Spinal Immobilization Harm

What do we do to protect our patients from injury when we immobilize them?

But spinal immobilization protects the patient from injury!

Maybe, but if spinal immobilization does offer any protection from any injury, it may only offer that protection when spinal immobilization is performed perfectly. We do not know what perfect spinal immobilization is, but it probably is not the method we currently use - strapping people to pieces of wood, or pieces of plastic.

Here is one example of spinal immobilization creating more of a risk of paralysis.

Imagine that we are dispatched to a motor vehicle collision. There is significant damage to the vehicles. Our patient is up and staggering around. We attempt to assess our patient and find that he is not cooperative. Mr. Charming is behaving in a way similar to other patients - patients who have stated that they might have consumed some alcohol, but only 2 drinks. However, Mr. Charming is not as charming as these previous patients. He does not even answer most of our questions, never mind demonstrating that his math skills become undefined beyond the number two.

Protocol states that Mr. Charming should be immobilized to protect his neck from possible movement during transport. We attempt to put a collar on Mr. Charming, but find that we have to wrestle with him to keep the collar on his neck. In a moment of inspiration, we call medical command for possible orders to either sedate Mr. Charming or to not immobilize Mr. Charming. Tonight, medical command is Dr. Charming (no relation). The doctor is about as charming as Mr. Charming, but no more reasonable.

Dr. Charming is worried about the possible harm that might come from not immobilizing Mr. Charming. It seems that this harm is legal harm that would affect Dr. Charming. The possibility that Mr. Charming's combativeness might convert a stable fracture to an unstable fracture, or an unstable fracture of the spine to a permanent injury of the spinal cord - these risks are insignificant compared to creating a legal alibi. Mr. Charming is applying significant forces to his cervical spine, by wrestling with us, by fighting with the collar, and once he is strapped to the board, those forces applied to the cervical spine are increased exponentially.

This understanding of mechanism, or kinesiology, is ignored by Dr. Charming. Mr. Charming will be laying on his back, his head taped to the board, wearing a cervical collar. He will be continually raising his head against the restraining tape. He will be applying the kind of forces to his neck that essentially clear his spine as far as unstable fractures are concerned, because if this does not result in paralysis, nothing will. Dr. Charming does not understand, but he has seen people play lawyers on TV and he is more worried about his theoretical legal problems.

Dr. Charming's concern about sedation is that sedation may mask the ability to thoroughly assess the patient. No, we're not considering sedating the doctor - that would affect the assessment. OK, we're not completely ruling out sedating the doctor, but don't tell anybody. Shhh. That will be our secret. Even though that ability to thoroughly assess Mr. Charming is little more than a hallucination, Dr. Charming believes it is significant. Dr. Charming believes that, if we do not sedate Mr. Charming, he will be the ideal patient. Dr. Charming is worried that a sedative may convert Mr. Charming from a combative and uncooperative patient, to a sedated and uncooperative patient. Dr. Charming does not realize that this is one of the benefits of sedating Mr. Charming.

Dr. Charming is also concerned about Mr. Charming's blood pressure, which appears to be elevated, but it is difficult to obtain, due to the way his combativeness does not exactly assist with our assessment. Mr. Charming says he will allow a blood pressure, but only if we agree remove the collar and remove him from the long board. Dr. Charming considers the inability to be able to obtain a clear blood pressure as a sign that it must be on the low side, perhaps dangerously low, even though all indications are to the contrary. Dr. Charming is worried that giving a depressant, and sedatives are almost all depressants, will lower Mr. Charming's blood pressure to even more dangerous levels, although there really is no indication that there is a problem with the blood pressure.

Number three on Dr. Charming's hit parade is the possibility that the sedative may induce nausea and vomiting. These are significant risks in the immobilized patient. We can deal with vomiting in a couple of ways. We can give anti-emetic medication, but Dr. Charming is afraid that the sedating effect of the anti-emetic may similarly compromise assessment. Not to worry - we can still turn the long spine board on its side, while we shovel the vomit out of Mr. Charming's airway. Remember, this is EMS. Immobilization is much more important than airway. In EMS, we consider it more important to keep the immobilization just so, than to make airway management the priority.

Let's see, the research on breathing vomit does not exactly include randomized placebo controlled trials, but the purely observational nature of the research does seem to have produced a consensus. Breathing vomit does not lead to a long life. Even I do not criticize this conclusion.

