Columns, Training

Old Habits Die Hard

Issue 2 and Volume 40.

Remember as a child when a teacher called you out for making a mistake? You stood up red-faced and corrected yourself. Well, that was me at our annual cadaver lab training, facilitated by Mercy Air Medical Director Daniel Davis, MD, (pictured above right) a well-known expert in advanced airway management.

At the start of class, he asked me to come up and demonstrate proper bag-valve mask (BVM) ventilation. I was a little confused; we’ve filmed airway management training videos together, and I hadn’t had any advanced airway patients lately. Why me?

So I went up to be his assistant and his punch line was projected onto the screen: the March 2014 cover of JEMS. In the photo (above left), I’m the one holding the mask seal to the patient’s face, using the “EC clamp” technique I’d been taught in the past. What I had forgotten was our most recent lesson on the “two thumbs up” technique (above right)—the latest research shows this technique allows the strongest fingers to facilitate the jaw thrust.

Photo courtesy Todd Blevins


Change is Constant

I can’t count the number of protocol, policy, drug and skill changes since I started my EMS career in 1988. Back then, my paramedic book had about 200 pages and weighed a pound or two. Today my students carry two volumes with thousands of pages, and they weigh a ton! We didn’t have computers, and the internet hadn’t been invented. We reused a lot of equipment that nowadays is obviously single-patient use. Latex was everywhere, we used wooden backboards, and we held the charged paddles as we defibrillated. Shocking!

Changes in technology and patient care come from scientific studies and from our profession growing and maturing. How many changes in CPR protocol have you witnessed? Compressions weren’t originally the main focus—it was the airway. We were like lightening to a rod to get them intubated, but continuous compressions were never stressed, and we never rotated compressors. But now we know the efficiency of those compressions degrades as time passes due to unrecognized fatigue. How many patients lost coronary perfusion pressure before that fact was known, or because of us stopping to do another task, not realizing all the priming we’d just done to their pump was lost? We also stacked our shocks without realizing the time off the chest we were causing. A little bird told me that may come back. And that’s the funny thing about change: Some things come full circle.

How about our most prized skill, intubation? Back in the day, when you saw the tube go through the cords, you were confirmed. Today, if you don’t have qualitative end tidal readings with waveforms, most agencies require the tube be pulled. Our protocols now allow pediatric intubation only in cases where the patient’s airway cannot be effectively managed with a BVM. For a rescue airway, we’ve gone from esophageal obturator device to Combitubes to our current King Airway.

We’ve had many versions of our confirmation acronym, but as of this article it’s LEADSD: lung sounds, end tidal, absent epigastric sounds, depth, size and doctor verification. The oversight on intubations is intense!

How about changes that aren’t so drastic, but still take a mental shift to accept? My biggest mind bend was no oxygen for stroke patients. I understand the vasoconstrictive and possible untoward effects, but who else had a hard time with that one? Again, that change was sciencebased, but change can be hard to accept, folks!

It’s a constant give and take, and accepting change is the first step to remembering change.