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Applying the KISS Principle to Writing Protocols

A Hebrew sage once said that before a man dies, he should have a son, plant a tree and write a book. I've got the son, and I'm working on the trees. I'd be happy to write a book, but as an EMS medical director I'm too busy writing protocols.

Protocols are interesting creations. Ideally, they reflect the accepted state of the art in prehospital care. But as the universal standard of care is still in question, they really illustrate the personality of a medical director, an EMS service and a community. And like everyone else, I'm sure the protocols I write reflect my personality and character (although I've been forced appropriately, I might add to eliminate the lame jokes). Lacking a true work ethic, I'm always looking for the easiest way out. So let me share with you three ways in which that philosophy has shaped my protocols.

Clinical diagnosis is a difficult art. I think one reason I like emergency medicine as a career is that patient disposition is more important than the diagnosis. How you identify immediate life threats, and what you do about them, is crucial. As brutal as it sounds, it doesn't matter if you know the exact cause of the problem as long as you know what to do about the symptoms. As someone with limited patience, I find this extremely appealing. This principle is even more applicable in prehospital care, where the diagnostic tools that physicians use are unavailable. In addition, several studies have cast doubt on the paramedic's ability to diagnose specific medical conditions (interestingly, symptom assessment skills, which I think are fairly reliable, have not been formally studied).

I've always been uncomfortable with protocols that try to be diagnosis-specific. Not only are they laden with clinical risk, but they also tend to be repetitive (I'll wager you real money that most asthma and chronic obstructive pulmonary disease [COPD] protocols, and most myocardial infarction [MI] and angina protocols, look exactly the same). As a minimalist by nature, I don't want to cut down more trees than needed. So I try to make all my protocols symptom-based. This feeds into the inherent strengths of the paramedic, unites common themes and minimizes repetition.

Using angina and MI as an example, we know that patients with each receive oxygen, nitroglycerin, aspirin, morphine sulfate and an ECG. They get the same care because you can't tell the difference in the field (unless you have a "flaming" ECG, but rarely do systems change the prehospital care based on ECG findings). So it makes sense to unite them in a "suspected cardiac chest pain" protocol. But patients with noncardiac chest pain get oxygen too, and you can always split out the positive ECG, if you're using thrombolytics, later in the decision tree.

I think this principle can carry into trauma as well. Because all trauma patients need complete assessments, why not have a trauma protocol constructed along the lines of the uniform airway-breathing-circulation (ABC) assessment process, with instructions to correct any deficit before moving on? In this fashion, you won't miss an airway problem as a result of focusing on a more obvious extremity injury; a diagnosis-specific protocol invites a lack of attention to other aspects of care.

A second ramification of this symptom-oriented approach is that it allows you to combine adult and pediatric care into a single symptom-oriented protocol. We'll discuss my theory that kids are just little adults in a later piece, but for now let's just say that I believe the fear factor we've created by labeling children special is one of the main drivers in poor pediatric care. We can minimize this fear factor if we consider kids as simply another patient group we care for. Certainly, anatomic and physiologic differences exist between kids and adults; but so do differences between pregnant women and the nongravid females, young adults and the elderly. Children may require drug dosing on a mg/kg basis, but we already know how to do this with many adult medications. The core clinical considerations of the ABCs are identical for any patient, regardless of age. In fact, in children, maybe it should be AAABC (airway-airway-airway-breathing-circulation) because the majority of true emergencies are related to airway control). So it's hard for me to justify splitting adult and pediatric protocols. (I make an exception for neonatal resuscitation, which follows a slightly different sequence and uses different assessment skills than adult protocols. But I'll admit that I keep these conventions distinct more by tradition than fact.)

I've also combined ALS and BLS care in the same protocol. Although many systems separate BLS and ALS protocols, I think this practice inhibits care. In any type of EMS system, EMTs have a responsibility to aid and assist paramedics in the performance of their duties. It's impossible for them to do so unless they recognize which ALS activities to expect. The need for BLS providers to have knowledge of ALS procedures is heightened by the fact that with the advent of semi-automatic external defibrillators (SAEDs), laryngeal mask airways (LMAs) and EMT IV programs, BLS and ALS skills are merging into a unified whole. From the paramedic's view, including BLS skills in the protocol not only informs them of the expected behaviors of their BLS colleagues, but also reminds them of their own BLS responsibilities and the clinical requirement to perform BLS prior to ALS procedures. The worst errors I've seen in a quality assurance process come when ALS providers neglect BLS skills, and it's my feeling that good BLS saves many more lives than great ALS.

Finally, it's crucial to note that a protocol document cannot cover all situations. Prehospital care takes place in an uncontrolled arena, and although we may develop a protocol to cover 99% of circumstances, constructing a protocol to apply to all prehospital contingencies is impossible. A protocol document must recognize this fact: Life is better at creating problems than we can ever hope to be at creating solutions. If standing orders fail to recognize this, it places the paramedic at risk due to a lack of protocol authorization for his or her actions. As a result, I put a caveat in protocols to indicate that:

"Patient care is by nature unpredictable, and patients may require care derived from multiple protocols, protocols not yet devised or in the absence of online medical control. The following protocols are written with this reality in mind. Deviations from protocol will be tolerated only when they are intended to further patient care. Such deviations must in no way detract from the high level of patient care expected from EMS personnel."

Notice this phrase does not give the paramedic a blank check. It only provides authorization to do what might be considered appropriate and reasonable given the circumstances involved. In no way does it excuse poor care or a lack of skill or knowledge. Recognizing the variance in life does not mean we accept mediocrity in practice.


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