4 Phrases That Should Never Be Said on an Ambulance

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.

  1. 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?
  2. 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.
  3. 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.
  4. 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?”
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About Joe Paczkowski

I am an EMT and a second year medical student at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific (COMP).
This entry was posted in Clinical EMS, EMS Operations and tagged , . Bookmark the permalink.

20 Responses to 4 Phrases That Should Never Be Said on an Ambulance

  1. michael says:

    If something gets me thinking, it must be good! Loved the Ayn Rand quote as well, I’ve been trying to sneak a little John Galt into Rescuing Providence for years, have yet to figure a way to pull it off!

  2. Kuo-Chih Chang says:

    Hey, nice blog and good articles.

    I am a 4th year med student from Taiwan (our med school lasts 7 years), and i am an EMT as well.

    Since i am probably the first med student in Taiwan who was also an EMT before getting into medical school, many emergency physicians ask me to write articles for our EMS providers. And i’ve been doing this for the past 3 years.

    Now i find it interesting that someone is doing almost the same thing, but thousands of kilometers away, lol. Let’s keep on doing this for a better EMS.

    Sorry for my poor English, btw.
    😛

  3. Ian Roberts says:

    Joe,

    Thank you for posting your thoughts on this subject. While I understand the thought behind your points, I would like to offer a slightly different view. Please note that I agree in basic theory with most of what you are saying, however; you violated your own tenant by saying phrases that should “Never” be said.

    1) – “Treat the patient not the machine.” Sadly, in a tiered system and in states such as New Jersey where I am a Paramedic, many on the EMT-Basic level do not see a high acuity of patient and have little experience in high volume EMS systems. (We all started somewhere.) While a great majority in the seven county area that I work are outstanding providers, some rely so heavily on secondary devices such as the dreaded pulse ox, that they completely overlook or miss the basics of initial impression and initial assessment. The same goes for many providers including RN’s in “skilled nursing facilities” that call for EMS simply based upon a low pulse ox reading taken at shift change on a patient with either ice cold hands or poor peripheral circulation, and without ever taking a moment to assess the patient. While devices such as the pulse ox have a place in the pre-hospital setting, they are flawed as a stand alone device and must be used in conjunction with a full and proper physical assessment. For this reason, there are occasions (Carbon Monoxide poisoning, where the pulse ox reads “stuff” bound to hemoglobin…not just oxygen) where some providers need to be reminded to “treat the patient and not the machine.” I am only using the pulse ox as one example, but; there are others. Indeed, the use of equipment such as the pulse ox, glucometer, monitor and other devices is key to full and complete ALS care..but again, it must be used as part of an assessment and not at the full assessment. (As an ACLS instructor, I have seen published advanced practitioners fail a scenario for reading a monitor and declaring the patient alive and well based upon a well organized QRS complex that they failed to check a pulse on when the given “Mega-Code” was a PEA.) Again, use the machine as an adjunct to treating the patient first. BLS before ALS.

    2) – “Always do.” You are correct in stating that “always do,” almost always does not apply. That having been said, there are some cases where an “always do” does apply. For example: Always perform a scene size up….your safety always comes first. Additionally, some states, such as New Jersey (my point of reference), require BLS to perform certain tasks. ie) 02 on all respiratory calls. In this example, I agree with you wholeheartedly as cases of hyperventilation (anxiety induced with carpopedal spasms present), actually are improved with no/reduced oxygen. As an ALS provider, there are certain things that we must always do during certain procedures such as Rapid Sequence Induction. Nonetheless, I understand your comment and agree that as two cases are rarely the same, the statement “always” almost never applies in the context you are using. (Of course, one should always perform a good basic assessment first.)

