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

- Rogue Medic

More Medics Means More Medical Misadventure – more commentary

This is another post that is a reply to Anonymous 30 year FF/Medic in the Southwest US. First, to clarify one important point.

I do not dislike fire fighters.

I do not disapprove of fire fighters.

We each could argue that the other group has dumber people forever. We all have our examples of evolutionary misconduct. There are plenty of single role medics, who would mess up an order for beer if they were tending bar. Keeping fire and EMS separate will not eliminate that, but I think that it will be a big step toward decreasing that. A step toward directing people to their aptitudes, if any.

There is little about being a good fire fighter that will help you be a good medic. There is little about being a good medic that will help you be a good fire fighter. Discipline and intelligence will help with both, but they are not exclusive to either job. They are not enough of a similarity to justify cross-training.

I do not like treating fire fighters any more than I like treating police or EMS. Everybody should be able to come home from their jobs safe.

Every day.

I think that being trained to do your job to the best of your ability is going to make it more likely that this happens. The bad guy goes to jail or the morgue and the police officer goes home without injuries. The fire is controlled quickly and put completely out and the fire fighter goes home without injuries. The patient is treated well, has the best chance of a good outcome and the medic/EMT goes home without injuries.

Anyway, I do not think that anyone commenting on these posts has been suggesting that this is the good guys vs. the bad guys.

Anonymous said…

“‘Subclavian lines? Why? Water saves lives in fires, but rarely in a patient’s veins. You put the wet stuff IN the red stuff.'”

“You lost me on this one.
A trauma pt needs some kind of blood pressure to make it to surgery. The IV is may not be first on the list of things important, but is is on the list.”

I think that Dr. Mattox has made some very good points about the need to control the bleeding before adding fluid, even if the fluid being added is blood. There is too much attention to treating the blood pressure at the expense of survival. The research is not at all clear on what is best. I prefer to avoid treatment, rather than follow what was expert opinion long ago when trauma research was more of a concept than a reality. I will write a bunch of posts about that, but not this week.

How much BP they need is something EMS does not seem to agree on. Systolic BP of 50? 60? 70? 80? 90? 100? The number may not be one number for all patients, but I think that the higher end numbers are a bad idea, similar to withholding appropriate pain medicine out of inappropriate fear of respiratory depression.

“If the limbs are busted up, burned or missing and there isn’t a peripheral IV site handy, central lines work just dandy.”

I’ve never started anything more central than EJs on a patient. I have seen doctors take forever to start subclavians. One took almost an hour. In a moving ambulance, this might have been abandoned earlier, or the decision to stay and play might have been made. Staying and playing is already a big problem. Part of the quality issue.

IO’s with a pressure infuser just don’t give decent volume in my experience.”

I do not think that the volume is as important as we have been led to believe.

“Don’t ‘stay and play’ but enroute to 1 of our 5 trauma centers get done what needs to be done. Even with 5 centers, I’ve had transport times over 40 min.
Urban sprawl at its best.”

This is true.

“‘If I want to be a helicopter pilot and want to be a flight nurse, should cross-train everyone so that I can have my dream job?'”

“Get your nursing license and your pilots license. Why would you train everyone?
Your employer doesn’t have anything to do with it unless you want them to pay for it. Once you have the license you want, get the job you want. :)”

This was a reference to your desire to be both fire fighter and medic. Your desire fits the framework of your employer, but there is nothing really connecting the two jobs. I think that my example just demonstrates that there are many ways of cross-training. Expecting people to do perform different jobs, by combining the job description, is not a good idea.

The response to the person who wants to be a fire fighter and a medic should be the same as the response to the person who wants to be a pilot and a flight nurse/flight medic – “Once you have the license you want, get the job you want. 🙂

“‘If you take a utility truck to EMS calls and rendezvous with the fire apparatus at the fire and have automatic dispatch of medics to all working fires, the result should be better.'”

“We do have automatic dispatch of medics. They’re on every engine.
I shudder at the thought of meeting the fire truck on the scene of a working fire.
If the truck gets there first and the homeowner sees nothing being done because there is no crew, now what?
If the crew gets there first, nothing is getting done because they don’t have any fire fighting equipment.
I wouldn’t want to have to explain that one to the news crews or defend the video that will show up on YouTube.”

