By Kelly Grayson
Stop me if you've heard this one:
"Heck, you go to any ER and watch the nurses. They need orders to administer oxygen, for pity's sake! We can do assessments, defibrillate, pace, cardiovert, give meds, needle chests, cric people… heck, we can even intubate! So why don’t they let us work in the ER and pay us like nurses? I mean, we can do more than they can anyway…"
If you've been an EMT long enough, chances are you've heard a similar statement from one of your colleagues. Perhaps it was a youngster with barely a year's experience, or perhaps it was a grizzled veteran with that same year of experience, repeated 20 times.
Either way, we should know better.
EMS is unique among the health care professions in that we have this peculiar tendency to define ourselves by a skill set rather than a unique body of knowledge. You don't see nurses or doctors doing it, but ask anyone in our profession, "What is an EMT?" and likely as not they'll answer not with what they know, but what they can do.
Perhaps it's understandable, given the physical nature of pre-hospital care, but defining ourselves by the patch we wear and our particular skill set limits the growth of our profession. It sets us apart from other health care professions at a time when we need, more than ever, to integrate ourselves into the allied health community. At a time when our entire health care system in this country stands on the cusp of a radical overhaul, the last thing EMS needs to be is what it has always been: an afterthought, the forgotten stepchild clamoring for a seat at the table with the grownups.
This point has been driven home to me over the past several weeks as I've followed various discussions on internet EMS forums and blogs. One EMS blogger has been engaged in a spirited debate on Paramedicine 101 over his series of posts, "Why Medics Can't Intubate."
The blogger, a gleeful gadfly who calls himself Rogue Medic, opined that not only are paramedics woefully inadequate at providing one of our core skills – endotracheal intubation – but that in the vast majority of cases requiring airway management, endotracheal intubation is usually unnecessary. He asserts that paramedics' poor intubation skills can be traced to three root causes: inadequate initial clinical experience, absentee medical directors, and all-paramedic EMS systems and the inevitable skill dilution resulting from dividing a finite number of procedures among a large pool of ALS providers. And unlike his opponents in the debate, he can defend his position with numerous citations.
While Rogue Medic poked the EMS establishment with a sharp stick on his blog, another debate raged on an EMS list server over paramedic-initiated refusals. Opponents of the concept pointed out that most EMS systems that instituted such programs eventually found them unworkable and fraught with legal liability. "Even ER doctors often wrestle with the decision to admit someone to the hospital," they said. "So what makes you think that medics can do it reliably?"
Proponents of the practice countered that many — perhaps even a majority — of our patients do not need Emergency Department care, much less ambulance transport. In a health care system staggering under the weight of uncompensated care and expensive Emergency Department visits, they saw EMS providers as the logical choice to screen most of those non-emergent patients and direct them to more appropriate avenues for seeking medical care.
"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.
All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools. Major U.S. cities have EMS systems whose medics cannot reliably wield a laryngoscope, or whose EKG interpretation skills are limited to reading the machine interpretation printed on the strip. Every few months, we see a news report of someone mistakenly pronounced dead by the EMS crews on scene.
EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal. Some, like Rogue Medic, would say that inadequacy in initial education is the rule and not the exception. With the implementation of the National EMS Educational Standards, hopefully that inadequacy will be addressed, but to add significantly to our skill set is going to require a corresponding increase in our knowledge base. That is a task that will require more than an augmentation of existing programs; it will require a wholesale overhaul of the way we educate EMTs in this country.
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. You may know of individual medics with the chops to not only get the toughest tubes, but the discretion to know when a tube isn't necessary. And they may even have the diagnostic acumen to safely triage non-emergent patients and screen out those not in need of EMS transport.
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.
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.
Only then are we going to be more than a patch and a skill set.
Much of EMS education is like education in general—it’s not all that effective at actually teaching. Education in the U.S. is still traditionally rigid, students sitting lined up in perfect rows at their desks, facing the focal point of the classroom—either a teacher pontificating or a flat screen PowerPoint. According to most experts, logic challenges, problem solving exercises and practical scenarios that require critical thinking are much more effective for student learning.
Incorporating realism into training is gaining popularity in medicine. High-fidelity simulation manikins, patient actors coached to demonstrate realistic signs and symptoms, along with wound simulation and moulage, are being included with increasing frequency to add realism to practical training scenarios. But even more important than adding visual clues to training exercises is creating challenging scenarios that require critical thinking and problem solving for successful mitigation. Of course, designing these scenarios takes more time and thought, but they will ultimately end up being much more educational than just about anything else you can do in a class.
Here’s an example of one of my favorite practical trauma scenarios. As a team of two students approaches the mock scene of a motor vehicle crash, I advise that having arrived on-scene just prior to them, I can answer any questions that are answerable. I also inform them I’m a police officer and EMT, so I can help them as a third provider if needed. My name is Officer Murphy, but my friends call me Murphy’s Law. Many of the students roll their eyes or moan, realizing the double entendre.
The students are then presented with a 50-year-old male trapped in a mid-sized car, which has struck a bridge abutment. The patient is conscious but anxious, pale and diaphoretic with a weak radial pulse of 88, delayed capillary refill, with cool digits, and respirations are slightly tachypniec but non-labored at 22 a minute. The patient was restrained with air bag deployment and recalls the entire frightening event, which was precipitated when he hit something in the road, his tire blew out and he careened into the abutment.
