A new technology, called “waveform capnography,” had been introduced to EMS. There wasn’t one shred of prehospital evidence to show that it worked on an ambulance. How to sell this, let alone teach it, to people who don’t even know what it is, seemed like a daunting task. How could we educate and lead clinical change in a high-performance organization with more than 250 employees? Answer: one person or class at a time.

We had several options: First, order mandatory inservices. We’ve all been to a few of those; they’re the equivalent of force feeding. Another option was to simply order the equipment and put it out there for everyone to play with until they felt comfortable. Still another choice was to ignore the problem and tell yourself, “I think they’re taught how to do that in their EMS school, right?”

This is life. It’s easy to say “no” to a new idea; we know that change creates problems and uncertainty. But advancements are important in EMS. We also know that waveform capnography is a clinical enhancement that’s here to stay, so we had better teach its use well.

For decades, capnography has been the standard of care in anesthesia for confirming endotracheal (ET) intubation and monitoring fundamental life processes during surgical procedures. In fact, the ability to measure carbon dioxide (CO2) had been around since the ’40s, and its usefulness was obvious in the operating room.

However, in the EMS world, the best we could offer were spot checks of CO2 detection by colorimetric devices (since called “quantitative capnometry” or “measuring the CO2 by the quality of the color change”). The quantitative devices of the past only worked for a short time before the filter would clog. We had a good eight to 10 years measuring EtCO2 this way. At that point, we thought we knew capnography, but it wasn’t capnography at all—it was capnometry. Little did we know, we had created a tube-placement capnometry paradigm.
Paradigms are defined as models, habits or patterns of behavior used to define our being. In the scientific world, a paradigm is a set of rules used to solve a problem. In the book Paradigms, futurist Joel A. Barker cites several examples of paradigm shifts in modern life.

One is the watch industry. In 1965, Switzerland controlled the watch-making industry with 65% of the market and 80% of the profit. In just 10 years, however, the Swiss market share fell to 10%. What happened? The rules changed. You’re probably wearing that change, a quartz-movement watch. When a paradigm shifts, past success guarantees nothing in the new paradigm.1

Dangers of Paradigms
Paradigm effect: That which makes you solve problems using only your paradigm. Paradigms act as filters that can accept or reject data depending on whether it fits your paradigm. In the book The Structure of Scientific Revolution, Thomas Kuhn points out that data conflicting with several scientists’ paradigm was literally invisible to them.2
All humans have paradigms. They’re what make change so hard for so many people. We all try to select data that best meets our rules and ignore the rest. What may be impossible under an old paradigm is easy under the new one.

Remember, paradigms set rules or patterns that limit your problem solving to the boundaries. They also show you how to be successful under those guidelines. Therefore, a paradigm is a problem-solving system. A paradigm shift is when you adopt a new set of rules.

Paradigms are common and useful. But if you aren’t careful, your paradigm can become the paradigm. This can lead to a nasty disorder called paradigm paralysis. Paradigm paralysis is a terminal disease of certainty. Have you heard this before? “That won’t work, we tried that before.” or, “This is the way we’ve always done it.” Some people even get angry when faced with facts that are contrary to their paradigm.

Barker also states that people who create or pioneer new paradigms are often outsiders.1 Does this sound like a new paramedic or EMT student? How about a newly graduated paramedic that you don’t want to hire because they have no experience? Encourage these students, because they’re what Barker calls “paradigm pioneers.”

So, how does all this apply to EMS education? It starts with instructors either creating or pioneering new paradigms. How many times have you heard this? “That may have been the way you do it in class, but it’s different here in the field,” or, “Our protocol doesn’t say to do it.” These statements are oozing with paradigm paralysis. Remember: Students make the best pioneers.

Students as Pioneers
Students may know a little about the current paradigms, but they don’t actively engage in them. So, we teach them the new paradigm, inspire them and have them emphatically practice the new paradigm—over and over. Then, in turn, it becomes their paradigm.