On the other hand, the evidence that the immobilization device actually protects the patient from further injury, even without the complication of a vomiting patient - that evidence does not exist. That evidence is really just expert opinion, just like the Golden Hour, prophylactic lidocaine, giving medication down the endotracheal tube, System Status Management, high flow oxygen is harmless and good for everything, MAST (Medical Anti-Shock Trousers) creates an auto-transfusion of blood from the legs to the upper body, if it wheezes it is asthma, if it crackles it is CHF and will have pink frothy sputum, and so on. All of those expert opinions have been shown to be wrong, so how much should we endanger our patients in defense of this not yet discarded expert opinion?

Is the concern about sedation leading to vomiting a legitimate concern?

Yes. And. No.

Huh?

Yes. One of the side effects of medication is vomiting. Even anti-nausea/anti-vomiting medication can cause vomiting. Combining the sedative with a condition that may lead to vomiting on its own (intoxication), may increase the chances of vomiting.

No. Mr. Charming probably has eaten chili, hot wings, pizza, and washed it down with some cheap imported beer (such as Budweiser), followed by some jet fuel/miracle semi-digested food propellant even cheaper home grown tequila. Therefore, Mr. Charming already has a total stomach evacuation scheduled. Maybe he will wait until he is safely being ignored in a hallway bed. Maybe he will not vomit at all, but not being prepared for vomiting is stupid, especially with such a charming patient.

While the one large study to compare a system with spinal immobilization and a system without spinal immobilization was not large enough to clearly demonstrate that spinal immobilization is harmful, that is the way the numbers were trending.^[1]

I am sure that none of us will ever deal with an intoxicated person, who has a mechanism where the protocol indicates full spinal immobilization be applied, it is good to think about what might happen in the rare event that we come across one of these trauma zebras.

First do no harm is a pithy phrase that is more of a medical punchline than a medical reality, but we should wonder if this spinal immobilization treatment is even as safe as any alternative. If we wish to claim that spinal immobilization is safe and/or effective, we need to provide some research to support it.

Without research, spinal immobilization is just another experimental treatment.

Should we be experimenting on our patients?

We do not have IRB (Institutional Review Board) approval

We do not have researchers.

We do not have control groups.

This is just a huge uncontrolled unauthorized experiment on the unsuspecting.

Can spinal immobilization be said to have satisfied any requirements to be treated as not experimental?

No.

But - It would be unethical to study this, because that would deprive some patients of this obviously beneficial treatment!

That is what doctors say about treatments based on expert opinion. They keep saying that - right up until the evidence of harm is unavoidable - or the doctors come up with a new and improved expert opinion treatment perhaps as a way of deflecting the claims about the discarded treatment.

Is there any evidence that those with spinal fractures are not harmed by immobilization?

Is there any evidence that those with spinal fractures receive any benefit from spinal immobilization?

As far as I know, the answer to both questions is No.


Footnotes:


^ ¹ Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed - indexed for MEDLINE]

RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.

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Comment on Emergency Medical Services Intervals and Survival in Trauma - Assessment of the “Golden Hour” by Anonymous

In this, and other posts, when I refer to paramedics, I am referring to basic EMTs as well, unless I am describing something that is outside of the basic EMT scope of practice. In the comments to Emergency Medical Services Intervals and Survival in Trauma - Assessment of the “Golden Hour”, Anonymous wrote -

Interesting research on an issue I have anecdotally observed for years. We've all got to stop treating speed in transport as an end in itself, and start treating it as a means to improve outcomes in patients who can truly benefit from it.

This is just an example of one of the big problems of EMS - we act as if the patient is there to serve the protocol/old wives' tale/need for excitement, when the reality is that we are there to serve the patient.

This is about the medical care of the patient, not about how cool the rescue squad/fire company/ambulance company is.

On a related note, back in 2000, I was lobbying my regional EMS counsel to stop letting people fly patients based on mechanism alone. Why use an expensive and (potentially) dangerous resource to shave 15 minutes off of what is fundamentally a non-critical transport? Treat the patient, not the vehicle was my mantra.

I will have several post on mechanism.

There is more than one problem, here.

