The Dilemma

Many years ago, prehospital providers would have needed to contact a physician before starting an IV, administering O2, or performing other procedures (including defibrillation) that are considered standard practice today. To avoid delaying patient care and to take a load off the ED physicians, standing order protocols were developed. This was progress in the right direction. EMS providers could now treat patients quickly without all of the “red tape.”

Fast forward a few decades and there is a different problem. Protocols have been developed for everything under the sun. Now the question we have to ask ourselves: “Was this effective? Or, was there just the creation of a culture of EMS zombies who operate under the ‘if this, then that’ algorithmic mindset?” Please do not misinterpret what I just said. The idea of an algorithmic approach to treating patients is not necessarily a bad thing in certain situations. It’s just that critical thinking must also be promoted.

The application and enforcement of these protocols is the culprit. During a QA process, the QA officer asks the question to a provider: “Why did you give Labetalol to this patient?” Their response? “Because her blood pressure was greater than 185/110.”

The QA officer shakes his head in dismay and thinks to himself: “Where did we go wrong?” The provider documented the patient’s complaint was flank pain due to kidney stones and had a blood pressure of 190/110 with a pain scale of 9/10. Of course, the pain was the cause of the hypertension. But the provider didn’t choose to manage this patient’s pain. Instead they chose to treat the high blood pressure. Why? Because the protocol said that they should. It sounds ludicrous, but situations like this are seen all the time. Again, we ask why?

This happens because some EMS providers have stopped learning and stopped thinking due to becoming reliant on protocols. Their knowledge base is restricted to within the walls of their agency’s protocols. Throw in a supervisor, QA officer, or training officer who sends chastising messages to them if a protocol was not followed to the “T” and now a recipe for disaster is created. When this happens, providers fear negative action and will treat patients according to a protocol despite the factors of the particular case. They may suspect something does or does not need to be done, but they follow through with the incorrect decision anyway. They do this because of this method of inappropriate and overly rigid protocol enforcement.

How many agencies out there enforce the concept that their providers must follow an exact protocol? It is seen all the time. It is manifested with questions such as: “Why didn’t you give this medication? Why didn’t you perform this procedure? Why did you do this? Why didn’t you do that?” If these questions are to stimulate critical thinking, then the interaction is on the right track. If the intent of these questions is to ask why a protocol was not strictly followed, everyone involved may be missing the point.

Providers should be taught the benefit of certain assessments. EMS Educators need to dive deep with their providers and discuss anatomy, physiology and pathophysiology to help them better understand the reasons why they perform certain assessments and render certain treatments. The concept is not to just do something because it is required to be done according to a protocol. We must strive to understand when medications should or should not be given and what valuable information can be gained from certain assessments such as 12 lead ECG, etCO2 reading or a vital signs trend. For example, when paramedics are adequately educated and they understand all the capabilities of a 12-lead ECG, it should not be necessary to tell them to acquire one in certain situations. The paramedic will do it on their own because they understand the benefits of the information they are acquiring and how to apply it.

Our Approach to a Solution

In August 2018, East Baton Rouge Parish EMS rolled out new clinical guidelines. We changed the name of East Baton Rouge Parish “protocols” to “clinical guidelines” as a representation of the new culture that is being promoted. We taught our providers the concept of treatment goals for each type of patient and that the “clinical guidelines” are your tools to achieve those goals. The clinical guidelines are not necessarily an exact process that must be followed every single time. This runs contrary to the concept of a protocol. We understand that every patient is different and sometimes a set protocol may not be in the best interest of every patient encounter. Critical thinking is necessary to know when to do or not to do something.

In today’s age of communications technology, personal devices can store everyone you talk to as either a contact or in a call log that eliminates the need to memorize phone numbers. While this is a great feature, making that same phone call without the device or access to its contacts would be a monumental task. The same concept can be applied to today’s protocols by crippling our clinician’s ability to critically think. It is time to look at guidelines that require a little more thought than a “see this, do that” mentality. We just cannot have an “easy button” for everything. This is especially true in the complex-dynamic prehospital clinical careenvironment.

