There is an old saying that states, “What gets you to the top doesn’t keep you there for long.” To be honest, I’m not certain of the origin, but I know that it has many applications. It is certainly true in the world of sports.
For example, take a college football team that starts the season ranked No. 1 in the sports polls. What’s the likelihood they will finish the year in that very same spot on top of the heap? More often than not it does not work out that way. In no small part that’s because every team ranked under them is motivated to ramp up their performance in hopes of taking them out and replacing them atop the rankings.
One can see the business application as well. Your company comes up with a more efficient, less costly way to produce a product and it is introduced to the market. Once the benefits and cost savings are shown to be true, every company that competes with yours now heads down the same pathway trying to create an even more efficient, less expensive product to recover their market share.
The parallel to medicine exists also. When you first graduate with your EMT-B or paramedic credentials, you should be on top of your game as far as knowledge goes. The real question is, how long will it keep you on top of your game? Unfortunately, not for long. The quest for evidence-based changes in medicine keeps moving forward with or without you.
One of the most exciting things about reading the literature is that it serves as kind of a preview of things that may come. As a general rule, one study does not change medicine, nor should it. Any important study will be redone several times in different venues, and if the outcomes remain consistent and beneficial, then a change in medicine occurs.
As a provider it’s important to stay current in regard to what’s on the horizon. Let’s say you volunteer to work on the upcoming revision of your local protocols. To truly do justice to the project, it’s critical that everyone on that committee be up to speed on what’s currently state of the art, so that the protocols reflect that status. Then there may be some changes that are up and coming, such as the quest for a non type-specific synthetic blood that effectively delivers oxygen to the cells and removes carbon dioxide.
Every bit as important as the up and coming is the identification of those techniques and interventions that are obsolete or non-efficacious. For example, let’s look at the use of sodium bicarbonate in cardiac arrest management. It took close to seven years of ongoing studies before researchers figured out that, in most cases, the use of sodium bicarbonate in cardiac arrest actually made acidosis worse. What was once one of three first line therapies (epinephrine, lidocaine and sodium bicarbonate) was relegated to a much less frequent level of use.
Another great example was the pneumatic anti-shock garment (PASG). We put them on unconscious patients and they regained consciousness. We put them on patients with cardiovascular collapse and suddenly veins popped up for easy vascular access. Based solely on those two items, the PASG looked golden. Yet it wasn’t until Drs. Paul Pepe and Kenneth Maddox published their meta-analysis of the use of the PASG in the prehospital setting that showed that applying the PASG on patients in Houston who had been shot or stabbed ABOVE the level of the garment actually worsened outcomes. Oops.
Clearly, one of the greatest threats to remaining on top of your game as a quality prehospital caregiver is that of complacency. It is just too easy to settle in to a brand of medicine that feels really comfortable and stay there. Sadly, and certainly unfortunately for your patients, it won’t be long until you are providing, at best, average patient care. Soon to follow, if you don’t get with the program, you will cease to be part of the solution and instead will become part of the problem for patients unfortunate enough to call 9-1-1 on the day that you are on duty.