Beyond the Box

   Under the British Columbia Ambulance Service's anaphylaxis protocol, you couldn't give epinephrine right away--a patient's blood pressure first had to drop below a defined threshold. There were legitimate reasons for that, but for providers treating anaphylactic patients who had not yet deteriorated to that point, it created some uncomfortable moments.

   "Knowing sometimes that a patient was having anaphylaxis and getting worse," says Karen Wanger, MD, BCAS' regional medical director for Vancouver and the lower BC mainland, "paramedics either had to break protocol and give epi earlier, if they thought that was the right thing to do, or they had to wait until the patient's blood pressure fell below 90. When you think about that, that's not the best way to treat anaphylaxis."

   It was, however, the kind of situation that got BCAS leaders to start thinking about their protocols, and how to give their providers more flexibility to do what's best for individual patients. The result of that process was a move from protocols to less-proscriptive treatment guidelines that allow BC medics to use greater clinical judgment in delivering care.

   The problem with protocols is that they force behavior. As well, patients have to be forced into protocols that may or may not fit all aspects of their presentations. That can lead to the practice of "cookbook" medicine--providers dutifully following prescribed care recipes and reluctant to deviate from them, no matter the individual peculiarities of a given patient. Under guidelines, conversely, providers are liberated to think and act more freely based on their training, experience and best professional discernment.

   "The long-range goal is to improve the critical thinking skills of our paramedics," says Wanger. "That's a move toward providing the care patients need in the moment, rather than a strict set of lockstep guidelines that don't always speak to the variable types of problems patients have."

   Critical thinking is an attribute that must be developed if prehospital caregivers are to evolve from mere technicians to true clinicians. Developing it requires some supporting elements. In British Columbia that began with education. An initial course introduced the new treatment guidelines; a second will delve more deeply into them. Newcomers are primed during orientation. Field personnel also get face time with service physicians to discuss the guidelines in practice. Wanger conducts monthly "interesting case" rounds where she visits stations to discuss unusual calls and applicable guidelines, then field questions. The goal is to catch near-misses and highlight good catches.

   Recognizing that some EMS providers will simply operate better with protocols, BCAS has retained some flexibility for them. All or some of the protocols can still be used by those not yet comfortable with the guidelines. The idea is to provide an entire "toolbox" from which providers can select what's appropriate and comfortable.

   "There are people who think in a more concrete fashion, and just aren't comfortable with that kind of open, varied critical thinking," says Wanger. "We hope to move them to the guidelines as time goes on. But our protocols are perfectly safe--it's not like they're giving lesser care. Frankly, at 3 or 4 o'clock in the morning, most people do well remembering something that's a bit more lockstep."

   The guidelines were also crafted in a ground-up way that helped optimize field folks' buy-in. The process began with a survey of providers' attitutudes about their care delivery. Many expressed desires to operate with a bit more freedom, outside tightly defined protocol boxes. The anaphylaxis protocol was one example.

   With key issues identified, topics were divided among BCAS' regional medical directors and passed on to physician-led teams of medics charged with researching relevant literature. Their findings and subsequent recommendations came back to the regional medical directors. Some identified areas weren't amenable to change due to things like scope of practice laws. Others were new. Everything had to be sorted, prioritized and formalized--an enormous undertaking.

   "It took our protocols, really, and broadened them into what we thought was reasonable," says Wanger. "We couldn't take everything that was suggested, but our field docs did a little synthesizing, and we developed, in some cases, reasonable compromises."

   In their final incarnations, the treatment guidelines have three parts: a single-page overview of the problem and its guiding medical principles; a list of potential interventions at each provider level; and a level-specific list of interventions for each provider.

   It's hard to apply metrics to a change like this--there are no easy values to gauge its effectiveness. Using guidelines won't make a difference in scene times, and privacy laws make it hard to connect them to patient outcomes. What's more obvious is paramedic satisfaction, and the degree to which collaborating in the process has enhanced the symbiosis between BCAS' clinical leadership and crews in the field.

   "We know we have paramedic satisfaction--they talk to us," says Wanger. "We believe there's going to be an improvement in patient care. With the critical thinking and a background that covers more pathophysiology, they'll be able to better speak to different things. They'll better understand how their interventions work and what red flags to watch for. We expect that will lead to better treatment and a better look at patients globally."

Sample BCAS Guideline: Hypo/Hyperglycemia
Patients with a history of type 1 and type 2 diabetes are at risk of developing hypo or hyperglycemia.
In the case of hypoglycemia, their history frequently reveals an imbalance of insulin or oral hypoglycemics by:

• An overdose of insulin or hypoglycemics;
• Insulin administration was not followed;
• Missing a meal;
• A recent change in diabetic medication;
• Overexertion without matching food intake.

In the case of hyperglycemia, history may reveal:

• Recent infection or illness;
• Gradual onset of symptoms of dehydration, lethargy, confusion;
• Excessive urine output;
• Insulin-dependent diabetics often smell ketotic (like ketones);
• Non-insulin-dependent diabetics can have high blood sugars, dehydration but no ketosis.

Guiding Principles
Measuring capillary blood glucose will guide treatment.
Symptomatic hypoglycemia does not occur unless glucose is less than 4 mmol.
Hyperglycemic symptoms are rare if glucose is less than 18 mmol, but many patients tolerate much higher levels without any symptoms.
In hypoglycemic patients who can still comply with directions, administering oral glucose may be enough to increase their level of consciousness and avoid unnecessary IV initiation.
All patients receiving IV dextrose require 50 mg of thiamine IV unless contraindicated.
Although many hypoglycemic diabetics decline transport following successful treatment, care must be taken to ensure a reasonable underlying cause of the event has been identified—i.e., the event is clearly attributable to a late or missed meal in the face of a normal dose of insulin, or the patient’s physical activity has been higher than usual in the period prior to the incident. These patients should never be left in the absence of another responsible adult.
Type 2 diabetics on oral hypoglycemic agents who require treatment in the field should be transported to hospital, as this is an extraordinary event and very likely to recur.
Beware the otherwise healthy patient with a history of recent illness who is unconscious, hyperglycemic and hypotensive. These patients may be as yet undiagnosed type 2 diabetics who have developed hyperglycemic nonketotic coma. These patients are at risk of dying and need careful management in the emergency department.
EMR/PCP Interventions
Correct hypoglycemia: Glucogel, 1 package applied to oral mucosa.
PCP only: Glucagon, 1 mg SC, if IV unattainable or for persistent hypoglycemia.
PCP IV only: Dextrose, 10–25 gms (100–250 cc) D10W IV; thiamine, 50 mg IV.