I have found that students are more than willing to pioneer new areas. It’s also helpful at times to allow students to find other ways to learn a topic or skill.

Take our first scenario for example. If you have a service where no one knows about capnography, teach all the new students to use capnography on everyone. Why not? We use pulse oximetry on everyone, and it’s probably less useful than capnography in many cases. Make capnography a vital sign—a ventilation vital sign.

The capnography paradigm also solves a lot of problems that the current respiratory assessment paradigm cannot. It can help you differentiate therapy for congestive heart failure (CHF) from chronic obstructive pulmonary disease (COPD). This is critical when you realize that almost 50% of CHF patients received unnecessary breathing treatments.(3)

Give paramedic students scenarios (not lectures) that can’t be solved using the old paradigm of respiratory assessment. Then, when you provide them the necessary physiology and pathophysiology, you’ll set the stage for a paradigm shift. Once they see what’s possible under the new paradigm, it becomes very clear. With some additional practice and positive reinforcement, the transition will be complete. They will now become pioneers.

Other Learners
Up to this point, we’ve only addressed the learner. But what about those currently engaged in the old paradigm? They’re much harder to reach under normal circumstances, but, it’s doable.
We all learned in Instructor 101 to know our audience: BLS, ALS, auditory learners, kinesthetic learners, visual learners, etc. The people I encounter fall into a few categories. First: the data purist who wants to see all the data before they change anything. Remember Kuhn’s findings that some scientists were incapable of seeing data contrary to the own paradigm. I’ve worked with people who were so paralyzed by their paradigm, even new data didn’t make them change. These people can be reached by making the cases real and logically applicable to their practice. More than a few were made believers by participating in the very study that changed the paradigm.

Another type of learner is the “it’s not going to change anything I do” type. Usually, these people don’t know the whole issue and don’t care to know. I refer to this as ignorance indifference. These learners tend to quote protocol more often and need more personal attention. They need to see results and have some direct relationship to what they’ve seen or done.

A third type of learner is the quiet follower. They don’t want to offend anyone and don’t rock the boat. These individuals do their jobs and are good co-workers. Although hard to read at times, you can count on them to follow policies, and they try to stay current. They represent the majority of your personnel. Quiet followers have paradigms as well and will follow until shown another way. To pioneer, however, they’ll need extra inspiration and buy-in.

The last subset I’ll mention is the top medic. These are clinical whiz kids, the top-notch paramedics. They’re always learning, are well read and attend conferences, where they’re exposed to speakers and outside experts. Top medics are on the cutting edge and push the boundaries of their protocols (another name for paradigms) and management. In fact, they’re the ones who probably annoyed their educators and management with constant banter until they adopted capnography.

These people are ready to pioneer. They’ll be your leaders in the future. Assign them a mentoring role for the paradigm shift, and they’ll become an enormous asset. I’d be willing to wager that they’ve already taught a good number of your staff what they know.

Paradigms are useful, and when they work, they work well to solve problems. But here’s my warning: Always be wary of the paradigms around you. Paradigm paralysis is a terminal disease. It’s highly contagious. Be careful that your paradigm doesn’t become the paradigm. Look to the fringes and outsiders for new ideas, and have the courage to pioneer new concepts.
In conclusion, when you finish reading this, ask yourself this paradigm-shift question: What do we think is impossible for us to do today, but if done would radically change the way we do things? Consider the approach you’re using in your classroom, organization or curriculum style. Once you have the answer, be ready to pioneer. JEMS

1. Barker, J. Paradigms: The Business of Discovering the Future. HarperBusiness. New York, N.Y. 1993.
2. Kuhn, T. The Structure of Scientific Revolutions. University of Chicago Press. Chicago, Ill. 1962.
3. Sheppard, Charles. Lecture. Management of CHF. St. John’s Hospital. Springfield, Mo. 2008.