Kelly Grayson of Ambulance Driver Files recently penned an article on EMS1 regarding the “protocol paradox” which he defines as:

“The more restrictive your agency’s protocols are, the more likely it is necessary to deviate from them, and the more likely that agency is to punish harshly for such deviations.”
Mr. Grayson makes some extremely valid points about the utility of protocols within EMS.  While he supports the use of protocols, he does so only so long as they do not restrict the provider’s ability to deviate should the need arise.  He puts the issue into four categories which each have their own compelling reasons for restricting the overuse of protocols.
  1. Experienced Novice – At times protocols they can be so restrictive that they remove all flexibility from care, thus creating machines in place of providers, and generating scenarios in which patients who deviate from the standard are at risk for further harm.  That said, it’s easier for a manager to put up with a mediocre provider so long as they keep their head down, follow the rules, and stick to the protocols.
  2. Higher for Attitude, Train for Ability – Good providers aren’t born, they’re made, but only if the base model has an attitude willing to learn.  Employees who feel respected and trusted can provide a substantial boost to agency morale and the bottom line.
  3. Protocol Deviation – Agencies can choose how they react to deviations from a protocol.  Some will recognize that so long as the exception is well-documented and reasonably warranted there is no issue.  Others advocate for a strict adherence that puts being a good employee above being a good provider.
  4. You Have a Choice – Providers can choose who they work for.  They can choose that an organizational culture isn’t right for them and find another agency that is a better fit.  Or they can choose to work to change a negative organizational culture.  “And the funny thing is, the paychecks cash just the same.”
I disagree with little Mr. Grayson has said, although I hesitate to think of the wrath that would rain down were I to do the opposite.  He provides insight that can only exist from years of experience and multiple levels of exposure.  While his arguments are convincing, I would suggest he fails to delineate between “protocols” and “protocol paralysis”, nor does he adequately explain the aim of a reasonable protocol system.

In a perfect system, the best practices for an industry would be developed from a systematic review of the evidence available.  If there wasn’t enough evidence available, more would be collected.  Once something was considered a best practice, it would be implemented nation-wide via protocols that allowed the best practice to be retro-fitted into the organizational structure of each agency.  But of course, this isn’t a perfect system.

Where Mr. Grayson appears to have the issue is with the final step, when individual organizations make a rule-book for how their employees should react to and treat patients that fall within a certain category.  I argue the problem starts much earlier in the process.  How can we expect every EMS agency in the country to have a reasonable set of protocols if we, as an industry, don’t even have a reasonable set of guidelines or best practices except for in a handful of scenarios?

As an example, a 2012 study in Resuscitation looked at the practice variability of EMS organizations that were submitting data to CARES in 2008.  While the organizations that were surveyed cast a wide net across the organizational setup options within EMS, what was more surprising was the variability in the protocols used by the agencies during out-of-hospital cardiac arrest (one of the most studied concepts within EMS).  With the exception of one clinical care protocol (providing 2 minutes of CPR prior to AED rhythm check), every other protocol was non-universal.

In January of 2014, Prehospital Emergency Care attempted to change this when they published a supplement on Evidence-Based Guidelines (EBG) in EMS.  In it they provided EBGs that had been developed using the GRADE methodology on pediatric seizure care, analgesia in trauma, and air medical transport of trauma patients.  Since then more EBGs have been developed or are being developed, but only at a rate that mirrors the the number of oppurtunities for research.

EMS is becoming a progressive industry.  Although some dinosaurs still linger, those that have made it this long have done so because of their ability to change with the times. There is a new generation of providers, directors, and ever researchers itching for the chance to influence change.  To do so they will need to work within the confines of the pre-existing system before they are able to move the needle.

There is a time and place for a reasonable protocol system.  Some scenarios call for flexibility while a select few call for a strict adherence to proven best practices.  It falls on EMS industry leadership to recognize the difference and effect the culture change necessary to influence protocol adherence standards on the ground floor.

-Catherine Counts