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All Things in Moderation

EMS is a special calling. There are few professions in which people can legitimately and daily make a difference between life and death. EMS is one of those professions. Further, there are few professions where a simple action or mistake can cause injury or death. EMS is one of those professions, too.

We each entered the challenging world of prehospital care for different reasons. However, most of us became EMTs and/or paramedics because we liked helping people. But it s more than that. We entered EMS because we like the good feelings that result from helping people. Today, EMS is one of the most respected professions in the world.

But during an average EMS career, a provider will reach a point when they suffer a significant amount of disillusionment. It s not uncommon. We all encounter it. The causes are usually varied, but a common feature is the realization that the majority of EMS calls are non-emergencies. That means that all of the skills and technology we were trained to use are rarely required. This is the dirty truth of EMS. A similar dirty truth exists in emergency medicine; 90% of most emergency department cases can be handled by a competent family practitioner. The specialized skills of an emergency physician are not needed that often.

How we respond and react to this disillusionment tells a lot about our integrity. Integrity can be defined multiple ways, but the best definition is: Integrity is doing the right thing, even if nobody is watching. The wise EMT will recognize that a lot of medicine is simply hand-holding and emotional support and that such actions are just as important as IVs, endotracheal tubes and waveform capnography and that basic support is honorable and fulfilling.

However, some people in EMS will respond to this inevitable disillusionment in a different way. They determine, often subconsciously, that they ll continue to use their skills and practices even if the patient does not stand to benefit. As this evolves, they ll find ways to rationalize their behavior. Before they know it, they will have violated medicine s most sacrosanct dictum primum non nocere (first, do no harm).

Why is it that some EMS providers have to do everything to the max? We re not happy ventilating a patient with a BVM; instead, we have to intubate them with an endotracheal tube. Better yet, on a 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 re not happy simply taking somebody to the hospital. We have to do something, and we 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 we can justify it in the name of the mythical Golden Hour or similar arguments. ET tubes, surgical cricothyrotomies, IO lines and helicopters are all important tools, but they should be applied only when the benefits outweigh the risks and costs.

At some point, a change occurs in some paramedics. They start to do things for their own ego and not to benefit the patient. Some pride themselves on the number of different helicopter pins on their uniform or the number of merit badge course patches that we believe tell others that we re important, save lives and should be revered. Is it insecurity? What would Freud say? There is a guy I see periodically in a community near my home in Texas who s always wearing a badge, an EMT shirt, trauma shears and a radio despite the fact he s toting five kids to Wal-Mart for Cheerios and Coco-Puffs. Who is he trying to impress? The Wal-Mart greeter?

Today, it seems the sign of a good paramedic is one who puts the most needles into bones, frequently calls the helicopter, intubates a child when a BVM will work, immobilizes somebody on a backboard even though most have a less than a 1% chance of a spinal injury, and runs precautionary Code 3 just for jollies. I ve been in nearly every state in this great union and often heard war stories from people proud of the number of crichs they ve done, the number of IOs they ve done, or the numbers if chests they ve needled. I always want to ask (but never do) if the patient got better.

Some of the best EMTs and paramedics I ever met were the humblest. In October of last year, I sat in a hangar in Sydney, Australia, with about 10 flight paramedics from New South Wales and the deputy commissioner of the ambulance service. The purpose of the meeting was to establish protocols to limit helicopter use to certain situations. They were receiving more and more calls for non-critical patients. The people who initiated the meeting were the flight paramedics, because they weren t going to risk their lives like the Yanks by sending their helicopter for non-critical calls. Thus, they put logic and science above ego.

As a textbook author, I m aware that many of us write page after page on how to be a good technician but never teach people how to be good neighbors. Thus, when one becomes disillusioned when they realize that all of the high-tech material in the EMS textbooks is used for only a small percentage of patients, we start playing this mind game. We delude ourselves with the mistaken belief that we re doing things to help the patient when, in fact, we may be placing the patient at risk from those actions. We re approaching this all wrong. We should be satisfied by practicing and using the safest and most effective modality before increasing to more complicated ones.

An old internal medicine professor at Texas Tech once told me two things that I follow to this day:

1. Being a good clinician 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 EMT means that you re 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.

American author Henry David Thoreau once wrote, It is characteristic of wisdom to not do desperate things, and essayist and editor Norman Cousins once wrote, Wisdom consists of the anticipation of consequences. All of us in EMS should heed these statements.


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