Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Flipping the Patient the Bird

There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.

vs.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.

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The Bird is the Word – Coma Toast

At Coma Toast, there is a thorough thrashing of the EMS addiction to flying uninjured patients just because we can. The Bird is the Word.

Now, there are a lot of arguments out there about the use of medical helicopters. It’s in the dispatch criteria….it’s in the protocols…..patients can get to the hospital faster. However, most of these arguments can be debunked by actually looking at patient statistics of those transported by ground ambulances verses those who were flown.

Another problem with helicopter abuse, perhaps the most deadly abuse of the helicopter, is to excuse the employment of medics and basic EMTs who cannot competently assess patients.

We don’t need to know what is going on – just put them in a helicopter.

We don’t need to be able to treat patients – we only need to be able to immobilize, get 2 large bore IVs, and hook up the ECG before the helicopter arrives. And don’t forget the non-rebreather mask with 25 liters per minute of oxygen flow.

Why think about patient care, when we have already decided what we are going to do to the patient – before we even see the patient?

We say – Look! The patient we flew the day before yesterday is driving a new car today. The helicopter saved him! We are so awesome!

No.

We should hang our heads in shame at flying uninjured people.

If we overloaded the cath lab with patients who do not have STEMIs, we would be the laughing stocks of EMS.

But put a patient with a bruised fender and a mangled bumper in a helicopter and nobody will criticize a thing.

A large percentage of the people we inflict perform needle decompression on, do not have even simple pneumothoraces, yet we treat them for life threatening tension pneumothoraces. We even document the rush of air escaping from the needle that never even reached the lung.

The needle wasn’t in the lung, so where did the air come from? A brain fart?

We immobilize even the witnesses to car crashes, because we are that bad at assessment.

We do a pathetic job of educating people to perform trauma assessment (of patients – not cars) and we do not remediate those who regularly demonstrate incompetence at trauma assessment. Maybe we need a White Paper on the abuse of patients by EMS.

We justify these treatment errors that injure and kill patients with, You can’t be too safe!

Injuring patients with incompetence is safe?

Killing patients with incompetence is safe?

Compared to what?

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First Few Moments – Mechanism Of Injury or Idiocy


On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.

Mechanism of Injury or Idiocy?

Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.

Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.

One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.

Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently transport the patient.

Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient and manage the airway.

50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.

Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?

The alternative is to limit EMS to effective treatments.

Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

It is important to train/educate EMS well enough to be able to provide this competent assessment.

It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.

Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess and manage the patient’s airway.

Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?

The alternative is to have competent EMS.

The answer seems to be that we need to improve EMS and EMS education – a lot.

Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.

Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.

If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.

If we do not understand what is going on medically with the patient, we should not be making patient care decisions.

Calling for a helicopter because I am too stupid to assess my patient is bad medicine.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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Helicopter Crash vs. Ambulance Crash

In the past week there have been a couple of EMS crashes that have made the news.

The first crash is from Maryland on Friday, August 27.

Captain Oscar Garcia, spokesperson for Montgomery County Fire and Rescue, says the ambulance had just refueled after dropping off a patient at Shady Grove Hospital and was heading back to Station 3 when for some reason, the ambulance went off the road and down a hill into a ravine on Falls Road near Liberty Lane.[1]

Elsewhere it was reported that the crash was a rollover –

MOI OMG Panic! Double Panic!

Get Me A Helicopter, Yesterday!!!11!!!!

A Rollover!

The four firefighters had minor injuries and were taken to the hospital to be checked out, but they are expected to be ok. The car failed to stop and left the scene.[2]

It seems that somebody on scene decided to actually assess the patients, rather than triage them according to Mechanism Of Idiocy.

The second crash, this morning, did not have such a positive an outcome.

The Air Evac Lifeteam helicopter was flying to pick up a traffic accident victim when it went down near the Scotland community in Van Buren County at about 4:30 a.m., Federal Aviation Administration spokesman Lynn Lunsford said.[3]

Air Evac has experienced several fatal crashes in recent years.

