Kerbside Conversations: James Oswald

Welcome to Kerbside Conversations – the College’s podcast capturing authentic voices and stories from across the world of paramedicine.

In this conversation, James Oswald, a paramedic and clinical guidelines specialist at Ambulance Victoria, discusses the role of clinical practice guidelines in healthcare. He emphasizes the importance of understanding these guidelines as tools for informed decision-making. The conversation explores the evolution of clinical guidelines, the significance of escalation of care, and the development of multi-variable risk assessment tools. James also shares insights on how aspiring paramedics can get involved in guideline development. 

Chapters

• 0:00 Introductions & role of the CPG specialist
• 2:57 Protocols vs guidelines
• 4:17 Escalation of care
• 5:11 Multivariable decision-making tools
• 8:18 Getting involved with clinical guideline development
• 10:15 Night shift guilty pleasures

Transcript

Laura Hirello: So let's start out. Can you please tell me your name, where you're from, and what your current primary role is?

James Oswald: My name is James Oswald, I'm a paramedic and clinical guidelines specialist at Ambulance Victoria, shockingly enough, in Victoria.

Laura Hirello: Makes sense, as you would expect. And so for those who are uninitiated, what exactly does clinical guidelines specialists do if you can do it in one sentence?

James Oswald: Yeah, so we provide expert clinical advice to the entire organization. The main way that we do that is through clinical practice guidelines. That's the most visible way that we do it. But we also provide that advice to other parts of the organization. For example, if we were buying a new ventilator, then we would be involved in the clinical component of that. And then, of course, the message that we want to capture in guidelines is a bit useless if people don't understand them. So, we have a role in explaining the guidelines as well. I do things like podcasts and videos and educational materials as well.

Laura Hirello: I didn't realize that you guys actually played a role in some of the equipment pieces and like advising, but that makes sense. If that has to work synchronously with the protocols, then it would make sense that you would inform on that. Yeah. that's interesting. Okay. And do you feel like there's a lot of maybe not disinformation or misinformation, but misconceptions out there about what clinical practice guidelines are and sort of where they've come from?

James Oswald: Yeah, I think there's a lot of really unhelpful legacy ideas about our clinical practice in general. A lot of ideas about how we as the guideline makers feel guidelines should be written. I often give a talk to new graduates and I say, how many of you think that I'm here to say follow the guidelines or you'll get sacked? And there's always a few people who put their hands up and that's really understandable because that is the cultural background that we have.

Laura Hirello: Legacy that we've inherited.

James Oswald: But that's not the message that I'm there to deliver. In short, guidelines are there to help you make an informed, justifiable decision. They do some of the heavy lifting for you, but they don't do the whole job. They're there to help, but they're useless in the hands of someone who is not an educated, thoughtful, reflective professional.

Laura Hirello: Yeah, they're resource, right? And they're meant to be used as such. So, controversial question. Obviously, you work with clinical practice guidelines. Do you feel like there are any particular areas where protocols are still more appropriate than a more guideline-based sort of resource?

James Oswald: Yes, two things come to mind. The first is escalation of care, because the entire point of escalation of care is to take human fallibility out of the picture. And so we actually don't want a lot of judgment dictating escalation of care. We do want people to say, you know what, this person has this feature or they have a heart rate of this or they have a blood pressure of that. I'll escalate care. It's permission to call. That's how the system should work. That's not to say the clinical judgment doesn't have a role on top of that because every escalation of care, guideline or algorithm or protocol has clinician concern as part of it, so that's important. But that's one part, escalation of care. The other part is areas where there is a high degree of stress and a single action that we want. And that there's really no, there's no reasonable variation from that action. The main one that comes to mind is can't intubate, can't oxygenate scenarios. And you may be able to make an argument for protocolizing other forms of high stress care. Perhaps some aspects of cardiac arrest care, I'd probably shy away from saying that with certainty, but certainly escalation of care and CICO are two areas that come to mind.

Laura Hirello: Interesting. OK, so when you were talking about escalation of care, you used the phrase permission. I think that's really interesting because we have all these clinical practice guidelines with the goal of guiding and empowering clinicians to use their own judgment. And so then, of course, there's this sort of counterbalance to that where there still have to be occasions and we have to be able to recognize and make it okay to say sort of, I'm in over my head. I need somebody else. Or maybe not, I'm in over my head. But this person needs more definitive care than what I can sort of offer. And so, I love the idea of a protocol as something that gives you permission to sort of not let yourself off the hook, but accept that you're in a situation where you are only one person, and you have limited means, and there are alternative pathways around. I think that's really fantastic framing. Precisely. Yeah. So interesting.

So when you are doing your clinical practice guidelines, I'm assuming you've worked on many, many, over the years.

James Oswald: Yeah, most of the book now.

Laura Hirello: Do you have a favorite?

James Oswald: I do.

Laura Hirello: What is your favorite? And it can be for any reason. I will ask you why, but it doesn't have to be a good reason.

