The Kohlberg Protocol

That sounds like a title for a great spy novel, doesn’t it?

My partner and I were called to a mall for an elderly fall. We found an octogenarian male patient who got his walker tangled in the escalator steps and fallen forward onto his knees. He had some skin tears and abrasions to his right knee and right hand. He was accompanied by his daughter, who explained that the patient had baseline Alzheimer’s dementia. His current level of confusion was more than his average level of confusion, but within the bounds of how his mentation normally waxes and wanes. 

I chatted with the gent while I cleaned him up and bandaged him as well as I could. The man knew his name and that his daughter was with him. He didn’t know where he was or anything time-related. He understood what had happened with the fall on the escalator, but once I began to discuss how dirty escalators were he kind of checked out. 

Because the patient obviously lacked decision-making capacity, I explained (mostly to his daughter) that I would be happy to take her father to the hospital, but what was most needed was soap and water. She understood the limitations of my exam and cleaning, and agreed that a hospital was unnecessary. I asked about a durable medical power of attorney, and the patient’s daughter said that nobody held POA for the patient. She also explained that they had an important appointment about an hour from that time which they absolutely couldn’t miss. (I asked if it was a meeting with a lawyer to get DMPOA paperwork written with a smile.  The daughter did not think me funny.)

What would you do? Would you take the patient to the hospital, after explaining that there was nobody present on scene with legal decision-making authority? That is what the protocol calls for. Would you let the obviously confused patient refuse further care and transport? Would you let the daughter refuse for the patient, even though she had no legal authority to do so?

My instinct was to work around the protocol. I understood the legal, moral, and ethical foundations of the refusal of care protocol, but I also understood that the protocol authors did not have this specific situation in mind when they wrote the rules. My preferred plan was to make base contact, explain the situation, and work out a way to leave the patient in care of his daughter. My partner felt the opposite. He explained to me that the protocols were clear and that I had to take the patient in the absence of decision-making authority. I told him that I would rather do what I thought was right. “Protocols are protocols, and they are written for a reason,” he told me.

What would you do?

Lawrence Kohlberg was an American psychologist who developed a theory explaining stages of moral development. Being that psychologists are crazy imaginative people, his theory is called “Kohlberg’s Stages of Moral Development.” The theory dates from about 1958 or so, but was expanded and developed since. There are three levels, each with two stages.

The first level is called the Preconventional Level. At this level, which is usually seen in children up until middle school, the morality of an action is based upon the consequences to the actor. 

• Stage 1 is the punishment avoidance stage. Children in this stage obey rules established by more powerful people. Rules will be broken if getting caught and punished is unlikely. Wrong behaviors are those behaviors that are punished. “Last time I did that, I got spanked. So I won’t do that again.”
• Stage 2 is the favor exchange level. Children in this stage will satisfy the needs of others if their needs are also handled. Right and wrong is still consequence based, but the consequence in this stage is a positive one.  “What’s in it for me?”

Kohlberg’s second level is the Conventional Level. Moral choice in this level is compared to societal expectations, with the actor accepting societal mores and morality. This level of morality usually appears in high school-aged children.

• Stage 3 is the “good boy” stage.  Actions are chosen based on which ones will please authority or high-status figures.  This stage of morality is based on the sharing, trust, and loyalty inherent in relationship maintenance.  “Being good makes people like me.”
• Stage 4 is the law and order stage.  A large part of society exists at this stage of moral decision-making.  Decision makers at this stage look to society for moral/ethical guidance.  Each member of the society has a duty to obey the rules – and the rules are inflexible and shouldn’t change.  “What if everybody did that?”

The final level of Kohlberg’s theory is the Post-Conventional Level. At this level of morality, principles take precedence over laws. It is rare to see this level used before college.

• Stage 5 is the social contract stage of moral thinking. In this stage, rules represent agreements and are a useful mechanism to maintain order. But rules are not absolute dictates; they are flexible and should be changed or abandoned as need requires.
• Stage 6 is thought to be a purely theoretical stage. It is rare to see an individual operating at this stage. In this stage, universal ethical principles transcend specific norms and rules. Individuals here have a strong inner conscience. That conscience is obeyed, rather than rules and laws. These individuals willingly disobey laws that violate their own ethical principles.