Our new clinical guidelines have completely redesigned our approach to taking care of our patients. Instead of having a restrictive protocol that limits our critical thinking abilities, we have clinical guidelines that allow the provider to utilize critical thinking and includes multiple treatment options to manage patients. The guidelines are provided in algorithmic form, but our providers understand that they have the autonomy (within the confinements of their scope of practice and medical direction) to apply the standing orders in a manner that is appropriate for their particular patient. We have seen that this method has promoted a culture of providers who now want to learn about prehospital medicine and not to limit themselves to merely remembering a protocol. Incorporating this concept of getting away from the strict protocol mindset and promoting critical thinking with the implementation of evidence-based practices ensures we are on the right path to changing the culture of how our patients are treated.

In addition to transitioning from a strict order of providing care to a critical thinking approach, we also had to ensure our staff was given the tools necessary to provide the best care possible. This change for us was not just an update but a complete overhaul of our entire clinical care approach. Two-to-three years were spent reviewing literature and researching evidence-based practices to design our new clinical guidelines. In addition to reviewing our own data, published data, position statements, PHTLS guidelines, AHA guidelines, and National Model Guidelines, we consulted with experts in our service area that included emergency medicine physicians (adult and pediatric), trauma surgeons, neurologists, cardiologists, pharmacists, and obstetrician-gynecologists to aid in the process of guideline development.

This was instrumental in order to ensure we were working to improve our whole system of care and not just the pre-hospital aspect of care. The use of evidence-based medicine has allowed our agency to feel confident in adopting many new procedures and medications. Some of the medications we added include Ketorolac, Ketamine, Norepinephrine, Dobutamine, IV Nitroglycerin, Neuromuscular Blocking agents, TXA, Nicardipine, Heparin, and Pepcid. New procedures include medication assisted intubation, apneic oxygenation, a modified Valsalva maneuver, heads up CPR, double sequential defibrillation, surgical cricothyrotomy, simple thoracostomy and pericardiocentesis.

Unit Commander Nick McDonner demonstrates the simple thoracostomy procedure.
Photo credit WAFB Baton Rouge
A close-up view of the thoracostomy procedure.
Photo credit WAFB Baton Rouge

New equipment included the Handtevy System, additional pediatric specific equipment, pelvic binders, cooling collars and fluid warmers. Although they are culturally accepted, certain medications, procedures, and equipment were eliminated due to evidence suggesting they may be harmful.

In November 2018, our department was invited to present cases treated under the new guidelines for review with a panel of experts at the annual McSwain EMS Trauma Symposium in New Orleans. During this conference we were able to share some of our data on improved outcomes with this panel. As we continue compiling data, we hope to analyze what is and is not working. We anticipate authoring future publications to share our findings with the EMS industry.

Next Step

The next step to ensure that we allowed for growth was the adoption of just culture concepts. If a treatment or a procedure does not go as expected or a Clinical Guideline was applied inappropriately, our employees know they can reach out to us without fear of disciplinary action. This adjustment to our culture has allowed the staff to feel comfortable asking questions and reporting errors. This has allowed us to grow as a department.

How to Continue Progress

EMS leaders, educators and physicians need to continue moving prehospital medicine forward to ensure that we are treating patients to the best of our abilities. Complacency will lead to poor patient care. As a profession, we need to keep up with the latest evidence-based practices and train our providers regularly. Finally, we need to ensure that we are creating an environment for our clinicians to think critically. Protocols and guidelines should not be written in an effort to force providers to follow specific steps in every situation.

They also should not be written to the level of your bottom performers, thus restricting your top performers. Many agencies do this because of liability. Our goal should be to set the bar high and bring everyone up to the highest level possible. Give your employees the tools they need to provide high-quality care to your community. The right set of clinical guidelines and the way they are utilized will be the key factor in achieving this goal.