You have the control freaks, who believe that we cannot teach EMS to properly assess patients. These are the ones who will claim that a doctor refusing pain medicine to a patient in severe pain, but without any contraindications/relative contraindications to the use of fentanyl/morphine/dilaudid, must know something the paramedic doesn't know and that because of this psychic ability that comes with a doctor's license, the abuse of the patient is not an example of why we should have standing orders for pain management. This is a bright shining example of the glorious doctor protecting the patient from the reckless and irresponsible paramedics.

There are endless examples of this error of logic. There are the rare cases that do support the idea of limiting what a paramedic may do on standing orders. However, these are actually examples of reckless and irresponsible medical directors authorizing dangerous paramedics to treat patients. If the medical director would not permit dangerous medics to work, the medical director would not have to be constantly stopping his minions from harming patients. The competent medical director does not allow dangerous medics to work as paramedics. The patients come first.


The other problem is from the You can't be too safe freaks. They believe that you can avoid mistakes by creating more and more rules. They believe that anything bad that happens must be because some evil person broke the rules and must be punished severely. Or the mistake is because we need more rules. One excellent example of this is a set of protocols that tries to come up with a rule for every possible patient presentation. They think that, if we can just think of everything that can go wrong, we can write rules to prevent the mistakes.^[1]

What they do not realize is that they are making the biggest mistake possible. They are viewing the possibility that the paramedic may make a mistake as the problem to be prevented. Yes, it is a problem, but their solution is to prevent the paramedic from thinking. They think that the paramedic is the weak link in the system. The weak link in the system is the reliance on rules, rather than critical judgment.

We should be taking advantage of the ability of the paramedic to think. We should be providing an environment that encourages critical judgment, an environment that develops the ability to use critical judgment. The decision to prevent paramedics from doing this is dangerous and encourages patient abuse.

Critical judgment is about figuring out what is best for the patient in this case, initiating treatment while constantly reassessing for changes, and changing treatment as indicated by reassessments. This is what is best for the patients.

Critical judgment is not about herding protocol monkeys.

You mention using helicopters to shave 15 minutes off of flight time, but I often see helicopters used where they delay transport. I used to work in a trauma center. The patients from a multipatient scene transported by ground would almost always arrive before those transported by air. There was only rarely a justification, such as entrapment. This was just use of a helicopter to delay treatment, but follow a protocol and/or become tumescent about a helicopter.

The medical command doctors, who want to know about the damage to the vehicle, generally do not have any experience working as auto body repair technicians and are not going to be repairing the car. The damage to the vehicle should only be in the radio report if it is relevant. One of the problems with being on the other end of the radio is that it is difficult to shut up and listen to the people on scene describe what is relevant. A report that estimates the amount of body damage is meaningless. An actual thorough physical assessment is valuable. Mechanism is only useful when it helps to guide us to find things that we might have otherwise missed in our assessments. Mechanism is dangerous when it encourages us to transport the patient in a way that increases the risk to the patient.

The response I got was rooted in a fear of liability. Better to have a few patients flown unnecessarily than to have one critical patient "slip through the cracks." It was never really clear to me who our medical director was more worried about form a liability standpoint: the EMTs who might forget to call the helicopter, or the rent-a-docs moonlighting in the local ER who might be forced to treat a critical trauma patient (the likes of which many of them haven't seen since med school).

Over-triage is important. We need to be erring on the side of caution, when there is good evidence to support that approach. Just sending everyone by helicopter to the trauma center is not rational over-triage. We need to use critical judgment. Mechanism is not critical judgment. Mechanism ignores critical judgment.

There is a balance of over-triage and under-triage that minimizes the number of slipped through the cracks patients and minimizes the increased risk that we inflict on patients in order for doctors to feel they are protecting their malpractice insurance. Maybe we need to have some lawyers go after the protocol writers, when patients with minor injuries are killed (or injured) in helicopter crashes and ambulance crashes, just because the protocols state to do everything so quickly that it endangers patients.

I suppose the "err-on-the-side-of-caution" approach is all well and good so long as you're not the one paying for the unnecessary helicopter ride, and so long as truly critical patients are not being turned away because the bird is wasting time on non-critical transports.

I think that we should have the trauma centers, or insurance companies, deciding if the helicopter ride is appropriate. If it is not appropriate, the ambulance company and medical director should pay the bill. In places like Maryland, that use taxpayer dollars to pay for the helicopter ride, just so that nobody ever feels that they have a reason to avoid calling a helicopter, we should have the ambulance company and the medical director reimburse the state for the waste of taxpayer dollars.