Why do you follow EMS protocols? It is kind of a weird question, I know. Is it to avoid getting into trouble? Is it because your boss gave you the protocols and they must be followed? Is it that protocols are guidelines, but you will do what you think best? 

I would argue that you shouldn’t follow protocols blindly. Do what you would be proud to defend. But to do that, one must have all the necessary information to make good decisions, including didactic and specific situational knowledge. Follow the protocols because you agree with them, not necessarily because you have to.

I’m not saying that a better person operates in the Post-Conventional level at all times. I constantly bounce back and forth between Stage 4 and Stage 5. I will run red left turn arrows constantly because I think they are an insultingly stupid waste of my time. But I show up to work on time because it is one of the work rules. I even operate at a Pre-Conventional level when I go the speed limit solely in order to avoid a ticket. 

In the case above, was being Post-Conventional and my partner was operating at a Conventional level. Like him, I considered the protocol requirements for transport. I thought they didn’t fit the situation well, though. Instead I decided to do what I thought best – release the patient to his daughter. As a backstop to my decision-making, I contacted the base physician. The doctor agreed and the patient was left at the scene. I don’t think that transporting the patient would have been wrong, however. It just depends on your own comfort level in a given situation, along with which of Kohlberg's stages you happen to be operating within at that time.

I find it interesting to think about those kinds of things, though. Isn’t it cool that a discussion of protocols can get into psychological theories and morality?

The Ex-Feline

As a medic, weird things happen to me. One day I was sitting in the airport paramedic’s office, minding my own business and watching The Andy Griffith Show, when a series of crashing blows upon my door alerted me to an emergency outside. Someone was pounding on my door as hard as they could, without stopping. It sounded like they might crash through it. Judging by the frantic beating, something really good or really bad was going on outside.

I opened the door and a man rushed past me into the office, out of breath and carrying several bags. The airport rep who had shown him my (unmarked) door told him he was in good hands now, quietly wished me good luck and scuttled off quickly. She is leaving in a hurry, I thought to myself. That’s a bad sign.

I don’t usually like to care for patients in the office, if I can help it, and I usually like to be the one to invite them in. I also like to shut off Andy Griffith, because it is weird to run an EMS call while Sheriff Andy and Barney watch. But that was not to be in this case. 

The agitated man with the luggage was obviously near panic. “It’s Oliver!” he said breathlessly, “I can’t wake him! You have to help! Can you help?!? Oh, Oliver!”

The paramedic in me quit thinking about how Andy was going to handle Opie’s problem and switched into responder mode. “Where’s Oliver?” I asked with my in-charge voice, as I grabbed my radio to notify dispatch of the emergency. I was already considering whether I needed the fire department to respond, as well.

“Here! Thank god! Please help him! Oh, Oliver!” the distraught man screeched as he thrust one of his bags at me.

Here? What do you mean here? What the hell is going on? I thought. Is that…

Yep. It was a cat carrier he was pushing into my arms.

Goddammit, I hope this dude’s cat isn’t dead, I thought to myself as I set the carrier on the desk. I unzipped the top and peeked inside.

That cat was dead as dead can be. It was lying on its side, with its eyes open and its lips curled back into a rictus grin. The eyes told me all I needed to know – you know how dead eyes start to dry out and look kind of sticky? That’s how this cat’s eyes looked; because it was a dead cat. 

Someone’s cat, Casper, lying in state… By RJB (Own work), via Wikimedia Commons    

The switch from Andy Griffith, to a possible emergency, to an unresponsive cat, to a dead cat so quickly put me off guard. I almost laughed out loud when I opened the carrier and saw the cat.

The hysterical man was pacing several steps in each direction and wringing his hands. It is hard for me to oversell how upset this fellow was. Well, this isn’t going to go well, I thought as I imagined how I was going to let the owner in on the secret. 

To buy myself some time, I put my stethoscope to my ears and pretended to listen to the cat’s chest for several seconds. Still a dead feline. It was even rigored. 

Crapcrapcrap. What if he expects me to work this cat? The thought of me pumping CPR into a cat flashed through my head and I almost laughed again. I pulled myself together.

“I’m very sorry. Oliver is dead.” I informed my visitor, as solemnly as I could manage.

