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

- Rogue Medic

Hindsight is always 20/20 or If had known then…

At Hot Lights & Cold Steel there is Hindsight is always 20/20 or If had known then…

While there are a few points that I do not completely agree with, overwhelmingly I do agree with what is written.

First, hindsight is NOT always 20/20.

Often hindsight is not remotely accurate. We recall things poorly. We tend to assume that we recall things accurately, but we also tend to assume that we are better than average drivers/politicians/singers/lovers/EMTs/medics/nurses/doctors/et cetera. At least some of us are wrong.

Even in looking back at events that are well documented, we tend to come to different conclusions. And our memories change. We want to deny this, but our experiences change our memories.

Here’s the thing that no one bothered to tell me – to understand a drug… ANY drug – you have to understand the physiological actions of the body process the drug effects FIRST in order to then understand how the drug alters that physiological action.

We know that NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries) is the most efficatious drug for hypertensive CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). NTG also appears to be very efficatious for normotensive and even hypotensive CHF/ADHD.

Do we need to understand the mechanism?

Too often we base our treatments on conclusions drawn from research that has been spun into a tale to explain why something works. This is narrative fallacy. I explain more in Some Research Podcasting Comments.

The only certainty in medicine is that we do not know as much as we think we know.

We get to the point where we believe that we understand all that we can about the way that a drug works. We believe that drug is great. We study that drug and find that the research does not agree with what we knew. The research can be wrong, but it is more likely that the theory, which is based on research and other theories, is wrong.

No matter how much we think we know about the ways the body works and the ways that drugs work in our bodies, we find more to learn and plenty of cases of people responding in ways the pharmacology books claim they should not.

This is one of the most important reasons to continually reassess.

There is a reason the word atypical is frequently used in medicine.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous.
Paracelsus (1493 – 1541)

By continually reassessing, I can often prevent an adverse reaction from progressing to a bad outcome.

However, the most important point written is –

here’s what I do regret –

Listening to all the paramedics who told me I’d never need to know most of what I was learning. The Krebs cycle (now called the Citric Acid cycle) Action potentials, Ph… the list I’m sure by the end of school will be extensive.

Just because we do not understand everything about the body, or everything about pharmacology, does not mean that we should deliberately choose to be ignorant.

Ignorance kills.


Learn more.


Kill less.




  1. You hit the proverbial nail on the head in regards to some of my ” sweeping over generalizations “.

    I no way meant to to suggest that we would ever understand everything there was to know, or that once we have a solid foundation we should be content with that knowledge base. Just as you point out – “reassessing our patients can prevent an adverse reaction from progressing to a bad outcome.” I was suggesting that we should be continually reassessing our knowledge base and understanding of how the body works and how the medications we give affect it to the best of our/medicines understanding. The pursuit for more knowledge and the desire to understand more is what sets someone like yourself out from the crowd in EMS.

    There are most certainly medications that have effects that aren’t what they were intended to be used for, in fact that would be the very definition of an off label use – this drug is approved for, but since it has been used we have learned that it may be effective for ______________ as well. However, without trying to understand why it is effective for those uses we are taking “tools” out of our toolbox

    The point from my perspective was understanding as much as you can about the pharmacokinetics and pharmacodynamics as well as having a solid base in pharmacology can help us find ways that an unexpected use of a specific medication may be to the benefit of your patient in that atypical case. We in EMS tend to take what we are told in class and run with it without ever questioning. For many of the providers I have worked with knowing that we give a medication like NTG for chest pain is enough… they have no idea why except that someone somewhere along the way told them that was the case, or because the protocol book says so.

    The idea I was trying to illustrate was – We must do better then that – learning for the National Registry exam and learning how to treat patients in the dynamic world we work in with patients who rarely present in “textbook” form are two very different things.

    I know we both are 100% in agreement on that one.