40 Years and Counting—Part 3: Show Me the Protocols

In the mid-1970s, when Illinois’ South Cook County EMS system had trained enough paramedics to adequately staff its rigs, it went online with ALS care.

You have to remember that paramedics were a new creature in the healthcare arena and no one was really sure what they could do, or for that matter, what they were supposed to do. As such, standard operating procedures (SOPs) were pretty much non-existent and the few that were written were very limited in scope.

With that being the case, calls followed a tight script. We arrived on scene, did our patient assessment and then called the hospital. After passing on the history, we got our “orders” from a base station nurse. Then we implemented our care plan driven by the orders we’d just received.
It became evident early on that this model was fraught with problems. The base station nurses would give an order, then about 2 minutes later they were back on the radio playing the game of many questions. “Is that IV in?” “How’s that IV coming?” “Have you got the patient on the monitor yet?” “What’s going on with that IV?” “Can you get an updated set of vitals?” After three weeks of that, things were heating up between the base station nurses and the medics.

The medics were frustrated because of what they perceived as needless interruptions that interfered with patient assessment, as well as patient care, essentially breaking up the flow of the call. The base station nurses were frustrated because they felt if they were truly managing the call, we needed to provide prompt replies to their many queries.

One of the ED medical directors came up with a plan to mediate the situation. Every base station nurse was required to pull a minimum of two 24-hour shifts, but they could only be on Fridays or Saturdays when the system was in what might best be termed “the South Side of Chicago hyperdrive mode.” They were also required to ride with our department exclusively since we were by far the busiest service in the still-in-its-infancy EMS system. Given that this mandate also paid the nurses time-and-a-half overtime pay, compliance was not just guaranteed, it came with a fiscal smile.

It took a few months to get all of the base station nurses through their ride-alongs, but the shift in base station performance came quickly. With the completion of each weekend rotation, another nurse returned to the controlled environment that is hospital medicine after having a massive reality check. Each and every base station nurse got a true understanding and a newfound respect for what it took to meet the challenges of working an emergency call with only two providers to accomplish all that needed to be done. With that, the game of 20 questions came to a halt.

With each passing month things continued to improve and shortly thereafter, the development of standing orders began in earnest. Over time there was less and less medicine that required permission before implementation.

For the most part, the protocols of today, especially in the northwest where I’ve now been for more than 20 years, are quite remarkable compared to the mother-may-I model of the early days of EMS.

Our typical protocols allow paramedics to do their job and then call in with an update of patient status, along with detailing what care has been provided. Pain can be managed with up to 10 mg of morphine or 100 mcg of fentanyl. Patients can be RSI’d and intubated. If a helicopter is needed as the transport platform, it’s called in. All this is done without base station contact.

Of course this transformation of prehospital medicine was by no means an overnight event, as it required a true paradigm shift. The relationship of trust between base station nurses and field medics took time to develop and cultivate. The entire process had to be driven by open lines of communication and active participation on both sides of the fence. In time, it became increasingly obvious that what are often termed “loose protocols” could only exist in an environment where a “tight” continuous quality improvement model was framed around it. Without that model, running emergency calls where all of the medicine is typically delivered with two providers in the dynamic and often unstable platform that is prehospital medicine could only be managed with an ask-then-do model of medical control.

With the continued maturity of prehospital medicine, the logical evolution of standing orders/protocols has served to provide tremendous latitude to perform on the part of field providers and deliver more seamless, high-quality medicine to the folks we come to serve—our patients.

Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.