In 2008, an Air Evac helicopter crashed in an Indiana cornfield killing three people. In 2007, another three-member crew was killed when an Air Evac helicopter crashed in Colbert County, Ala.

In 2006, an Air Evac helicopter crashed in Gentry in northwest Arkansas, killing the three-member crew.

Last month, an Air Evac helicopter made a forced landing near Tulsa, Okla., after the aircraft’s hydraulics failed. No one was hurt.

(This version corrects to delete information on a crash in western Tennessee; that helicopter did not belong to Air Evac.)[3]

At least the patient was not yet on board.

There is no information provided about what kind of injuries the patient was being flown for – that is assuming the patient actually was injured and not being flown for MOI (Mechanism Of Idiocy) by a protocol monkey.

Maybe the patient did have serious injuries, but considering that most patients sent to the trauma center by helicopter do not have serious injuries, betting on serious injuries would be a bad bet.

Our study demonstrated that the majority of trauma patients transported by medical helicopter from the scene had nonlife-threatening injuries.[4]

Our findings are similar to other studies that have documented that a significant number of trauma patients transported from the scene to a hospital by medical helicopter do not receive any added benefit from helicopter transport.[4]




Even though these patients receive no benefit from being transported by helicopter, these patients are exposed to significant risk and exaggerated costs.

This is the difference in outcome between a rollover crash of an ambulance and a crash of a helicopter.

Rollover crash

Minor injuries. None of the patients transported by helicopter.

Helicopter crash

Dead Pilot.

Dead Flight Medic.

Dead Flight Nurse.

The patient being transported by someone else.

Air Evac has identified the crew members who died in the crash as pilot Ken Robertson, flight paramedic Gayla Gregory, and flight nurse Kenneth Meyer, Jr.[5]

Helicopter services do not even seem to care how many of their employees and patients they kill.[6]

Footnotes:

[1] Four Hurt In Maryland Ambulance Accident – All onboard suffered non life-threatening injuries.
JEMS.com
Article

[2] Ambulance Rollover Injures 4
Firegeezer
Article

[3] Three Dead In Arkansas Medical Chopper Crash – Medevac was enroute to pick up a patient.
Chuck Bartels
Associated Press
Tuesday, August 31, 2010
Article at JEMS.com

[4] Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Review.
PMID: 16766969 [PubMed – indexed for MEDLINE]

Full Text PDF

[5] Medical helicopter went down near Scotland in Van Buren Co.
todaysthv.com
Pictures are also from here.
Article

[6] Not Clear On The Concept
Too Old To Work, Too Young To Retire
Article

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A Conversation on Mechanism of Injury


I was talking with one of the long time, weekend, night shift nurses. The people I count on to do what is right for the patient, because the administrators are not around.

Well, I mentioned in passing – I thought it was going to be just in passing – about the recent comment kerfuffle about MOI (Mechanism Of Injury criteria for trauma triage, or just mechanism). This is the assessment skill substitute for assessment that people use as a justification for flying uninjured patients in helicopters.

As if that is safe.

All of a sudden, the nurse started a little tirade about a medic who brought in a patient to this non-trauma center ED (Emergency Department) because he did not bother to report on the MOI when calling for medical command destination decision.

I do not remember what the mechanism was, but it was something vehicular and must have sounded bad, because that’s what MOI means –

The 911 call sounds bad!

or

That dent looks like it is going to cost a lot to repair!.

That has nothing to do with the patient, except that the mechanism suggests things to be more careful in assessing for.

This is all that mechanism means.

You might want to pay extra attention to these things suggested by mechanism.

Mechanism is not assessment.

Mechanism is the equivalent of stereotype, or prejudice, or bias, or racism.

Mechanism is not about understanding.

Mechanism is a shortcut that encourages ignorance.

Mechanism is just a superficial substitute for a patient assessment.

Mechanism is for those who cannot assess real patients.

Anyway, being the blunt person that I am, I interrupted the nurse’s rant, because my shift is only 12 hours long and her rant was looking like a filibuster. I didn’t even have to ask the obvious question about what a simple assessment showed, because the nurse mentioned over a dozen rib fractures and a flail chest.

