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Letting go: Organizational phantom limbs

Don’t let bygone policies and procedures prevent evolution in EMS


A good friend of mine lost his legs after being hit on the highway while working a wreck. I was visiting him in the hospital after one of his several follow-up surgeries and he said, “My right foot is itching like crazy and it’s cramped up and killing me.”

He knew that both of his legs had been gone for months, but his “foot cramp” was bad enough that it nearly brought him to tears.

According to the Mayo Clinic, “The exact cause of phantom limb pain is still unclear, but it appears to originate in the spinal cord and brain. During imaging scans such as magnetic resonance imaging or positron emission tomography, portions of the brain that had been neurologically connected to the nerves of the amputated limb show activity when the person feels phantom pain.”

A similar dynamic happens in EMS systems and EMS professionals. Something that’s no longer there still causes pain and problems.

Rooting out phantom policies

The first time I noticed this phenomenon was in a 911 EMS dispatch center. A new leader was trying to improve response times by implementing a pre-alert process for suspected critical calls. Her goal was to get EMS units heading to the scene of a call as soon as the call taker had an address and a notion that the call was critical, before they completed the emergency medical dispatch protocol.

The training on the new process had been completed and memos about it were posted on the bulletin board. Yet pre-alerts were not happening.

Call takers were sending the addresses over to the dispatchers as soon as they had a hint that the call was critical, but the dispatchers were not sending units until the call dropped into their send queue on the computer-aided dispatch system. When their supervisor asked them why they were not sending crews based on the pre-alerts, most of them said something like, “I’m not going to risk getting fired.”

The baffled supervisor responded with, “I’m your boss and I’m telling you to send units as soon as a call taker gives you a pre-alert with an address. I’m not going to fire you for doing what I tell you to do.”

The dispatchers replied, “You’re new around here. There are some policies that will get you fired if you don’t follow them. Dispatching calls that are not in the queue is one of those.”

No one knew who wrote the original policy, but it must have been someone scary. The dispatchers dug through dusty old policy manuals, rule books and collections of memos looking for the policy to prove their point.

They couldn’t find it, but they knew it was there. It was the phantom policy. After weeks of nudging, hand holding and encouragement, they finally started sending crews before calls showed up in their queue.

Chances are good that you have some phantom policies, protocols or practices in your own brain. It’s been 26 years since I’ve passed a nasal-tracheal tube, but when I’m riding with a crew today and we run a call for someone with fulminating pulmonary edema, a nasal tube always pops into my brain before CPAP.

No matter how many times I’ve visited London, I’m at much greater risk for being hit by a car the first few days of each visit. Even though I know that they drive on the left side of the road, when I’m walking, my deeply ingrained habit is to look to the left before crossing the street. I still look left first even though I know that the closest cars will be coming from the right.

In EMS systems, the phantom limb or deep mental rut dynamic usually becomes a problem when you’re trying to change something to make an improvement. I know of one EMS system where first responders reported their paramedic ambulance colleagues to the state for malpractice when they quit strapping everyone involved in a car crash to a backboard. In another community, a loud verbal altercation broke out on scene when the paramedic didn’t want oxygen administered to a patient with chest pain whose oxygen saturation was 96 percent.

Removing obstacles to EMS improvements

Effective treatment for real and organizational phantom limb pain is challenging. Different patients and systems respond to different approaches. The current choices for actual phantom limb pain include medications, nerve stimulation, acupuncture, spinal cord stimulation, nerve blocks, mirror boxes, brain stimulators and stump revision surgery. Several places are currently experimenting with virtual reality.

For organizational phantom policies and practices, here are some tools that help:

Resistance is a gift

When people resist change, most leaders have a natural impulse to push harder, trying to overcome the resistance. One powerful, yet counterintuitive trick is to see resistance as something that will help you be successful. There is a reason, real or imagined, why the resistance has come up. If your response to resistance is respect and deep listening, there is a very good chance that you’ll learn something that will help you implement change. Even if you don’t learn anything, the fact that you responded with respect and curiosity is likely to decrease the strength of the pushback.

Communicate fully

Often, the decision to make a change comes after a long and thoughtful process, but what gets issued to the people who must implement the change is sparse. One system spent months reviewing the literature and debating back and forth with trauma surgeons and emergency medicine physicians about the use of backboards. What was issued to the crews was a memo that said, “Starting Thursday we will be implementing the Selective Spinal Immobilization protocol. Patients who are alert, not intoxicated, neurologically intact, with no significant mechanism of injury, no distracting injury, and no point tenderness over their spine do not require spinal motion restriction.” The resistance was big and loud. It would likely have gone easier if they had described the impetus for the new protocol, their decision-making process and shared some of the studies they used before making the change.

Allow for grieving

It sounds strange that changing a protocol to improve patient care might trigger a grief response, but for some people it does. I was visiting with a group of older medics last week when one of them wistfully said, “I really miss the MAST pants. Blowing those things up was the only time in my career that nearly dead trauma patients woke up and talked with me. That’s never happened since.” He didn’t actually tear up, but I could see that he was genuinely sad that something he believed made a difference was no longer available to him. Help them through the grieving process by acknowledging their loss and supporting them while they let it go so that they can embrace the new order of things.

No one likes to lose a limb or have organizational change thrust upon them. With effective treatment, the pain and suffering can be relieved. 

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