Why Mobile Medicine Matters, Part 1: Ethics & Evidence

A person wearing black gloves with simulated blood on them uses a stethoscope.
U.S. Air Force photograph by Airman 1st Class David D. McLoney

Here is the true story of the first death that one of us encountered in Mobile Medicine:

The dispatch came in for choking and we were riding shotgun. Our partner grumbled that by the time we reached the scene, the food would have been swallowed, pulled out or vomited, and we will have trudged up the stairs with all our gear for nothing. We reached the apartment and found that another rig was on-scene. Now she was really annoyed because we would have even less to do.

Up we went… and found an eighty-something year old man face-up on the floor, his eyes bugging out, hypoxic, and pulseless. His wife (who looked like our grandmother, making the scene feel even more personal) was terrified: her life partner of fiftysomething years was dying. What could she do to stop it? Their daughter rushed in, bracing to find her father dead on the floor of the apartment where he raised her. To that day, we had never seen people spring into action so quickly. The medics were astonishing. A three-inch piece of meat was removed; oxygen was provided; his heart was restarted. 13 BPM… 35 BPM… 48 BPM…aaand we’re back!

He was awake, conscious and looking around. The crews would take him to the hospital about five minutes down the road and his family could meet him there. They wheeled him across the threshold of the emergency department and he coded instantly. The CPR was so deep that we swore his sternum touched his spine. The man never woke. His family never said goodbye.

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Some will read this story and think: “The crews did exactly what they were supposed to do: they gave the man a chance.” Others will think: “The crews gave the family false hope.” Some will learn that the story has a tragic and wonder what could have gone differently, because the patient care outcome was ostensibly negative (after all, the man passed). What lesson can be learned? How might the clinical quality be improved? Others will feel the fickle touch of fate, and take a more stoic approach: “But people die.”

(Note from the authors: Stoicism is not cynicism. To the contrary, compartmentalizing trauma can be psychologically risky because every brain needs catharsis (even more so after twenty-four hours of strain). Recognizing the inevitability of death simultaneously pays homage to the sacred power to give life that flows through the fingers of each person who wears a Mobile Medical patch—regardless of education level, private or public service status, or even the color of the patch.)

Each interpretation of the above facts is correct. Some things went right (“He’s back!”); some went wrong (“We lost him”). Some were hopeful (“You’ll see him soon”); some smashed the heart and stirred empathy, reminding us why we do this work despite easier ways to make a buck. The answer “What should I have done?” is a complex one—as are all ethical quandaries. Ethics ultimately ask one question, but it is arguably the question:

What should we:

  • Do?
  • Say?
  • Study?
  • Measure?

When should we:

  • Restart a heart?
  • Let a heart stay stopped?
  • Break a grandfather’s ribs so he can kiss his granddaughter’s face again?
  • Not break a grandfather’s ribs because if he only lives a few more days, and they are all in the hospital (which he would not want anyway), his granddaughter’s last memories will involve labored breathing, morphine, tubes and beeping machines?

How should we tell the new widow that her husband of fifty-plus years isn’t going home?

Rarely do we get to go into work, sit at our desks and make easy decisions. If the only decisions we had to make were delineated black or white, right or wrong, then anyone could do our jobs—including a computer. We rarely face such questions or problems. We work in shades of gray and rely on our ethics, policies and experience to make the best decisions we can. It is little coincidence that Plato, a godfather of Western Ethics, described “Hippocrates [as having] a philosophical approach to medicine,” some four centuries before Ezra the Scribe, who is credited with assembling the Hebrew Bible into the book that birthed Judeo-Christianity.1

Ethical quandaries are old problems, yet they persist. Answering them rarely makes everyone happy. They also challenge medicine because philosophy is subject to opinion, and so, to politics. Philosophy is often about convincing others to align with one’s perspective. Medicine does not think it should have to, because biology, chemistry, physics, and so on; each work in particular ways. Until the advent of a recent pandemic, nature’s methods were not seen as “negotiable.” (There is an exception to every rule, and we would argue that logic is the one philosophy that aims to be objective.)

More than a millennium after the Bible, the scientific method sought to distill away the matters of perspective using a structure that is not “solely based on…observation and thoughts.”2

That is, the scientific method is rigid and constrained in its design and produces results that are isolated from real environments and that only address specific issues. One of the most important features of the scientific method is its repeatability. The experiments performed to prove a working hypothesis must clearly record all details so others may replicate them and eventually allow the hypothesis to become widely accepted. Because the scientific method is basically a “trial-and-error” scheme, progress is slow.”3

We live in the age of social media, viral videos and “bumper-sticker politics.” As Mobile Medical agencies are being asked to do more with less, and to justify their existence, the scientific core of our industry—its objective, methodical, and indeed, slow parts—face a new existential challenge. In July 2021, Tom Bouthillet, a retired EMS battalion chief from Hilton Head Island (SC) Fire & Rescue, suggested during a Twitter discussion that it would be important for cardiologists to know that the “job [of Mobile Medicine is] to get ROSC and transport the patient safely to the hospital. It’s their job to do their best to ensure neuro-intact survival. Meaning, not to hem and haw over taking the patient to the cath lab because they’re worried about a mortality ding.” He continued: “No one has a quarrel with improving end of life education, decision making, and communication, and no one wants to participate in unethical resuscitations that prolong suffering.” 

One of us replied: “Despite multiple studies that show epinephrine achieves return of spontaneous circulation (ROSC) but can have drastic neurological deficits, why does EMS continue to follow guidelines we know could hurt our patients?” 

While our purpose here is not to answer this particular question, it is to ask whether we are doing enough to even try to answer it. Ethics often demand that we face the Man in the Mirror: “Are we doing what we should?” Translating the language of philosophy to that of science, how much evidence is enough to justify what we are doing—and to suggest that we are doing it rightly

Then again, do we even need evidence? In 2019, a renowned medical director, who has written textbooks on emergency medical services, declared on social media: “I work in a busy public hospital ED with a separate Level 1 trauma center and separate peds ED. I barely have time to go and pee—much less sit at the computer and look at contemporaneous EMS data. Also, I doubt it would change anything I do.” 

Without delving into the mathematics of decision science, haven’t Freakonomics, Neil deGrasse Tyson, and every Malcolm Gladwell book taught us that humans fare quite poorly when it comes to following our instincts? As an industry, we tend to follow fads and “cool stuff” versus following the science. Does Mobile Medicine still qualify as science if our “gold standards” and “best practices” emerge from single-sample studies that “seem okay to me,” because retests are expensive and risk offending whoever has been disproven? Can we cast politics aside because, as another of us has said: “Though at times we must tread lightly—nevertheless, tread we must”?

References

1. Encyclopedia Britannica [Internet]. “Hippocrates”. [cited 2021 Jul 28]; Available from: https://www.britannica.com/biography/Hippocrates.

2. Castillo, M. “The Scientific Method: A Need for Something Better?” American Journal of Neuroradiology. September 2013, 34 (9) 1669-1671. Available at: http://www.ajnr.org/content/34/9/1669.

3. Ibid.

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