Clearly, this is not a patient who should have been transported to the local ED with several trauma centers less than 20 minutes away by ground. This is a case, if reported accurately, of an incompetent medic. And not just a little bit incompetent.

Back to mechanism.

What does mechanism add to the assessment of a patient with a flail chest?

A flail chest is a portion of the ribs acting like a trap door. The ribs are broken in so many places that there is no resistance to pressure, except when the patient exhales.

Breathing is not very complicated. The diaphragm creates negative pressure. On inhalation, the diaphragm pulls away from the chest and the accessory muscles also cause the chest to expand. This sucks air in.

On exhalation, the diaphragm and accessory muscles relax and create pressure. This forces air out.

With a flail chest segment, breathing mechanics are mostly normal for everything except the flail segment. The rest of the chest is creating a pressure difference that moves the air. As long as the ribs are intact, they will all move together. When there is a flail segment (2, or more, ribs broken in 2, or more, places is the textbook definition) that broken part of the ribs will move the opposite direction from the rest of the ribs. The flail segment will move in the opposite direction from the intact part of the ribs.

When the ribs are expanding out to create negative pressure, the negative pressure is pulling air into the chest, but the negative pressure is also pulling the broken ribs inward.

When the ribs are relaxing and creating positive pressure, the positive pressure is  forcing the air out of the chest, but the positive pressure is also forcing the broken ribs outward.

This is one of those assessment findings that is hard to miss. The patient may be trying to keep you from assessing that part of the chest, because . . . well . . . it hurts. It doesn’t hurt a little bit. This isn’t just a hairline fracture that hurts a lot. This is a bunch of broken bones that are moving around – a lot – with every bit of breathing.

Not – It only hurts when I laugh.

Not – It only hurts when I move.

But – It only hurts when I breathe.

The normal response to the first two is pretty easy. If it hurts, when you do that, don’t do that.

That doesn’t work very well for breathing. Go ahead. See how long you can hold your breath. Now take a hammer and break a bunch of your ribs. Now, how long can you hold your breath? Not the same thing, at all.

The only time that a flail chest should be missed is when the ribs are not completely broken, in which case, it is not really a flail chest, except for the textbook definition of 2, or more, ribs broken in 2, or more, places. That is the textbook definition. The textbook definition should include the paradoxical movement. Paradoxical movement is what everyone is supposed to be looking for.

Paradoxical means the opposite of what we would ordinarily expect. We would ordinarily expect the ribs to all move together. With a flail chest, the flail segment is moving in the opposite direction from the rest of the ribs.

If the patient is conscious and not disoriented, the pain should be a clear clue to examine the part of the chest being protected. The patient’s arm may act as an excellent splint. Expect to use a lot of morphine/fentanyl/Dialudid. Pain will interfere with breathing more than the opioids will. Fentanyl is less likely to affect cardiac output (blood pressure), so that is my preference.

If people are missing flail chest, we need to ask Why?

We don’t need to complain that the person is ignoring mechanism.

Focusing on mechanism just ignores everything we understand about assessment.

Or do we just not understand assessment?

Mechanism Of Injury criteria for trauma triage encourage incompetence.

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That’s not Klingon It’s One Word Dyspnea: EMS Garage Episode 98

We were supposed to be talking about the potential harm from the way we use oxygen in EMS, but we ended up with That’s not Klingon It’s One Word Dyspnea.

First, I mentioned that I am blogging at a new location – here. Also at EMS Blogs will be Black Hearts Incorporated, EMS Bloggers, EMS Office Hours, Medical Author Chat, Ready Fodder, The Social Medic, and Too Old To Work, Too Young To Retire. So far, EMS Office Hours, Too Old To Work, Too Young To Retire, and I are posting while things are being worked out. The blog transfer has not been fun, but it has been educational. I expect to learn a lot more. And I have to thank David Konig, who has been putting his blog, The Social Medic, on hold and guiding us through this. He has also come up with a nice simple design for my blog that I like a lot.