James Oswald: My favourite is our sepsis and infection guideline. Not for a good reason.

Laura Hirello: There's, I don't think you can preface it like that. Whatever reason you choose to have a favorite CPG is, is valid.

James Oswald: Yeah, I'll rephrase that. It is for a good reason, but not the reason that some people would think is a good reason. It's because it's introduced for the first time a multi-variable risk decision tool in the form of NEWS2. And we're really familiar with existing single parameter escalation of care tools. You know, their blood pressure is less than 90 or their heart rate is greater than whatever. And that's a bad thing and it means we do a thing.

But that's a really low fidelity way to make a decision on the basis of one piece of information. And for a long time it's been true that taking multiple pieces of information into account in a tool is the way to go, but it's hard to operationalize at the point of care because you kind of need a calculator or something. We have that now at Ambulance Victoria in form of the app. We have a NEWS2 calculator, which is great. It is the first step towards using more and more variables in our decision making, particularly around risk. So that has moved us from making a decision around risk on the basis of one variable to about 10. And I think the next step in the next few years is to make the decision around risk on 100 variables or 1,000 or 10,000. Obviously, that's beyond the realm of a human to do at the bedside. And we're talking really about AI.

Laura Hirello: But that's so interesting that, we have always used these sort of if-then statements. If the blood pressure is less than this, then you have to do that. And it sounds like this one is really taking and operationalizing a much more sort of critical thinking approach, where we're looking at somebody more holistically. We're looking at sort of a whole series of variables, and then still with a guideline behind us, using that to sort of guide decision making. I think that's really interesting.

James Oswald: Yeah, it just gives a more nuanced view of what the risk is and it tends to capture people around the edges a bit better. So if their heart rate was borderline and their blood pressure is borderline and their resp rate is borderline, with a single variable system, they don't tick any of those boxes, but with multivariable systems like NEWS, that adds up to a high degree of risk. And as you allude to, that still doesn't make the decision for you. You can spit out a score. And it's seven, you go, gee, that's not good. Still gotta do something with that and make a decision. So it's useless if the clinician using it is not thoughtful and reflective and well-educated and experienced. Doesn't do our job for us.

Laura Hirello: No, absolutely not. But it is quite literally a resource that helps us do our job better and helps us do our job more consistently across the board and across clinicians. And so for all these young up-and-coming paramedics out there who might be interested in getting involved in developing clinical practice guidelines, how would one start? Is there a way in?

James Oswald: That's an excellent question. I think the first place to start is understanding the science that underpins what we do. That's my answer to an awful lot of questions about how should students X? It's to understand the science. I've got a real thing about memorization being only part of the picture and excessive focus on memorization. think an awful lot of the answers for every aspect of our profession comes from understanding rather than memorization. It's not to say memorization doesn't have a role, but that's another conversation. So the first step is to immerse yourself in the science. then...

Laura Hirello: I love that answer as a researcher.

James Oswald: Yeah. And the second then is to pursue formal education in some related field. We often get contacted by people asking how they can become more involved in research. Is there a project they can help out on and so forth. And I totally understand the interest. But it is its own skill set. Guideline development itself is its own skill set as is research. And so it is difficult simply to take an existing clinical skill set and walk straight into research or guideline development or leadership or any of the other related kind of disciplines that paramedics might want to do. And no different than if someone had come to a paramedic and said, how can I be more involved in paramedicine? Well, go and get a paramedic degree is a good answer. To pursue a formal education in research, I chose to do a master's public health and that was great. That was what worked for me, but there are all manner of different ways that people can do it. Expanding our horizons in relation to postgraduate education is really the future for us, I think.

Laura Hirello: Absolutely. Yeah, and like research is a skill and it's sort of like one of those things that you can, you know, start with just basically research literacy but you can build up over time and can be really helpful in a number of different areas. All right, so our final question, and I ask this as somebody who researches shift work, what is your night shift guilty pleasure? Either when you're on a night shift or post night shift, what do you do to make yourself feel a little bit more human?

James Oswald: A souvlaki. Between 10 and 1. And this is terrible answer from the point of view of health. The souvlaki is not a great answer from the point of view of health either. But I used to drink around about 2 litres of Coke Zero on a night shift and I would just stay up the whole night and read. I didn't like sleeping on night shifts because if you happen to work in a branch where that was an opportunity, I didn't like it because I hated being woken up. And so I would just...

Laura Hirello: Avoid that.

James Oswald: I would just take in an incredible amount of caffeine and I'm a night owl. I love the night and I would just pore over science. I mean you would not be shocked to learn that if you know anything about me. I loved night shifts the quiet and the science.

Laura Hirello: As somebody who also used to hang out at branch with their textbooks, I can very much appreciate that answer. But thank you so much for chatting with us today about clinical practice guidelines.

James Oswald: Thanks for the opportunity to speak with you.