The Protocol / Skill Breakthrough

Once you understand the protocol / skill connection you might come to see a host of problems with the way we develop, use and teach our protocols. I’d like to tell you about two biggies.

As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.

The problem with our protocols is that they were written with the expectation that everyone would use them the same way.

The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.

Let’s look at both of these problems a little more closely.

1.) The problem with our protocols.

Your protocols were developed by a group of physicians who were trying to give direction to a competent EMT or Paramedic provider. Remember the competent caregiver? She’s the one who feels safe operating inside of her protocols and still depends primarily on rules, guidelines and routines.

This Goldilocks approach to protocols is neither too hot nor too cold but it leaves a large segment of caregivers wanting something more. Our novices want more detail. Our advanced beginners want more structure to the prioritized treatment lists. Our proficient caregivers want to be able to operate outside of the protocol with less formality and scrutiny and our experts want to work without the protocol book at all.

This can also create problems if your quality assurance manager has an idea that everyone should adhere to the protocols as if they were an advanced beginner. If the care provider is an advanced beginner, that level of compliance may be entirely appropriate. If the caregiver is proficient, there are going to be some problems.

With both of these situations, the clear answer is to build protocols with detailed direction meant to guide the caregiver through an example of what ideal care might look like with an emphasis on flexibility. Protocols should guide appropriate care; they should not dictate appropriate care.

The necessity of that guidance will change as a caregiver’s skill and knowledge advance. When we are reviewing field care, we should always focus on the appropriateness of the care given, not the strict adherence to protocol directed treatment. If our field personnel are giving appropriate care that falls outside of the protocol, the problem is with the protocol, not with our providers.

2) The problem with our field education.

In the documentary movie Hearts of Darkness, Francis Ford Coppola describes his frustration with actor Dennis Hopper’s improvisation from the script. Hopper would want to enter the scene and just begin filming and see how the scene flowed from there. For a brilliant (Read expert) actor like Hopper, this type of improvisation was appropriate.

There was just one problem. Hopper hadn’t read the script. Coppola and him would have yelling matches with each other where Coppola would lament, “You can’t improvise from the script if you don’t know the script!” Well said Francis.

As new providers enter the field we need to account for the fact that they will be highly dependent on their protocols. They need to learn the script. A certain level of protocol dependence needs to be OK…in fact, in needs to be emphasized.

The problem we can run into here is when we take on a new trainee and we have an expectation that they will act as a proficient provider immediately. The new provider needs to know the rule book before they can deviate from the rule book. As field instructors, we can’t rush into demanding improvisation from the script until we have emphasized the need to learn the script.

We need to teach the script. And we need to recognize that it can be hard to teach someone a script that we haven’t been using for years. It’s easier to just say, “Do it the way I do it.” But that is a recipe for disaster.

If we are the new trainee we can also get ourselves in trouble by wanting to eschew the formality of protocols when we haven’t yet developed the skills to do so. This isn’t a field known for attracting people who are willing to take the long slow approach. That just isn’t in our DNA. But skill development in something as dynamic as EMS is a long slow process. It flies in the face of our impatience.

When we put our protocols in the context of the Dreyfus skill acquisition model our view changes dramatically. We change our perspective and recognize that protocols are not a one-size-fits-all endeavor. We change the way we see this essential element of EMS care. Hopefully this model will eventually change the way we write protocols, the way we perform quality assurance, the way we educate our EMS novices and the way we use the protocol book during patient care.

All of these changes can start with you.

What do you think? Are these the two most significant challenges to our protocol use? What are the others? Does the Dreyfus model change the way you see your protocols? Leave us a comment and join the discussion.

Read more stuff like this:

The Protocol / Skill Connection

What is an EMS Nonconformist?

Why Do Bad Ideas Stick Around?

Written Protocol vs. Common Sense

Quality Assurance in EMS


  1. What are some examples of appropriate protocol deviations and why are they appropriate?

  2. Steve Whitehead says:

    @Timothy For every care provider the list is going to be a little different. And it tends to get longer as our career progresses.

    For me, I tend to administer pain control medication a bit more aggressively than my protocols permit.

    I’ll also give some “base contact only” medications prior to base contact if the situation dictates, I’m confident in my assessment and base contact isn’t immediately available.

    I’m very cautious about giving Amiodarone in ROSC. It’s indicated, but I’ve had some bad experiences with it.

    If a chest decompression or cricothyrotomy is indicated, I’m never going to waste time calling a doctor before performing the intervention.

    The mechanism of injury portion of the trauma alert criteria is often flat out wrong. If a patients mechanism of injury meets criteria for trauma activation but the injury sustained is not trauma activation worthy, I won’t call the alert and I may not transport to a trauma center.

    Elderly fall victims, especially those with hip injuries, often shouldn’t be placed on long spine boards. They can be immobilized adequately on a soft pram mattress with pillows around their head. And some combative patients will fight vigorously against head immobilization but will keep relatively still if you remove the head restraint. I’ll take them in with no head restraint if it reduces their overall head motion.

    Those are a few circumstances that come to mind for me personally.

  3. Steve Whitehead says:

    @Timothy As for the “why are they appropriate?” part of the question, it’s important to note that I believe these deviations are appropriate for me, based on my experience, my protocols and my relationships with my ER doctors, medical director and QA coordinator.

    I don’t believe that this list should be distributed among caregivers as appropriate protocol deviations. For many caregivers, some of these deviations would be inappropriate and could get them into trouble.

    But that’s really the whole point right? How we use our protocols changes over time.

    Thanks for the question. I’d like to hear some other readers take a stab at it too.

  4. Medtech 21 says:

    Excellent article Steve, and sorry for the late post. Im finding myself right now in a similar situation. I am halfway through my Paramedic Internship, and I am slowly learning the protocols for the area I do my ride time in. However much of what I was taught in Paramedic school is much different than the way it is stated in our protocols. My Preceptors have a hard time watching me perform my therapies the way I have been taught in school, and not the way they are in the protocol book. AND just like you said, I am still trying to nail down the skills the way I was taught, step by step, while they flow through things and manipulate the protocols to get the results they need from the call.

    Another thing is I dont feel that any two medical calls with the same CC, can be lumped into a generalized treatment plan, just because thats how the protocols state we treat that type patient. Yet I see every day people following the protocols to a T, when half of the patients dont need most things outlined in the protocol, or would benefit much more from something completely different that what is listed, but people are too afraid to deviate.


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