Oliver’s owner’s shoulders sagged and his arms went limp. His head fell backwards, his mouth came open, and a wail of despair moaned out. Bawling loudly, Oliver’s owner ran for the door.

Crapcrapcrap. What do I do with Oliver if dude leaves him here? Trash? Fridge? (Note: I rarely use the refrigerator.) I don’t want a dead cat in my office looking at me!

As soon as the owner got to the door, he ran back to Oliver and me. Oh good. He grabbed the cat carrier with the corpse still in it, and sprinted for the door again. He still held his head backwards and was shouting his grief as he ran out of the door and out of my life. The whole contact took less than thirty seconds.

Phew! That was a close one! How should I write that up?  Wait. Should I write that up? I went back to Andy Griffith and pondered the question. My guess is that the owner gave Oliver some "be-good" pills before the flight and over benzo-ed his cat.

And for my favorite dead pet video: check this out...

The Tale of the Too Loud TV

My partner and I once responded on a Sunday afternoon in autumn to an elderly cardiac arrest. If I were feeling poetic, I would tell you that the leaves were changing and a chill was in the air. It was a long time ago, and I know that because it was the first time I placed a King airway in the field. It was planned – a few weeks before, I said to myself: Self, the next arrest you work, you need to use one of those new-fangled King airway things. So I did.

We arrived at a little bungalow on a quiet street to find the fire department demolishing the torso of a little old lady. She was alone in the house, with an unknown downtime, but was warm and non-rigored. She was asystolic, got one round of ACLS love, and then I pronounced her. As per my previously designed plan, my first King airway was placed. It was a run of the mill arrest, beyond that. I rarely go to the second round of ACLS with an asystolic patient if I can help it. Asystole isn’t a rhythm – it is a sign of death. That isn’t to say that I don’t put effort into resuscitating patients; I have high hopes for every arrest I run. But this patient got one round of ACLS and was pronounced.

There were a few memorable things, though.

First, I wonder how I would feel to have the terminal events of my life be described as being “…asystolic, got a round of ACLS love, and we pronounced…” Seems like a big event, after a long time on this Earth, to distill into a simple sentence like that. If I get the choice, I want to be a spectacular resuscitation, not a run-of-the-mill arrest. Something involving multiple etiologies. I want the medic who runs me to say, "I once ran a dude in cardiac arrest. He had an MI during intense sexual activity and then got struck by lightning! He may have survived all that, except for the rattlesnake. And actually, the snake didn't do him in, per se, but the fall that followed being bitten..." Something awesome like that. Yeah.

Second, I think she may have been close to deaf when she was alive. The television was still on while we worked her.  It was quite loud. Really loud.  We had to shout to be heard over QVC. This comes into play later in the story.

Third, I discovered a profound new piece of knowledge: Once Fire has bagged up a patient’s belly to a profoundly tympanic state, it is a sub-optimal time to insert a King.  Vomit squirts out of the suction port.  A lot of vomit. Like, a lot. Vomit. Lots. I didn’t think it would end. The amount of vomit being expelled under pressure was disconcerting and made me hesitant to ever place a King airway again. I tried to put my thumb over the hole, but it just shot further; like when you put your thumb over the end of a garden hose.

No Comment. Source

Fourth, I remember the cops on scene after I pronounced the lady. They were going to have to wait on scene for the medical examiner to arrive. You see, in my city the medical examiner is to be involved on any out-of-hospital death. In this case, on a weekend, the ETA for an ME to arrive was probably a couple of hours. One of the officers asked me to help find the television’s remote control.  Which made sense in my head, being that the television was so loud.

“Here it is,” I said. “You’re right – the volume is crazy loud. Let me turn it down for you.”

“No, dumbass.” The policeman said with a look of incredulity on his face, “Who cares about the volume? The Broncos are about to start playing…”

Oh. How silly of me. Of course. 

The Terrible Twos

I’m sorry to be the one to let you in on a horrible secret, but here goes: Medics around their second year are hitting the nadir of their medical skills and knowledge. They are commonly terrible paramedics and terrible employees. I guess there is never a never and never an always, but it certainly happened to me, and it is a normal finding to watch happen with other medics. Sorry – but that is just the way it is. 

