Authority: protocols, quality, and the hard calls

A protocol is an order

Under a therapist-driven protocol, the assessment you perform is the order. Titrating oxygen to a documented target, escalating bronchial hygiene by findings, or holding a treatment for a heart rate outside the stated range is practicing correctly, not exceeding scope.

The boundary is a patient who no longer fits the protocol's assumptions. When the physiology has moved outside what the protocol contemplated, you stop, you call, and you say which criterion was not met.

The note is the defense

Document the finding, the protocol criterion it satisfied, the action, and the reassessment. A note that records only the action leaves the judgment invisible — and invisible judgment is indistinguishable from no judgment when the chart is reviewed later.

Out of control means stop

When quality control falls outside acceptable limits, no patient sample is run until the problem is identified and corrected. Repeating the control and hoping is the single most common wrong answer on this topic, and the most common real-world shortcut.

A single point far out suggests random error — a bad vial, a bubble, an operator slip. A run of points drifting steadily in one direction suggests systematic error: a failing electrode, a reagent nearing expiration, a temperature problem.

Look backwards, not just forwards

If control failure is discovered after patient samples were reported, those results have to be evaluated and, where appropriate, corrected and re-reported. The obligation runs back to the last known good control.

Your job is clarity, not persuasion

Families ask therapists what the ventilator would 'do' because we are the ones in the room. Describe what the intervention accomplishes and what it does not, in plain words, and then route the decision to the team responsible for goals of care. Accuracy is your contribution; steering is not.

A valid do-not-intubate order is followed. When a directive conflicts with what is being requested at the bedside, that is an ethics consult and a documented conversation — not a decision made quietly by whoever is holding the bag-valve mask.