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Another Angle: Not Helpful, Possibly Harmful

Arguing the efficacy of long-standing practices has been an EMS pastime since Johnny met Roy. Stop by any 9-1-1 outpost, and you’ll hear plenty of paramedics and EMTs offering cautionary anecdotes about mainstream therapeutics. Once in a while our industry even reverses course on products or procedures that don’t work as advertised (think c-collars and bicarb), but only after years of debating downgrades from “probably helpful” to “possibly harmful,” as the AHA might say.

Wouldn’t it be nice to have one list of stuff we need to unlearn? Ten researchers from three U.S. universities compiled such a summary for medicine in general. Reading that report of 396 discredited interventions made me wonder what an EMS-specific version might look like in, say, 2030.

Here’s my take on prehospital customs headed for obsolescence:

Two-milligram loading doses of naloxone—It’s hard to imagine CME more extraordinary than this video of an Appleton, Wisc., firefighter and two others shot by an overdose patient who’d been awakened by IV Narcan. The case begs review of EMS and law enforcement procedures, none more important than naloxone dosing. Protocols should prescribe titration to maintain life, not consciousness.

Twenty-four-hour shifts—Some of my colleagues are so happy with twice-a-week 24-hour tours, they’d opt for monthly 176-hour shifts if they could. However, studies like this one point out the greater risks of fatigue and reduced alertness once we’ve been on duty for more than 12 hours. Agencies will have to prioritize safety versus lifestyle. That should be interesting.

Lights-and-sirens transports—To get a sense of how counterproductive lights and sirens can be, start with this piece by Jeff Clawson, MD, inventor of the priority dispatch system. Obsolete may be too strong a word for how we’ll characterize this practice by 2030, but the subset of patients presumed to benefit from Code 3 transports needs to keep shrinking.

Traction splints—I’ve been skeptical of traction splints ever since my wife had to beg a fellow EMT not to apply that device to a fractured knee. Using x-ray vision to steer clear of contraindications is only one impediment, though, as this article explains. Do we use traction splints in the field often enough to justify hours of training and testing? I don’t think so.

Drugs administered during cardiac arrests—I’m speaking of epinephrine, atropine, and antiarrhythmics. That they hardly ever preserve life—the kind worth living—is a given, as ACLS and PALS attest. I’m just wondering how long we have to wait to retool all those algorithms. Would a decade be enough?

AEMTs—According to this data from the NREMT, AEMTs make up only 4% of all nationally registered providers. Pardon my impertinence, but why bother? As BLS and ALS become seamless parts of the same spectrum, what’s the point of an intermediate level of training?

Somebody look me up at the Home for Deranged Medics in 10 years and let me know if I guessed right about any of this. I’ll be the one playing with a traction splint.

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at



Submitted byalelkins on 08/03/2019

Point by point:
*2mg loading dose for arrest is warranted, but otherwise titration is key. Why are we talking about this?
*I work 336hr shifts (24 @ 14/14). It isn't about how long the shift is, it's about how you manage fatigue and the other affecting factors. Our system works well for us and our patients.
*Lights & sirens, when used appropriately. can benefit some patient in some situations. Notice I referenced appropriate use...
*Traction splint is just like PASG, SMR, or using lights and sirens. There is an appropriate time/place for each. We as providers bear the responsibility for ensuring appropriate utilization.
*Drugs during arrest? I have seen drugs make THE difference. I've seen them make no difference. Back to appropriate administration.
*The algorithms are reviewed every 5 years. They change when there is a compelling reason to do so.
*AEMT level makes it easier to ascend for some. Back in da day, North Carolina had AA, EMT, EMT-D, EMT-I, EMT-AI, and EMT-P. Eat that big 'ole paramedic training elephant one bite at a time. This system was developed when the vast majority of field providers were volunteer. I digress.
Appropriate is a word that just keeps rearing its ugly head. Appropriate is the crux of the issue. None of these things you discussed are inherently bad. We, as an industry, all too often improperly utilize or apply the said resource which con contribute to less than favorable outcomes. We are the weakest link.

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