What NOT To Do in EMS

Like many of you, I have the privilege of administering practical tests to EMS personnel. As I arrive at the examination site, two thoughts tax my limbic system: Where's the coffee? and I sure am glad I'm not the one being tested.

     It's not that I don't know the material. It's just that 15 years in EMS have left me feeling more confident of my street skills than my recall of contrived scripts.

     As I hear students recite, "First I would…then I would…," I recognize subtle aspects of each scenario that should alert the candidates to not take some of the steps they are parroting--at least not without further consideration. This makes me wonder: Are we overemphasizing a bias for action in the field? Do we spend enough time warning our students about the medical consequences of bad decisions? Should we add scenarios where "monitor and transport" is the right answer?

     I scanned the 11 algorithms in the 2005 American Heart Association Guidelines to see how many instances of "Danger, Will Robinson!" I could find. There were seven. Well, sort of. Three were understated reminders to minimize interruptions in chest compressions; the other four cautioned providers about inappropriate medication administration. Only two warnings began with attention-getters like "do not" or "avoid."¹

     Primum non nocere (first, do no harm) is the prime directive for all medical professionals. As educators, we can reinforce this philosophy by discouraging prehospital practices that not only lack evidence of effectiveness, but may be hazardous to our patients. Such caveats can be melded with relevant algorithms and protocols to present a balanced view of prehospital risks versus benefits.

     Here's one observer's Top 10 list of what to avoid in the field.

Delaying To Play
     Most of the EMS people I know are proactive. Our training demands it and weeds out those lacking the temperament to do something.

     For example, after being grilled and drilled for hundreds of hours on cardiology and pharmacology, we feel empowered to heal the heart with high-tech monitors and dozens of drugs. Sometimes we mistake prehospital meds and machines for definitive care.

     An instance of such futility is delaying CPR during cardiac arrest to push medications. Early, effective, uninterrupted CPR is more responsible for ROSC (return of spontaneous circulation) than any intervention, other than immediate defibrillation, during witnessed VF/VT arrests.¹ In fact, there is no evidence that any medication is solely responsible for survival to discharge.

     Another example is major trauma. When we linger on scene to attempt IVs, splint extremities or bandage wounds, we are denying injured patients access to advanced diagnostic procedures, operating rooms and specialists.

     During the first minute of our initial patient assessment, we should ask, "Can I fix the problem?" If the answer is no, transporting the patient is more appropriate than prolonged on-scene attempts to cure the incurable.

Lights and Sirens Because We Can
     There are approximately 12,000 emergency vehicle accidents a year in the U.S. and Canada, and ambulances are 13 times more likely to be involved in collisions than other vehicles.² In a 1995 study, use of lights and sirens reduced average transport time by only 43.5 seconds!³ Not much of a payoff.

     Traffic accidents are not the only consequence of expedited transport. A siren's sound causes a fight-or-flight response in both the driver and passengers.⁴ An increase in myocardial oxygen demand accompanying that surge of epinephrine could be harmful, or even fatal, to cardiac patients.

     Clearly, we should be cautious about our mode of response and transport. Salt Lake City EMS is doing just that; they no longer use lights and sirens on every response. Not only did they detect no change in patient outcome, but some units actually improved their response times.⁵

     Safety, not sirens, should be routine.

Making A Withdrawal
     There's a scene in Joe Connelly's Bringing Out the Dead where two medics amaze onlookers by resuscitating a comatose junkie with a hot shot of Narcan (naloxone). The rescuers are hailed as magicians, or perhaps even deities.

     Who among us hasn't felt a surge of mastery on those few occasions when we "cure" an unstable patient prehospitally? It is unwise, however, to assume that Narcan is, at worst, benign.

     Narcan reverses opioid intoxication by occupying narcotic receptors in the brain. However, sudden withdrawal from opiates can cause vomiting and combativeness, thereby creating a scenario that often is more dangerous for both the patient and caregivers than the initial complaint. Unless the patient is suffering from profound respiratory depression or hypotension, it is best to titrate Narcan with small doses below 1 mg until the patient's respiratory rate and blood pressure stabilize.⁶ Achieving a GCS of 15 is not a priority.

     Agitating a peaceful, hemodynamically stable patient is not the only consequence of impulsive Narcan administration. The astute practitioner should consider the possibility that the patient has overdosed on more than one medication. For example, it was not uncommon for narcotic addicts in New York City to mix scopolamine with heroin during the 1990s. Blunting the opiate with Narcan left the anticholinergic properties of scopolamine unopposed, leading to tachycardia, restlessness and even seizures.