You make an excellent point. Although, I expect that there are several crews responding and do not know how common the YouTube experience might be. This would probably generate an auto-lynch response from the public.

“Witness noted: ‘The medics aren’t terrible as a whole, but there are several merchant medics of death who continue to practice their deadly art.'”

“There are some turds floating in every punch bowl. (why I drink beer) If you see a turd, make whoever is in charge of EMS or training do their job and cleanse their mortal souls.
We have had guys given the choice of dropping their patch or going through another medic training course from day one to graduation.”

You have beer in your fire house? Now that is a persuasive argument! 🙂

One of my goals in writing this blog is to try to persuade people to do something about the bad medics. They are dangerous, do not ignore them. I think that the person most responsible for eliminating them is the medical director. An absentee medical director is worse than no medical director.

“Question…
What are you guys seeing in the new hires quality wise?”

I don’t think that they are that much worse than they were years ago, but everybody seems to tolerate a lot more misbehavior than years ago. There is a bit of a problem with kid gloves preventing quality improvement.

A disturbing trend I see is a lot of youngsters (say 19-24) haven’t had a real job yet. They’ve been in school, lived with Mom & Dad and now they get hired here.
Some take to hard work and long hours like a duck to water because they have been blessed with parents that showed them what a work ethic was.
A small but very visible minority have the attitude of “hey, I’d rather be…you know…like, at the lake on my boat.”
By all means, take your boat to the lake. Maybe it will sink and backflush the gene pool of your DNA!

I agree. I had worked in various construction jobs for over a decade before EMS. Part of it is the schools and preceptors not pulling the plug earlier. If they aren’t getting it, get a tutor, repeat the class, or move on to some other career path. Too many people view a good outcome grade-wise as a right or something they deserve for just showing up.

Everyone seems to be afraid of discrimination, but that is what school is supposed to teach us to do. To discriminate between things on a logical basis. That definition of discriminate seems to have been replaced by the fear of someone not being treated as the “beautiful or unique snowflake” we would like to be. Empathy and compassion are important as a medic, but we should not encourage students to use others’ empathy and compassion as a tool to coerce them into giving an undeserved passing grade. Choosing appearance over substance is a bad choice.

The educational system has been moving this way in leaps and bounds. Somebody needs to pull on their leash, good and hard.

I think that one of the differences between fire and EMS is the type of person who excels at the job. In my opinion, good medics tend to be comfortable doing their own thing and not worrying about the protocols, or some other rules. Their job is to take care of the patient. While good fire fighters need to work as a team. You need to know that the fire fighter is going to be where assigned, not going off and trying something else or backing out of the fire without notifying anyone or just not remaining in contact on a scene with limited visibility.

These goals are divergent. Some people are able to adapt to both roles well, but that is not normal.

A medic who is primarily worried about matching the patient with the closest protocol, so that they have some rules to follow, is not a good medic. A fire fighter who needs to do things his own way is not a good fire fighter.

.

Comments

  1. Hey, Tim, found ya!!!

  2. Eureka!

  3. Rm: “I do not dislike fire fighters.I do not disapprove of fire fighters.”Sorry if my responses were strong. I get defensive when I read that ‘fire and medic’ aren’t related and ‘not a good idea.’ To me they mesh very well in the public safety arena. Critical thinking, risk/reward assessment and being able to think on your feet while all hell is breaking loose descibes both job skills pretty well. It’s also the only job I’ve had for 3 decades so I’m kinda proud of it. (other than that short stint working as a medic for a private ambo as a side job. I was putting in so many hours a week the dog didn’t even remember who I was.)Regarding central lines: Anyone who would take an hour to do a subclavian needs to get to a cadaver lab sooner rather than later! I hope this guy doesn’t move to my city.I’ve had good luck with subclavian IVs. The central approach to the internal jug is way faster but you need to turn the pts head – not exactly spine immobilization friendly. “I think that Dr. Mattox has made some very good points about the need to control the bleeding before adding fluid”I don’t know who Dr. Mattox is but controlling bleeding is so obvious I didn’t even think it needed to be mentioned.You noted that sources vary on what B/P should be maintained. That ball will probably get kicked around until an asteroid destroys the planet. I don’t really have a B/P number in mind and personally prefer to use the pulse rate as a general guide. If the pt’s pulse starts to climb or just won’t slow down even a little, I add fluid to the tank. Not the swimming pool that we used to pump into them in the old days, but a fast liter should be enough to see a change for the better if there is going to be one. “You have beer in your fire house? Now that is a persuasive argument! :-)”Not even on our BEST day!!!Stay safe,30 yrs (23 months till retirement WOO HOO!)

