The List

[Guest guest]

One of the reasons I stay on this list is that it gives me some great

insight into the world of Texas EMS and it gives me ideas for some of my

writing. I have a contract to do a monthly feature in JEMS as well as a

large quarterly article (JEMS Grand Rounds). I am always looking for topics

and this list and others are sometimes my muse.

With his last post, Wes has helped be crystallize in my mind something I

have been struggling with. Thus:

1. What is it in EMS providers that we have to do everything to the

max-balls to the wall? We are not happy ventilating a patient with a BVM.

Instead we have to intubate them. Better yet, on " good call " we get to cut

somebody's neck open. We start an IV on everybody despite the fact that

studies show that less than 50% of prehospital IVs are ever used for

anything. Now the trend is to put a needle into everybody's bone. We are not

happy simply taking somebody to the hospital. We have to " do something " and

buy technology we don't really need to " do something " . We are now carrying

more people by helicopter who don't really need it because " it is neat " and

we can justify it in the name of the mythical Golden Hour or similar horse

hockey. ET tubes, surgical cricothyrotomies, IO lines, and helicopters are

all important tools that should be applied only when the benefits outweigh

the risks and costs.

2. Some pride themselves on the number of different helicopter pins on

their uniform or the number of merit badge course patches which we believe

tells others that we are important, save lives, and should be revered. Is

it insecurity? What would Freud say? There is a guy I see periodically

around the Wal-Mart in Waxahachie. He always is wearing a badge, an EMT

shirt, trauma shears and a radio despite the fact he is toting 5 kids to

Wal-Mart for Cheerios and Coco-Puffs. Some of the best EMTs and paramedics I

ever met were the humblest. I was recently talking with Thom Dick and he

reported that he had never called for a helicopter in 30+ years of EMS work.

In October of this year, I sat in a hangar in Sydney with about 10 flight

paramedics from NSW and the deputy commissioner who is a friend. The purpose

of the meeting was to set up protocols to limit helicopter use to certain

situations. They were having a doctor call the helicopter for non-critical

patients. The people who initiated the meeting were the flight paramedics.

They were not going to risk their lives " like the Yanks " by sending their

helicopter for non-critical calls. Thus, they put logic and science above

ego.

3. We are now buying bigger and bigger ambulances when the smaller ones

are cheaper and work as well. Is it just macho or necessary? What would

Freud say?

4. We are all deluding ourselves if we say we did not get into EMS for

the excitement. We did. Don't deny that. We also all got into EMS because

we genuinely like the feeling derived from helping the ill and the infirm.

Thus, at what point in our careers (and this is not true for all) did we

start doing things for OUR benefit and NOT THE PATIENT. Putting needles

into bones, placing patients on helicopters, intubating a child when a BVM

will work, immobilizing somebody on a backboard that has less than a 1%

chance of a spinal injury, running " precautionary Code 3 " are things we

start to do for our ego and no the benefit of patients. I have been in

nearly every state in this great union and often heard war stories and

people proud of the number of crichs they have done, the number of IOs they

have done, or the numbers if chests they have needled. I always want to ask,

but never do, is whether the patient got better. Doctors can be as bad as we

used to brag about the number of times we had opened a chest. I think it

occurs when we come to the realization that EMS is 90% being a good neighbor

and 10% being a good technician or practitioner. We write page after page on

how to be a good technician and never teach people how to be a good

neighbor. Thus, when one become's disillusioned when he or she realizes that

all of the crap in Dr. Bledsoe's textbooks are only used for a small

percentage of patients, we start playing this mind game. We delude ourselves

with the mistaken believe that we are doing " things " to help the patient

when, in fact, we may be placing the patient at risk through those actions.

5. Young Attorney Ogilvie is right. We are approaching this all wrong.

We should be satisfied by practicing and using the safest and most effective

modality before increasing to more complicated modalities. The analogy to

police and restraint is a good one and I am sure I will steal it. In our new

CCP book, in the airway chapter I authored with Gene Gandy, we used the

inverted pyramid to illustrate when airways should be applied. Surgical

airways are at the bottom and basic positioning is at the top. That is how

it should be.

6. An old Internal Medicine Professor at Texas Tech once told me two

things that I follow to this day: 1. Being a good physician (or EMT) is

more about knowing when not to do something as opposed to knowing when to do

something and 2. Never be the first to use a new drug or procedure nor the

last to give up an old one. These teachings are in my mind and probably

explain why I write and speak the way I do.

Being a good paramedic means that you are first a good human, then a good

neighbor, and then a good EMT. Just like 90% of emergency medicine could be

handled by a family practitioner, 90% of EMS can be handled with BLS skills.

That is NOT saying that emergency physicians with our specialized skills and

paramedics with their specialized skills are not needed. They are very much

needed for the right patient at the right time.

Thant's my story and I'm sticking to it.

BEB

I entered EMS in 1974 and graduated medical school in 1987. I have NEVER had

to do a cricothyrotomy on a real patient and have only used an IO once.