    3) – “We can’t clear spinal immobilization, we don’t have an x-ray.”
    This has become a topic of some debate as we can look at mechanism of injury and, based upon our experience, gain a fairly good idea as to the index of suspicion for spinal injury. How many times have we taken patient’s to the ED in full c-spine immobilization, only to have the ER Physician walk in, perform a similar evaluation as we conducted in the field, and immediately roll the patient off of a long-board without an x-ray? (Clearing c-spine.) Much of this seems to stem from the concern for liability as well as for the fraction of cases where the patient has indeed sustained that unforeseen injury from an incident with a low index of suspicion. Again, the standard of care for pre-hospital providers (including National Registry), calls for spinal immobilization. Many states require this as part of the state protocol and even have provisions for revocation of certification when c-spine protocols are not followed. Given the choice, I believe most pre-hospital providers would go ahead and c-spine patient’s rather than risk legal liability, potential suspension or loss of certification, departmental disciplinary action, and; most importantly, potential injury to a patient with an undetected injury. The fact remains that x-ray is most often the definitive method of clearing c-spine. This having been said, the ability to base our decision whether or not to secure c-spine would be an advancement of our profession.

    4) – “We’re not Doctors.” On this point, I agree with your sentiments completely! While we as pre-hospital providers (in this case, a greater focus on EMT-Paramedic/Mobile Intensive Care Paramedic, as it is the advanced provider that is trained to perform advanced interventions) are not Physician’s, we operate under the license of our command Physician’s and are the eyes, ears and hands of these skilled professionals. As such, the expectation is that we perform to this level while we deliver the patient to the more definitive care of the ED Physician. In many areas, it is the Paramedic or EMT who has anywhere from a few minutes to a few hours with the patient before a Physician can be reached. In these critical minutes, the advanced provider can perform everything from a basic assessment, to critical and potentially life saving interventions such as IV access and medications, to endotracheal intubation, chest decompression and diagnostics that can provide a “heads-up” to the receiving facility so as to be better prepared to provide immediate and seamless care to critical patients. Personally, I have been part of the team that has, on many occasions, delivered patient’s such as active STEMI’s, directly to PCI with B/L, large bore IV access, multiple 12-Lead EKG’s, the appropriate 02 therapy (not always high flow), as well as a full compliment of first line medications delivered such as Aspirin, Nitroglycerin, Morphine and Metoprolol. In this respect, we must indeed push ourselves to “think outside of the box) and realize that while our title may be “EMT-B/I/P,” the function that we perform at that time is that of the Physician’s hands.
    I am proud to work in a system where I always think, “What would my command Physician do” as there is a relationship of trust and respect that ultimately results in exceptional patient care. Through constant improvement, including viewing the QA/QI process as educational and progressive as opposed to punitive, our profession will continue to grow and progress, and our patient’s will continue to receive the care they deserve. Thank you for allowing me to respond to your well written article. I wish you all the best and hope to meet you someday.

    Respectfully,

    Ian Roberts
    NREMT-P/NJMICP
    Instructor ACLS, PALS, BLS
    Field Preceptor
    Member – Advisory Board/School of Paramedic Science

    • Thanks for the response.

      “While devices such as the pulse ox have a place in the pre-hospital setting, they are flawed as a stand alone device and must be used in conjunction with a full and proper physical assessment.”

      That’s the sentiment that I’m trying to get at. Fixation on any specific point is generally a bad thing. However, when used in conjunction with a history and physical, if everything isn’t meshing properly my point is to question everything, not just the machine.

  4. Brad says:

    I completely disagree with all of this. If I ever need an ambulance I hope this joker never serves in my community.

  5. Jim d says:

    Treat the patient not the monitor. Yeah
    Dead guy no monitor CPR
    Deaf guy with monitor vfib shock
    asystole/emd don’t shock

  6. George says:

    I would agree with the majority of these I do have a slight problem with the first point. I one picked up a patient that was a regular and again complaining of chest pain. So I placed him on the monitor per protocol and it showed V-fib. Umm he is sitting Ther talking to me and had a normal pulse checked manually. So according to the statement I should have shocked him correct? Then the pulse ox. It has it’s place agreed yet again the hospital demanded I place it on a pt and it read his heart rate was 450 and his O2 was 4. It stayed that way and did not change. Pt was pink warm and dry. So do I treat this piece of equipment also? Use them as tools not a sole source of information.

    • I’m not arguing that machines need to be elevated, just that when contradictory information is present, everything should be up for reconsideration. Yes, often times troubleshooting the machine clears things up. In the first case, are the leads on securely? Anything else that could be causing the artifact? In the second case, the entire purpose of the pulse on a pulse ox is to correlate the displayed pulse to a measured pulse in order to ensure that the pulse ox is getting a good reading.