  4. Anonymous said… Rm: “I do not dislike fire fighters. I do not disapprove of fire fighters.” “Sorry if my responses were strong. I get defensive when I read that ‘fire and medic’ aren’t related and ‘not a good idea.’ To me they mesh very well in the public safety arena. Critical thinking, risk/reward assessment and being able to think on your feet while all hell is breaking loose descibes both job skills pretty well.”One of the problems of the internet and of my writing style is that it is difficult to convey some things clearly.Those descriptions apply to a lot of jobs, or ought to. “It’s also the only job I’ve had for 3 decades so I’m kinda proud of it. (other than that short stint working as a medic for a private ambo as a side job. I was putting in so many hours a week the dog didn’t even remember who I was.)”I’m hoping the dog had someone else to do the walking and watering stuff while you were schlepping. I’m not saying that you shouldn’t be proud, but that your ability to do both of these is not typical. So, I am actually saying you should be very proud. “Regarding central lines: Anyone who would take an hour to do a subclavian needs to get to a cadaver lab sooner rather than later! I hope this guy doesn’t move to my city. I’ve had good luck with subclavian IVs. The central approach to the internal jug is way faster but you need to turn the pts head – not exactly spine immobilization friendly.” “‘I think that Dr. Mattox has made some very good points about the need to control the bleeding before adding fluid'” “I don’t know who Dr. Mattox is but controlling bleeding is so obvious I didn’t even think it needed to be mentioned.”Maintaining spinal immobilization should not be that important. There is no research to support it, yet we delay or avoid certain beneficial treatments in order to apply this lawyer deflection device. Not because it can be shown to improve the patient’s outcome, but because it makes the doctors feel better about the possible legal outcomes.Dr. Kenneth Mattox is probably the most vocal proponent of EMS withholding fluid entirely, until bleeding can be controlled. Especially, internal bleeding that will only be controlled by a surgeon. “You noted that sources vary on what B/P should be maintained. That ball will probably get kicked around until an asteroid destroys the planet. I don’t really have a B/P number in mind and personally prefer to use the pulse rate as a general guide. If the pt’s pulse starts to climb or just won’t slow down even a little, I add fluid to the tank. Not the swimming pool that we used to pump into them in the old days, but a fast liter should be enough to see a change for the better if there is going to be one.”The problem I see is that we are addressing a surrogate end point. This is something that we can measure, but that we cannot prove makes a difference in survival. We need to keep the patient from becoming pulseless, but how high does the systolic BP need to be for that to happen?I think that it will be much lower than just about everyone is comfortable with – 50 to 60 systolic, with the exception of head injuries, but the research is not yet persuasive enough for any particular vital sign goal.We need good research by doctors good enough to make the study large and well enough controlled that the results are meaningful. Something that has been ignored too much in favor of expert opinion. I feel that this should, in Catch-22 fashion, disqualify these doctors as experts. “‘You have beer in your fire house? Now that is a persuasive argument! :-)'” “Not even on our BEST day!!!”Oh, well. Stay safe, 30 yrs (23 months till retirement WOO HOO!)Stay safe as well. Definitely enjoy it when you get there.

