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The Ambulance Driver's Perspective
by Kelly Grayson

The Two Most Important Words in an EMS Protocol

By Kelly Grayson

Allow me to introduce you to the two most important words in an EMS protocol:

May and consider — please take a bow.

No really, stand up and take a bow. You’re both far too modest. You two words are what make clinical decision-making possible. Without you, we’d be nothing more than well-trained monkeys, performing tasks we don’t understand for reasons we can’t fathom, all for the promise of a nice bunch of bananas on payday. Without you, we’d all be doing procedures of questionable benefit to patients who may or may not need them, all because it’s in the protocol.

Oh, wait a minute. We are doing unnecessary things just because they’re in the protocol.

Years ago, I was asked to draft a new set of medical treatment protocols for the small, private system where I worked. I spent a great deal of time researching model protocols from other EMS systems, tweaking and adapting those I liked, and writing a few of my own from scratch when I wasn’t happy with the way other agencies approached treatment. It was exhaustively researched, incredibly detailed, and incorporated all of the cutting-edge EMS treatment of the day. It was liberally sprinkled with another set of words — shall and must.

It was a disaster.

Oh, my medical director loved it. So did my bosses — the people who owned the service. Finally, someone had written a protocol that required their medics to render top-notch emergency medical care. We served a rural area of 963 square miles. Communications failures were quite common, so the protocols were written as standing orders, requiring on-line medical control only in the rarest of circumstances. We were fond of proudly saying, “Our medics can do anything short of opening the cranial cavity without first consulting a physician.”

For a time, we did render top-notch medical care using that set of protocols. In short order, the local hospitals stopped questioning why we had rendered certain treatments, and came to expect it instead. It got to the point where our medics were measured by how many steps they implemented in the treatment protocol.

Then, some new medics came around, guys who didn’t approach treatment like we did. Some of them refused to follow the protocols. Others followed the protocols to the letter – except that they were the wrong protocols. The medical director and the service owners made me QA patient care reports, and deliver these little “nastygrams,” which we called Protocol Exception Reports, to any medic who dared deviate from our doctrine.

That’s what it had become by then — a doctrine. It was highly regarded enough that a number of services in surrounding parishes adopted our protocols lock, stock and barrel. In the “Church of Standing Orders,” I was high priest. Education directors from other services called me for advice on how best to deal with their heretics.

It got to the point, though, where I became less of a champion of paramedic autonomy and more of my system’s version of Tomás de Torquemada. More than one medic has referred to our QA process as “The Inquisition.”

I came to realize a few things — first among them that individual medics approach treatment differently, and that different does not necessarily mean worse or better. It just means different. I learned that you can’t mandate competence in medical treatment protocols. That’s what pre-hire screening, continuing education and CQI are for. I also learned the true purpose of medical treatment protocols:

Treatment protocols are designed to assure that the least competent medic in your system renders the same minimum level of care as your most competent medic.


If the protocols are well written, they provide a virtual floor for medical care, ensuring that all the system medics will provide a consistent level of stabilization and treatment.

If they are poorly written, they establish a ceiling beyond which good medics cannot rise. Effectively, they force the most competent medic to lower his level of care to that of his least competent colleague.

Enter the words may and consider.

I rewrote our protocols from scratch. Everywhere I had written shall or must, I seriously considered whether may and consider would serve our purposes better. The new document wound up being radically different from the one that had preceded it, and only half as long. Best of all, it still allowed our medics the freedom to practice their arts without having to interrupt assessment and treatment to ask “Mother may I?” of a busy ER doctor.

It got to the point, though, where I became less of a champion of paramedic autonomy and more of my system’s version of Tomás de Torquemada.
Of the times we did call for medical control, it was less of a request for orders than it was a physician consultation on a particularly thorny patient. It was collaborative rather than authoritarian, and both the patients and the medics benefitted from the new approach.

Of course, in opening up the protocols to allow for judgment calls and encourage critical thinking, I had to improve our CQI process and continuing education accordingly. You can’t expect medics to use their judgment and education if you don’t provide them with the tools.

In my experience, poorly written protocols far outnumber the well-written ones. There are protocols that try to mandate a level of care, resulting in medics that wind up strapping an 80-pound, kyphotic grandmother to a hard spine board simply because she rolled out of bed at the nursing home – with absolutely no neck pain or neuro deficits. Or refuse to give nitro to an MI patient because they were unable to establish an IV first, even though the patient was instructed by his cardiologist to take up to three nitro without the benefit of an IV line. The other end of the protocol spectrum requires medics to request OLMC for the most trivial of conditions, or even worse, the sickest of patients who can ill-afford the delay in treatment.

Poorly written protocols are everywhere, even at the national level. The proposed National EMS Scope of Practice Model is just such a document. Rather than establish system benchmarks that will serve to standardize EMS certification and levels of care nationwide – a floor - it instead does just the opposite, effectively establishing a ceiling that thwarts progress. Innovative and progressive EMS systems will be forced to downgrade the level of care they provide, and sub-par systems will receive a tacit seal of approval disguised as an official government document.

They’d do better by doing what I did – scrapping the entire thing and inserting may and consider wherever you can.

About the author


Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (www.facebook.com/theambulancedriverfiles), or email him at kelly.grayson@ems1.com.

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