The Rise of The EMT
Or…How to Save A Life
I just received another e-mail from an eager EMT preparing herself for paramedic school. I’m always encouraged to hear about EMTs looking to advance their knowledge and skills. I’m always
supportive and reassuring. And then she said it. She said the line that makes me cringe every time I hear it. “I can’t wait to start learning the real medicine.”
Ouch.
There are many ways I hear EMTs express this sentiment.
- “I’m so excited to learn the more advanced techniques.”
- “I want to start practicing actual medicine.”
- “Now I get to break out of the basic, simple stuff.”
- “I want to start doing some real good for my patients.”
- “I want to be more useful on scene.”
- “I’m ready to start running the show.”
- “Now I’ll be able to do the important stuff.
Well…yes, and …no. Sit down, grab a cup of coffee.
Let me tell you a story about the treatment of myocardial infarction. Over the past few decades we’ve done some amazing things for our heart attack patients. We’re carrying twelve lead ECGs into the field and localizing infarctions. We’re activating whole cath lab teams right from the patients living room with cardiac alert programs and then prepping those patients to go immediately to the cath lab table. It’s amazing. (And it’s fun.)
Of all of those amazing advances we’ve accomplished in cardiac care what single intervention has had the greatest positive effect on patient outcomes? What single intervention has proven itself to have the greatest benefit to the patient? Time’s up! It’s Aspirin.
But wait…Aspirin? That’s in the EMT scope of practice. I hope you don’t pass over the Aspirin while you’re focusing on all that real medicine.
Let me tell you a story about the treatment of cardiac arrest. Maybe we should call this story the search for the wonder drug. I’ve been a bit player in this story for the past 20 years. Most paramedics who have been around for a while can tell you a long list of cardiac arrest drugs that have come and gone in the search for the magic bullet.
Off the top of my head, I recall Sodium Bicarbonate, Isuprel, High dose Epinephrine, Lidocaine, Bretylium, Glucagon…I’m sure there are a bunch that I’m forgetting. Now I hear that we’re going to start looking at estrogen as the next secret weapon in the fight against sudden death. (No, I’m serious about that.)
All of these magical ACLS drugs came and went. None of them ever lived up to their initial promise. Not even intubation and defibrillation ever really worked the way we hoped they would.
So what has worked? What single cardiac arrest intervention has improved save rates more than anything else we’ve tried? Give yourself a prize if you said CPR -first. That’s right. The idea of two solid minutes of on-like-Donkey-Kong CPR before that first defibrillation has show greater improvements in ROSC than any wonder drug we’ve ever tried.
But wait…that’s an EMT skill. We’re teaching CPR-first to EMT’s. How could it possibly be more effective than our advanced, paramedic level, “real medicine?” I hope you don’t pass over the CPR-first algorithm while you’re focusing on all that real medicine.
Now let me tell you a story about trauma care in the 21st century. I just came from a great class on the management of trauma patients. (By the way, that wasn’t writers creative license. I literally just came from the class.)
The instructor, an outstanding flight nurse for Air Life here in Colorado, was explaining some of the lessons we’re learning from recent research in trauma care, as well as the last 8 years of war in the middle-east. Here’s a list of things that will make the biggest difference for your next trauma patient.
1. Stop the bleeding. Pack wounds with gauze, apply direct pressure, and elevate limbs. Do whatever it takes to control that bleeding. We let far too many trauma patients die from manageable bleeding. I wonder what advanced techniques caregivers might be focusing on while their patients are bleeding to death. (I’m going to guess that IVs are number one and intubation is number 2)
2. Apply tourniquets. We learned that these were a big no-no back in EMT class. Now we’re realizing that letting people bleed to death from extremity wounds is the big no-no. Newer tourniquets are faster, more manageable and less destructive to tissues than we once imagined.
Expect to see tourniquet application become a greater priority in the future of trauma treatment.
3. Manage the airway. I didn’t say drop a tube, just manage the airway. Managing the airway is critical and often neglected while we wait for intubation or RSI procedures. If we simply manage the patients O2 saturation above 90% we could see much better outcomes…especially in our head injury patients.
This is well within the capability of BLS airway adjuncts. We shouldn’t be delaying the transport of significant trauma for advanced airway procedures. OPA, NPA, BVM and go. Intubate enroute to the trauma center.
4. Prevent hypothermia. We bring most of our major trauma patients in hypothermic. Between heat loss from injuries, exposure for assessment and the standard several litters of cold fluid we tend to administer, we make people very cold. Cold trauma patients don’t survive as well as warm ones. Keep em warm. It’s easy.
5.) Back off on the massive fluid challenges. We’re messing with the patient’s ability to clot and we’re flushing out the clots they do manage to create before they can do any good. Big fluid boluses do bring the blood pressure up temporarily and they make us feel a lot better, but they don’t seem to help the patient.
Permissive hypotension is going to be the order of the day in non-head-injury trauma management. Some systems may even go so far as to say one IV TKO and that’s it in major trauma.
So there’s the whole list. Really. I’m not hiding some super secret, life-saving ALS intervention that only paramedics practicing “real medicine” will be able to deliver.
