Administration and Leadership, Patient Care

Oklahoma Leads the Way in Evidence-Based EMS

Issue 2 and Volume 38.

What an amazing time to be in the practice of EMS medicine. If you’re like many in EEMS, you may not fully appreciate that you do, in fact, practice medicine. In all fairness to many state regulations that restrict the practice of “medicine” to licensed
physicians, consider this:
>> As an EMT or paramedic, do you ask your patients (or when they are incapacitated, ask their family and/or survey the scene for clues) about symptoms of illness or injury and how those symptoms developed? In medical school, they call that “taking a history.”
>> As an EMT or paramedic, do you perform an organized examination to elicit confirmation signs of illness or injury? In medical school, they call that “performing an examination.”
>> Based on the history and exam (or some variant thereof in the unique practice of street medicine), as an EMT or paramedic, do you make some conclusions about what you think is happening to the patient? In medical school, they call that “making a diagnosis.”
>> And finally, as an EMT or paramedic, do you perform clinical interventions to stabilize the illness or injury? In medical school, they call that “treating the patient.”

It seems to us that if you take the patient’s history, conduct the exam, make the diagnosis and treat the patient … well, then, you’re practicing medicine.

Don’t ever sell yourself (or your colleagues) short on the important responsibility of practicing medicine. Part of upholding that responsibility is to practice EMS medicine that is supported by scientifically proven concepts—this is often referred to as “evidence-based medicine.” In fact, the evidence supporting EMS medicine is better than it’s ever been.

Gaining Recognition
In September 2010, the American Board of Medical Specialties (ABMS) recognized that evidence supported EMS medicine as a unique medical practice, and declared EMS a medical specialty on par with specialties recognized for many years. You may have read about this decision when it was first made. The reality is that the ABMS decision further legitimizes what we’ve all worked collaboratively to achieve: recognized medical practice in the field. We’re unique in taking the “medicine” to the patient—home, roadway, extreme terrain, in any weather, at any hour. The ABMS decision honors us all. This is indeed a whole new generation in the maturation of EMS medicine.

One cornerstone in modern EMS medicine is the prominence for evidence-based medicine in treatment protocol development. We’ve come a long way (or should have) from incorporating a treatment or device into our standards of care just because it’s new or the neighboring service is doing the same. We must apply the rigorous criteria demanded throughout medicine—standards of care should change based only on trusted, verifiable grounds.

The Oklahoma Example
The Oklahoma State Department of Health (OSDH) has supported EMS for years by supplying voluntary EMS protocols and through review of agency-specific protocols. The voluntary protocols were getting dated, so in September 2010, OSDH leaders approached the Department of Emergency Medicine at the University of Oklahoma School of Community Medicine with an interesting challenge: Develop a comprehensive set of EMS treatment protocols, wherein every protocol is supported by evidence-based medicine literature citations. No “best guesses,” no “conventional wisdom”—just “here’s what the science says to do.”

We gladly accepted the challenge, and contractual work began approximately one year later—once a contract could be specified and work its way through multiple state governmental agency approval processes.

We began this protocol set development by first creating a comprehensive index of needed protocols. We benchmarked multiple protocol sets from around the U.S. at multiple levels—statewide and regional, as well as large and medium municipalities. Using these resources, we developed the index of protocols that would drive all other phases of protocol development.

Each individual protocol was then subjected to a comprehensive medical literature review for peer-reviewed original research and/or review articles on subject matter directly germane to the clinical situation being addressed by that individual protocol. We primarily used the medical literature research tool at, managed by the U.S. National Library of Medicine, National Institutes of Health.

Each clinical situation was used as a search term and cross indexed with multiple terms relating to the medical practice of EMS, such as “emergency medical services,” “emergency medicine,” “prehospital,” “paramedic” and “ambulance.” We favored the latest literature possible, with many individual protocols having literature references within weeks of the protocol’s drafting. Particularly landmark research papers or position papers were factored into the evidence used to draft a protocol.

Establishing the Protocols
Figure 1 shows a sample protocol from Oklahoma 2013 EMS Protocols. Each treatment and procedural protocol delineates scope of practice by the EMS professional levels currently recognized by the OSDH—emergency medical responder (EMR), emergency medical technician (EMT), EMT-intermediate 85 (EMT-I85), advanced EMT (AEMT) and paramedic. The scopes of practice for each certification level were reviewed with OSDH EMS leaders. The Medical Direction Subcommittee of the Oklahoma Emergency Response Systems Development Advisory Council (OERSDAC) also reviewed and endorsed these scopes of practice for approval by the OSDH Commissioner of Health.

The procedural protocols were designed to be visual, often showing a step-by-step process to successful procedural performance. Our thinking was that although many EMTs and paramedics across our state have routine opportunities to perform many of the skills, others do not. Each protocol is designed for self-review as well as use in agency-specific continuing education courses.

During their review process, the OERSDAC Medical Direction Subcommittee made several additions to the EMT scope of practice, including use of supraglottic airways, non-invasive positive pressure ventilation, waveform capnography, acquisition and transmission of 12-lead ECGs, and epinephrine autoinjectors for anaphylaxis and severe asthma exacerbations. This committee of EMS medical directors strongly supported the axiom that no one should die of anaphylaxis or severe
asthma for lack of an EMT being able to administer epinephrine.

Although the end products are lengthy, they are reasonably complete in anticipating nearly all day-to-day incidents an EMS professional might encounter in Oklahoma. Bookmarking each protocol makes it relatively easy to navigate as well as organizing the protocols by function (e.g., airway) or anatomical and organ system location (e.g., cardiac—non-arrest).
Many EMS systems have already indicated they will carry these protocols exclusively in electronic format on responding apparatus, storing them on an mobile data terminal or tablet computers. OSDH allows electronic formats for the “official” protocol copy required to be present on emergency response apparatus.

Put It to Use
This protocol development was exhaustive, representing more than 1,200 hours to complete. But it was illuminating and encouraging. A relative wealth of evidence-based medical literature germane to EMS does exist—more than we in EMS give ourselves credit for using. Although this body of research will continue to grow, adding important discoveries in advancing the practice of EMS medicine, we can celebrate today how far we’ve come in the past 25-plus years. We invite you to review the Oklahoma protocols and use them to review and update your local standards of care. Take as much or as little as you wish. We encourage you to work with your local medical oversight in using many of the cited research works to further support your own practice of EMS medicine.