Who knows when or if common sense will ever prevail. The only thing I know for sure is that when you ask me why I decided to fly a patient out, my response will be something other than "you should have seen the car."

Exactly.

The scary thing is that so many doctors are not smart enough to recognize this.


Footnotes:


^ ¹ MIEMSS Maryland Medical Protocols
Effective July 1, 2008
348 pages of trying to predict everything that can go wrong.
Free PDF


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Emergency Medical Services Intervals and Survival in Trauma - Assessment of the “Golden Hour”

There is a very important paper due to be published in the Annals of Emergency Medicine.^[1] I expect that there will be a lot of criticism of this paper. There will be many reasons for being cautious in implementing the suggestions of the authors, but bad research is not one of them.

One of the difficult things about this paper is that the authors are very good about identifying potential confounding influences. They explain that there are many factors that may have affected the results. They are thorough in pointing out the many different ways they analyzed the data to try to minimize any potential confounding influences. While many may look at this study, see the amount of doubt the authors express throughout the study, and conclude that there is too much uncertainty to pay any attention to this study, they would be wrong to do so.

Trusting in the certainty of those promoting the Golden Hour is the true error. Anxious exhortations to Panic! and Faster! and Panic faster! are not substitutes for good patient care.

The Golden Hour has been around for decades. This is the idea that seriously injured patients need to receive definitive care within 60 minutes of that serious injury.

The amount of information used by Dr. R Adams Cowley to concoct the Golden Hour could fit onto a cocktail napkin. According to legend, it was dreamed up in a bar, so maybe it did fit onto a cocktail napkin. The Golden Hour is not science. The Golden Hour is marketing, and very successful marketing. There are still plenty of people citing the Golden Hour as their excuse for all sorts of mistreatment of patients - But we have to get them to the trauma center inside the Golden Hour. A more appropriate term is the Bogus Hour.

The commonly used 8 minute response time (or 8 minutes 59 second response time in some places) limit (in at least 90% of responses) is based on the AHA's (American Heart Association's) Chain of Survival. The interesting thing is that cardiac arrest survival appears to be the only condition that has good science supporting a short response time.

To date, patients with out-of-hospital cardiac arrest remain the only field-based patient population with a consistent association between time (response interval) and survival.^18,19[2]

The authors of this study probably looked at far more data on trauma time intervals than any other study. They evaluated the data in as many different ways as they could think of, to see if there were any ways that there could be a connection between prehospital time and survival. In spite of all of these different ways of evaluating the data, the conclusion based on all of the evidence is - time does not make a significant difference in survival for unstable trauma patients.

This was not a study just looking at all trauma patients, the patients meeting only anatomic criteria were not included. The same is true for patients only meeting mechanism criteria. In other words, they excluded most of the patients transported to trauma centers.

Why?

Because these patients do not have serious enough injuries to expect time to make a difference. Even though these patients are rushed to trauma centers, their injuries have not resulted in unstable vital signs/level of consciousness. Therefore, they are not considered to have significant injuries for the purposes of this study.

Here are some representative anatomic criteria and mechanism criteria for trauma triage -

Anatomic Criteria:
• Penetrating injury to head, neck, torso and extremities proximal to elbow or knee (unless obviously superficial)
• Chest injuries with respiratory distress (for example, flail chest)
• Two or more proximal long-bone (humerus or femur) fractures
• Pelvic fractures
• Limb paralysis (spinal cord injury)
• Amputation proximal to wrist or ankle^[3]

None of these qualify to get the patient into the study - shooting, stabbing, nibbled at by a lion, - unless the patient has signs of being unstable.

Mechanism of Injury:
• Death of another occupant in same vehicle
• Auto vs. pedestrian (bicycle) injury with significant impact
• Pedestrian thrown or run over
• Extrication time > 20 minutes
• Falls from > 20 feet
• Ejection from vehicle
• Vehicle rollover
• High-energy vehicle crash (e.g. significant intrusion into
passenger compartment)
• Motorcycle crash with separation of rider from motorcycle
Other factors combined with traumatic injuries:
• Age < 5 years or > 55 years
• Combination of trauma with burns
• Known heart disease, CHF, or COPD
• Known bleeding disorder or taking coumadin/ heparin
• Pregnancy (>20 weeks)
• Rigid or diffusely tender abdomen
• Amputation of fingers with possibility of reattachment^[3]

These are the kind of criteria that Maryland was using to fly patients. When they had their fatal crash last year, these mechanism criteria required permission from medical command to fly patients. Flights dropped by about two thirds and outcomes do not appear to have changed. Few of these criteria are useful for predicting instability. This study was only concerned with patients who really are unstable, not those with significant damage to their cars or trucks.