  5. You have beer in your fire house? Now that is a persuasive argument! 🙂We used to have beer in the fridge, along with the OJ to mix with the vodka in the med cabinet at a hospital where I worked. No, wait. That was for the patients. Seriously. I think that Dr. Mattox has made some very good points about the need to control the bleeding before adding fluid, even if the fluid being added is blood. There is too much attention to treating the blood pressure at the expense of survival. I notice that so many of these kinds of things are written with the assumption that certain resources are always available to everyone, everywhere. Creates some difficulty for those who simply don’t have those resources available. Some of us have to travel 70-100 miles to get to the nearest trauma center, some area counties don’t even have hospitals. It’s certainly not “one size fits all” or even “one priority fits all” as I gather the “experts” who create the “standards” like to try to turn it into.

  6. Sorry, in editing the previous comment for brevity I wound up completely deleting my point. Oops!My point is, that in the case of bleeding that can be controlled with external pressure, that’s all well and good. Internal bleeding, which I’ve seen a lot more of…particularly around here those IVs (plural) better be a top priority. It’ll be a long time before they see a surgeon, we just wanna make sure they make it that far and that if they survive, their organs do too.

  7. The systolic blood pressure appropriate for the best chance at survival has not been clearly demonstrated, yet. There are good points made by those who advocate withholding fluid. At what point should fluid be added?Should heart rate affect this decision?What about capnography?Would an impedance threshold device be a good idea?How much does time to treatment affect this?How much does type of fluid affect this?What can be done to decrease the high rate of sepsis among those who receive blood products?How important is the ability of the fluid to transport oxygen? If the problem is the continuing loss of blood, what about giving recombinant factor VIIa?Should we be using therapeutic hypothermia, similar to cardiac arrest? The concern is that reperfusion seems to do more harm than good and we are approaching resuscitation in a different light. How much of this will affect trauma treatment?Where is the consensus in the trauma research? The studies tend to be small. The doctors tend to be uncomfortable with the idea of depriving patients of the treatment that they “just know” works, because they have seen it work.We could turn back the clock a few dozen centuries and have a similar approach to medicine. The trauma doctors need to set up randomized, blinded (as much as possible), strictly controlled studies and await the results. Until they come up with truly objective research, we are all guessing at what the results would be.I believe that we should avoid giving fluids as much as possible. We should avoid providing unproven treatments when the alternatives have not been shown to be worse for the patient. Is there anything to show that a patient with a pressure maintained at 100 systolic does better than a patient with a pressure maintained at 50 systolic? Especially when the patient’s pressure is not changing.I copied part of this review of available studies and included it below.Janine Dretzke, Amanda Burls, Sue Bayliss, and Josie Sandercock.The clinical effectiveness of pre-hospital intravenous fluid replacement in trauma patients without head injury: a systematic review. Trauma, July 2006; 8: 131 – 141.”This updated systematic review shows that the evidence base to support pre-hospital IV fluiduse remains uncertain, which is consistent with the findings of the Cochrane systematic review (Kwan et al., 2003).Of the four RCTs concerning fluid delay or different fluid volumes, three were methodologicallyflawed or unsuccessful in their implementation. Only one study (Bickell et al., 1994) allows sometentative conclusions to be drawn and suggests that there is some harm associated with givingpre-hospital IV fluids.”

  8. Dude. Rural area. Small budgets. Tiny pool of people resources. Stabilize and ship. That’s our whole goal. But hey. If you don’t want to start fluids, then at least give me a couple of large bore HEPLOCKS before they come in the door because they’re gonna need blood and they don’t need to be waiting on it while I stick them before going to the blood bank. Absolutely no capability of inducing hypothermia, capnography might or might not be available depending on the budget. The only thing anybody on a truck is going to be able to give is IVF anyway, and they’ll get O-neg squeezed in shortly after they hit the door while we call for the chopper (picture arm up, O-neg in one hand, cordless phone in the other as I call them, and I’m the only nurse on – that’s how it goes). Most of my docs like 90 syst if possible. IVF may not be capable of transporting oxygen but they will help to keep the pressure high enough for the circulating blood to actually deliver whatever it has. If the bleeding can’t be controlled without surgical intervention, what other choice do you have? Can we try to avoid adding hypovolemic shock to the mix? Research: generally a standard “Country” mentality: nice if you can afford it and have the staff with the credentials, but a bit out of reach and “wait till the jury comes in, one study doesn’t mean anything”. When something’s proven, then they’ll try to take it on if they can. Hospitals are on the verge of closing quite often have trouble meeting payroll (two in particular I can think of right off the bat), ambulance companies are owned by those hospitals – some large, some small or when the hospitals shut down they get taken over by the counties. I’m sure our local EMS probably has a medical director but honestly I’d never even heard of that until speaking with AD. Probably just whoever is chief of staff at the hospital, since we have a hard time keeping doctors in this area too. So when it comes down to it, all that modern “big city stuff” is a luxury. We’re country folks with country hospitals and country trucks. We do what works and we call the chopper and we get ’em outta Dodge. And you know what? It works just fine. People have to be smart and resourceful in such a situation and I’ve seen more than one city fella fold in a rural healthcare environment. More and newer isn’t always better.

