-transfuse blood from the lower extremities to the trunk.

Now we know better. We know that spinal immobilization benefits very few, if any, patients, and may indeed harm some. Aggressive volume replacement, at least among trauma patients with uncontrolled internal bleeding, does harm. The Golden hour was a PR tool, not scientific fact, and as it turns out, the length of time spent outside the hospital makes very little difference in mortality most trauma patients; some die immediately despite our best efforts, some die weeks later from infection or organ failure, and the ones who make it out of the operating room alive don't seem to notice the difference between twenty minutes or three hours in getting there. Lately, it even seems that supplemental oxygen administration - the most sacred of EMS cows - doesn't make much difference for many of our patients, and may even harm some.

So yeah, we're ignorant. But the difference between you and your instructors is, at least they have some inkling of how ignorant they are. So until you learn a little more, listen to what they have to say. Pay attention in class. Don't ever let the words, "Why do we have to learn all this shit we're never gonna use?" escape your lips, because right now, you're too ignorant to know what information you will or won't find useful. Much of the knowledge I've found useful over the years wasn't even covered in my initial paramedic training, while much of what we spent the most time learning us has proven utterly irrelevant to patient care.

You're going to be performing procedures on real, live people. You're going to be administering chemicals that alter the function of the human body. It behooves you to know how that body works, and that requires a helluva lot more than being able to accurately label a diagram of the abdominal organs or the bones in the human body. When your car breaks down, are you going to take it to a mechanic, or to the pimply-faced kid behind the parts counter at Autozone? Because if your knowledge of the medications you give, and their effect on the body, extends no further than, "That's the next drug in the algorithm," all of your expensive paramedic education has done little more than make you the EMS equivalent of that pimply-faced kid manning the parts counter at Autozone. And would you really want to be that guy's patient?

Whether it's the intricacies of the Krebs Cycle and electron transport or membrane thresholds and action potentials, or a million other pieces of medical minutiae you may not appreciate now, a functional understanding of human anatomy and physiology is imperative to your success as a paramedic. You may not need to know the inner workings of the human body as deeply as, say, a physician, but you almost certainly need a greater depth of understanding than paramedics educated not even ten years ago. EMS as it is practiced today is a different creature than it was ten short years ago, and ten years from now if will be a different profession than you're practicing today.

Your understanding of the human body will help you adapt to ever advancing changes in medical theory. That understanding will serve you in good stead when faced with the surprising revelation that something you've done for years doesn't really help patients at all, or may even do them harm. Like aggressive volume resuscitation, for example. Or spinal immobilization. Or PASG application. Learn how the human body works, and you'll be more likely to face those revelations with a bemused smile and a, "Well, that makes sense, when you look at it that way," equanimity. What you don't want to be is that dinosaur who looks around and no longer recognizes his profession, forever grousing, "That's not the way we learned it in school."

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Experience ain't all it's cracked up to be.

Hardly a week goes by where I'm not asked a variation on the question, "So, I'm trying to figure out where I go from here. Do I work as an EMT for a while, or do I go straight into paramedic school? How much experience do I need before I'm ready for paramedic school?"

You see, "experience" is such a nebulous word. Speaking as an educator, I find that for every EMT whose street time has honed his assessment skills and taught him the clinical presentation of various disease pathologies, there is another who has learned little more than the location of all the fast food joints that offer EMT discounts.

If I'm lucky, that's all he's learned. All too often, that street experience has taught him how to be lazy, cynical and rude, and I have to devote precious classroom time to helping him unlearn all that experience. Give me the green EMT every time; they're easier to teach.

Many of my colleagues would advise green EMTs to gain several years of street experience before enrolling in paramedic school. They fail to consider the great variable in the equation: the partner.

Every new EMT envisions being paired with a grizzled veteran who can take a green individual under his wing, mentor and teach him the tricks and wisdom that can't be taught in the classroom. Frequently, they get the other type of partner — the one who despises rookie EMTs and couldn't teach an armadillo to dig a hole in the ground.

As the saying goes, "There are a few paramedics with 20 years of experience, and there are many more with one year of experience, twenty times."

That's the value of education, folks. It gives us the framework to learn from our experiences. It gives us the context to interpret that unusual presentation correctly, and realize that a clinical zebra is simply a horse with a custom paint job.

I've learned that every student views a new learning opportunity through a prism of their past experiences. If they have the right attitude and a strong educational background, that prism can refract a muddied clinical presentation into something much clearer. With the wrong attitude, however, or a weak education, that prism can distort the clearest of pictures into something unrecognizable.