Lazy RMA's
     RMAs (Refusal of Medical Assistance) are among the most time-consuming, labor-intensive calls in EMS. It is tempting for caregivers in busy systems to take shortcuts when encountering patients who do not wish to be transported.

     Bad idea, unless you are intrigued by your state's legal system.

     The three most important steps in processing an RMA are document, document and document. Documentation is important in all areas of EMS, but never more so than when you are advocating a prehospital course of action that contradicts the patient's preference.

     Two RMA scenarios to be avoided are allowing a patient to refuse transport without assuring and documenting his awareness of risks and alternatives; and enforcing transport against the patient's will, in spite of his acknowledgment of risks and alternatives. The former can lead to charges of abandonment, while the latter could be construed as false imprisonment.⁴

     According to a 1998 study, it is wise to involve a physician in the RMA process, not only because of his/her superior assessment skills, but also because it is more likely that a doctor will succeed in convincing a patient to seek definitive care.⁷ Many EMS systems make RMAs cooperative ventures between field personnel and physicians. Prehospital providers contact medical control if they are unable to convince sick or injured patients to allow transport by ambulance.

     There are medical consequences of sloppy RMAs, too. A 2002 study revealed that 32% of patients age 65 and older who refused transport were subsequently admitted to a hospital for the same or a related complaint.⁸ It makes sense to consider high-risk factors, such as age and medical history, in addition to the patient's presentation when con-fronted with an RMA.

Knee-Jerk Traction
     One of the more complicated scenarios that we study as EMTs is use of a traction splint to stabilize a suspected femur fracture. The specialized training associated with assembly and application of these bulky devices signals us that this is not just another first aid course. Anyone can apply a 4x4; we're learning to align broken bones and alleviate pain!

     Here's what we're not taught: Traction splints were initially designed for in-hospital treatment, not prehospital stabilization, of femur fractures.⁹ Patients were meant to be assessed by physicians prior to application of a traction splint. Prehospital providers lack the advanced training and diagnostic equipment to differentiate femur fractures from hip or knee injuries. During a 2003 prospective study, traction splints were applied despite these and other contraindications 38% of the time.¹⁰ Guessing wrong can lead to neurological, structural and/or circulatory complications.

     When used appropriately, traction splints can reduce pain and bleeding associated with femur fractures. A 2001 study found, however, that only three of 4,500 cases (fewer than one-tenth of 1%) met prehospital criteria for use of these devices.¹¹

     In the absence of x-ray vision, stabilization and immobilization of suspected femur fractures might be a wiser course.

The "IV-B-CS"
     In a prior life, I supervised medical control for a large EMS system in the New York metropolitan area. One of my responsibilities was to review and critique prehospital care. Occasionally, a presentation from the field would sound something like this:

     Tech: I have a 65-year-old male complaining of chest pain since this morning. No cardiac history. The patient's NSR on the monitor with an IV in place, and we're six minutes out from Have Mercy Hospital.

     Medical Control: What are the vitals?

     Tech: I'm working on that now.

     The dialog is a bit contrived, but the problem is clear: ALS before BLS.

     Part of the maturation process for new medics is to recognize that advanced procedures supplement rather than supplant basic skills. Sometimes that message gets a little fuzzy during training. Progressive topics like cardiac monitoring, advanced airway management and IV access are front-loaded in the classroom, by necessity, and occupy a disproportionate amount of attention and reinforcement. Students begin to see psychomotor skills as endpoints of care, instead of a means to an end.

     Another impediment to proper prehospital prioritization is "tunnel vision," defined as "the focus of attention on a particular problem without proper regard for possible consequences or alternative actions."¹² We see this happen in EMS when, for example, patient assessment and monitoring are disregarded during multiple IV or intubation attempts. Many of us have bargained with partners, or even with ourselves, to try "just one more time" when success eludes us. We need to self-impose limits on invasive procedures, e.g., no more than two attempts per patient, or risk skewing prehospital priorities toward self-indulgence.

Flat-Out Distress
     Spinal immobilization would make any EMT's Top 10 list of most practiced skills. OK, I admit that I have absolutely no research to support that statement. I'm basing my hypothesis on observation in the classroom and in the field. Prehospital providers are preoccupied with collars and backboards. You might be as surprised as I was to learn that there is no solid research concluding that routine prehospital spinal immobilization of trauma patients is either good or bad.¹³

     At the very least, caregivers should recognize scenarios where immobilization could be harmful. Patients with respiratory conditions, such as CHF or COPD, represent one such subset. A 1999 study discovered that supine immobilization impeded respiration by 15%.¹⁴ Most of us have seen evidence of that when we encounter reclining respiratory patients.

