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

- Rogue Medic

EMS 2.0: Critical Thinking in Prehospital Training

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

Even though EMS 2.0 may not be any more successful at changing EMS than previous efforts at improving patient care, it does seem to be getting more attention. One place is EMS1.com. The names do not share etymology beyond the letters EMS, although both have been wise enough to get Kelly Grayson to contribute. Kelly is also the author behind A Day In the Life of An Ambulance Driver.

Kelly wrote an article called EMS 2.0: Critical Thinking in Prehospital Training. In the article, he does make reference to my blog, but that is not the reason for this post. Although, he does summarize many of my points very nicely.

He also mentions a debate on paramedic-initiated refusals. A debate that I have not commented on, because I have not been able to sit down and read through enough comments to get caught up to the current comments. This is a debate that has also taken place many times before.

Here is an example of the commentary –

“We’ve got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!” they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.

This is the essence of the problem. Too many people still believe that the right technology will produce a foolproofTM paramedic/nurse/doctor/et cetera.

Too many people still believe that the right technology will produce a foolproofTM human.

This completely ignores the Law of Unintended Consequences.TM This law is far too important and entertaining to ignore.

In another article on EMS1.com, Stop Talking, Dan White suggests that providing continuous transmissions of all of the information we are looking at in the ambulance – ECG, SpO2, EtCO2, BP, et cetera – will lead to more concise communication with the ED. While he means well, I think that he is overlooking the probability that the Unintended Consequence gremlins are just waiting to pounce. As Kelly writes –

All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools.

Many places have made pulse oximetry a BLS skill. How many of them use it appropriately? Nursing homes regularly send patients to the ED because of a low sat.

The fancy equipment does not lead to better care. It often only leads to toggle switch care. Sat of X or less = emergency. Sat of more than X = no problem. There is nothing in between. Everything is either an emergency, or does not meet treatment criteria.

Less than 8 – intubate. More than 8 – procrastinate.

Or should our patients receive airway management from someone who has an understanding of airway managment that goes beyond a nursery school rhyme?

Kelly continues with –

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal.

Adding to the EMS scope of practice presumes that we are already good at what is in our scope of practice. The debate about paramedic-initiated refusals is an example of this. How many paramedic schools spend any time on education about which patients do not need to go to the ED? It is not really something we receive training to do, so it is no surprise that when we arrogantly do what we are not trained to do, we provide many examples of incompetence.

At one place where I used to work, they kept track of what happened to patients who refused or were triaged to BLS after being assessed by paramedics. Their main criterion was whether the patient ended up in the ICU. Unless something changes dramatically in the patient presentation, none of these patients should end up in the ICU. Yes, some stubborn refusals will, but the chart should reflect that the paramedic saw the potential for significant complications and did not just say, OK. Sign here.

I have seen refusals, where the full narrative is – Medical command consents to refusal. Patient signed AMA form. Available at XX:xx. Indicating a total scene time – leaving the vehicle, assessing the patient, contacting medical comand, getting a signature from the patient, and notifyinging dispatch that the medic is available – of less than 5 minutes. The medic is only surpassed by the medical director in lack of attention to the problem.

Some of you may argue that things aren’t that bad. You may know of EMS educational programs that excel at turning out capable EMTs.

There are excellent programs. These excellent programs exist in spite of the National Registry’s No Paramedic Left Behind dog and pony show.

The National Registry does not just share responsibility with the bad EMS programs for the pathetic state of EMS education, the National Registry pushes the envelope to the point where stupid, dangerous, and irresponsible all begin to sound like compliments.

But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it’s not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.

Sad, but true.

It’s when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we’ll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.

There are many, who suggest that all we need to do is to require more education to improve EMS. All it takes is a degree to make EMS a respectable profession. As long as we keep doing things the same way, does it matter if we require 3 months of misinformation?

What if we require 6 months of misinformation?

What if we require 1 year of misinformation?

What if we require an Associate’s degree in Misinformation?

What if we require a Bachelor’s degree in Misinformation?

What if we require a Master’s degree in Misinformation?

Should we just pile it higher and deeper?

Until we get rid of the misinformation in EMS education, it does not matter how much time we spend making students memorize misinformation – we are not providing a useful education. We are not protecting patients.

There are schools that do a good job. We need to find out what they are doing well. We should not be telling everyone that more of the same is the solution to bad education.

For some other perspectives on this, Unconventional Thoughts On Emergency Services by Steve Whitehead at The EMT Spot. Not really an education post, but all of his posts are education posts. Nice clear posts that get us to look at things differently.

And I’m Hangin’ Up My AHA Spurs by Buckman at Gomerville. Great writing and he tells a story as well as Kelly does, which is no small achievement.

^ TM Unintended Consequence
Like Murphy’s law, again a humorous expression rather than an actual law of nature, this law is a warning against the hubristic belief that humans can fully control the world around them.

Possible causes of unintended consequences include the world’s inherent complexity (parts of a system responding to changes in the environment), perverse incentives, human stupidity, self-deception, failure to account for human nature or other cognitive or emotional biases. As a sub-component of complexity (in the scientific sense), the chaotic nature of the universe – and especially its quality of having small, apparently insignificant changes with far-reaching effects (e.g., the Butterfly effect) – applies.

Robert K. Merton listed five possible causes of unanticipated consequences:[8]
Ignorance (It is impossible to anticipate everything, thereby leading to incomplete analysis)
Error (Incorrect analysis of the problem or following habits that worked in the past but may not apply to the current situation)
Immediate interest, which may override long-term interests
Basic values may require or prohibit certain actions even if the long-term result might be unfavorable (these long-term consequences may eventually cause changes in basic values)
Self-defeating prophecy (Fear of some consequence drives people to find solutions before the problem occurs, thus the non-occurrence of the problem is unanticipated)

The Relevance paradox where decision makers think they know the areas of ignorance about an issue, and go and obtain the necessary information to fill the ignorance, but neglect certain other areas of ignorance, because, due to not having the information, its relevance is not obvious, is also cited as a cause.