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Education/Training

Guest Editorial: Keepers of the Basement 

Cookbook medicine—defined as “the practice of approaching clinical problems using rigid, non-individualized ‘diagnostic recipes’ or ‘pathways’”1—has occupied the attention of every clinical manager at one point or another since the beginning of time, and it’s still being practiced.

A decade ago, when I graduated from my college-based paramedic program, my instructors had in place a course with a solid reputation for education and research. This reputation often led to students seeking easier paths at a “patch factory” or “medic mill” elsewhere—to the detriment of both them and their patients.

There are students passing the NREMT today with abysmal knowledge of pharmacology, inadequate knowledge of pathophysiology, and a complete inability to speak to patients…but they know how to read a cookbook.

The push toward in-hospital algorithmic medicine seems to have been born of the idea that such practice reduces liability and likelihood of lawsuits and makes it easier for the bean counters. The Affordable Care Act and so-called “pay for performance” metrics are partially to blame for this phenomenon. This belief in cookie-cutter treatment plans results in unnecessary bills to patients, facility costs for unneeded tests, and increased workload for the nursing staff. 

As a paramedic in Texas, I am fortunate to be employed under a model of delegation. In Texas we can perform tasks authorized, trained, and overseen by a physician. Although all EMS providers work under some form of delegation or protocol, it is still our responsibility to know where and when not to perform a task, deliver a medication, or accept a refusal of transport. The almighty cookbook does not absolve us of the responsibility we shouldered when we assumed the title of paramedic/EMS provider. 

Developing our practice requires the furtherance of our education. CE requirements are set as a building block, a foundation, minimum standards to be met, not as a ceiling. Assuming the title of paramedic mandates personal accountability and personal responsibility. It takes drive, initiative, and a quest for betterment and discovery of the unknown to get the most out of this profession. 

Most services would be deauthorized by their medical directors with a first-pass percentage rate in the 60s for intubations. In “bakeries” where the cookbook rules, medics who perform an RSI that leads to a critical desaturation are given a pass as long as they followed the cookbook. Cookbook medicine and a lack of training and oversight prolong discomfort and kill patients. This is not what Hippocrates had in mind.

Paramedics shoulder much of this responsibility by not demanding protocols and education based upon evidence-based medicine. With the number of studies being done today and the technology and education available to us via FOAMEd, the Internet, and conferences, there’s no excuse for suboptimal patient care being delivered in the backs of our boxes and aircraft. 

For those of you already composing your hate mail, this is not a demand for carte blanche paramedicine. The education disparity between a physician and a paramedic goes without saying. Physician oversight of medics is needed now more than ever, with the rapid progression of medicine and advances such as prehospital ECMO and others. 

EMS is only shooting itself in the foot by utilizing the cookbook method of medicine. Our lack of progress is more obvious now with ePCRs and advances in record-keeping technology. Your sins can be mercilessly dissected with a keystroke. 

The days of explaining why you pushed a drug or performed a procedure with “Because the protocols said I could” need to be swept into the past as a reminder of where we were, not where we’re going. What is your plan when the cookbook doesn’t address the patient’s complaint or the recipe doesn’t solve the problem? What will you say on the stand when the prosecutor asks if you knew better than to proceed with a treatment you should have reasonably known could cause the patient harm?

We took on this responsibility knowing our duty is to be a solution to a problem, a knowledgeable resource, and a provider. Let’s not lose sight of the reasons why we put ourselves through two years of having no life and the accompanying stress. 

Skillful providers are the wave of the future. It’s way past time to hop on the education train and develop our staff, and ourselves, into the tip of the spear, not the keepers of the basement. 

Reference

1. Wen L, Kosowsky J. When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. New York: St. Martin’s Press, 2013.

Phil Haebe, NRP, is owner of Advanced Aid Solutions and a paramedic in central Texas. Reach him at advancedaidsolu tions@gmail.com. 
 

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