Exposé: Behind the Guidelines

If you’re a paramedic pretty much anywhere on this planet, you’ve almost certainly got a booklet/app/eight-volume encyclopedia that is you prehospital bible. These are your clinical practice guidelines, or whichever nice name your service gives them.  I’m very happy that ours are called guidelines, and we’re told they are just that. That’s all well and good, until of course you deviate from them, in which case you find out very quickly that they are in-fact protocols.

Whilst I remove my tongue from my cheek, I must say, there’s a pretty good reason those responsible for clinical audit of paramedics (usually senior, experienced prehospital clinicians) get a bit narky when you wander a little outside authorised practice regimes. Clinical practice guidelines, standing orders, standard operating procedures and the like are usually (or at least should be) there for a reason. In my service, like many others, this is because in a world of unregistered and unregulated paramedic practice, we are essentially not allowed to do much without authorisation from a higher power.


In my service, we have a Medical Advisory Committee that meets quarterly to assess proposed guideline changes. This committee consists of paramedic representatives, senior ambulance managers, and senior consultant physicians from a range of specialties including anaesthesia, intensive care, emergency medicine, cardiology, retrieval medicine and respiratory medicine.


Sitting under this committee is a clinical practice development committee that meets each month to collate the research and trends in prehospital care. This means many hours of work (on top of clinical duties, mostly in personal time) to prepare and present proposals that are contemporary and evidence-based, in order to establish new guidelines, or update existing ones. Once they’ve been developed, they can go to the quarterly medical advisory meetings for approval or rejection (“Come back when you can convince me!”).


I have been a member of the above committee in my service for the last two and a half years. Often, in my day to day prehospital work, I hear the cry of many an ambo “we should be doing this, we should be doing that!”. A dollar for every time I’ve heard a colleague say “we should be using “X” drug!”. Well, “X” drug has to be affordable. “X” drug has to have a good safety profile for all paramedics to use. “X” drug should have a strong evidence base to suggest it’s actually going benefit patients. And, importantly, the medical advisory committee or board of your service has to be willing to allow you to use it, under their authority.


Every time a paramedic intervenes, it’s under the permission of the docs on that committee. You don’t actually have the autonomy to do as you please. The medically approved guideline or protocol tells you what you must do. So, whilst some of your procedures or protocols may seem conservative, remember that the development of the proposals for change or creation of new guidelines, is an incredibly laborious process. Also, play the “devils advocate for a second” and put yourself in the shoes of a medical advisory committee physician. Are you willing to authorise 3500 tired, overworked paramedics to give “X” drug? Change is often very good, and it’s often essential, but it takes a whole lot of motivated, like-minded individuals to make it happen.


So, are you “that ambo”? The one who wants things done differently? Are you frustrated by your guidelines? Well, have I got a deal for you! Here’s how you contribute:


  1. Next time you see you paramedic representative on your medical advisory board or committee, buy her or him:
    1. a coffee*
    2. a beer*
    3. <insert beverage of choice>


(*dependent on social/professional context)


  1. Next time there is an expression of interest to be on such a committee or board, put your hand up. Make a difference. You may even get a free drink!


  1. If you’re not ready for that level of commitment, then offer to assist your paramedic representative in the development of a guideline you are passionate about.


  1. Draft a proposed guideline, and submit it through the appropriate channels in your service.


  1. Join the push for paramedic registration and regulation in Australia by contacting your local Member of Parliament and follow Paramedics Australasia on Twitter




& the hashtag #ParamedicReg


If you want change, you have to drive it. It’s not a quick and easy process. Patience and commitment is vital, but the rewards are significant.




Twitter: @prehospitalpro


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2 Responses to Exposé: Behind the Guidelines

  1. Great post Ben, you have described me to a T!

    I think one of the issues is that life as a paramedic (especially those of us who work on our own) is rather isolated. We live in our own little bubble where it is easy not to see the bigger picture.
    I may be treating a patient and think “I wish I had drug X, I could really help this person”

    Of course I do not think of the cost, the potential harms, issues with storage and transport, the safety of giving it to a wide spectrum of paramedics in very different places and contexts and so forth.

    In fact, you have almost convinced me to put my hand up at the next opportunity for the Clinical Practice Development committee!

    Great to have you on board mate.


  2. Glen Ellis says:

    Very good post Ben. Being from Ireland we actually have a pre-hospital registration for paramedics and your post reflects our Clinical Practice Guidelines development here also. Never has a post been more currently relevant as we embrace FOAMed. I find it frustrating when I listen to podcasts from around the world and see what you guys are doing in Australia to then looking at my own service and saying why are we trying to reinvent the wheel here. But then it comes down to exactly what you say if you were the medical director of your service would you be happy with every medic having the judgement to give certain meds at 4am in some dingy low light bedroom as the residents are abusing you from the room next door. Really enjoying your posts Ben.

    Glen Ellis
    Dublin Ireland

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