A note on Clinical Practice Guidelines

Have you ever been annoyed at a change in your clinical practice guidelines? Have you ever been frustrated because of moving goal posts? Want to understand your clinical practice better? Start here.

 

1.  No-one knows what “right” is. 

Occasionally I hear people complain about changes in paramedic guidelines. “I can’t keep up!”. “They’re always changing the guideline!” “Why can’t they leave things as they are?”

Apart from acknowledging that “they” are hard-working paramedics like themselves, there’s a very simple reason for this: science. The truth is that we often don’t know what the right way to manage a certain condition is. We have to try things and see whether they work. No-one has a crystal ball, and changes aren’t being made to frustrate anyone. They’re just our best guess at the moment.

Often a study will be done or new medication will be developed which radically changes how we approach a certain pathology. The recommendations will change to match the best available evidence, and sometimes that makes for an ugly guideline. I’m sorry, but there’s nothing much we can do about that.

We used to use leeches and laudanum to treat pretty much all medical complaints. Then we phased out the leeches and refined laudanum to morphine. Now leeches are back in a limited capacity.  No-one was wrong, we were just doing the best we could. And millions of medical leeches are no longer unemployed, so that’s good.

 

2. Medicine is statistics

Let’s say that you have a favourite intervention. You’ve seen it work a number of times and perhaps save someone’s life. But then it’s removed from your clinical guidelines and you’re no longer authorised to practice it. Injustice!

Maybe. But maybe not.

These days, medicine is statistics. The days of doctors and paramedics experimenting and following their gut feelings is on its way out. This is not due to lack of ability – it’s down to the large numbers involved. Anecdata just isn’t reliable enough.

Perhaps your intervention worked for a few patients. But without using some biostatistics to model whether it’ll work at a population level, we can’t be sure that it’s a good idea. Unfortunately we don’t have individual, genetics-based medicine quite nailed down yet. Until we do, we’ll have to rely on ideas like “the greatest good for the greatest number”, informed by statistical analysis of probably flawed studies.

 

3. Sometimes the best option isn’t the best option. 

Sometimes a guideline is in use which is clearly not the best thing to be doing. It might have been shown to be overkill, or unnecessary, or just plain wrong.

Understandably this upsets some paramedics. If Medication X is clearly superior in every clinical respect to Medication Y, then why aren’t we using it? Y indeed?

Unfortunately, clinical appropriateness isn’t the only criterion that is used. Ambulance services these days are big, complex organisations. There are many factors that feed into decisions about clinical guidelines, not only clinical ones. These may include

  • Monetary cost
  • Government regulatory rules
  • Skills maintenance considerations
  • Frequency of use vs risk of use
  • Equipment availability
  • Manual handling and safety concerns
  • Impact on other guidelines
  • Buy-in from other stakeholders
  • and about a million other things

These factors sometimes change, so options that were formerly impossible suddenly become possible. Medication X coming off-patent or being formulated differently might turn the equation around. A spike in patient presentations requiring Equipment Z might overcome problems with maintaining skills.

 

4. No-one likes a sooky lah-lah

Ultimately a lot of concerns around clinical guidelines come around to attitude. Paramedics love a good whinge, as do most people. But moaning and complaining about things is a great way to make yourself, and those around you, unhappy. It’s best avoided where possible.

When I hear people kvetching about how clinical guidelines are written, it really bothers me. It displays a lack of appreciation of the thought and consideration that is involved in generating a guideline. They aren’t randomly spewed out on a whim – if anything, they’re over-thought.

Most modern ambulance services have a mechanism whereby frontline practitioners (paramedics) are able to recommend changes to clinical guidelines. Use it. Moaning about constantly changing clinical practice improves nothing. Let’s change our culture of complaint.

If nothing else, it’ll improve the level of conversation in the write-up room.

 

 

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Talk less, listen more, drop the attitude

Sometimes I just have to scratch the itch and have a rant.  This time the itch is a recurrent one, about radio communication.

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Tick tock

Ultimately, a lot of what we’re doing in EMS is ferrying people towards their deaths. 

In the literally-true-but-irrelevant sense, we’re all dying. But that’s not what I mean. Pre-hospital and Emergency workers spend a lot of time around people in their final hours and days, even though we don’t always think about it. 

It’s easy to get fixated on the “glory job”, the case where our care may be able to prevent the death of a young and healthy person. But those cases are relatively uncommon.

