Who is correct when EMS providers defend strict protocol adherence?

Well-written protocols leave room for both the novice EMS provider and the expert

The “Remember Two Things” video on NPA use created a bit of a stir, generating hundreds of comments. In the video I asked viewers to use the device more frequently and to consider inserting multiple NPAs.

When I create articles and videos it’s hard for me to predict what will resonate with the audience. Which articles and videos will create a huge reaction and which will get swept to the lonely corners of EMS1’s database? It’s almost impossible to know until the editor hits the publish button.

Each time the NPA video was shared, a reader would comment that the NPA should never be used in the presence of a head injury. And then the comment stream would explode. Apparently there’s quite a bit of debate over the use of this relatively benign device when the patient may have a head injury or skull fracture.

Some comments implored readers to not listen to anything I was saying, warning readers that my advice was dangerous. One reported that he had "personally seen" many examples of NPAs that had been inserted into the cranial vault. Research links were posted. Names were called. Even a faculty member for Advanced Trauma Life Support threw his proverbial hat in the ring.

Skull fractures never mentioned

I never referenced the use of NPA’s in the presence of a possible skull fracture. I only encouraged people to use them more often. To be fair, I did say that I could think of no good reason to not use one on an apneic patient.

Before you read any further I’d like you to take a moment to answer the question for yourself.

Would you use a nasopharyngeal airway on a patient with a head injury?

Why or why not?

Really think about it. Your answer is important.

Comments pit novice vs. expert providers

The video comment stream debate over the proper use of airway adjuncts is a great example of the battle between the novice practitioner and their strict adherence to the rules and procedures that they were taught, and the expert practitioner and their ability to synthesize more complex information. When the two sides face off, the results can be spectacular.

Expert-level providers may flippantly dismiss the novices concern with a wave of the hand and a reference to EMS mythology. Terms like “low information voter” and “protocol monkey” will likely enter the discussion. Links to research may follow or pictures of Michael Jackson with popcorn.

Novice level providers paint the more experienced practitioners as reckless and dangerous rule breakers who don’t respect their protocols. At the heart of all of this discussion is the underlying belief that one side is really right. One answer is correct and someone else is simply doing it wrong. And that is part of the problem.

Multiple correct answers

So who is really correct?

When you answered the question for yourself about NPA use, I’m guessing that your answer sounded similar to one of these two examples.

Example A: If the patient had any type of significant head injury I would not use an NPA. I was taught by my instructor that this device could enter the cranial vault and harm the patient. Further, my protocols list possible skull fracture as a contra-indication to the use of an NPA. I would be in violation of my protocols and could face some disciplinary action for doing this. It’s safer for me and my patient to not use the NPA in the presence of a head injury. It just isn’t worth the risk.

Example B: In all but the rarest of circumstances, I would use an NPA on a head injury with a potential skull fracture. Proper airway management is critical in this patient and intubation might be delayed or impossible. The benefits will almost certainly outweigh the risks. The risks are minimal and easy to assess. Signs of high level Le Fort fractures with facial instability would make me reconsider sticking anything in the patient’s nose for obvious reasons and alternatives would be considered. If I was ever questioned about my decision I could easily explain why my patient care was clinically appropriate even if it did deviate from the letter of the protocol.

The reason all of this gets so heated is because both example A and example B are correct.

For the novice provider, example A is a perfectly reasonable rationale for not using the NPA. (Notice I say novice, not inexperienced. There are many very experienced EMS providers who are still novices.) When we are at a novice level of understanding we depend on the rules and protocols to guide our decisions. Until we are able to synthesize more information, understanding the rules and following them is necessary and desirable.

For expert providers, example B is also a perfectly appropriate answer. Expert providers not only understand the rules but they understand why the rules were made. They recognize when the rules apply and when they do not. They can synthesize multiple patient care priorities and make decisions based on the patient’s particular presentation and current needs. They feel comfortable using the most current clinical information to guide their care and they aren’t afraid to explain their judgement and reasoning.

This leads me to several observations:

1. There’s nothing wrong with being a novice-level provider. We all start as novices. Until you have moved to a more advanced level of skill, experience and understanding, there is no shame in being completely dependent on your protocols to guide your care.

At this level of care it’s important to have a good understanding of exactly what your protocols say and to follow their instructions. Only when you feel like you have a good understanding of why your protocols are written as they are should you consider deviating significantly from their boundaries.

2. The very best protocols leave room for both the novice provider and the expert. When I run calls, I’m guided by the Denver Metro protocols. They are well written and maintained by a group of top notch emergency medical physicians to give guidance to the novice and latitude to the advanced provider. In the Denver protocols, the following statement appears on page six.

“The following protocols were written with innate flexibility. The desire is not to dictate or confine medical practice, but rather to provide an example of what is to be expected of prehospital performance. Please remember that protocols define process; people provide care.” (Italics included in the original document.)

When the Metro Physician’s Group decided to include this statement in our protocols, they were attempting to make room for the novice and the expert. They wanted to create a thorough resource for novice providers and also give latitude to expert practitioners. In prehospital care, there needs to be room for both.

3. Seek first to understand. Sometimes, the best response we can have to someone who’s opinion differs from our is to say to ourselves, “How interesting.” The phrase, “How interesting” can put us in an exploratory mindset. Instead of rejecting an idea outright, we might be more inclined to explore why the individual believes the way they do.

The expert provider may have an opportunity to recall what it was like to think their way through a patient assessment, back when their thinking was a bit more linear and their care was driven less by understanding than by memorization of rules and axioms.

For the novice provider, they may find themselves developing a more advanced understanding of why their protocols are written the way they are. This is a critical first step in becoming an expert.

Only a few medical mysteries

I’m often amazed by how quickly many knowledgeable contributions to articles and videos are drowned and forgotten among the melee of me-versus-the-world medical debate. There are some amazing insights available in the comment streams, but you need to be curious and willing to find them.

I find that there are few real medical mysteries. Most of these debates can be sorted out with the basic recognition that we are all at different places on the knowledge and skill bell curve. We could all benefit by bringing a little more respect, patience and understanding to the debate.

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