So, what is unstable in the study?

The criteria from the study -

Injured patients with one or more of the following criteria were included: systolic blood pressure (SBP) less than or equal to 90 mmHg, Glasgow Coma Scale (GCS) score less than or equal to 12, respiratory rate less than 10 or greater than 29 breaths/min, or advanced airway intervention (tracheal intubation, supraglottic airway, or cricothyrotomy). “Injury” was broadly defined as any blunt, penetrating, or burn mechanism for which the EMS provider(s) believed trauma to be the primary clinical insult.^[2]

And still they have 10 physiologically unstable patients per day, if averaged over a year - with a few left over. Remember, this is after excluding most of the patients who would automatically be flown to trauma centers, because the authors do not believe that those patients are injured enough for time to make a difference in their outcomes.

Editor’s Capsule Summary

What is already known on this topic

The “golden hour” concept in trauma is pervasive despite little evidence to support it.

What question this study addressed

Is there an association between various emergency medical services (EMS) intervals and in hospital mortality in seriously injured adults?

What this study adds to our knowledge

In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.

How this might change clinical practice

This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.^[2]

So, if time is not making a difference in survival, maybe we should stop killing people just to get patients to the hospital a little bit faster.

Some more details from the paper -

. . . total EMS time was not associated with mortality . . . for every minute of total time . . . When the sample was assessed with 10-minute increments for total EMS time, there was no evidence of increased mortality with increasing field times . . . Similar results were obtained when total times were grouped by quartile . . . We were also unable to demonstrate independent associations between mortality and any other EMS interval for the overall sample . . . ^[2]

No matter how they broke down the time intervals, there was no detectable change in outcome.

For categorized response interval, there was no association with mortality for patients with a 4- to 8-minute interval . . . or greater than 8-minute interval . . . compared with patients with a response less than 4 minutes.^[2]

The same for response times.

In multivariable logistic regression models, there was no demonstrable association between time and mortality for any subgroup.^[2]

Although some seriously injured individuals may require time-dependent EMS interventions to survive (eg, airway obstruction, respiratory arrest, external hemorrhage at a compressible site), faster application of such interventions may not have a measureable effect on outcomes for most trauma patients.^[2]

There may be isolated patients, who benefit from less prehospital time, but there are not enough to make any detectable difference in the outcomes of these unstable patients. No difference in the cumulative outcomes. No difference in any of the subgroup analyses. No difference in any of the time subgroups. How many people are being injured and killed, just to get EMS crews there faster, because in EMS we just know that faster is better. Are we killing more people trying to get to the occasional patient who might benefit from a more rapid response, or a more rapid transport, than we are helping?

That little bit faster is insignificant, except psychologically. Perhaps we should refer those in need of lights, sirens, speed, and helicopters for CISM (Critical Incident Stress Management) in stead. Oops, that is also a treatment that lacks evidence to support it.^[4]

The authors conclude with this bit of common sense -

In the setting of a perceived “emergency,” the public may not necessarily value whether faster EMS time and expeditious care have been shown to save lives for the majority of clinical conditions. However, meeting these expectations costs money (eg, establishment of fire houses and positioning of EMS crews to achieve predefined response intervals), can place EMS providers, patients, and the nearby public at risk,^20-22 and is a common reason (ie, emergency vehicle crashes) for tort claims against EMS agencies.^58[2]

The big questions are -

Will more than a handful of people in EMS pay any attention to this?

Will we wait until lawyers force us to do what is right?

Why do we continue to choose mythology and expert opinion over science?

Dr. Bledsoe provides his own commentary on this trauma paper.^[5] Peter Canning also writes about this.^[6]


Footnotes -


^ ¹ Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed - as supplied by publisher]


^ ² This is the same as footnote [1].


^ ³ Statewide BLS Protocols Effective November 2008
Pennsylvania
Page with link to the full text PDF of the protocols.