From this ambulance driver's perspective, that experience is best gained in an educational program with a strong clinical component - not on the job. Many prospective students shy away from such paramedic programs because they often take longer or are more expensive. Don't make that mistake.

A "boot camp"-style paramedic program may graduate you quicker, but you likely won't get the clinical experience under a trained preceptor that you'd get in a longer program. On the flip side, the college-based, "zero-to-hero" programs designed to take a raw student all the way from layperson to paramedic won't teach you much relevant EMS knowledge unless that program includes an extensive clinical component. Not every program is created equally, and there is more to consider in choosing a paramedic program than the tuition cost.

There are loads of paramedics out there who will sagely advise, "The real learning begins once you hit the street," and they're right.

But what is equally true, and often not said, is that much of EMS continuing education is simply a rehash of information you should already know, and many of your more experienced colleagues have been unknowingly repeating the same mistakes for twenty years. My advice is, learn as much as you can in class. Mistakes there are far less costly than the ones you make in the field.

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You aren't here to save lives.

I know that flies in the face of every recruiting pitch we use to draw students into paramedic classes in the first place. It contradicts every piece of PR propaganda we use to educate the public about EMS. It may even contradict your very motives for choosing EMS as a profession.

Doesn't make it any less true, though.

Bottom line is, we don't save many lives. One the rare occasions we do, it's largely the result of luck and good timing, and pretty much any yahoo with a CPR card could have performed the lifesaving intervention. Ask any experienced EMTs how many lives they've saved, through their actions and their actions alone, and if they're honest the number will be damned few.

And frankly, if saving lives is the only thing you're about, you might as well stay an EMT-B. Of the existing research on the efficacy of EMS, the only things that are proven to reduce mortality are BLS interventions: early CPR and defibrillation. But before you go patting yourselves on the back about how wonderful EMTs are, keep in mind that those two things are also considered layperson interventions as well.

But if your motivation goes beyond the adrenaline rush of lights and sirens and the occasional code save, paramedicine has much to offer. Much of what we do, if administered appropriately and in a timely fashion, makes the patient's injury or illness less stressful, and makes the job of the Emergency Department staff much easier.

A few years ago at an EMS conference, after our respective sessions were done, a colleague and I set forth down Sixth Street in downtown Austin in search of beer and hot wings. Over a platter of spicy wings and not a few pitchers of beer, we proceeded to solve all the problems of EMS. Of course, most of those solutions were lost in the fog of the next day's hangover, but one thing my buddy said to me that night stuck with me ever since.

"Kelly," he had said, "it's not our job to score touchdowns."

"More hot wings, less beer," I advised. "You're starting to babble."

"No, seriously," he insisted, punctuated with a gentle belch of Fat Tire Ale. "We're the special teams of emergency care. It's not our job to score touchdowns. That's the job of the offense."

"I see where you're going," I mused, eyeing him speculatively. "So who, exactly, is the offense in your little analogy?"

"The Emergency Department," he answered. "The offense is the doctors and nurses in the Emergency Department, and occasionally the surgeons or the cath lab."

"And EMS is special teams… how, exactly?"

"We receive the patients and advance them as close to the goal as we can. We provide the ED staff with good field position. It's hard to score touchdowns if you're consistently stuck with bad field position. On the other hand, if your special teams are very good, it makes it that much easier for the offense to score. We don't save many lives ourselves, but we can make it much easier or much harder for the ED staff to save a life, depending upon our performance."

"We score touchdowns… er, I mean save lives," I protested.

"Yeah, but only a tiny fraction of the time," he explained, "and only if we're very good or very lucky. Our job is important, dude. We can't win the game by ourselves, but we can damned sure lose it for everyone else. You can't win consistently without good special teams. But it's not our job to score a touchdown on every play."

"Screw you, Brosius," I retorted. "I'm a game breaker, baby. I'm a threat to score every time I touch the ball."

My bravado aside, you'd do well in your careers to heed my buddy's analogy and consider yourselves the special teams of emergency care. The plain truth is, you're not going to save many lives in your career, and you're setting yourself up for a world of disappointment and disillusionment if that's what you expect.

On the other hand, if you're not all about the glory of scoring touchdowns, you can find a great deal of career satisfaction by making your patient's time in your rig a little less stressful, no matter how trivial their chief complaint, and delivering them to the hospital in a little better condition than when they started.

And occasionally, when you do score a touchdown, no one will begrudge you celebrating with a funky end zone dance.

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Learn how to evaluate medical research.

It may surprise you to know this, but it shouldn't: most of the information in your textbooks is outdated, by as much as five years, by the time you read it. Moreover, the material in that textbook is written at a 10^th grade reading level. If your education comes exclusively from that textbook, you're only getting half the picture, and a frightfully blurry and superficial picture at that.