      Let’s use blood glucose as an example. 60 y/o, history of type 1 diabetes, a friend states that she hasn’t eaten much today, and is now unconscious. What’s your first impression? If the patient’s BGL is 90, would you still administer dextrose anyways or would you consider an alternative cause?

  7. Clif says:

    It’s interesting that you talk about the NEXUS study. Nearly 10 years ago Maine rolled out a revised spinal immobilization protocol based heavily on the findings of the NEXUS study. Whereas prior to the revised protocol MOI was the first indicator for spinal immobilization, it is now only considered as part of the “big picture” when deciding wether or not to immobilize a patient. I can say from my personal experiences that it has been a success. Giving trained providers the ability to perform a complete assessment and providing the appropriate level of care based on that assessment has led to a steady decline in the numbers of patients being immobilized simply because mechanism exists. The rollout documentation for Maine’s Spinal Assessment Protocol can be found here and here

  8. funny that i came across this post… some time ago i started posting every now and then about ems cliches, depending on when i have free time.

  9. Although I find many of the thoughts here quite insightful and I agree with alot of what Ian said as well as you Joe.

    I do have a few comments of my own, as with everyone in this world we all have an opinion.

    So here it is,

    1). I agree with both you and Ian on this, but I think that the comment “Treat the patient not the Machine” still has some merit, regardless.

    2) “always do” well I agree with both points of view here too, but I think it’s a double edge sword, given that medicine changes so frequently, so today’s “always do” is tomorrows “don’t ever do”.

    3) C-spine clearing: I agree with Cliff, 10 years ago, plus now, Maine had used the NEXUS study as well as other areas around the country. In my personal experience with similar protocols, there has never been any issue either.

    Of course clearing c-spines isn’t widely used, for many reasons, but I think those reasons are seriously unfounded. 20-30 years ago, 12 lead interpretations were unheard of, now it happens all the time. Are we wrong from time to time, of course! yet it doesn’t stop us from doing it. I believe this issue can be solved with education.

    However, if we (EMS) believe we are ignorant medical provider, then doctors and nurses will believe it too. Putting a stop to the ignorance is the only way to combat these issues.

    4) Were Not Doctors” I think this is an ignorant comment, coming from anyone who dares say it, from my point of view. We are medical provider, some of us maybe inexperience and other very experienced, like myself.

    With the scope of our position in EMS forever being redefined; how can anyone think they are not working at a senior medical level? Having said that, I don’t believe any EMT-A/I or P regardless of their status in the pecking order i.e.( Critical care medic or Flight Medic or any subspecialties medic) has every indicated such silliness (i.e. they are a Doctor).

    As an educator and mentor on top of the long laundry list of credentials, including the above, we are paramedics! Medical professionals (emergency/critical care etc), as such, it has weight to it in the medical community. I try to impress to my students including doctors and nurses and the general public, that we as Paramedic and EMT make an initial diagnoses and established care. If we didn’t, we’d be doing the following , not making decisions, going where I am told to go and not treating anything, we’d be cab drivers.

    What happens is we are told signs and symptoms, we use tools such as the cardiac monitor, ultrasound and labs values etc., to form our medical opinion as to what should be done, what type of treatment and where one should go. Some might have more latitude to operate with extended protocols, some might operate within their states or department minimum medical standard, regardless, we are all making a clinical diagnose and treating.

    If you don’t believe that you are acting as a senior medical provider (i.e. pseudo doctor). I then ask who shows up to these calls or transports. The doctor isn’t there dispensing medical advice, we are, the nurse isn’t there at 2am with a patient with GERD, asking if he need to go to the hospital, we are.

    We give medical advice and make the diagnoses every day. Of course it might not be the definitive diagnoses, which come from several doctors. Many times, as you know all, what happen is they say, yep the paramedics were right. We are responsible for the right choices many time, we need to tell each other that.

    I find this comment “were not doctors” coming from those providers who do not want to do their jobs, or are uncomfortable with any given situation and their lack of knowledge.

