One of the more unfortunate aspects of EMS is that the low education requirements often leads to a large gap in what the new provider knows and what the demands of the job expects the provider to know. In order to fill the information vacuum, providers often latch on to the first thing said by someone who sounds like they know what they’re talking about. Similarly, a number of important issues of patient care are glossed over. The unfortunate side effect of both of these is the creation of a number of phrases that should never be mentioned, but are a part of EMS culture. So, here are my top phrases that should never be uttered on an ambulance.
- Treat the patient, not the machine. With the exception of automated blood pressure cuffs (technically auscultation is a form of NIBP), essentially all of the machines EMS uses in our assessment are to give us information that we can’t otherwise obtain. You can’t look at a patient and see if they’re mildly hypoxic. You can’t look at a patient and see if they’re hypoglycemic. You can’t look at a patient and tell if they’re having a STEMI. I think it takes great hubris to say, “My history and physical is perfectly done and 100% correct every time.” As such, diagnostic tests shouldn’t be discarded simply because they disagree with our assessment. As one of the actual useful Ayn Rand quotes from Atlas Shrugged goes, “Contradictions do not exist. Whenever you think that you are facing a contradiction, check your premises. You will find that one of them is wrong.” We need to troubleshoot both the test itself as well as our assessment. Did I miss something? Is there some preexisting condition that I’m missing? Am I assuming that there is only one new condition?
- Always give/do _____.Exams are supposed to mirror real life, and one useful test taking strategy is that “always” and “never” answer choices are almost always wrong and never right. Anatomy and physiology does not change if the patient is in the ambulance or the emergency department. If you’re sticking all of your patients on a non-rebreather mask at 15 liters per minute oxygen, then you’re either doing your patients a disservice or you work for one hell of a service. The vast majority of our patients do not need supplemental oxygen. The vast majority of patients who do need supplemental oxygen do not need a non-rebreather mask. Think it through. Is hypoxia (“hypoxia” and “ischemia” are not the same thing) the problem? What am I hoping to achieve with providing this patient oxygen? Will supplemental oxygen actually achieve this?Similar to the oxygen issue is restraints and AMAs for patients with psychiatric issues. Not all patients with a psychiatric history is incompetent (assuming they are not currently on a legal hold) nor do all patients with a psychiatric history need restraints (including those on a hold). While, yes, the bar is lower in a moving tin can, the patient (you know, that exam thing and all) and the staff should be talked with before deciding to use restraints.
- We can’t clear spinal immobilization, we don’t have an x-ray. First, is selective spinal immobilization “clearing c-spine” or tightening the indications for spinal immobilization beyond “trauma is present?” Do you clear patients from the need for oxygen? Do you presumptively get out an OB kit for all women until you can clear pregnancy? What other treatments are presumptive besides oxygen and c-spine? Finally, one of the two major selective immobilization criteria (NEXUS) actually has nothing to do with spinal immobilization. The National Emergency X-ray Utilization Study (NEXUS) looked at a clinical tool to help emergency physicians decide who needs to get a spinal column x-ray. It’s a short putt to go from “these patients that meet these conditions do not need an x-ray” to “these patients do not need a backboard,” and neither conclusion requires the actual presence of an x-ray.
- We’re not doctors. Yes, EMS providers are, by and large, not physicians. EMS providers are not expected to command the same fund of knowledge and diagnostic ability of physicians. However, more often than not this phrase is used to shut down independent thought and intellectual curiosity than any legitimate criticism. Is it any wonder that there are so many problems in EMS when EMS is one of the few, if any, fields that actively teaches their students to not think about what they’re doing past the cookbook? After all, why question any of the care you’re providing if you’re “not a doctor?”