But those textbooks are based upon research, however outdated it may be. At the end of each chapter, you will find a bibliography of that research. Take the time to read those studies, and any related ones that you may find. Subscribe to a few peer-reviewed emergency medical journals, or at the very least read what you can find in your college library. Learn how to use Medline and Pubmed. Keep abreast of the most current research as it pertains to emergency medical care.

That college statistics class isn't to prepare you to do dosage calculations, folks. Any fourth grader has the math tools to do dosage calculations. No, the statistics class is intended to make you a more discerning evaluator of the numbers liberally sprinkled throughout scientific research. Hopefully, you'll retain enough of it to be able to tell which study authors do or do not know their confidence interval from a hole in the ground.

The future of your profession is going to be shaped by two factors: knee-jerk reactions from politicians and regulators, and by medical research. The better you understand and use the latter, the more you'll be able to prevent the former.

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You are what you write.

An EMT-B receives little, if any, training on proper patient documentation. In many EMS systems, medical documentation is not the EMT-B's responsibility. Thus, there are some of you who, when you write the report on your first patient as a paramedic, will be writing your very first patient report, ever.

I hope that prospect frightens you as much as it does me.

If your EMT instructor made you practice writing mock reports, be thankful. If your employer allows you to act as the lead EMT on BLS calls, including the documentation, be grateful for the experience. If your paramedic program requires an English composition or technical writing course, thank your lucky stars.

Because when it comes right down to it, every essay and research paper you type, every mock run narrative you scribble, is useful practice for the day you will need to document a complex patient presentation, and the treatment you provided, in such a way as to make it easily understandable by twelve people who were too stupid to know how to avoid jury duty.

And trust me, that day will come. It's not a matter of if, but when.

Clinical competence and a friendly disposition are usually enough to keep you out of court. Good documentation will be the thing that saves your ass when they aren't. The attorneys in a negligence case have fairly straightforward jobs. The job of the plaintiff's attorney is to make you look like the dumbest, laziest, sloppiest medic who ever lived. Your attorney's job is to make you look like a combination of Johnny Gage and Marcus Welby, MD. He wants the jury to see you as competent, intelligent and conscientious.

And the weapon each attorney will use is your run report.

Which side finds your run report more useful is entirely up to you. If you can't apply basic concepts of grammar, punctuation and spelling to organize your thoughts into a coherent written report, it doesn't matter if you provided stellar patient care. You are what you write.

If you gradiate hi skul not noing how too rite reel gud, it's time you learned.

Keep a list of commonly misspelled medical terms in your clipboard. There is no excuse for being unable to spell the language of your profession.

Use a report template if necessary. Doesn't matter if it's SOAP or CHART or whatever mnemonic you choose, just use some sort of organized format.

Buy and read The Missing Protocol: A Legally Defensible Report. It is an essential part of every paramedic's library. If you don't have a personal library, start acquiring one. The more you read, the better you'll write.

Put some effort into your assigned essays and research papers. The quality of your writing in class has a direct bearing on the quality of your writing in the field. And at least in class, your work will be graded in terms of percentage points in a GPA, and not zeros in a settlement offer.

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Don't just do something, stand there.

It is a curious habit of the EMS profession that we insist on defining ourselves by a skill set and not a body of knowledge. You see medics do this sort of thing all the time. They make ludicrous assertions like, "We can intubate! We can do more procedures than the nurses! They ought to let us work in the ER, too!" All too often, medics are judged by how much treatment they are willing to provide. We call these folks aggressive medics, as if the willingness to intubate first and ask questions later was a quality others would wish to emulate.

You don't see other professions doing such things. Nurses don't proclaim, "I am RN, wielder of the sacred Foley catheter!" Respiratory therapists don't say, "I nebulize, therefore I am." Yet medics do it all the time.

EMS attracts action-oriented people. I know of very few EMTs, myself included, who weren't adrenaline junkies at least at some point early in their career. The thrill of lights and siren has, at one time or another, entranced us all. But at some point though, you will mature beyond viewing your patients as interesting puzzles to solve, or the ultimate high fidelity skills manikin. Hopefully you will reach that maturity level sooner rather than later, and will unwittingly harm relatively few patients before you get there.

Bottom line is, the skills are easy, and that's why we focus on them so often. It is relatively easy to learn a psychomotor skill through constant repetition and apply it according to a narrowly defined set of protocols. It is far more difficult and expensive to educate someone on why, and most importantly, why not to apply that skill. And more and more, research indicates that many of those skills are not beneficial, or so rarely needed that maintaining proficiency in them is impossible.

