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

- Rogue Medic

TOTWTYTR vs. Indoctrination in Iatrogenesis

Too Old To Work, Too Young to Retire has an excellent post about, well his title gives it away.

The One where he Rants about EMS Education

TOTWTYTR is right on target with this latest post. Mandatory reading for everyone involved in EMS.

In paramedic school, which is ALS (Advanced Life Support), the approach to airway management seems to be that medics will intubate the patient, so they do not need to be good at the BLS (Basic Life Support) aspects of airway management. The result is medics who do not understand the most essential part of airway management. There is nothing more important than competence in BLS airway management. Assessment is critical to competent BLS airway management, but there are plenty of medics who do not recognize esophageal tubes. Do they understand airway? Even a little bit? No.

Where is the assessment? Playing peek-a-boo with the life of the patient. Now it’s here! Now it’s not!

There should not be ALS without excellence in BLS. Teaching ALS without confirming and reinforcing excellence in BLS is bad instruction.

The medical directors for these schools should not allow this. The instructors should not, either. Nor should the students allow this.

Of course as you move from sentence to sentence, in the previous paragraph, the order of responsibility is dramatically decreasing. We should not expect the students to take responsibility for the curriculum. A bunch of people think that the medical director, the one who says that idiocy is permitted or that idiocy is not permitted, should not be held accountable for the results of his actions.

We allow medical directors to set up a system that proclaims:

Idiocy, Incompetence, and Iatrogenesis are permitted here.

Why?

If you look at what happens when these students have graduated and are developing as medics, the next big influence on the way they treat people is, surprise, surprise, the EMS medical director.

I believe that the difference between the ALS services that have excellent quality and the rest . . . .

What do you mean the rest?

There is no bronze medal in medical care, unless you believe in the government quality indicator rankings.

There are places that uniformly provide excellent care.

Excellent.

After excellent it is just a matter of naming the abuses the patient may suffer.

Statistically, many of these patients will arrive at the hospital unharmed, but there will be plenty who do not escape harm. So, what method of medical misadventure will they come up with this time?

I believe that the difference between the ALS services that have excellent quality and the rest lies in the involvement of the medical director.

An absentee medical director means that on a regular basis these are some of the medical misadventure menagerie that the medics will be inflicting on patients:

  • Unrecognized esophageal tubes,
  • Furosemide (Lasix) for pneumonia,
  • Delayed transport for IVs,
  • Patients treated according to the dispatch information instead of their actual medical condition,
  • Poor pain management,
  • Et cetera.
Absentee = Not being there.

  • Performing chart review is the same thing as not being there, because you aren’t.
  • OLMC (On Line Medical Command) requirements are the same as not being there, because you aren’t.
  • Having monthly/quarterly/yearly continuing education is the same as not being there, because you aren’t.
  • Telemetry (transmitting ECGs to be read by the doctor) is the same thing as not being there, because you aren’t.
  • Et cetera.
Being there to take report from medics at the hospital, showing up on calls, following up (with the patient and with hospital staff) on all unstable patients, . . . . are part of being there.

Do you know your medics?

Investing in some smart technology is a good thing (waveform capnography) when it is part of improving the abilities of the medics. Investing in telemetry is just a waste of money, an admission that you are trying to keep it stupid, and that you don’t know how to run ALS. Spending money on technology instead of a medical director, who WILL be there, is a waste of money.

Idiocy, Incompetence, and Iatrogenesis are permitted here.

Would you want this inscription on your certificate/diploma/degree?

Would you want this inscription on the side of your ambulance?

Would you want this inscription on your EMS patch?

The NR (National Registry of EMTs) should come up with a nice round patch EMT-P-III?

This is not the New York level of EMT-III (intermediate). It is quite a bit different.

Iatrogenesis = inadvertent and preventable induction of disease or complications by the medical treatment or procedures of a physician.

Being There, the book or movie, is not the same as a medical director being there.

.

Comments

  1. OK,..so where do Combi-Tubes and King Tubes fit into all of this?

  2. There are many airway devices available, or that should be available. Read Ambulance Driver’s article The Airway Continuum at EMS1.com. These devices are not the answer to incompetent staff, but part of competent management of the airway.