Then the topic turned to the recent medical helicopter crashes and Ambulance Driver’s post Is that helicopter really necessary? in response to the M.D.O.D. post Do You REALLY Need the Helicopter? Before the podcast, I wrote a post mostly about the comments on Ambulance Driver’s post. Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out.

It should come as no surprise to people who are familiar with any of the participants, that we were very critical of the abuse of helicopter EMS by medical directors, by ED physicians, and by ground EMS personnel.

Why should we try to justify abuse?

The comments in support of helicopter abuse (on Ambulance Driver’s post) are depressing for those of us trying to improve the quality of EMS. These comments do point out the problems I wrote about in Confirmation Bias and EMS. Many of us do not appear to make any attempt to be objective in evaluating what we do in EMS. We only seem to look at things through the filter of our biases. The people writing these comments seem to have decided that helicopters always save lives and they deny that helicopter crashes are a problem.

The purpose of the helicopter is to make a significant difference in transport time for the patient who really is unstable. These patients are not as common as many suggest. They seem to be most commonly encountered by the least experienced people. In other words, as people become more skilled, they panic less and fly fewer patients. The people denying the problems with helicopters seem to be trying to demonstrate that they cannot assess patients well enough to recognize which patients are unstable, which are stable, and which were never even injured.

The people denying the problems with helicopters also seem to demonstrate that they do not understand that they are not saving significant amounts of time. They often are delaying a patient’s arrival at a trauma center just so they can put the patient in a helicopter.

Finally, we did briefly mention harm from oxygen, but that should be covered in an upcoming podcast. Preferably a show with at least one physician on it. There is a lot to discuss, when considering the over-use of oxygen, and it does appear that we use too much oxygen. We have too many patients receiving oxygen without any evidence of hypoxia.

In the absence of hypoxia, there is not evidence of benefit from oxygen, but there is evidence of harm. This goes back to at least 1950, so the idea that oxygen is harmful is not at all new. This is another example of what I write about in Confirmation Bias and EMS.

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Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out

Many people think that my posts on science and logical fallacies are not related to EMS. For a Fantastic Feast of Fallacies, head on over to A Day in the Life of an Ambulance Driver. Read his post Is that helicopter really necessary? More important is to read the comments.

Ambulance Driver is referring to a post at M.D.O.D. by the title of Do You REALLY Need the Helicopter?

First, Ambulance Driver writes this:

Over at M.D.O.D., ERdoc85 wonders if some of his patients are being transported inappropriately via helicopter.

And the answer to that question is, “Hell yes, most of them.”

Ambulance Driver does not write a lot of words in his post, but he does provide a lot of evidence.

The Cult of Mechanism
ems1.com
The Ambulance Driver’s Perspective
by Kelly Grayson

Mechanism of Injury in Prehospital Trauma Triage
ems1.com
The EMS Contrarian
by Bryan E. Bledsoe

Alright, I’ll Say It
ems1.com
The EMS Contrarian
by Bryan E. Bledsoe

Two Dead in Oklahoma Medevac Crash
EagleMed chopper crashed enroute to pickup a patient

JEMS.com
by Ken Miller, Associated Press Writer
Friday, July 23, 2010

Ambulance Driver finishes up with this:

And if your primary justification for the flight is mechanism of injury, or the helicopter is the quickest way to clear an ER bed, or to allow your ground EMS crew to go back into service sooner, you’re part of the problem.

Nice and concise with a lot of evidence and some recent news about the real dangers of HEMS (Helicopter EMS).

Dr. Bryan Bledsoe, often wrongly accused of hating helicopters, hating flight crews, and just hating EMS, concluded Alright, I’ll Say It with this paragraph:

I had better bring this tirade to an end. While flying home today from Philadelphia, it hit me that I knew more people who have been killed in a medical helicopter accident than by virtually any other means. At some point in my life I have met or spoken with at least five people who later died in medical helicopter crashes. They were all great people and died doing what they loved. We owe it to their legacy to assure that not a single flight nurse, flight paramedic, pilot or patient dies unnecessarily.