But wait…bleeding control, tourniquets, rapid BLS airway intervention, warmth and conservative fluid usage? Aren’t those all BLS interventions? How can the entire recipe for how to save a trauma patients life be comprised of BLS care?
The more we study what works in EMS the more we keep finding that the really important stuff, the real life saving interventions are all well within the scope of the EMT basic provider. EMT basic skills aren’t basic…they are foundational. EMT basic interventions aren’t basic…they are the all important first steps. They are essential. Don’t forget about them in your rush to practice “real medicine.”
Now it’s your turn: Am I overstating the importance of strong BLS care? Is the future of emergency medicine going to be about advancing the paramedic skill set farther, or recognizing the importance of the basic skill set we already practice? I’d like to hear what you think. Leave a comment below.
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Awesome post as are all your others. In just finishing up my EMT-B class now and this post reminded me of something both my instructors said at the beginning of my class. “paramedics save lives, but emts save paramedics” I think this is why emts and medics work so well together. Emts keep the patient alive by using foundational techniques while the medic provides care that will help the patient get better in the long run.
As usual a very good post leaving us a lot to think about. We always see the same problem with our ambulance courses that take people from first aiders to ambulance crews…. they often neglect the basic principles of first aid i.e bleeding, BLS ect and focus on the toys on the ambulance. we see it time and time again in their assesments – not making the grade because they havnt done the basics! Its all very well and good having them imobilised with perfect strapping, but if they havnt done the basics like airway managment it all goes to waste!!
Great post Steve. The best medicine is the one that works, not the one that looks cool or complicated. Sometimes (often) less is more when it comes to good patient care. Before I went to Paramedic school, My cousin ( a medic 9 + years my Senior ) stressed the importance of good solid BLS. “BLS comes before ALS” he would say, and he was right. I pass that on to students and colleagues alike, and who could argue?
An excellent article, for sure. It’s easy to get overly excited about the new, cooler, more advanced techniques for patient care…I know I look forward to having a more expansive “tool box” for treating people. I just hope I don’t get ahead of myself and accidentally skip steps.
Do you think the medics who start from scratch and go through basic, EMT, and then Paramedic training all one after the other (without gaining street experience along the way) are more prone to making these mistakes? Or would it be the other way around?
Steve,
The other big take away from larger than life fluid boluses that I’ve learned is that saline doesn’t carry oxygen, it’s a false sense of security to buoy up the BP without realizing that we’re not changing their O2 carrying ability and as you said frequently neglecting their our O2 delivery by forgetting the basics. A CRNA was one of the best BVM instructors I’ve ever had and made me realize how poorly providers of all levels usually ventilate non-intubated patients in the field.
Along the ventilation thought process, I was thinking about non-herniating head injuries that like most arrests get ventilated @ staggeringly high rates dropping their ETCO2 and causing insult to their potential viability. Whether capnography is available on scene or not, ventilation should be accomplished in a calm, controlled manner @ approximately 1 breath every 6 seconds. With two exceptions when capno is available ventilate to maintain a capnometry of 20 mm Hg and ventilate herniating head injuries @ a rate of approximately 20 breaths. Would you agree on these thoughts?
Paramedic school has taught me that something as “basic” as airway management and ventilation really needs a lot more focus than we give it and that we all need to be better @ our practice of this skill. Because, it is all about the basics.
I think many basics also get frustrated by that common statement- “paramedics save lives, but emts save paramedics”. Basics DO save lives, every day, but don’t get enough “thanks” from the paramedics they work with. I’m sorry, but that statement minimizes the efforts and skills of basics. We’re not doing it to make our partner look good. We’re doing it to SAVE LIVES.
Just my 2 cents…
Good call! We can do a fair bit to provide solid care for our patients and maybe even prevent the worst from happening. I guess we Basics should focus on the relevant tools we are givin instead of chasing the dream of higher skill sets and “bigger paychecks”.
My thoughts
There is something that I have always been amazed of since my “first save” (As an EMT-B) is that everyone looks down upon the Basic as someone who is just there for support. It was a BLS call and ALS was 15 min out. WE saved him. Without ECGs, Without IV’s. Without anything but asprin then CPR then the ol’standby AED.
Personally, I blame the over use of ALS and the pedestal it is placed upon as “it’s not a real emergency unless it’s ALS”.
Good post. Another item/skill that is a ‘basic’ but vital skill is what I call patient interaction. It’s everything from greeting the patient to interviewing them to interacting with family members.
I have passed this on to the crews at the Hood.
First thing I’d like to mention is that aspirin isn’t in EMT-B scopes everywhere.
The next set of questions I’d like to ask (Socratic method… yea) is about “BLS” v “ALS” nomenclature. If “BLS” and “ALS” categories are so important, what is a “BLS physician?” What is an “ALS physician?” If physicians don’t fall into the “ALS” or “BLS” categories, and the categories are so important, what is missing from medical education? Could the subjective categorization of “ALS” and “BLS” interventions and assessment tools be one of the causes of paramedics “forgetting” about “BLS” interventions? Would EMS be better off if, instead of telling providers that this intervention is “BLS” and this one is “ALS” and instead introduce assessment tools and interventions as a continuum of patient care?