The One Thing That Never Changes in EMS Is…Changes in EMS

Speeding ambulance

By Stephen Marsar

Above photo by Tim Olk

Over the last several decades in the fire and EMS services, we have learned that the one constant – particularly in EMS and more recently on the fire side—is change. Additionally, as an instructor, I have also learned and preach that we should avoid using the word “change” as often as possible (I know, I know, I’ve used it four times in this article already, but hear me out).

As an EMS Instructor, course sponsor, or EMS officer, how we approach change is key to being successful and cutting down on the stress for our members.

Chump Change

Change is simply a bad word. Some people loathe it, some people fight it, and others try to ignore it. Almost everyone is uncomfortable with it. The EMS side of the house gets it. Instead of the “C” word, we’ve grown accustom to using the word “update.” For decades that has served us as a more comfortable and reflective term for what we do.

Based on scientific and medical research, trends, and (probably) lawsuits, EMS is constantly reflecting on what we do and how it affects our patients both positively and negatively. The powers that be in state health departments, the Federal Department of Transportation (yes, that’s who we fall under), and regional and local EMS groups (councils, committees, or whatever they’re called where you operate) are usually the ones who adopt protocols and mandate updates from on-high. We – EMS providers, educators, and course sponsors – are expected to disseminate them in our classrooms, on the street, and in the back of our ambulances.

Reflections on Protocols

After 10 EMT refreshers, becoming a certified instructor coordinator, and state regional faculty member, I’ve also had to endure between four and six protocol updates (who can remember the exact number?) What I do recall is the frustration and uncomfortable feeling that the mere term protocol update conjures up (could you imagine the added emotional stress if they were called “protocol changes”?!). Although it seems that most EMS care protocols come and go only to come back again in some way, instructors and course sponsors are often left holding the bag when it comes to interpreting and disseminating the updates to our brother and sister EMTs. So how might we best approach this task?


Managing Change

The Impact of Change

More Change Lessons

Effect Change the Right Way

In the old days, the New York Department of Health (DOH) would print and disseminate protocols in written form (books) and send it to every EMT or course sponsor in the state. Once the costs of doing that became prohibitive and as electronic communications became mainstream, they have resorted to printing the most up-to-date protocols on their website for all to access and download or print to your heart’s content.

The shortfall apparently lies in the understanding of exactly what items have been updated and, even more importantly, why they have been updated.

Examples of Circular Protocols

Understanding that the “why “of each updated protocol might be a logistical challenge in the context of printed protocol updates. Perhaps the easier question to identify is simply What has been updated. Looking at the newest update from my state DOH as an example (available at,  which takes effect in August 2019, I noticed that great care has been made to color-code the different levels of BLS and ALS care, respectively. The written protocols flow in a logical order and bullet points are used rather than longer written narratives. These are all good additions and make the protocols easy to understand and follow at a glance. Where we instructors and officers need to delve deeper is what has been updated since the last set of protocols. Some old items may have been resurrected and some new or updated items may be clarified. If we skim through the new protocols these nuances may easily be missed.

Two-Way Street

There are two schools of thought on identifying updated, deleted, or added items in a protocol. In my mind, I’d like to see the new, updated and/or added sections printed in black, bold, italics. From an instructor or course sponsor stance, this would make updating PowerPoints, lesson plans, lectures, and so forth a much easier and a less time-consuming proposition. Additionally, for refresher classes this simple measure would help us know what to concentrate on to assist the EMT students to truly get refreshed, receive the updated material, and learn the newest ways of applying their professional skills and patient care modalities.

The other thought process is that the new protocol is just that – the new protocol – and now they represent the only acceptable standard of care for that jurisdiction. Therefore, patient care providers at every level should read through the entire protocol and understand it as the law of the land. Although this approach makes sense and avoids the human tendency to merely skip through the updates looking only for the bold italics noted above, it does not allow for a comparison to be made to the former protocols. For patient care providers this may make sense, but from an instructor or EMS officer perspective it may add time and open the door for interpretations that may not be based on sound medical knowledge or fact.

Bridging the Gap

Bridging the gap between protocol updates and EMS care on the street may simply require instructors and officers to take a deep breath, acknowledge that some things are out of our control, and remember that disseminating the new updates to our crews – which will ultimately provide the best patient care – is really what it’s all about. Attitude isn’t the only thing, but perhaps it’s the most important thing for the people whose job it is to take any new protocol updates and demystify them for our troops in a war that never ends.

If you see a need for improving the way your jurisdiction’s protocol updates are prepared and disseminated, don’t just complain about them. Complaining will never solve the issue and you will simply be known as a whiner. Instead, write down your ideas, give at least two solutions to each of your misgivings, and send them through your chain of command (and don’t forget your local EMS academy or program sponsor for their input or endorsement). Get them in front of the individuals who are in charge of producing protocols and updates for your state or region and ask for their feedback. This is a professional and positive approach to making updates to the way that our updates are updated (Whew!).

The Waiting Game

In the meantime, when you are invariably given updated protocols, in place of the obvious identification of what is new, read every word that has been printed in them. Try to think of it as a fresh look at what we’re expected to know and to follow in our line of work. Highlight the items that you identify as being different, new, or deleted. Get together with other instructors, officers, or EMS course sponsors to ensure that nothing is missed or misinterpreted. Take a team approach. Break down the protocol into sections and assign individuals (or small groups) to go over their respective protocols, identifying all additions, updated, or deleted material. Afterward, get together to discuss and document what was discovered. Consider typing up a “cheat sheet” that highlights the differences between the new and old protocols for your members and EMS students.

Stephen Marsar, MA, EFO, CIC, is a 29-year veteran of the Fire Department of New York (FDNY) and a battalion chief in Battalion 6. He served as chief and commissioner of the Bellmore (NY) Volunteer Fire Department. Marsar’s certifications include National Incident Safety Officer; FDNY IMT—Type 1 unit leader; National and New York State Fire Instructor level II; and Department of Health regional faculty member. A two-time winner of the Federal Emergency Management Agency National Outstanding Research Award, he is an adjunct professor at Nassau Community College and a chief instructor for the FDNY and Nassau County Fire Service and EMS academies. He is an advisory board member of Fire Engineering and JEMS.


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