The highlighting is mine. The hating is not there, no matter how much people would like to believe that the only way anyone could point out the problems with HEMS, or with EMS, is to hate HEMS, or to hate flight crews, or to hate EMS.

How many people spend as much time trying to improve EMS as Dr. Bledsoe does? Certainly not those who ignorantly criticize him.

You might think that any contrary opinions expressed in the comments would be well thought out, so that those commenting would not completely embarrass themselves. You would be a hopeless optimist. Maybe some quotes from the comments will cure you.

Reading the comments, I wonder how these Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out types even mange to put decipherable sentences together. These comments certainly do not demonstrate anything that passes for understanding.

Even in the week since that post, there has been another fatal HEMS crash.

Arizona: Helicopter Crash Kills 3
By The Associated Press
Published: July 29, 2010

Here is a sampling of the commentary in defense of unnecessary helicopter flights and in defense of the unnecessary deaths of flight crews and patients.

I find this article insulting.

. . . and yes I have lost friends in airmedical crashes, but I still continue to fly and support our system.

Because if he were to admit that a lot of them died unnecessarily, that would really mess with his cognitive dissonance.

Did he read any of the linked articles?

Maybe.

Did he understand any of the articles?

Not much chance of that, assuming he did read any of them, with his cognitive dissonance protecting him from the truth.

Support our system, even if it is killing us! Go Team! Rah! Rah! Rah!

Better to be insulted, than to think.

Another writes:

I WOULD RATHER BE SAFE THAN SORRY.

This is safety?

This is not being sorry?

Then this clown accuses Ambulance Driver of being a city slicker.

Someone else criticizes a flight medic for agreeing with Ambulance Driver about the unnecessary flights.

i am sorry to hear that you get silly calls, but that is part of the job and you go when you are requested. if you dont take it then we get called as the ground crew, then you get to get back to your nap or tv show you are watching.

This one appears to think that the danger involved is limited to missing one’s favorite TV show and having to watch it later on TiVo®. He probably only remembers this bit of poetry:

Their’s not to make reply,
Their’s not to reason why,
Their’s but to do and die:

This from a raconteur wanna be:

Or better yet, when we get launched for an MVA and then declined because they end up taking the patient to the local hospital. Then invariably we’re called about 4 hours later to pick up a soup sandwhich and take them to the Level I trauma center. And what was the Rx given at the hospital, other than a cashechtomy?

Invariably?

adverb
in every case or on every occasion; always:

He is describing a problem. It might only be an imagined problem, since he does seem to have wandered, more than a little bit, from the path of the truth. He seems to be very interested in providing an entertaining story about how he could save the day, if only they would call him earlier. He does not seem to have much interest in improving anything for his patients, unless it involves him swooping in from the sky to rescue them.

Are any of these comments not great examples of the failure of logical thinking and the victory of bias?

Better safe than sorry imagines that transport by HEMS is not any more dangerous than transport by ground. Not only that, he claims that transport by HEMS is safer than transport by ground EMS. I do not doubt that this is the case, when he is the one treating patients in the ambulance. He does seem very dangerous.

Then he assumes that Ambulance Driver must not be familiar with rural EMS, even though Ambulance Driver regularly writes about rural EMS. Better safe than sorry seems to think that the only way anyone would not agree with him is to be unfamiliar with what he deals with. I do not know much about what he deals with, but I can tell you that it is not reality. In his mind, he redecorates reality with a Feng Shui that is pleasing to his prejudices.

Then there is the guy who thinks that the most dangerous part of HEMS is repetitive stress injury from overuse of the TV remote.

Picture Credit

A real medic would walk away from that, with the patient in one arm and the pilot over his shoulder. Piece of cake.

Just put down the remote and fly, you sissies! We need to sacrifice you on the altar of the Magic Rotor Cure! Think of the Glory!

EMS flight crew is only the most dangerous job in the US, so why not abuse them to death – the patients, too.

