Taking it to the Streets: Practical Tools That Increase Provider Autonomy

Every profession requires some level of training and education. In order to succeed at any occupation, you must possess some level of ability and capacity for learning. EMS, in particular, also requires common sense and the ability to remain calm and in control during chaotic situations.

As the EMS profession has evolved, so has its scope of practice. Far from its often humble and basic origins, current practice requires more knowledge than ever. Practical application of that knowledge requires the use of critical thinking to foster continuous development of clinical judgment.

From Student to Provider

You likely have or will encounter four categories of certified personnel. The first is someone who might have become certified due to lax standards or luck but hasn’t learned what’s required and is just as unable to apply what little has been gained to clinical practice. While it would be ideal for those who aren’t capable to be weeded out in training or orientation, some manage to get by in services that are content with warm bodies.

The ideal candidate for any agency is someone who learned well and became certified while also becoming able to practice autonomously. Somewhere between those poor and excellent newly certified providers are those who excelled in class but are unable to apply their learning in the field and others who may have been poor students but develop into calm clinicians with well-developed common sense.

EMS has a place for everyone who is willing to learn and adapt. The difference is often a preceptor with patience who can provide the model and support needed for success. There is only one major disqualifier that cannot be overcome: a bad attitude. Mediocre students can be molded into competent providers if they are willing to learn and adapt.

A Real-Life Example

A recently witnessed medical event prompted me to share my thoughts in this article. EMS educational standards continue to increase in length and training programs add requirements, but, in order to be a successful provider, there is a required transition from the classroom to the streets.

An adult patient complained of chest pressure that was likely caused by an acute onset of uncontrolled atrial fibrillation. While there were three experienced medics at the scene, the treating medic on the ambulance was fairly new but well-trained by his program. Initial assessment was fairly standard and the patient remained alert with an adequate blood pressure and no distress beyond the chest pressure.

After some mild prodding, the decision was finally reached by the newer medic to perform rate control with diltiazem. Having administered the drug multiple times each, we all simultaneously calculated a dose of 15 mg, which is often a standard adult dose in many agencies.

Keep it Simple

While often administered as a slow IV push over a few minutes, some agencies I work with simplify administration by putting the indicated amount in a 50 mL bag and administering it wide open with a 60 gtt/mL set, resulting in an approximately two-minute infusion. This is a simple way to administer any of several drugs over that time period without diverting attention from the patient.

As we all nodded in agreement over a dose of 15 mg, which is a simple amount of 3 mL, the ambulance medic produced their cellphone, determined the exact weight in kg but then incorrectly calculated a fractional dose that also would have been difficult to draw up. In the end, 15 mg was administered with appropriate rate control achieved during transport.

(As an aside, this somehow resulted in my realizing that the weight of the patient in kg, divided by 20, would give the exact starting dose of diltiazem in mL. While I would not recommend this as the initial calculation, it is a simple method for checking the actual amount of fluid to administer.)

Avoiding Errors

While the ambulance medic was almost technically correct, with only a minor error, calculating drug doses during a call presents the opportunity for potentially serious deviation. There are two simple ways to avoid this: the use of standard yet appropriate doses or a validated tool for assistance. Many adult doses have been standardized for years while pediatric drug administration generally requires calculation.

Four decades ago, the need for a simple method of calculating pediatric dosing was addressed by Dr. James Broselow and Dr. Robert Luten, resulting in the widespread use of their length-based system of calculation, the Broselow Tape. While this became a seemingly easier way to avoid error, the result still required calculation of an exact fluid amount to be administered, still allowing room for error. Later versions incorporated these measures, but were still unable to keep timely pace with advancements in care.

A simpler and more adaptable system was created in 2010 by Dr. Peter Antevy and led to a readily customizable and agency-specific mobile app that can be updated as needed. The Handtevy System is accessible from any tablet or cellphone and provides exact drug dosing and equipment sizing for all ages and weight ranges from preemie to a large adult. It also incorporates a simple age-based method to calculate critical results prior to scene arrival.

Increasing Autonomy and Complexity

In the early days of advanced life support, care was often based on direct medical control involvement with specific orders given as indicated. As care has become both more advanced and autonomous, so has the potential for error. Regardless of what method is endorsed by your agency and its medical director, simple access to either standardized or readily available calculations can help to prevent potentially harmful outcomes.

The difference experience makes was evident with the patient described above. Years of experience resulted in a rapid calculation of an appropriate drug dose. Recent initial training led to an attempt at precision dosing resulting in a minor error. If your agency doesn’t already use standardized dosing, the use of an appropriate aid can assist with cognitive offloading and help to avoid potentially serious deviations.

References

Hospira, Inc. Lake Forest, IL. (2017). Diltiazem Hydrochloride Injection.

Luten, R. (2002). Managing the Unique Size-related Issues of Pediatric Resuscitation: Reducing Cognitive Load with Resuscitation Aids. Academic Emergency Medicine, 9 (8), 840-847.

National Highway Transportation Safety Administration. (2021). National Emergency Medical Services Education Standards.

Pediatric Emergency Standards, Inc. Davie, FL. Handtevy Mobile.