What is accountability? Although I think we all sort of know what it means, it's a hard concept to put into words. Take a moment and think about how you would define it. To one source, accountability means "an obligation or willingness to accept responsibility or to account for one's actions."1 Another definition is "the obligation to bear the consequences for failure to perform as expected."2
According to Dr. Herbert Swick, who has been guiding our discussion of professionalism, "Physicians exercise accountability for themselves and for their colleagues."3 He goes on to say that accountability is related to members of a profession setting and enforcing standards of practice for their field. Society has granted the practice of medicine the privilege of autonomy; accountability is the key to that autonomy.
Although we as EMS practitioners are not fully autonomous--we practice under the auspices of a physician's license--we are most often assessing and treating patients without direct supervision. Sometimes we make contact with a medical command physician, but in many places, in many systems, there is little or no need for online medical control. In those circumstances we follow protocols or standing orders. These are part of our standards of practice. If we aspire to practice professionally, we should endeavor to hold ourselves and our colleagues accountable to our standards of practice.
What are the other components of our standards of practice? There is the National Scope of Practice, which is part of the ongoing initiative to implement the EMS Education Agenda for the Future. There is likely enabling legislation in your state or commonwealth that describes the limits of EMS practice there. In my commonwealth, Pennsylvania, the current scope of practice is defined by legislation. This legislation will soon be replaced by new legislation, Act 37, and there are rules and regulations that will follow. Additionally, we have protocols. These detail the expected course of action for EMS practitioners related to various patient complaints and assessment findings. Most of these standards concern clinical aspects of our work.
Do we have other standards of practice? As we discussed in an earlier article, the National Association of EMTs has an EMT Oath and Code of Ethics on its website (www.naemt.org). How many of us swore the oath or know the ethical code? What do they mean to us as practitioners? To help us understand, let's look at some hypothetical cases.
You are on your sixth call of the day. A middle-aged man called because he was feeling short of breath. You've placed nasal cannula and completed your assessment. When you ask the patient about his medications, he says he can't remember the names of all of them, but they are organized on the dresser on the other side of the room. Your partner goes over to check, and you see him writing them down. He tells you, "He's taking Lasix, Theo-Dur, prednisone, some pressure meds and some other stuff. I'm making a list." As you prepare to establish IV access, you glance over and think you see your partner put something in his pocket. You think nothing of it at the time. You transport the patient and go on with the day.
Later, back at the station at the end of the shift, you see your partner talking with one of the oncoming crew. He reaches into his pocket and takes out a pill bottle. He opens it and dumps some pills into the hand of the guy he's talking with. They laugh, fist bump and head out to the parking lot. Seeing this makes you think. Your partner has been out sick a lot lately. He has been moody, and sometimes he is rude and impatient on calls and around the station. He seems to be tired all the time. "What," you ask yourself, "is going on?"
What can you do? What should you do? What would you do? This is a complex and disturbing situation.
Your regular partner is on vacation, and today you're working with a paramedic you don't really know. So far the shift has gone well. You've responded to three calls: a patient who broke a window and suffered a serious laceration; a softball player who ran into another player and injured his knee; and an asthma attack. So far everything has been fine.
Now you're on location with a patient complaining of chest pain. The patient has a history of previous heart attacks and says she feels just like she felt the last time she had one. Your partner sets up and runs a 12-lead ECG while you're putting away the equipment and preparing to drive to the ED. You ask, "Should I call a STEMI alert?" Your partner says, "No, the 12-lead looks good. Let's go to Memorial, it's the closest." You say, "You know Memorial doesn't have a cath lab, right?" He says, "Yeah, I know, but this 12-lead looks fine. Just go to Memorial." You contact the communications center and put yourself en route to Memorial.
When you arrive at Memorial, you help move the patient to the bed and go out to restore the ambulance. On the way out you see your partner talking to the ED doctor. The conversation seems to be very animated, and the doctor does not look happy. When you go back into the ED, the doctor pulls you aside. He says, "Why did you bring that patient here? You know we don't have a cath lab. She is having an inferior wall MI, and now we have to transfer her over to General. I know you know better!" The doctor walks away shaking his head.
You are dumbfounded. You think, "What the heck just happened?" Your thoughts are racing. "Now what am I going to do?"
Who made the mistake here? Who is responsible? Who will be held accountable?
Although these events are fictional, I have been a member of several EMS systems in which similar events have occurred. I have read about events involving EMS practitioners that required those involved to be held accountable for their actions--the recent certification issues in Massachusetts, for example (see EMSResponder.com).
If accountability is taking responsibility for your actions and an obligation to bear the consequences for failing to perform as expected, how can we apply these ideas to the first case? You suspect your partner stole medications from a patient. His recent behavior supports the possibility that he has been using drugs. We must ask several questions. If your partner actually stole medications and has been using them, did your partner perform as expected? On several levels we can answer no. We already discussed trustworthiness as an expectation of professionals, including EMS practitioners. Can you continue to trust your partner? Should you expect your patients to place their trust in him? What is your responsibility in this case? I suggest that anyone in a situation like this has an obligation to try to help on several levels. The obligation is professional, to protect your patients. The obligation is personal, to protect yourself and help your partner. And you also have a responsibility to your organization and to our discipline.
I believe your first action is to talk to your partner. Everything else in your course of action depends upon how he responds. Where it might go from there is beyond the scope of this article, but one thing is clear: You must act. This applies when dealing with the second case as well.
Swick said, "Meaningful peer evaluation becomes one mechanism to enforce standards of practice and hence exercise accountability."1 Peer review is important to our clinical practice. It is a process that allows us to safely examine situations that did not go as planned or have optimum outcomes, and to learn from them. Peer review also allows us to share cases where we learned lessons or came up with particularly good solutions for problems. This is a topic for another day, but suffice it to say, we can use peer review and evaluation as part of our accountability system.
It is important for students to know all the standards of practice to which they're expected to adhere. They must also know the consequences of failing to follow those standards. This must be included in all of our EMS education programs, particularly the components outside the National Standard Curriculum. Instructors must cover this material and instill the idea of accountability in their students. One method is to have students discuss the concept and how it applies to EMS practice. Instructors, preceptors and all members of organizations should model this critical behavior, and must also know how to respond, how to act and what to do when situations arise that call someone's actions into question.
Holding ourselves and our colleagues accountable is not easy. It can lead to uncomfortable situations. However, the discomfort is usually a consequence of not knowing what to do. Thinking about appropriate actions in such situations will help. Discussions with peers and formal peer review are tools we can use. It is important for all of us to be accountable for ourselves and our colleagues. We will all be better off if we are.
1. Merriam-Webster Online Dictionary, www.merriam-webster.com/dictionary/accountability.
2. Answers.com, www.answers.com/topic/accountability.
3. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612–616, June 2000.
Michael Touchstone, BS, EMT-P, is chief of EMS training for the Philadelphia Fire Department. He has been involved in EMS since 1980 as an EMT, paramedic and instructor. Contact him at firstname.lastname@example.org.