The Successful Non-Visual Practitioner

Hi,

The practice of using paramedics in communication centers using AMPDS is neither recommended nor discouraged by the IAED. There are both benefits and detractors in having a paramedic or EMT background while working in a communication center. We have seen times when a paramedic, because of their training, has made good decisions and was able to work “outside the box” when dealing with difficult  circumstances,  and we have seen several critical errors made by paramedics due  to  their  experiences or situational bias relating to how they managed an incident (failed to follow protocol). Paramedics are trained to assess patients  visually  and  tactically, and they typically use a differential diagnosis approach,  trying  to  ascertain the most likely cause of the patient’s presenting symptoms.

The EMD should never do this; they are taught instead to choose a Chief Complaint Protocol and then follow that protocol to identify signs and symptoms pertinent to that complaint type that assist in choosing (i.e., coalescing all data received determining) an appropriate Determinant Code. Non-clinical EMDs have demonstrated an excellent and scientifically proven history of doing this safely because they are specifically trained to do so and, in essence, they know no other way. There are many paramedics that do the same thing because they have been specifically trained in non-visual, protocol-driven EMD, and their agency’s quality improvement process supports them. However, it has been our experience that a paramedic’s clinical knowledge and visual-based training can hamper her/his “blind” EMD efforts if not managed properly.

The best non-visual practitioner is that person who follows the protocol, understands the psychology of DLS, and has excellent listening communication skills while working with someone in crisis. Historically, the Emergency Priority Dispatch System Protocols were designed with the non-practitioner in mind. As stated in the National Association of EMS Physicians EMD Position Paper originally published in the Journal of Prehospital and Disaster Medicine in October 1989: “Training as EMDs is required for all dispatchers functioning in medical dispatch agencies... This training includes content and results in competence which differ substantially from that standardly provided for EMTs and paramedics. It must be taught by specially trained instructors… Training in these priorities must be detailed and dispatch-specific (not EMT or paramedic training per se).” “Since much of the knowledge and many of the skills required by the EMD are dispatch-specific, a curriculum for their training differs substantially from those used in the preparation of EMTs or paramedics. Training as an EMT or paramedic does not adequately prepare a person for the role of an EMD.”

You asked if the IAED has any research on AMPDS compliance comparisons between paramedic-trained EMDs vs. civilian EMDs. In the early 1990s, while in a paramedic fellowship program studying research and quality improvement in Pinellas County (Florida, USA), I [Brett Patterson] conducted a study related to this question: Is there a benefit associated with using field clinicians, specifically paramedics, as calltakers in an EMS communication center? Unfortunately, we never published this informal study as it was done to answer an internal question, and I have always regretted that because now the subject is an FAQ.

Our public utility model EMS system used EMD-certified paramedics as EMS calltakers. It was actually a promotion from the field to enter dispatch,  and we had to be not only county and state-certified paramedics, but nationally certified as well. Our question was, do these credentials enhance the EMD process? Our method was relatively simple. During the routine QI call review process, which I conducted alone at that time, I would listen for any ad-libbed questions or advice asked or provided by the paramedic-trained EMD and record whether or not the intervention had a pre-arrival impact on safety, patient care, response allocation or mode, or information for responders. These were the criteria used simply because they are considered to be the primary roles of the EMD.

While I do not have a record of the results of the study, our assessed impact of paramedic knowledge in dispatch was miniscule. While there absolutely were questions asked and instructions given that were not included in the AMPDS, we found virtually no pre-arrival benefit, with the exception being one or two cases of complications during childbirth. However, one must now be cognizant of the fact that the childbirth PAIs at that time were rather basic in the sense that they handled only normal childbirth and very common complications; the protocol has evolved a great deal since then and now handles a wide variety of childbirth complications including various forms of breech birth.

What we did learn from the study, at least in part, was that paramedics tended to revert to their field methods and practices with regard to their questioning, and they were prone to ad-lib instructions as well. This fact obviously affected protocol compliance (as well as call processing times), which was just beginning to be formally evaluated by the then NAEMD.

It is important, at least in my opinion, to address the common argument that field or hospital clinicians, trained essentially in visual and tactile assessment, make bad EMDs because they tend to be protocol non-compliant. In my early days in dispatch, when QI was non-existent or in its infancy, this was certainly true. However, my personal experience as a CTO, and then the first QI coordinator for my agency, eventually dispelled this myth. By simply using the manufacturing industry’s QI techniques I was learning in the fellowship program, i.e., measurement, feedback,  and education,  we raised our overall compliance from 17% to current accreditation levels in less than 6 months. My conclusion was, and still is, that anyone can make a great EMD, provided they have a sound appreciation for the unique nature of non-visual medicine, and are provided the feedback and education necessary to foster continuous improvement.

Collectively, we feel very comfortable that the Academy-certified EMD can manage almost any situation they are presented with, and protocol compliance allows this intelligent system to do the right thing. Since 1979, we have not seen any successful litigation against any certified EMD using the AMPDS, and we take this as precedence the system works well, and was specifically designed for any EMD-trained and certified person who compliantly uses it, regardless of their previous clinical experience or training.