Most of our time is spent with the very old and terminally ill. It takes a lot less to kill these people and a lot more to “save them”. And they’re not glamorous.

It’s not the car crash, it’s the third pneumonia in a year. It’s not the knife wound, it’s the complications from surgery for a broken hip. Some people have the smell of death on them.

Most of the time we can’t prevent death, we can only ease the suffering.

We can treat the patient with dignity. 

We can leave a coin for the ferryman.

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A better bridge?

Head on over to Emcrit to read Rory Spiegel’s take on mechanical CPR.  I’m fairly sure Rory has been reading the sporadic ranting of a certain paramedic on this topic, hence his brilliant, insightful work.  I’ll let him have his moment though 😉

The key to mCPR being useful is selecting the right patient who can benefit from other therapies (and being good at applying it).   Some patients should not be resuscitated; some patients should; and some, who fail an initial trial of human CPR (hCPR), should be considered for mCPR as a bridge to further treatment.  Routine use of mCPR in the place of hCPR has routinely proven useless.

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Seriously, just Kalm Down!

Following on from my previous post on managing the agitated patient…

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Eustress in emergency medicine

Link time: First10EM.com has published an interesting article/brain dump on performing under pressure in the setting of emergency medicine.

There’s a lot in there, but the key takeaways are that “stress” is inevitable, but varies a lot from person to person. The trick is to optimise your response to stress so that it helps you to do your best work.

Have a read.

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Just Kalm Down!

It’s time for another post on everyone’s favourite drug: ketamine!  Hooray!

Ok, so this is not entirely about ketamine, but ketamine does come into it.  AV paramedics have recently received training to administer IM ketamine to agitated patients as part of a greater focus on paramedic safety when managing these situations(MICA paramedics have had ketamine for a while, it is now used by all paramedics)

Speaking with crews since the roll-out, there seems to be some confusion around some  aspects of managing these patients, so I thought I would attempt to exacerbate alleviate that.  This post is pretty specific to Victoria I’m afraid, so everyone else might want to find a more useful blog to peruse (i.e. any other blog).

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Not cool man, not cool.

Just when I thought I knew what I was doing…along comes a study to prove me wrong.

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Wheels rolling for exciting advance in stroke therapy?

Happy New Year, and welcome back to the sporadic blog known as AmboFOAM.  I thought I would start the year on a positive note, and what better way than by looking at one of the new initiatives happening here in Melbourne: an Australian first Stroke Ambulance!

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Smile! You’re on Candid Camera.

As many of you will know, there have been significant changes to Ambulance Victoria in recent years. We have a new board, a new CEO, and arguably a new lease on life. I am excited by the changes, and I think we are going in a good direction. One of the key issues management is addressing is paramedic health and safety, which is fantastic. Paramedicine is inherently unpredictable, and sometimes dangerous, for a variety of reasons.

One of these reasons is violence towards paramedics from patients or bystanders. On this note, there has been an announcement from AV and government this week that we will be trialing body worn cameras for paramedics to reduce occupational violence.

This makes me a little uncomfortable.  Reducing occupational violence is important, and I absolutely believe that the organisation is genuine in their desire to improve paramedic safety.

I’m not sure that cameras will achieve that though. Indeed, in the media campaign, a paramedic recounts being assaulted – while police were on scene. If uniformed, armed law enforcement officers being present doesn’t stop assault occurring, I’m not sure that cameras will.  Violence towards paramedics is a complex issue, with drug and alcohol use, and mental health issues being common factors.  I am not excusing assault of emergency workers, however I don’t know that those who will swing a punch at a uniformed paramedic will be thinking through the ramifications of their actions given the other issues they often have.

With regards to recording patients, issues of consent and privacy also concern me. I am sure AV and government have carefully considered all of these issues and have suitable structures in place to ensure the proper use, as well as storage, and security of footage, however at this stage no detail is available.

Nonetheless, I asked Dr Michael Eburn, barrister and Associate Professor at ANU his opinion on body worn cameras for paramedics. Dr Eburn writes the Emergency Law blog, covering legal issues specific to emergency work, and is also the author of the textbook Emergency Law. Dr Eburn’s post can be read below:

I shared the link to the story on the ABC on the FaceBook page for this blog.  There have been a number of comments on the story as well as some questions sent to me so this post will try to deal w…

Source: Body cameras for Victorian paramedics

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