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How bureaucrats are hampering EMS

We should all be taking our state EMS officials to task over outdated and overly restrictive protocols

"The nine most terrifying words in the English language are, 'I'm from the government, and I'm here to help.'"  ~ Ronald Reagan

In a previous column, I lamented the sorry state of EMS continuing education, and laid part of the blame on hidebound regulatory agencies restricting types of continuing education or mandating outdated content.

They do no better when it comes to regulating practice or formulating protocols.

Protocols are intended to be a floor for good medical care, not a ceiling.
Protocols are intended to be a floor for good medical care, not a ceiling.

I'll confess that much of my disdain of government regulation stems from my libertarian sensibilities, but the fact remains that government moves quickly only when it comes to collecting your taxes or adding new ones. The rest of the time, it moves with the blistering speed of a geriatric sloth with a serious Xanax habit.

And when it comes to a field that is in such a constant state of flux as health care, that just won't do. Not only can't the regulations keep up, they're written by committees, whose members, as a general rule, never practiced in EMS or traded direct patient care for a laptop computer and a smartphone many long years ago. They are bureaucrats first, and health care providers second.

Supraglottic airways 

What brought this rant to mind was a recent discussion thread about supraglottic airways in an online EMS forum. Aside from the usual fare - my service's airway can beat up your service's airway - one distinguished and well-known EMS educator stated that, in his state, dual-lumen airways were the only ones approved by his state's EMS scope of practice. In his words, "single lumen airways are out of scope for all levels of EMS providers."

Herein lies the folly of trying to mandate competency via bureaucratic fiat. Not only does it invite the inevitable search for loopholes - does the gastric suctioning lumen in a King LTS-D make it legal to use in that state? How about the gastric suctioning lumen in a LMA Supreme? Does it count as a second lumen if it only provides for removal of stuff, and not delivery? - but it sets up artificial practice barriers that have no bearing on patient care.

What does it matter if a supraglottic airway has one lumen, two lumens, or looks like the muzzle of a friggin' Gatling gun? It's a supraglottic airway; it delivers ventilations at or above the glottic opening, distinguished from the only subglottic airways out there - endotracheal tubes and the various tracheostomy/cricothryotomy tubes.

Those oropharyngeal and nasopharyngeal airways that are permissible for use by EMTs in that state? Supraglottic airways. An OPA is an NPA is an LMA is a Combitube is a King is a Cobra is a SALT is an EOA is an EGTA.

But presumably, if you add a cuff to that OPA to make it seal better, it magically becomes too complex for EMTs to use, dangerous to patients, and illegal. Maybe even immoral and fattening.

And of course, it is in the nature of regulations to become more arcane and restrictive with each revision, not less. This educator, after consulting his state's practice act, discovered that the phrase "dual lumen airway" had been replaced with "esophageal/tracheal multi-lumen airway."

Well now, that certainly clears things up, doesn't it? Not only did they make the language more precise, but in such a way that it seems to exclude their already-approved airways even more. Adding to the insanity is that Laryngeal Mask Airways have long been approved for use in that state, despite the fact that the air is delivered through only one lumen.

It is bureaucratic minutiae like this that bars progress in our profession every bit as much as provider ignorance and apathy.

No panacea

While I'll concede that states with regional and local protocols often have an incomprehensible mishmash of regulations that make a medic into a BLS provider if he steps across a geographical boundary, or deny him the right to practice altogether because he hasn't been blessed by that county or hospital's medical director, a statewide protocol is no panacea, either. There are still state protocols that mandate that ambulances carry an EOA, and that crews be trained in its use.

I may be mistaken, but the last EOA I saw was excavated from beneath four feet of permafrost somewhere near the Arctic Circle, in the midst of a vast bed of fossilized Thomas half-ring splints, Chokesavers, Kansas boards and other extinct EMS doodads.

Protocols are intended to be a floor for good medical care. They're written to ensure that the least competent provider in a system delivers the same basic care as the most competent provider …

… when they're well-written.

But all too often, they're so poorly written that they represent a glass ceiling of care, stifling innovation and lagging behind current research and advances in technology. They force the most competent medic in a system to treat patients on a par with the least competent medic.

My point to my screed (and I'm sure you're wondering by now if I had one) is that the ceiling well and truly is glass. All it takes is a handful of people stubborn and vocal enough to keep butting their heads against it until it shatters.

All too often, outdated and silly regulations persist simply because no one bothered to challenge them. The cynic in me often wonders if that tendency isn't part of the bureaucratic calculus in drafting the regulations in the first place; they simply bank on the majority of us doing what we're told.

Take your state EMS officials to task over outdated and overly restrictive protocols. Keep in mind that, at least at the state and federal level, regulations are promulgated in steps. Advisory committees are formed, input is sought from the various stakeholders, drafts are written, and there is typically a comment period during which those affected may offer their input.

This is where we come in. Have your arguments well-formed, and be able to cite current research where necessary. Be objective, be factual, be passionate. But most of all, be vocal.

Remember, a great many of the "stakeholders" in this process last worked on ambulances when "Rescue 911" was on the air, or never worked in EMS at all. When our profession is regulated by people who have never practiced it, it is incumbent upon us to educate them. To be silent during the process is almost as great a sin as to be ignorant of it.

Or even better than educating the regulators, replace them with people with real-world EMS experience that includes something more recent than a LifePak 5 and a high-top Cadillac ambulance.

We have to learn how to play EMS politics, or we will forever be at the mercy of EMS politicians. 

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