  9. Let me show you something, just to illustrate my point that there should be at least some acknowledgment of the volume of people served by smaller services that do not have those resources available, and it would be wonderful for these research folks to address ways to accommodate that without being wasteful of expensive resources that come with expiration dates on the packages. This is my own home state in that pic. The population of the areas served by that cluster around Atlanta and then numbers 9 & 11 is around five million or so. The population served by 2, 3, 4, 5, and 13 are another 5 million. Just to give you an idea, the distance between 2 and 4 is about 165 miles straight down I-16. And of those five, only 2,3,& 4 are level 1, so many often wind up crossing state lines for care (to get to Tallahassee, Jacksonville, or Dothan). So that’s a large underserved population due to lesser population density (and thus, lesser utilization). But that’s still a lot of people spread out there. So again, when you look at that, much of the stuff that comes down about all this wonderful technology and all these new studies are only Ivory Tower stuff to many of these areas. There’s all this talk of getting in a new trauma network system, but that’s all politics and money and red tape so what these folks need is to have some suggestion of what they can do with what they already have. All the rest is great for those with access, but for the large percentage of the population that doesn’t have access, it wastes precious time as they’re just ignored completely by these things, and all the debates in the world about whether this technique or that resource is better is meaningless for half of the population of my state (I can’t speak to the rest of the country) unless it addresses and accommodates for lack of resources.

  10. “So when it comes down to it, all that modern “big city stuff” is a luxury. We’re country folks with country hospitals and country trucks. We do what works and we call the chopper and we get ’em outta Dodge. And you know what? It works just fine. People have to be smart and resourceful in such a situation and I’ve seen more than one city fella fold in a rural healthcare environment. More and newer isn’t always better.”How do you know what works if there is no research to demonstrate effectiveness?I did include, in the questions that need to be answered by research, the consideration of time. There is, as you have mentioned, a big difference between treatment when a trauma center is within a few minutes and when one is not available. I was not claiming that IVs should not be started, but that there is no research on when to run them at faster than KVO. Access and fluid administration are two different things.The first site, It’s About Time, continues the sloganeering of “The Golden Hour.” This is not anything more than a sales jingle, but people love it. Time does matter to a lot of patients, but there is nothing critically important about one hour vs. half an hour or vs. two hours. The sooner a patient, who needs surgery, is in the OR, the better the person’s chances of survival. I have seen doctors waste time on the transfer of critical trauma patients, because as long as they get to the trauma center within an hour everything is OK.Claiming that there is no role for research, that what you are doing “works just fine,” is more than a little optimistic. How do you know that it works? Anecdotal evidence is like a magic. You see what you want to see.Apparently, even some “‘big city stuff'” does get through out there, because you are using the internet and probably more than a few other things that are the result of research. Dismissing science is not a good thing. Discouraging one type of improvement, because you are interested in another type of improvement is also not a good thing.We do not know what the best treatment for uncontrollable bleeding is. We do not know at what point fluid should be added.We do not know what our vital signs goal should be, other than they should have some. We do not even know if our treatment should be guided by vital signs.We do not know if more of your patients would have a good outcome with different treatment. We need good research to improve our care. Otherwise, it is just a bunch of people making the vital signs less annoying and convincing themselves that what they are doing is making all of the difference. The survival of some patients is intermittent reinforcement. This is what makes gambling so attractive to some. The inevitable positive outcomes lead them to believe that they know what they are doing. It does not mean that they are killing fewer patients than if they used a different treatment. We come up with a scientific reason for the treatment. The blood vessels need to have pressure, or whatever the “explanation” is for the treatment being favored. Then we end up changing the explanation, when later research shows the “explanation” was not correct. It isn’t the explanation that matters, but the result. The patient usually doesn’t care about why.Avoiding research means that we do not want to know what is best for our patients. Big city, small town, rural, on an island with a ball named Wilson, wherever. Research does provide us with answers that make a difference between life and death.