     Another condition that contraindicates supine positioning is pregnancy. A pregnant woman beyond 20 weeks' gestation can suffer supine hypotensive syndrome when transported flat on her back. The weight of the fetus compresses the inferior vena cava and impedes venous return to the heart. If a pregnant patient must be immobilized, the board should be tilted 20-30 degrees to the left.

     Airway compromise and increased intracranial pressure are two other possible consequences of supine immobilization, which begs the question: Should we be collaring and boarding patients in the field, or can we safely position patients with possible spinal injuries on their sides?¹⁵

     While we wait for a definitive answer to that question, let's not forget what we already know about proper positioning.

Treating the Rhythm
     Practical testing for paramedic National Registry (NREMT) certification includes a station known as "Static EKGs." It's similar to the lightning round of the old TV game show Password, where contestants tried to guess five words in 60 seconds, based on clues offered by their partners. The EMS version, also known as "You Bet Your Certification," requires interpretation of four rhythms and verbalized treatment of the accompanying scenarios in six minutes.

     I remember drilling for this station as a student. One of my practice scenarios involved an asymptomatic patient in rapid atrial fibrillation. The intent was to make sure I wouldn't overtreat the patient. I called for cardioversion. Oops.

     After the obligatory and well-deserved lecture from my instructor about SDT (survival despite treatment), I realized I had focused on matching a patient to an algorithm for tachyarrhythmias without paying sufficient attention to the signs and symptoms. I had treated the EKG rather than the patient. Subsequently, as an instructor, I saw almost every student make the same kind of error at least once.

     An even more common scenario in the field, based on my observations at medical control, is the stable or mildly symptomatic patient with borderline bradycardia. Taigman's Advanced Cardiology describes the making of a "cardiac cripple" through aggressive administration of atropine, dopamine and isoproterenol to a patient with a pulse of 56. The authors argue that, even in the setting of hypoperfusion secondary to bradycardia, "a little gentle atropine" is more prudent than a drug box full of sympathomimetics.¹⁶

     ACLS advises us to go easy on atropine for another reason: Bradycardia may be a sign of acute coronary ischemia.¹ Atropine could worsen an infarct by increasing myocardial oxygen demand. Nitrates, aspirin and perhaps morphine might be better options for the normotensive patient with symptoms of an MI.

     Slavish devotion to rate-related algorithms can lead to distress for patients and providers.

I Think It's In
     I don't think there's a more fundamental rite of passage from BLS to ALS provider than achieving proficiency at endotracheal intubation (ETI). There is a "thrill-of-victory/agony-of-defeat" aspect to ETI, perhaps because airway management is both challenging and important.

     Unfortunately, a 25% rate of tube misplacement in a 2001 study revealed that many paramedics lack competence in this critical area.¹⁷ ACLS warns, too, of ETI complications caused by inexperienced providers.¹

     Additional training helps, but manikins are no substitute for field insertions. Auscultation, end-tidal CO₂ measurement, capnography and esophageal detector devices offer confirmation of placement, but don't compensate for oxygenation that didn't occur during missed or prolonged attempts. Providers who lack the opportunity to achieve mastery of ETI should consider alternatives.

     One option is as old as EMS: the bag-valve mask (BVM). Although the BVM does not address airway management, several studies have shown that survival of cardiac arrest patients is no more dependent on ETI than on effective BVM ventilation.^18,19 This is especially true of pediatric patients.²⁰ Airway adjuncts like the Combitube and laryngeal mask airway (LMA) are acceptable alternatives to ETI,¹ but the Combitube requires correct identification of either tracheal or esophageal placement.

     Know your limits, and don't forget that good BLS is better than bad ALS.

Assuming, Instead Of Assessing
     Humans are very good at pattern recognition. We categorize stimuli (e.g., sights, sounds, smells), try to match each subset to a nugget of experience, develop an assumption and then act accordingly.^21,22 We do this hundreds of times a day, and we're usually right.

     Pattern recognition is essential in EMS. It helps us anticipate unsafe scenes, diagnose illnesses, make transport decisions and choose treatment modalities. Sometimes, though, reliance on pattern recognition causes us to rule out prematurely or fail to consider less apparent causes of prehospital signs and symptoms.

