5 tips on how to apply EMS protocols

Your understanding of standard operating procedure may evolve from rulebook to guidebook

Updated May 6, 2015

One of my favorite EMS authors is EMS1 columnist Kelly Grayson. I enjoy his humor and tongue-in-cheek style as much as I enjoy his tell-it-like-it-is wisdom. Recently, while reading Kelly’s blog, I encountered a term that got my mental marbles rolling. Kelly described a subset of EMS providers that he calls “protocol monkeys.”

The protocol monkey is an EMS caregiver who clings tightly to their written protocols regardless of the best interest of the patient or the subtleties of the particular presentation. For the protocol monkey, written protocol trumps all other arguments.

Kelly didn’t coin the term, but his use of the phrase sparked my interest in the idea of how we all choose to interpret our protocols. The relationship between the care we provide and the protocols that we are provided is a complex one. While we don’t often think about them, they are critically important to our decision making process. 

Reality versus rules

Consider these scenarios:

A patient with chest pain has been given three doses of nitroglycerine, the maximum dose allowed by protocol. The patient’s pain has decreased from a nine on the one-to-ten scale to a four. The patient’s blood pressure remains adequate. You have fifteen minutes of transport time remaining. What would you do next?

You are transferring a trauma patient from an urgent care clinic to a regional hospital. The patient is not immobilized and has no indication for cervical immobilization, but the transferring physician insists on full spinal immobilization. How would you respond?

You strongly suspect that your patient is presenting with moderate sepsis and will soon transition into septic shock. You recently encountered information on EMS1 about the need for aggressive oxygenation and fluid resuscitation in these patients, but the patient is not yet profoundly hypotensive. Your protocol still calls for a single IV line, low flow oxygen and non-emergent transport. How would you care for this patient?

Your quality assurance manager calls on the rig phone. He has a question about a recent call in which you documented that the patient’s vehicle struck a tree at thirty miles per hour. You transported the minor-injury patient non-emergent. Your Q.A. manager reminds you that this mechanism of injury meets criteria for emergent transport and a trauma alert. How do you respond?

Your personal understanding of the nature of your protocols has an enormous impact on your decision for each of these very real scenarios. In fact, your ideas about what your protocols are intended to be will affect just about every aspect of your care and your development as a clinician.

Limitations of protocols

Consider the following tips the next time you feel there is a conflict between doing what is best for the patient and following your written protocols.

1. Most protocols have some sort of statement near the front about the intended nature of the protocols themselves

In my protocol book, The Denver Metro Protocols, this statement occurs on page six:

“No protocol can account for every clinical scenario encountered, and the DMEMSMD recognize that in rare circumstances deviation from these protocols may be necessary and in a patient’s best interest. Variance from protocol should always be done with the patient’s best interest in mind and backed by documented clinical reasoning and judgment.”

The Denver EMS Medical directors are clear that they expect both sound clinical judgment and acting in the best interest of the patient to trump written protocol. This statement is a specific written directive from my medical director asking me to not be a protocol monkey. Your protocols probably have a similar statement. Find it and highlight it.

2. Doing what you’re told to do is not always the right thing to do

Doing what we are told to do can be like a comforting blanket. We want to wrap ourselves up in the certainty that we can’t be held completely accountable for our actions because we were doing what we were told to do. This is not the case. You are expected to know right from wrong and to act appropriately, even when faced with a direct order.

Don’t be lulled into a false sense of security because your protocols or a physician told you to do something inappropriate. "I was just following orders" is not an excuse to disregard appropriate medical care.

3. Medical knowledge often moves faster than protocol revisions

Protocols that are more than five years old are littered with outdated advice and direction. They aren’t necessarily wrong; they were just written at a time when our understanding of appropriate care wasn’t as advanced as it is now. You still have an obligation to keep up with advances in emergency medical knowledge. With resources like EMS1 at your fingertips, you have no excuse to not know about the latest research.

4. Your dependence on protocols will change as you become more experienced

This isn’t my opinion. It’s a well-known learning progression known as the Dreyfus model of skill acquisition. The Dreyfus brothers explained that, when mastering a new skill, each of us will move through five phases of skill acquisition. Until the third phase (competence), we will be heavily dependent on written guidelines to direct our decision making.

If your response to each of the scenarios was along the line of  “Easy answer, do exactly what you are told to do in the rule book,” it's likely that your experience is not yet at the competence level.  

I don’t mean that as an insult. It’s OK to be completely dependent on your protocols as long as you recognize that this is a phase in your development. As you progress, you will develop a greater understanding of the moments when your written protocols restrain you. Like a potted plant, you should eventually outgrow the confines of your present place...or die.

The tighter you cling to the dogma of protocol-above-all, the more you will struggle to break into the true competence phase of your learning.

On the other hand, when you reach that place of competence, your protocols will transition from being your rulebook to being your guideline. They will represent the typical performance of your duties, not the immutable word of authority.

5. If you are not sure, ask your medical director, preferably before you encounter a protocol conflict

Your medical director is the ultimate authority regarding your protocols. While it's possible that your system is particularly militant about protocol deviations, having a serious discussion about clinical appropriateness is key. Address questions such as:

  • When I am asked to choose between doing what the protocol directs or doing what is clinically appropriate, which should I choose?
  • If there is an apparent conflict between what is in the best interest of the patient and what is written in the protocol, which should take precedent?
  • In a case in which my care deviated from the protocol, could you explain what I did that you felt was clinically inappropriate?

Know what is written in your protocols and also know what constitutes good patient care. Always be willing and able to defend the latter when it conflicts with the former.

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