  11. Yeah, difference in mindsets there, is all. Not everyone is all that research-minded nor believes that it’s all it’s cracked up to be. Not everything in creation is measurable. In fact, the most important things aren’t.

  12. Although I never said to avoid research, I said we take it with a grain of salt until all the juries are in. It’s a fair assessment to say that many folks are skeptical of this study or that study, because they too often contradict each other. It’s like the old CPR/BLS and ACLS from years back. “Do it this way.” “No, this year we’ll do it this way.” “No, you know what? The old way was really better.” “Nah, here’s another way.” We look at that and decide that if people can’t make up their minds, they don’t know what they’re doing. But that was completely beside my point. My point is that none of it is helpful at all if it doesn’t address what people can do to accommodate these nice new concepts when they don’t have ACCESS to the resources needed to carry out these wonderful suggestions. And there are a huge number of people and services who don’t. That makes it all completely useless to those people. In in my state, that’s roughly half the population.

  13. One of the problems with the CPR/ACLS guidelines is that the research is then looked at by committees. The committee members then have a lot of influence over the weight given to individual studies. The most recent guidelines recommend 30 compressions then 2 ventilations, but the research showed that more compressions and fewer ventilations were better.People are afraid of not ventilating, because it doesn’t make sense to them. Who really cares if it makes sense, as long as it works. The places that have done away with ventilations seem to be multiplying their resuscitation rates by several times.Is there any good reason to not do research on this?Medical ethicists will whine about all sorts of nonsense, but until large enough studies are done, and done well enough to provide some answers, all patients are involuntary participants in a huge uncontrolled experiment.We’re just spinning our wheels, burying bodies, and learning nothing.Can anyone say that giving fluids is better than not giving fluids?No. There is no science to support this statement. Nothing I write is likely to get you a trauma center, but maybe I can nag somebody, who can nag somebody, who might be able to help do some meaningful research.

  14. … until large enough studies are done, and done well enough to provide some answers, all patients are involuntary participants in a huge uncontrolled experiment.Bingo. Thus research is, by its very nature, questionable. One of the few things ever consistently proven by research is its own unreliability. What amazes me more than anything is how this earth and our species has managed to survive untold number of millenia without the benefit of modern-day knowledge and research techniques. Quite astounding, no? ;)Have a wonderful weekend (what’s left of it) 🙂

  15. “Bingo. Thus research is, by its very nature, questionable. One of the few things ever consistently proven by research is its own unreliability.”Please provide some basis for this. Research leads to changes as more information is obtained. Change may make some people uncomfortable, but the only absence of change is death. Adapting to new information by changing is very rational and the alternative is to abandon science. “What amazes me more than anything is how this earth and our species has managed to survive untold number of millenia without the benefit of modern-day knowledge and research techniques. Quite astounding, no? ;)”It is pretty simple. We reproduced in large enough numbers, had enough offspring survive enough births, and those offspring lived long enough to reproduce to continually expand our numbers, with a few brief corrections. That the infant mortality rate is as low as it is is purely due to science. That the life expectancy, largely due to the drop in infant mortality, is now about 80 years is purely due to science. We have both have exceeded the life expectancy of those who lived at the time of the founding of this country.That the life expectancy has more than doubled since then is due to science.My comment about patients taking part in a huge uncontrolled experiment is no criticism of science, but of those who are ignoring the progress that could be made in finding out what will help keep patients alive, not just until transferred to the next provider, but to discharge and for years after. Alive with a good quality of life.Choosing to not learn from these patients is preventing improvements in patient care and forcing many to experience similar fates.Tradition is the antithesis of progress.You enjoy your weekend as well.

  16. Spam deleted.