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Double Edged Swords

Also posted over at Paramedicine 101. Go check out the rest of what is there.

A post at Paramedicine 101, by Medic999, raises some important questions. Chronicles of EMS – A double edged sword? This is what I think addresses the most important part of the way we do things and why we do them differently in different places.

Before all of this crazy show started, I lived and practiced in my own little bubble. I used to naively think that we were the best at what we can do.

That is the human thing to do, to assume that our leaders are making the right choices.

I take the opposite approach. I want our leaders to prove that what they are doing is good for patients. Not that their way is the best way, but that their way can be demonstrated to be good for patients.

Most of what we do in EMS fails that test.

Why should we continue to use these experimental treatments?

Why should we continue to we continue to be guided by ignorance?

Medic999 points out that he was unaware of some possible improvements to patient care. Now he wonders why his protocols do not include treatments like therapeutic hypothermia.

We often will dismiss something because it is a foreign idea. If you want to have a political idea ridiculed, one of the quickest ways is to suggest that it came from France, except if you are in France. As if the origin of an idea has anything to do with the quality of the idea.

There is nobody so perfect that he/she never produces a bad idea. Conversely, we should not assume that there is such a perfect fool, that he/she never produces a good idea. To assume that the origin of an idea is more important than the idea, is itself a bad idea.

Unfortunately, Not originated here means not used here is EMS dogma in many places.

We come up with excuses to avoid changing things.

We act as if our patients will be better served by avoiding improvements in EMS care.

If we are not here to provide the best care to our patients, shouldn’t our patients be protected from us?

One objection that I repeatedly hear from EMS traditionalists is that, We have to be able to say that we did everything we could for the patient.

The parts they leave out are –

As long as the idea originated here!

As long as we don’t have to change the way we do things!

As long as we don’t have to sit in a classroom, or read, or do anything else that would be considered learning!

As long as the patient does not expect us to provide excellent patient care!

As long as we get to spend more time stroking our egos than we spend on improving patient care!

Chronicles of EMS is a double edged sword. Through Chronicles of EMS, Medic999 has more knowledge about what EMS does in other places. Now he is less satisfied with the way things are done where he works. His satisfaction level has decreased because his knowledge level has increased. This is where the term ignorance is bliss comes from. The more we know, the less satisfied we are with traditional solutions.

But this is not about satisfaction. The decrease in satisfaction is only due to looking at things the wrong way. With more knowledge we have the ability to make improvements that make things better for patients.

When we learn that most patients flown to trauma centers did not benefit from being flown, we realize that we are contributing to the excessive death rate among flight crews when we call for more flights, which leads to more helicopters, which also leads to a greater dilution of experience for flight crews. Tradition tells us to fly patients based on mechanism of injury. This allows the blissfully ignorant EMS personnel to think that they snatched the patient from the jaws of death.

When we learn that by rushing to perform ALS procedures during CPR, we have been neglecting the quality of chest compressions. When we improve the quality of chest compressions, we triple the survival rate – the real survival rate, not the misleading and short term return of a drug induced pulse. This is the first improvement in survival to discharge. This only came by discarding the traditional way of doing things.

When we learn that intubation is performed horribly in many places, some of us work to improve our intubation skill, some move to alternative airways much more quickly, some do both, while traditionalists just claim that it is more important for them to intubate, than to provide competent airway management.

Ignorance can be bliss. Tradition can be bliss. Both can also be deadly for our patients.

Knowledge is a double edged sword, but it is much better to provide excellent patient care than to hide behind That’s the way we’ve always done things!

Medic999 is not suggesting that blissful ignorance is better. He is pointing out that the more he knows, the more problems he becomes aware of. This is not a bad thing.

If we are not aware of the problems, we will not correct the problems.

If we do not correct the problems, our patients suffer.

The more we know, the less satisfied we are with traditional solutions.

Our goal should be the protection of our patients by the destruction of our traditions.

Over at Medic999, there is a vigorous discussion in the comments to CoEMS – A Double Edged Sword.

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