Patient Care, Training, Trauma

EMS Instructor Explains Changes to TBI Management

Issue 8 and Volume 37.

Editor’s note: A presentation related to this article will be featured at the 2013 EMS Today Conference and Expo. Click here for more information and to register!

It’s easy to introduce a new drug, device or procedure. EMS responders welcome innovations. It’s also easy to remove drugs, devices or procedures that haven’t shown to be effective. In most cases, you simply taking them off the rigs. 

Bringing about more subtle changes in practice, however, can result in resistance, resentment and outright rejection. This article is about how to effectively anticipate and overcome resistance to bringing about changes in practice. So let’s discuss how to effectively anticipate and overcome this resistance.
EMS has many “sacred cows”—practices that are almost universally considered to be the “gold standards” for care and have been deeply ingrained as the standard of practice for many years. It’s inconceivable to many EMS responders that there could be a better way of delivering patient care. When reflecting on past practices, however, many of the former standard practices that were once thought to be critically important to good patient care were subsequently shown to be useless, or worse, more harmful than beneficial. 

This article will focus on how an instructor can effectively teach a change in practice that, in effect, reverses one of those “gold standards.” Instructors may face a great deal of skepticism, resistance and, often, outright hostility. Still, it’s “the job” of the EMS instructor to effectively deliver the new practice recommendations.  

The Theory

Lasting learning can’t take place when barriers are raised.1–3 Instructors must be 100% invested in the instruction and prepared to convey the information with authenticity and commitment. Half-hearted and begrudging deliveries, with facial gestures and wisecrack comments, will only result in mockery and wasted time. 

Instructors should also understand that extensive EMS experience, education and mastery as a provider, no matter how well founded in theory and practice, can be barriers to learning.4 For example, experienced practitioners or educators may have accurate but insufficient prior knowledge. This can occur if they’re technically excellent at performing the skills but they lack theoretical understanding of the underlying pathophysiology or mechanics of how the procedure or medication works was never learned at depth or was forgotten over several years. The experienced EMS responders may also have inappropriate or erroneous knowledge based on prior theories that have evolved to newer thinking. 

The Practice

In the early 2000s, the Traumatic Brain Foundation (TBF) started a reversal in the way patients with traumatic brain injury (TBI) were ventilated. The long-standing, “logical” and universally established way of ventilating patients with suspected herniation of the brain was to hyperventilate them.5
The current recommendation is to limit the depth and rate of ventilations in the adult to no more than 20 breaths per minute to avoid hyperventilation. The TBF’s approach to reversing the practice serves as an effective model for bringing about a revolutionary educational change. 

TBF began by developing a self-contained Train-the-Trainer course that would be delivered in the traditional classroom setting.6 The TBF instructors received a comprehensive training manual, instruction provided by a nationally recognized EMS educator and peer, a complete package of the scientific evidence and rationale for the change in ventilation, and lesson plans and support materials (e.g., instructor notes for slides and workshops, new algorithms, guidelines for instruction to each EMS provider level, sample scenarios, quizzes and cases, ventilation rate exercises, procedure algorithms, and pre- and post-tests). 

Such an impressive, well-designed and expertly presented course provided instructors with convincing evidence of the benefit of the new ventilation recommendations and extensive resources to present the instruction to their regional EMS communities. The change in thinking about care of TBI patients moved quickly in the industry. 

The TBF initiative, however, was supported by a respected national organization that had substantial federal funding. Individual instructors who want to accomplish this type of change on their own are unlikely to have that level of funding, nor the capability of producing such comprehensive courses, evidence, experts and support materials. Thus, the instructional goal at the local level is to deliver training on the new protocol or procedure within the constraints of a refresher course, a routine continuing education session or through other some other medium.

Individual Approach
To teach changes in procedures that have been thought to be highly effective for years, the instructor needs to first become thoroughly knowledgeable about the changes and develop a deep rationale for them.. This step is essential because the skeptical learner will sense any doubt the instructor has, and the instructional process will be compromised. 

The instructor doesn’t need to work in isolation. It’s best to begin by assessing the receptivity for the new recommendation through casual conversations. The discussion should focus on the risks and benefits of the new recommendation and the underlying rationale. 

