Why I care less and less about following EMS protocols

As we mature as providers, where once we saw rules and absolutes, we begin to see guidelines and nuance

I have found that the longer I practice in EMS, the less I care about protocols. I haven’t followed mine in years.

Got your attention, didn’t I?

Right about now, some of you are nodding in agreement, while the rest of you are aflame with righteous indignation, wondering, “Who does this EMS cowboy think he is, and is his medical director aware of his attitude?”

When I say I don’t follow my protocols, I mean that my thought processes and patient care decisions no longer involve, “What’s the next step in the algorithm?” That doesn’t mean that my actions are in contravention to my medical director’s wishes. Far from it. It merely means that I have matured beyond the type of provider for whom most protocols were intended.

Believe me, I was once a big believer in protocol adherence. I hated the first set of protocols I worked under, mostly the barriers between those procedures I could do on my own, and those for whom I had to obtain orders from medical control. And when I was given the opportunity to rewrite our system protocols, I jumped at the chance, and set about erasing as many of those barriers as I could.

I found out rather quickly that some providers needed those barriers. Some of them needed the reassurance of having rules to follow, and little responsibility in the way of decision-making. Other providers needed the ceiling until their skills and knowledge caught up with their confidence and ego.

I was that second type of provider.

I didn’t do any overt harm in those days, but I did perform a slew of unnecessary invasive procedures under my mantra of, “Over treat many, under treat none.” It took me a solid five years before I realized that the greatest ALS skill I could muster as a provider was restraint. The more I knew, the less I did.

What brought this to mind were Steve Whitehead’s recent columns on protocol adherence. In one of them, Steve talks about the Dreyfus Model of Skill Acquisition. I first encountered a condensed version of the Dreyfus model years ago in one of Bryan Bledsoe’s lectures, in which he categorized EMS providers in three levels; novice, competent, and expert. If one were to draw parallels with EMS provider certifications, one might see EMTs as novices, experienced EMTs or AEMTs as competent practitioners, and paramedics as expert practitioners.

That was the goal of paramedic education as far back as 1999, when the one of the stated goals at a 1999 DOT Paramedic Curriculum rollout was to “turn out a graduate paramedic with the skills and knowledge of a five-year paramedic trained under the previous curriculum.”

That may have been the goal, yet rarely was it the reality. In practice, what most paramedic programs do, even now, is turn out another novice practitioner with an expanded skill set and drug box. They are no more capable of clinical decision making than they were as new EMTs. They have merely demonstrated the ability to memorize algorithms, protocols and drug dosages, because that’s what their educational programs and certification exams deemed as competency. And there’s nothing wrong with that. There is a place in EMS for people all across the competency spectrum, even the novices.

But there is everything wrong with being content to stay there. Mastering your craft often means outgrowing your protocols, and sometimes even your agency. In a perfect world, every agency’s protocols would allow room to grow and mature as a provider, but in the world we live in, many don’t. And if you’re content in working in such a system, that’s okay too. Many EMS systems only require that their crews drive safely and not kill any patients.

Oh, and turn in their billing paperwork on time.

But let’s not kid ourselves that being a better protocol monkey than your peers makes you an expert at your craft. Protocols, policies and procedures cannot anticipate every situation. At some point, you have to make judgment calls, and sometimes that judgment call may mean deviating from the protocol in the patient’s best interest. If your agency is one that punishes such judgment calls, then it’s time to admit that you have outgrown that agency.

As we mature as providers, where once we saw rules, we begin to see guidelines. Where I once was taught absolutes, and in turn taught those absolutes to my students, I now see nuance. When partners ask me about my patient care decisions, or peers seek my opinion on a patient presentation, my answer is often, “It depends.”

And there is no answer more confounding to a novice provider than, “It depends.” They want answers, and all “it depends” offers is more questions.

When rules may be better off broken

Case in point, a colleague was involved in an ambulance accident not long ago. He was responding to an emergency call, lights and siren activated, and keeping to the left lane, as our driving policy dictates.

But he was a new EMT, and still thundering in his mind was the repeated admonition in his emergency driving class, “Never pass on the right.” When you’re a new EMT, rules like that may as well be carved on stone tablets.

So he kept to the left lane, just as policy dictates. And when it came time to turn right at an intersection, he did so… from the inside left lane. He smacked a car on the outside lane. Nobody was injured, but a response was delayed by minutes, and that delay could have impacted patient outcome adversely.

When I asked him, “Why did you turn across traffic lanes to make that turn, when you had plenty of room to merge into the outside lane before turning right?” he answered, “The policy says we always pass on the left. I was following the rules.”

“And what if those rules had injured you or the other driver?”

For that, he had no answer. Or more accurately, he had an answer, but it took wrecking an ambulance to make him wonder if it was indeed the right one.

My colleague learned a valuable lesson, and hopefully so did my agency. He wasn’t disciplined, and I feel confident that our employer’s just culture management strategy will determine that a flawed policy was at least partly to blame for the accident. Frankly, I don’t remember being told that rule in my new hire orientation, but among our novice EMTs, it’s practically dogma.

Hopefully, it doesn’t take harming a patient to make them challenge the dogma.  

You can judge the quality of your agency by how it handles your questioning. If such questions are unwelcome, then you can either mature somewhere else, or remain an untrusted, lowly paid novice where you are.

Your choice.

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