     For example, we've all treated motor vehicle operators who present with altered mental status after a collision. In the trauma setting, how often do we look for medical causes of AMS? According to a 1996 article, "It is imperative that emergency physicians consider hypoglycemia in all patients with any mental status abnormality--even when the findings seem to be explained by other etiologies."²³ Blood glucose measurement is one of the easiest, safest, least time-consuming diagnostic tools we have in the field. Limiting its use to "diabetic calls" is like checking EKGs only on patients with cardiac histories.

     Another fertile area for erroneous assumptions is dispatch information. According to a 2006 study, 71.4% of calls dispatched as cardiac-related were non-cardiac in nature.²⁴ Other research has shown that, except for cardiac arrests, it is difficult to discern the etiology of emergent cases based on information from the caller.²⁵

     It is easy to think "MI" when we are sent to a "heart call." Rather than jump to conclusions before we assess our patient, we should ask ourselves what else it could be, then use a minute or two of en route time to mentally review differentials.

     It seems we are most susceptible to hasty assumptions during two phases of our career: when we have a little experience and when we have a lot. We tend to be more open-minded and less cynical early in our tenure, but lack the insight to anticipate outcomes. A good compromise would be to assume little about our patients, stay current with the standard of care, and treat each case as an opportunity to learn.

     One of my favorite movies is A Christmas Story, based on author Jean Shepherd's memories of childhood in 1940s Indiana. The principal character, nine-year-old Ralphie, asks for a BB gun for Christmas, but is discouraged by his mother's dismissive reply: "You'll shoot your eye out."

     Yes, mom could have been more constructive ("Gee, Ralphie, if you practice every day with that rifle, you might make the Olympic biathlon team!"), but her highest priority was to protect her son from harm. Primum non nocere mandates the same diligence from EMS educators as we prepare our students for a world without scripts.

     Mother knows best after all.

References

1. American Heart Association. ACLS: 2005 Guidelines. 2005.
2. Houser A, et al. Emergency Responder Injuries and Fatalities. RAND Technical Report, 2004.
3. Hunt R, et al. Is ambulance transport time with lights and sirens faster than without? Ann Emerg Med 25(4):507-511, Apr 1995.
4. Henry M, Stapleton E. EMT Prehospital Care. Philadelphia, PA: Elsevier, 2004.
5. Bledsoe B. An EMS epidemic. JEMS.com. 2006 Aug.
6. American Heart Association. ACLS for Experienced Providers, 2003.
7. Burstein J, et al. Refusal of out-of-hospital medical care: Effect of medical control physician assertiveness on transport rate. Acad Emerg Med 5:4-8, 1998.
8. Vilke G, et al. Follow-up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care 6(4):391-395, Oct 2002.
9. Bledsoe B. An EMS relic? JEMS 29(8):65-69, 2004.
10. Wood S, et al. Femur fracture immobilization with traction splints in multisystem trauma patients. Prehosp Emerg Care 7:241-243, 2003.
11. Abarbanell N. Prehospital mid-thigh trauma and traction splint use: Recommendations for treatment protocols. Am J Emerg Med 19:137-140, 2001.
12. Webster's New World College Dictionary, 2002.
13. Baez A, Schiebel N. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med 47(1):110-112, 2006.
14. Totten V, Sugarman D. Respiratory effects of spinal immobilization. Prehosp Emerg Care 3(4):347-352, Oct-Dec 1999.

15. Bledsoe B. Insanity. www.jems.com.
16. Taigman M, et al. Taigman's Advanced Cardiology 9-12, 21, 1995.
17. Katz S, Falk J. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 37(1):32-37, 2001.
18. Guly U, et al. Paramedics and technicians are equally successful at managing cardiac arrest outside hospital. BMJ 310:1091-1094, 1995.
19. Stiell I, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 351:647-656, 2004.
20. Gausche M. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. JAMA 283:783-790, 2000.
21. Wikipedia. 2007 Mar.
22. Jasen J. The neural approach to pattern recognition. Ubiquity (ACM) 5(7), Apr 2004.

23. Luber S, et al. Acute hypoglycemia masquerading as head trauma: A report of four cases. Am J Emerg Med 14(6):543-547, 1996.

24. Reilly M. Accuracy of a priority medical dispatch system in dispatching cardiac emergencies in a suburban community. Prehosp Dis Med 21(1):77-81, 2006.
25. Bledsoe B. Anecdote-based EMS. www.jems.com.

Mike Rubin, BS, NREMT-P, is an EMS educator and consultant based in Nashville, TN. Contact him via e-mail at mgr22@prodigy.net.