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Patient Care

Another Angle: Interrupting Inertia

In this era of alternative facts, it’s important to have alternative sources. That’s why I rely on Dr. Bryan Bledsoe, one of the most credible and least obnoxious truth-tellers I know, to cull discredited EMS practices from the rest of what we do.

Bledsoe, an ED physician, author, and former paramedic, made his bones as an iconoclast by questioning such traditions as spinal immobilization, air medical services, and critical-incident stress management. His views, often expressed through social media, are plainspoken and routinely supported by evidence. I was paying attention when he posted this rhetorical question about hyperoxia: “How can we stop the belief that the indication for oxygen is the presence of a patient in the ambulance?”

I wouldn’t know how to answer that, but I can think of a few reasons why O2 overdosing is still such an issue within EMS:

The urge to do something—There’s a proactive bias to paramedic and EMT training that’s not necessarily a bad thing. If the goal is to encourage responders to make decisions quickly, fine, as long as “monitor and transport” remains an option. Prehospital care should be driven by patient-specific risk assessment, not by a menu of meds and machines.

Failure to stay current between refreshers—Having to pass credentialing exams every few years doesn’t relieve EMS providers of responsibility for keeping current between refreshers. CME helps when it offers more than stale knowledge repackaged. Instead of settling for summaries of what you knew yesterday, learn what you’ll need to know tomorrow.

Instructors who trivialize or ignore new findings—When I started in EMS, the primary source of education seemed to be war stories. Instructors often used them to accentuate personal preferences—e.g., “You can do it that way, but here’s what works for me…” I understand the reluctance to embrace isolated studies, but it can be just as harmful to reject new findings simply because they challenge old habits.

Prehospital providers who believe they know best—I’m amazed when I hear paramedics disparage physicians whom they assume don’t have practical skills comparable to their own. Dismissing a decade of “book learning” because it’s not needed to handle a laryngoscope is as good an example of Dunning-Kruger as you’ll find in our industry.

Cultural imperatives to offer oxygen in emergencies—Difficulty breathing is usually obvious and often dramatic. I’m pretty sure that’s why we see it portrayed so often on video and film. And if the script calls for a save, portable O2 will likely be front and center. What you won’t see is some supporting character with a pulse oximeter warning rescuers, “Enough already!”

Recognizing reasons for clinical inertia shouldn’t be a stopping point. EMS needs to actively promote therapeutic changes bolstered by persuasive evidence. Otherwise, our biggest problem won’t be alternative facts; it’ll be alternative outcomes.

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

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