    Which brings to a comment that Ian said that “ we operate under the license of our command Physician’s”. we operate under a physician?; this bothers me on so many levels. WE (EMS) all are responsible for our actions, we make decision based on OUR medical licenses which is issued by our state. Regardless of the legal lingo whether it’s a certificate or license, you are a licensed medical provider. Just like any other medical provider, such as a PA or NP we have rule and regulation and laws which govern us.

    For the life of me cannot understand why EMS professional believe“ we operate under the license of our command Physician’s” It’s like a mantra. I can assure you as a paralegal and having been personally involved in a situation, this is false statement. Your command physician / medical control as we call it here, IS NOT responsible for any action taken by any EMT or Paramedic, YOU ARE.

    If you call for a medical consult, you might have a leg to stand on IF something goes wrong with the protocol or your treatment plan, but it’s all on you. Ignorance of the law is no excuse, nor is ignorance of proper medical treatment and assessment.

    We in EMS can be prosecuted and can go to jail, on top of a tort case, for a bad decision. Unlike the command physician/ medical control, where perhaps a tort case might happen for our actions.

    Now, Im not go to get into the law and what if’s and/or how an Attorney General or judge might think, nor any case law etc. I am just mentioning it as it always upset me to hear this comment.

    Well, thats that, Overall I enjoy the article, including the thoughtful comments made by everyone.

    Thank you for your time,

    Charles Robichaud

  10. CBEMT says:

    “We’re not doctors.”

    I use it all the time on people who want to refuse but need to go to the hospital. It’s part of my regular shtick. I have little shame when it comes to someone who I believe is risking their life by denying themselves my care.

    I’m also more than willing to admit that I know a lot, and I might even know more than a lot of people and providers. At my level of care, and in my area, I’ll go out on a limb and say I’m just plain better than most.

    But I don’t know enough. I’m getting there, but I’m not there. The advantage I do have is that I know what I don’t know.

  11. Man when some of these people get on the web and comment their ignorance and stupidity is displayed of all to see.

    I love this article and have spread it around to others. I want to speak to some of the comments. I didnt read them all because its frustrating to see the lack of intelligence so rampant in our field. I place the cardiac monitor on almost all my pts. There is soooo much you can learn simply by looking at the heart rhythm you wouldnt have known otherwise. (IF you know what to look for) Regarding the guy who said pulse ox machines can be misleading. Thats true, if you dont know how they work. In all instances you mention, the user obviously had no idea how it worked and obviously lacked the basic anatomy and physiology knowledge to work in this profession. (George, Im talking to you) If the pulse ox is reading low the pt appears in no acute distress check the wave form. Is it clear and regular? If there is no clear waveform then there is a problem with the sensing. If you have a person on the monitor including pulse ox and a NSR I can tell from another room if that pt has a pulse or is in PEA. If there is a pulse ox waveform there is a pulse!!!!!!! The monitor is something that will only help you treat your patient if you REALLY know how to use it. Checking a pulse when watching the monitor go into Vfib is not treating the pt not the monitor its treating the pt with the help of the monitor. Its a tool, know how to use it or cause harm to your pt and yourself.

    “always”
    avoid using the terms always and never. Its easy to prove someone wrong who uses these types of words. In the field of medicine there are NO ABSOLUTES. EVER. Pts CAN be in V-FIB and still be talking to you with a pulse! LVAD anyone?

    Cspine

    C collar and long spine board have been proven in some pt populations to be statistically more harmful than beneficial. Its no secret that MOI alone is not a good predictor of spinal injury. Thats where the assessment comes in… http://ambulancedriverfiles.com/2011/04/on-the-cult-of-mechanism/
    xray is NOT the best way to evaluate spinal injury. CT and MRI are far superior.

  12. Pingback: Treat the patient, not the machine | Rogue Medic

  13. Brandon O says:

    Great post — really loving your blog here, new find for me. I put in my two cents here: http://emsbasics.com/2011/06/30/treat-the-patient/

  14. R E S says:

    i’ve been an EMT for 12 years. this is an excellent post and i will share it with my colleagues. thank you for sharing your thoughts!

  15. Pingback: Comment on ALS is Oxygen, IV, Monitor, and Transport – Part II | Rogue Medic

  16. Just curious, since I’m seeing a spike from Facebook today, would someone be willing to point me back towards the group that this got linked at? Thanks in advance!

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