A major “prior knowledge” barrier to overcome is the powerful anecdote. That’s prime face evidence, or evidence which appears so logical and obvious that it is undeniable. In fact, prime face evidence underlies most of the practices of prehospital care, as well as most medical practices today. There will likely be a number of instances for which the well-established, “effective” procedure has “saved patients.” Those anecdotes are difficult to counter, especially when the recommendation is based on weak clinical trials with complex statistical analyses that are difficult to comprehend. Still, the anecdote can’t hold up as the “best evidence” when compared with randomized and blinded clinical trials that have been independently validated by other respected researchers. 

The point is that the statistical clinical research evidence must be presented in a clear and understandable way. One way to overcome this barrier is to approach a statistician at a local university, or even correspond by e-mail or telephone with the authors and researchers who published the articles. They can help to explain the results in clear language that will make sense to everyone. Instructors should acknowledge the beliefs in the effectiveness of the traditional practices and address them head on with the new evidence (research studies), analytic arguments (critical thinking) and an appeal to keep an open mind.1  

After the instructor has taken the initial steps to gain thorough knowledge about the new recommendations, they can begin to plan ways to deliver the instruction effectively. EMS instructors can use several core principles to deliver the recommended practice changes when anticipating resistance. Consider using the following approaches:

  • >> Preparation (nothing is more important than solid preparation);
  • >> Expert presenters (e.g., having a nationally recognized educator present in person, and when not available, possibly presenting remotely by using a DVD, YouTube or Skype);
  • >> Evidence (e.g., handouts with source citations, abstracts, original articles, and expert interpretations and opinions);
  • >> Presentation materials (e.g., videos, PowerPoint presentations);
  • >> Case presentations (ideally, real cases for which the proposed treatment would have made a difference in the outcome and the established method was either ineffective or harmful);
  • >> Workshops (opportunities for applied practice sessions, which are ideal for reinforcing the theory and cognitive learning); and
  • >> Quizzes (having the learners acknowledge the new practice by marking the “correct answers” on the quizzes will not only validate the instruction, but will also imprint the commitment to the learner as the quiz is taken).

Instructors can use several other subtle ways for instructors to make a lasting impact.
Silence. Learning is most effective when the environment, the body and the mind are silent. In this context, the “silence” is really a state of mind. Outside distractions and preconceived ideas are set aside, and the collective minds are prepared to receive the new information. 

To clear the mental clutter, the instructor can begin by “resetting” the minds of everyone in the room with an icebreaker or an amusing anecdote or joke. Lighthearted videos are especially effective introductory approaches for resetting the minds in the room to be ready to learn. 

Von Restorff effect. Another way to lower tension and open minds for learning is to make it fun, new and dynamic.7 Instructors should be imaginative and search for ways to be innovative, engaging and amusing when presenting the new recommendations. The overall effect will be greater, and the students will remember the material longer. 

Poetzel effect. The instructor can use subliminal influences to have instruction taking place without direct mental engagement.8 In the Poetzel effect, the instructor might “seed” the environment with posters or displays that depict the procedure, drug or device.
A video about the recommendation can be playing as the students enter the classroom. The instructor can start with stimulating casual discussions about the changes.

It’s an honor and a privilege to teach EMS. EMS is powerful because it makes a difference between life and death, recovery and health or permanent disability after illnesses and accidents. It’s disconcerting when practices that were held to be highly effective are proven to be harmful or ineffective. Worse, it seems that if one practices EMS long enough, the “old ways” return in cycles. Thus, the challenge of presenting new and radically different treatment recommendations is one that must be met with dedication, commitment, deep knowledge and understanding, and savvy educational mastery. JEMS

1. Bridges W: Managing Transitions: Making the Most of Change. Harper-Collins: New York, 1991.
2. Newcomb T, Hartley E: Readings in Social Psychology. Henry Holt and Company: Troy, Mo., 1947.
3. Schein E: Process Consultation, Vol. 2: Lessons for Managers and Consultants. Addison-Wesley: Reading, Mass., 1987.
4. Ambrose S , Bridges M, DiPietro M, et al: How Learning Works: Seven Research-Based Principles for Smart Teaching. Jossey-Bass: San Francisco, 2010.
5. New York State Department of Health. (2008) Statewide Basic Life Support Adult & Pediatric Treatment Protocols EMT-B and AEMT. In Scribd. Retrieved July 5, 2012, from
6. TBF (2005). Prehospital Management of Traumatic Brain Injury Instructor Course.
7. Smith A: Keys to Student Mastery of EMT Training. National Association of EMS Educators: Pittsburgh, 2010.