Much of your EMS education thus far has focused on lots of doing, and relatively little thinking, and it's fair to say that timely application of BLS will always be the cornerstone of good patient care. There will always be instances in which we must act, and act quickly, and the more we practice those skills, the more reflexive they will become.

But as paramedics, we have at our disposal an array of assessment techniques, diagnostic equipment and treatment options that are fairly sophisticated, and our thought process in applying all those things needs to be equally sophisticated. Quite often, our patients derive the greatest benefit from the treatments we don't provide.

In other words, don't just do something, stand there. More thinking, and less doing.

As new medics, you'll need to practice your newly acquired ALS skills until you gain proficiency. It will take time. But what will mark your arrival as a real medic is the realization that you render your best patient care by being what my friend TOTWTYTR calls a "stand back, big picture, non-interventional, direct-the-work-of-others paramedic."

More thinking, and less doing. Don't just do something, stand there.

Good luck in paramedic school.

Can you remember what you thought EMS was before you had a job responding to 911 calls? I bet you were like me, you though that EMS was comprised of trained professionals that saved lives on a daily basis. Someone had better be dying or damn near close, for you to consider calling 911. I can remember breaking bones or being ill on numerous occasions, and my mother driving me to the ER in her makeshift mommy ambulance, a Dodge Caravan. We waited and waited in the triage area of the emergency room, not once did we think we should have called 911 for quicker treatment.

[Pubmed 1]

Severe pain is a common presenting symptom for emergency patients. One major challenge in the management of severe pain is the objective measurement of pain. Due to the subjective nature of pain, it can be very difficult for clinicians to quantify pain intensity and measure the qualitative features of the pain experience. A number of measurement tools have been validated in the acute care setting, with some appropriate for use in the prehospital setting. This paper reviews the characteristics required of a prehospital acute pain measure and appraises the relative utility of a number of currently used pain measures. At present, the verbal numerical rating scale appears the most appropriate pain measure to administer in the prehospital setting for adult patients as it is practical and valid. Either the Oucher scale or the faces pain scale is suitable for prehospital care providers to assess pain in children.

OBJECTIVE: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting. METHODS: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, chi2 test, and logistic regression. RESULTS: Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84). CONCLUSION: Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.

Pubmed

PURPOSE OF REVIEW: To discuss recent findings surrounding the role of ventilation during cardiopulmonary resuscitation for individuals with out-of-hospital primary cardiac arrest. RECENT FINDINGS: Active assisted ventilation during primary cardiac arrest may not always be beneficial and, in some circumstances, may lead to worse outcomes. By interrupting chest compressions and thereby decreasing vital organ perfusion, rescue breathing may be deleterious. In addition to the time required to administer breaths, the delay due to the insertion of advanced airways, even by well trained individuals, is often extensive. Furthermore, once intubation is completed, excessive hyperventilation occurs frequently, even by recently trained medical providers. Although most experts agree that excessive ventilation is harmful during out-of-hospital cardiac resuscitation, the optimal rate, tidal volume, timing, and technique of ventilation is still unknown. There is increasing evidence that, in patients with witnessed arrests and a shockable rhythm, the optimal form of ventilation is passive oxygen insufflation. SUMMARY: Assisted ventilation during the initial provision of cardiopulmonary resuscitation is less important than previously believed. It is hypothesized that, by training prehospital medical providers to utilize passive oxygen insufflation for individuals with primary cardiac arrest, critical organ perfusion will increase and, therefore, survival after out-of-hospital cardiac arrest will improve.

Background: Several investigators have emphasized the positive effect of hypothermia therapy on patients who have suffered from cardiac arrest. Salvaging patients from circulatory collapse is a pivotal task, but it is unclear whether additional hypothermia can practically contribute to an improvement in the neurological outcome. Methods and Results: Since December 2005, our hospital has been using hypothermia therapy. Forty-six comatose patients after recovery of spontaneous circulation were consecutively enrolled in the present study. Twenty-five of the enrolled patients received hypothermia therapy and 21 did not because they were treated prior to 2005. The time from collapse to spontaneous circulation (P=0.09), the rates of performance of bystander CPR (P=0.370) and presence of a witnessed collapse (P=0.067) were not significantly different between the recovery group (n=28) and the non-recovery group (n=18). The additional hypothermia therapy was an independent predictor of neurological recovery (P=0.005, OR 6.5, 95%CI 1.74-24.27). The recovery rate was significantly higher in patients who received hypothermia therapy (80%) compared to those who did not (38%). Conclusions: Hypothermia therapy is very useful for treating patients who have had an out-of-hospital cardiac arrest; it should be induced rapidly and smoothly.