As the students perform a quick trauma survey they find no obvious injuries to the head, neck, chest, abdomen or pelvis. The patient is trapped from the mid-thigh of both legs by the seat being displaced forward and the dashboard collapsing around the patients’ legs. The patient says he can feel and move the toes on both legs, but both legs hurt equally as far as he can tell. The distal legs cannot be directly assessed because of the wreckage, but a puddle of blood can be seen on the floorboard. Fire rescue’s arrival is reported to be delayed.
Perplexed by the ambiguousness of the scenario, most students review their findings out loud. “No head, chest or abdominal injuries, but the patient looks shocky.”
“How long ’til extrication?” they inquire, half asking and half pleading.
“Unknown,” I reply.
They start to feel the heat. This is also where there is an almost equal divergence in patient care management among students. Half decide to default to doing what they’re comfortable with doing—starting IVs. For those who do, they’re told there is no venous access; all attempts are unsuccessful. All quickly transition to IO, as most of EMS is now well trained to do. Some have a moment of pause when they realize the site which they’re most familiar with starting IOs—some exclusively so—is not available due to the leg entrapment. In all cases vascular access is eventually established via the humeral head. After IO access is established, the vascular access enthusiasts end up returning to the problem at hand, which the other half of students remained struggling with—where is the patients’ life threatening injury?
Most repeat assessment questions, but eventually all come back to the reality that the only obvious injury is the legs. Some attempt to drag out more information from me, but there is none to be had; legs trapped, blood puddle on the floor board. So time to turn the heat up a notch and force some action.
“The patient is losing consciousness,” I announce.
“He’s bleeding out,” several students quickly conclude.
“Where from?” Murphy’s Law sometimes inquires.
“His legs. It must be his legs,” most now conclude. “And we can’t get to them?” they ask again, hoping I’ll change my mind.
“Nope! What you see is what you’re stuck with.”
“So, there’s no way we can get to his legs?” some repeat in disbelief.
If looks could kill at this point, Murphy’s Law would be put out of his misery. But, as in real life, it’s never that easy.
About half of the providers grudgingly realize the necessary intervention. Those still unsure are prompted by an ever needling Murphy’s Law.
“So what do you want to do?”
“Tourniquet!” almost all of them ends up concluding at this point. And at this point I remove a tourniquet that was hidden in the first-in bag I have. If the tourniquets would have been left out in plain sight it would have been an unfair hint.
“Great!” I reply.
“Which leg?” either they or their partner ask out loud.
A brief pause and then, “Both!” they reply, with a combination of exaltation and resignation. At which point I produce a second tourniquet. Each student takes a leg and starts cranking down on the tourniquets, much to the delight of the victim whom we could never pay enough.
The vast majority of students struggle through the scenario to save the patient, but only after some fits and starts, a lot of stress and some occasional stumbling.
One of the most common questions asked in the post-course critique was why the patient wasn’t tachycardic if he was in shock. I cite a couple reasons. The obvious, and most familiar, to EMS providers is the patient was on a beta or calcium blocker, which blunted the increase in their heart rate. Another less common but not unheard of reason is they just weren’t. There is a subset of otherwise healthy patients out there who, for whatever reason, just don’t tach in response to physiological stress. No physician has ever been able to explain to me why, other than they’re basically one of those patients who didn’t read the book and didn’t know they were supposed to be tachycardic. Unfortunately, these patients not only don’t present without the most common sign we’re looking for as a clue of their cardiovascular stress, they also don’t have the benefit of that compensatory mechanism and therefore tend to crash quicker, as our practical scenario patient did.
The other point frequently made is the possibility of our patient having significant internal injuries, which we simply weren’t able to appreciate during the head-to-toe trauma survey in the less than optimal environment we were presented. Liver rupture, aortic tear or other major vessel bleeds are all other possible life-threatening injuries this patient could have had. Of course, there’s presently nothing EMS providers can do about any of those injuries, but uncontrolled hemorrhage from inaccessible leg trauma is an injury we can treat.
Among the many challenges of convention and management in this scenario, the life-saving treatment employed was not the textbook indication for tourniquet application. Traditionally, tourniquets are reserved for arterial bleeds. In the case of our scenario though, do we ever actually know whether the bleed was arterial or venous?
The answer was discovered about year after we first ran this exercise. One of the students who took this class ended up facing an almost identical situation on an actual call. Instead of a car crashing into a bridge abutment, a tractor trailer crashed into a tree. The patient was heavily entrapped with an extended extrication time. The only identifiable injury to this real patient, as in our training scenario, was trapped and injured legs with a copious amount of blood evident on the floorboard.
As devious as the Murphy’s Law of our trauma training was, life can be even crueler. The real patient happened to be on Coumadin. After hearing that I kicked myself for not thinking of it on my own. The student turned real-world rescuer, having seen a training scenario so similar, was surprisingly quick to control bleeding by applying bilateral tourniquets even though only one leg ended up actually requiring it. And, amazingly, just as in our training scenario, IV access was unobtainable, so the well-trained medic quickly and efficiently placed a humeral IO. It’s also worth noting that, just as in our training scenario, the real patient also had a good outcome.
These types of training scenarios are worth their weight in gold, and we need to be presenting them more frequently to challenge our students to think critically and solve the difficult problems of prehospital emergency medicine. An evil genius capable of thinking like Murphy’s Law, or borrowing from real-world cases, will be your best resource in designing these scenarios.
Traditional education that disseminates the latest standards in patient care is important, but practical scenarios that require critical thinking in order to successfully mitigate are invaluable in preparing EMS providers for the real-world challenges that will inevitably be thrown their way.
Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at email@example.com.