How I "Discovered" The Protocols

Greg Scott

Greg Scott

Best Practices

Greg Scott

Many of us remember our first experiences learning dispatch protocols—and they were often not pleasant. Perhaps it was those long days in the classroom learning to use a highly structured calltaking process that seemed overly complex. Or the course exam that meant you had to demonstrate that you absorbed and made sense of all those scripted questions and instructions, new terminology, and case scenarios.

Indeed, for those of us who started our emergency calltaking careers without following a protocol every time we picked up that emergency phone line, there was an extra dose of skepticism. After all, when an emergency dispatcher has lots of experience under one’s belt, who needs a cookbook telling you what questions to ask, what instructions to give, and when to disconnect the phone call—isn’t that what we’re already trained to do? Next, you’ll be asking us to check our brains at the door before we enter the dispatch center!

You might be surprised to learn that’s exactly the way Dr. Jeff Clawson viewed protocols as a young physician intern at the huge Charity Hospital of New Orleans (Louisiana, USA) many years ago. In medical school he learned that doctors should be knowledgeable and experienced enough to figure it all out on their own—no need to rely on any crutch to help you do what you should already know. That mindset was quickly challenged when young Clawson was rudely introduced to the chaotic setting of the patient clinic at the venerable New Orleans hospital. In the following article written by Dr. Clawson himself, you’ll learn how he “discovered” protocols—and how they changed his career.

Over the years, dispatch protocols have proven themselves time and again as a tested decision support tool that empowers us to make faster and better decisions when we pick up that phone line, not knowing which of thousands or more possible problems and complaints that await us. And as it turns out, it’s those well-worn protocols that free up your brain to focus on the one activity that really requires your expertise—interpreting what the caller is really saying to you.

Perhaps the fast-paced, often helter-skelter environment of today’s emergency dispatch center may be not so different than the turbulent setting that a struggling young physician found himself in 45 years ago. Reading his story may give you a better perspective on your own role, and perhaps even a better appreciation of the tool that has become the standard of care and practice in emergency dispatch centers throughout the world.

“How I ‘Discovered’ the Protocols”

Note: The following column is reprinted from "Principles of EMD," Chapter 13, The Evolution of EMD, Page 13.3.

by Jeff Clawson, M.D.

In 1975, I was an intern at Charity Hospital of Louisiana at New Orleans (CHNO). After a few months, I found myself working in the large medical clinics at Charity. The “clinics” were much different than anything I had experienced in my limited medical practice to date, especially compared to my medical student experience back in the relatively sedate setting of the University of Utah Medical Center in Salt Lake City. Sick people came to Charity—lots of them. For the patients, clinic began as early as 6 a.m. Not that we saw the patients quite that early, but since clinic was “first come, first served,” 100 to 150 patients had generally been waiting in the queue several hours each morning.

Upon entering any of the small evaluation rooms, each intern was confronted with stacks of patient charts leaning high upon the wall at the back of each work table—and I mean thick charts. Most adult patients at Charity, if not born there, had received all their medical care at CHNO. That often represented 50 to 70 years of medical documentation for each patient in Hypertension clinic. In addition to “High Blood Clinic” as it was called, other clinics included “Sugar Clinic” (diabetes) and “Pus Clinic” (surgical follow-up).

After a few weeks “working the clinics,” I became increasingly frustrated. Each patient I evaluated and treated seemed to be a new experience. I knew as a physician, albeit a very new one, that I should be able to “figure out” what to do with each patient. After all, this is what I had [been] trained for years to do. However, I often couldn’t remember what I had done for a similar patient two hours, two days, or two weeks before.

I sensed I was moving too slowly and patients weren’t getting their money’s worth from me (even though Charity’s medical care was basically “free” at the time).

At one point, my growing despair drove me to seriously consider quitting to return to Salt Lake and become a paramedic with several of my friends at Gold Cross Ambulance. Late one morning, as “High Blood Clinic” ended, I confronted the senior resident on the LSU service, Dr. J. V.
Jones, an imposing, stocky fellow from Baylor. “Look J.V.” I said, “I think I’m killing people here. How do you keep it all straight, patient after patient, with all these complaints, symptoms, lab values, medications, and everything?”

He slowly put his arm around me, laughed, and said, “Clawson, that’s why I’m the resident and you’re the intern.” I was definitely caught off guard, but then I was given some needed advice. He opened his coat, revealing an inner pocket from which he pulled a set of worn, dog-eared 4-by-6-inch cards held together with a dirty rubber band, and said, “What you need, my man, is a protocol.”

“Protocol?” I frowned, “You mean a cookbook?” They had warned me at Utah that cookbooks were bad. “You’re a doctor now. You should be able to figure it out yourself.” Silently for a moment, he turned, pointing toward the now empty, but trashed, waiting room of a hundred folding chairs, and said, “Cookbook, my ass! At the Big Free, Clawson, you can’t live without ‘em.”

Needless to say, I was a bit shocked. For the next 10 minutes, he sat down and showed me through his “protocols,” which he lent me overnight. I made a set and went to clinic the next day with a different feeling—a bit skeptical, but definitely curious. Soon I was having a very new and remarkable experience. Things went smoother and faster, and my time was better spent gleaning the necessary information from the patient rather than reinventing common medical care. In a short time, I found myself, leaning out of my little evaluation room, much happier, and much more often, calling spiritedly to the next of dozens of patients still waiting, “Mary Jones, come on down!”

Not everybody should have to learn the hard way that there are certain times and places for protocol use within the patient evaluation and care process regardless of where you practice your medicine. I guess, in a way, the first life I ever “saved” with a protocol was my own. J