Also posted at Star of Life Law.

This post was generated from an email I received from Mark over at Medic999. One of Mark's readers posted the details of a call he ran wherein the patient had a valid DNR order, and he was uncomfortable with the way the the DNR limited the available treatment options. You can visit Mark's blog for a full run down of the opinions there.

For the readers outside of the United States, you should be aware that each State sets its own laws and regulations regarding DNR orders; there is no nationwide standard. Each State's law may be different.

First a bit of a disclaimer: I am educated in United States common law and most specifically educated in the law of South Carolina, the State of my bar admission. I am also registered as a NREMT-P in South Carolina so I am most familiar with South Carolina’s laws on DNR orders.

I will focus first on the law within the jurisdiction I practice law and ride an ALS truck. I will then discuss my thoughts as to the call posted by Matt, and will end with a sampling of DNR regulations from other States for comparison.

Here in South Carolina we have the Emergency Medical Services Do Not Resuscitate Order Act. To establish a DNR order in South Carolina, the patient must: (1) have a terminal condition; and (2) the terminal condition must have been diagnosed by a health care provider and the health care provider's record establishes the time, date, and medical condition which gives rise to the diagnosis of a terminal condition. Thus, it is a pre-requisite to have a physician established terminal condition.

When EMS personnel are presented with a valid DNR order EMS personnel must not use any resuscitative treatment. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.

Okay, that is some great lawyer-speak, but what constitutes the “resuscitative treatment” we can’t give, and what does “that degree of palliative care called for under the circumstances which exist at the time treatment is rendered” mean for those of us in the street?

For that guidance we must consult South Carolina Department of Health and Environmental Control Regulation 61-7, Sections 1406 and 1407. In the event that the patient has a valid DNR order, the following procedures shall be withheld or withdrawn: (1) CPR; (2) Endotracheal intubation and other advanced airway management; (3) Artificial ventilation; (4) Defibrillation; (5) Cardiac resuscitation medication; and (6) Cardiac diagnostic monitoring. These 6 items are defined as prohibitive resuscitative treatment in the presence of a valid DNR order.

The following treatments may be provided as appropriate to patients who have executed a valid DNR order: (1) Suction; (2) Oxygen; (3) Pain medication; (4) Non-cardiac resuscitation medication; (5) Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management; (6) Control of bleeding; and (7) Comfort care. These 7 items are defined as the permissible palliative measures that can be given in the presence of a valid DNR order.

Okay, so that is what I can do and can’t do in the presence of a valid DNR order. But wait, there is more. When presented with a valid DNR order, I must honor it, regardless of the circumstances. If I can’t or won’t honor it, then I must immediately transfer patient care to another EMS provider or other health care provider who will honor it.

That is the law in the State I work.

Let’s restate Matt’s patient presentation: Elderly male, lungs full of fluid, SpO2 mid to high 60s on a nasal cannula, improved to about 69-70% with a non rebreather, respirations about 24, mental status , about a GCS 5. Nursing home staff states aspiration of vomitus, suction attempted with no relief. Valid DNR presented to EMS on arrival.

If I was presented with the above in my jurisdiction, right off the bat there are several things that I cannot do for this patient in the presence of the valid DNR order. I cannot drop an ET tube, King Airway or LMA. I cannot use a BVM to artificially ventilate. I cannot attach my LifePak 12 for cardiac monitoring.

My patient revoked my ability to use these tools, and I will respect their decision, but I won’t just watch them circle the drain. There are things I can do that may really help this patient. First, I will do my own assessment, as I do not trust NH assessments. I can still suction, so I would try to clear the airway as best I can. Here, an OPA is a basic skill, so dropping an OPA to maintain an open airway would be permitted. I can administer oxygen via non-rebreather over the OPA. (A tougher question would be whether CPAP or BiPAP is considered artificial respiration. I’ll punt on that one for now.)

I can also establish an IV and check a BGL. Who knows, maybe his blood glucose is 20 and an amp of D50 perks him up. I can…well, you get the idea. There are things we can do and should do to care for our patients.

I encourage you to become familiar with your State's laws and regulations regarding DNR orders and your local protocols on DNR orders so that when presented with a valid DNR order you know what you can and can't do to care for your patient.

These are tough situations for us because we are used to doing all we can with all we got. But we must remember that our primary purpose is quality patient care, and sometimes that means respecting our patient’s wishes regarding the end of life too.

Other State DNR order regulations for comparison:

State of California

State of North Carolina

State of Texas