What NOT To Do in EMS

Like many of you, I have the privilege of administering practical tests to EMS personnel. As I arrive at the examination site, two thoughts tax my limbic system: Where's the coffee? and I sure am glad I'm not the one being tested.

     It's not that I don't know the material. It's just that 15 years in EMS have left me feeling more confident of my street skills than my recall of contrived scripts.

     As I hear students recite, "First I would…then I would…," I recognize subtle aspects of each scenario that should alert the candidates to not take some of the steps they are parroting--at least not without further consideration. This makes me wonder: Are we overemphasizing a bias for action in the field? Do we spend enough time warning our students about the medical consequences of bad decisions? Should we add scenarios where "monitor and transport" is the right answer?

     I scanned the 11 algorithms in the 2005 American Heart Association Guidelines to see how many instances of "Danger, Will Robinson!" I could find. There were seven. Well, sort of. Three were understated reminders to minimize interruptions in chest compressions; the other four cautioned providers about inappropriate medication administration. Only two warnings began with attention-getters like "do not" or "avoid."¹

     Primum non nocere (first, do no harm) is the prime directive for all medical professionals. As educators, we can reinforce this philosophy by discouraging prehospital practices that not only lack evidence of effectiveness, but may be hazardous to our patients. Such caveats can be melded with relevant algorithms and protocols to present a balanced view of prehospital risks versus benefits.

     Here's one observer's Top 10 list of what to avoid in the field.

Delaying To Play
     Most of the EMS people I know are proactive. Our training demands it and weeds out those lacking the temperament to do something.

     For example, after being grilled and drilled for hundreds of hours on cardiology and pharmacology, we feel empowered to heal the heart with high-tech monitors and dozens of drugs. Sometimes we mistake prehospital meds and machines for definitive care.

     An instance of such futility is delaying CPR during cardiac arrest to push medications. Early, effective, uninterrupted CPR is more responsible for ROSC (return of spontaneous circulation) than any intervention, other than immediate defibrillation, during witnessed VF/VT arrests.¹ In fact, there is no evidence that any medication is solely responsible for survival to discharge.

     Another example is major trauma. When we linger on scene to attempt IVs, splint extremities or bandage wounds, we are denying injured patients access to advanced diagnostic procedures, operating rooms and specialists.

     During the first minute of our initial patient assessment, we should ask, "Can I fix the problem?" If the answer is no, transporting the patient is more appropriate than prolonged on-scene attempts to cure the incurable.

Lights and Sirens Because We Can
     There are approximately 12,000 emergency vehicle accidents a year in the U.S. and Canada, and ambulances are 13 times more likely to be involved in collisions than other vehicles.² In a 1995 study, use of lights and sirens reduced average transport time by only 43.5 seconds!³ Not much of a payoff.

     Traffic accidents are not the only consequence of expedited transport. A siren's sound causes a fight-or-flight response in both the driver and passengers.⁴ An increase in myocardial oxygen demand accompanying that surge of epinephrine could be harmful, or even fatal, to cardiac patients.

     Clearly, we should be cautious about our mode of response and transport. Salt Lake City EMS is doing just that; they no longer use lights and sirens on every response. Not only did they detect no change in patient outcome, but some units actually improved their response times.⁵