I think the reason is that paramedic school sends you out into the world on the high point of a pendulum swing. A brand-new medic just spent between six months and two years studying their chosen craft. In addition, they are probably just finishing up their field internship, with irritable medics evaluating their every move. All the little EMS facts and medical knowledge are fresh and accessible in their brains, and they have been studying like mad for the National Registry test. 

Career roller coaster is a metaphor that works too. This is what my coaster looks like...
Picture source

Immediately after that, in many cases, they are hired into a paramedic service and begin a field training process. Once again a grouch is watching and nagging about their every move. Between calls, trainee paramedics are quizzed. Situations that trip them up are found and corrected. Trainees spend time studying protocols and medications. They are constantly asked: Why did you do that? What did you think was going on with that patient? 

The skill and knowledge pendulum is pushed higher.

Then a new paramedic clears the field training process, wherever they are, and begin to work as an independent medic. All that career pressure, going all the way back at least to the start of paramedic school, is suddenly relaxed. Now is when the skill/knowledge pendulum swings back to the suck end of the scale – but it takes a little time. There is no longer an irritable trainer looking for mistakes to hammer. A medic finds that they can palpate blood pressures, rather than auscultate, and in most cases nobody will call them out on it. Physical exams become progressively lazier until the point that they may even be skipped altogether. If-then statements fill their day, without thought or reasoning. General work habits slowly decline, patient and citizen complaints increase, and (being that they are progressively more comfortable with the experience of driving an ambulance fast) crashes and near-miss crashes start to occur. As the pendulum keeps swinging back away from the peak of skill that they had, the rate of patient non-transport calls increases. Unnecessary refusals increase. The new medic gets more bitter and acts like a burnout. 

Don't be sad, little medic.  It happens to everyone... Picture source

At least, this is a pattern that I commonly see. I will admit it happened for me. Mostly what is happening is that the pendulum overshoots the mean and falls to the below average end of the scale. A medic, especially in a busy system, has seen a lot of patients and begins to feel comfortable with their job. Ninety percent of patient presentations present no challenge to them. Unfortunately, these two-year medics think 100% of presentations present no challenge to their skills and knowledge. The gap between 90% and 100% is where problems arise.

I think it is related to the Dunning-Kruger Effect. This psychological finding is a failure of metacognition described by David Dunning and Justin Kruger in 1999.* What it describes is that relatively new or unskilled people experience “illusory superiority” and cannot correctly place their skill level into context. A person doesn’t know enough to accurately assess if they know enough. They don’t know enough about the scale to precisely place themselves on it. They don’t miss on the low side, though. Like an underheight middle schooler who thinks the NBA is in their future, the cognitive failure is to evaluate their skill level too highly. (On the other side, though, high skill individuals may underestimate their relative level of competence, thinking that tasks, which are easy for them, should be easy for others. But that is a topic for a later discussion.)

Looking back, I can completely see that I felt this way. I had two years in a high-volume system under my belt. I had run enough calls to get comfortable. I was good at my job, but I thought I was excellent at my job. I thought I was an incredible medic without even having to work at it. I was a prodigy medic, in my own head. I was lucky that I had a call or two that scared me without harming anyone. Looking stupid is better than causing harm. Even more beneficial to me was when I got to see a twenty-year medic work at full speed. Not work fast; work at their full speed. A salty old street dog doesn’t often feel the need to work as fast as he or she can – it only happens once or twice a year. Watching that, I went from feeling like I was a bad-assed über-medic to sitting in the captain’s chair with my mouth open, gobsmacked, wondering why I sucked so bad. 

Those near-miss calls and incredible partners were enough to wake me up and start the pendulum swinging back the other way, away from lazy and dumb. I’m glad that my poor skill level didn’t affect anyone else. 

For me, the pendulum swings got smaller and smaller, until it essentially stopped altogether. There wasn’t a whole lot of variability from day to day or week to week in my job performance. At this point, a great medic would push the pendulum to the skill end of its arc, and kept on pushing without letting it swing back to the lazy end. Keep pushing for excellence, not comfort. Reset the pendulum’s range. For the rest of their career, they would keep pushing to expand the length of the skilled side of the pendulum’s range.

*Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personality Social Psych. 1999; 77(6): 1121-34.