^ ⁴ Critical Incident Stress Debriefing and Mythology
Rogue Medic
November 10, 2009
Article


^ ⁵ Speed and Time in Prehospital Trauma Care
The EMS Contrarian
by Bryan E. Bledsoe
EMS1.com
Article


^ ⁶ The Golden Hour
Street Watch
Article




Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, Aufderheide TP, Minei JP, Hata JS, Gubler KD, Brown TB, Yelle JD, Bardarson B, Nichol G, & Resuscitation Outcomes Consortium Investigators (2009). Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort. Annals of emergency medicine PMID: 19783323


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Zero Tolerance For Bad Behavior

TJC/JCAHO (The Joint Commission/the Joint Commission for Accrediting Healthcare Organizations) decided that it would expand its influence in hospitals. While the problem they address is real, their solutions are as unrealistic as ever.

According to this study, their results may match their logic - negligible. Or were things that much worse before JCAHO/TJC became involved? It is hard to believe that anything improves with them. Maybe they justify their behavior with the myth that in spite of being a mass murderer, at least Hitler Mussolini made the trains run on time.^[1]

The survey comes almost one year after the Joint Commission began requiring health care facilities to implement zero-tolerance policies that define intimidating and disruptive behaviors. The commission also required that facilities establish disciplinary procedures for medical staff and other health care professionals who violate the standards.^[2]

What does Zero Tolerance mean?

How little is required to get a doctor’s privileges suspended?

How little is required to get a nurse fired?

Imagine if this were applied to EMS. I know of several medics who might not make it through the week without indulging in all of these misbehaviors. Some agencies do not seem to believe that medics should talk to EMTs at less than 80 decibels, unless they make up for it with gratuitous projectile spittle.

Is there to be a specific decibel level that is measured? There are decibel monitors at some nurses' stations already. If JCAHO/TJC were to run this, they would probably require a deafening alarm that would be activated above a certain decibel level.

The real reason the hospital is so noisy, is to drown out the sound of all of the alarms going off. If anybody were aware the alarms, they might feel the need to do something about the alarms - such as hit the silence for 2 minutes button.

Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%

Just think of the benefit to those trying to get someone unjustly disciplined or unjustly fired. Now they will have more excuses to document as justification for their misbehavior.

The AMA developed a policy model that calls for distinguishing between good-faith criticisms and actions that truly rise to the level of disruptive behavior, and for implementing fair medical staff review processes.

Paul M. Schyve, MD, senior vice president of the Joint Commission, agreed there are appropriate moments for speaking up. But he said the ACPE survey findings highlight types of behaviors that exceed constructive criticism, and if left unchecked, can inhibit others and ultimately can undermine patient care. "We can't let the little things slip."

Don't worry. We do not intend to have anyone punished for constructive criticism. Just remember that we decide what is constructive - and we are intolerant of anything that might be disruptive.

Will it be considered disruptive to criticize this policy? Clearly, if TJC/JCAHO states that this policy will make things better, then criticizing the policy is an example of exactly what they are trying to stop. As Dr. Schyve let slip -

"We can't let the little things slip."

TJC/JCAHO has repeatedly demonstrated that they are all about the little things.

The problem with JCAHO/TJC is that they end up paying more attention to the enforcement, than to the actual problem. They look for rules that will be very sensitive, while ignoring the greater need to be very selective.

Inappropriate joking?

I can't even mention JCAHO/TJC without the use of inappropriate joking. Of course, I do not see it as inappropriate, but I do not make the rules. Those making inappropriate rules will determine what is appropriate. They might consider this post to be a malicious rumor, as well.

Zero Tolerance should not be tolerated.

If we are going to have any JCAHO/TJC Zero Tolerance policies, the policy should be to ban all of their people from health care facilities. We should not tolerate their counterproductive rules. I really would not want this to be a Zero Tolerance policy, since they are foolish (both the policies and JCAHO/TJC), and because even a blind administrative nut might find something that is not completely squirrelly within all of its plotting.


Footnotes:


^ ¹ Did Mussolini make the trains run on time?
snopes.com
Article


^ ² Disruptive behavior by doctors, nurses persists a year after crackdown
A survey of physician and nurse executives raises questions on how to implement zero-tolerance policies required by the Joint Commission.
amednews.com
By Amy Lynn Sorrel, amednews staff.
Posted Nov. 16, 2009.
Article

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