Bottom line up front: How do long-standing EMS practices evolve, especially when new evidence challenges what we’ve “always done?” Using recent discussions around cervical collar use as a case study, the recent NAEMSP Town Hall examined how research, protocol development, education and field experience shape clinical decision-making and ultimately redefine the standard of care.
At the December NAEMSP Town Hall, Drs. Ben Abo, Carol Cunningham, Jeff Jarvis, Doug Kupas, Matt Sholl and EMS attorney Doug Wolfberg discussed the evaluation of emerging evidence, how to understand risk-benefit consideration. and navigating changes that impact patient outcomes and operational consistency.
The latest Town Hall wasn’t really about cervical collars however — it was about how EMS decides what good care is. Using spinal care as a vehicle, the panel walked through how research, protocols, education and street experience collide with the legal concept of “standard of care,” and what that means for leaders trying to move their systems from tradition to truly evidence-based practice.
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Standard of care: A legal verdict, not a medical slogan
EMS attorney Doug Wolfberg opened with a reality check many of us don’t like to think about: standard of care is a legal determination, not something we declare in a protocol book. We can publish position statements, write protocols and teach “best practice,” but in the end, a jury, judge or hearing officer decides whether a reasonably competent clinician, with similar training and in similar circumstances, acted reasonably. That answer can look different in an EMS disciplinary case, a civil lawsuit or a criminal trial — but the common thread is that the legal system gets the final word.
Professional society statements and consensus documents from groups like NAEMSP carry real weight. They are strong evidence of the standard of care, but they are also lagging. By the time committees meet, argue, draft and publish, practice on the street may already be changing. If we wait passively for the next consensus paper before we adjust care, we may be behind what a court could already see as “reasonable.”
Evidence plus disruption: How much proof do you need to change?
In terms of when does new evidence justify changing what we do? Dr. Jeff Jarvis offered a practical framework for medical directors and chiefs: the level of evidence you need should be proportional to the disruption, cost and risk of the change, balanced against potential benefit. If you’re adding a new indication for a drug you already stock, with no extra cost or operational impact, you can reasonably act on modest but credible evidence. If you’re about to overhaul your clinical model or buy an expensive device for every unit, you should expect high-quality trials and strong data before you make the leap.
This lens was then applied to spinal care. The point wasn’t just “are collars helpful?,” but rather, “are we honest about the benefits, harms and opportunity costs of long-standing practices — and are we willing to revisit them when the evidence doesn’t match the dogma we grew up with?”
The panel also warned about premature closure — the moment we decide we already know “why” something happens, we stop looking. In spinal care, once we assumed secondary cord injury was all about bony fragments “pinging” the cord, we stopped exploring alternative mechanisms, such as hypoperfusion. The message for EMS was broader: don’t let attractive physiology stories shut down ongoing scientific curiosity.
Protocols: Clinical roadmaps and legal exhibits
From there, the conversation moved to protocols — another place where science, education and law collide. Drs. Matt Sholl and Carol Cunningham described protocols as both our promise to patients and evidence in court of what we believed reasonable care to be at the time. Well-maintained, evidence-informed protocols, paired with real education and implementation, can support clinicians and strongly demonstrate contemporary practice.
Poorly written or outdated protocols can do the opposite. Dr Cunningham, who often serves as an expert witness, highlighted how words like “must” and “shall” can become traps. Absolute language and arbitrary time limits are easy to weaponize after the fact, especially when the real-world call didn’t fit cleanly into the checklist.
Doug Wolfberg reminded everyone that protocols themselves can be found wanting. In some cases, courts look at deviation from protocol as proof of negligence; in others, they look at the protocol and conclude that it failed to reflect reasonable, modern care. Simply having a protocol doesn’t grant immunity — leaders must ensure those documents evolve with the science, the resources and the realities of their system.
Education and field experience: Shortening the 7-year gap
The Town Hall also tackled one of the most familiar frustrations in EMS: it takes years for new evidence to filter into daily practice — a commonly quoted number is 7 years from publication to widespread adoption. The panel argued that today we have new tools to shorten that gap – structured literature reviews in society statements, focused podcasts, Town Halls like this one, and modern online education. But those tools only work if leaders use them intentionally:
- To explain why protocols are changing, not just what changed
- To connect abstract research findings to the real calls crews are running
- To challenge long-held habits when they no longer make sense under the current evidence
Field experience still plays a vital role. Real-world observations, operational feasibility and resource constraints all matter. But they should be in dialogue with the science and legal realities, not a refuge for “that’s how we’ve always done it.”
What this means for EMS leaders and clinicians
By the end of the hour, it was clear the discussion wasn’t trying to hand down a single spinal-care commandment. Instead, it offered a roadmap for any long-standing practice under review:
- Understand that standard of care lives at the intersection of science, protocols, education, field reality and the law.
- Be honest about the strength of your evidence and the size of the disruption you’re considering.
- Treat protocols as living documents, written in language that supports clinical judgment and reflects the true weight of the data.
- Use education and communication to bring your crews — and your community — along when practice changes.
Cervical collars just happened to be the vehicle for this journey. The bigger takeaway was a challenge to all of us in EMS leadership: if we want to claim we practice evidence-based medicine, we have to prove it not only in our journals, but in our protocols, our classrooms, our street decisions and, if it comes to it, in court.
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