February 2004 Letters

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Non-Stick Trick

I am writing in reference to Mike Smith's Beyond the Books column in October. Smith's method of making the patient's arm and one's hands function as one unit is the technique I use to insert a needle into a drug port. I don't remember where I learned the technique; it may have been one of the many columns Mike has written over the years.

I hold the drug port of the IV line between the index finger and thumb of my non-dominant hand. Trying to "aim" the needle into the drug port can be a painful experience in a moving ambulance. This can be alleviated by placing the syringe against the palm of the same hand. As in Smith's technique, all the components (drug port and needle) will move as a single unit and reduce the likelihood of a needlestick.

Knute Mlott, EMT-P
Onslow Co. (NC) EMS
Hubert, NC

Things Science Can't Measure

I have followed with interest the responses to Bryan Bledsoe's May 2003 EMS Mythology column concerning CISM (EMS Myth #3: Critical Incident Stress Management Is Effective in Managing EMS-Related Stress). His August 2003 response to several letters, in which he maintained that CISM results are not based in science, illustrates why successful emergency responders understand the human side of medicine as well as the scientific side.

It is unsettling to try to scientifically establish the number of emergency responders who have left their professions after traumatic incidents because of the absence of CISM. The use of science to quantify the psychological and emotional trauma that occurs after a stressful situation is impossible. Did Joe the firefighter have three quarts of sleeplessness? Did Sarah the paramedic suffer 15 pounds of anxiety after the death of that four-month-old? Did the state trooper really take early retirement after three or six traumatic vehicle-death investigations?

Yes, professional mental health personnel can do marvelous things with counseling. However, the most important aspect of counseling is the ability to ask the correct questions and respond in the correct manner. Some of the science-based providers use medications to affect outcomes. However, the ability to discuss these events is the tool to heal the mind and soul.

I have been involved in three incidents over the last 14 years that resulted in my using CISM. One involved an infant, one involved a law enforcement death and one involved a coworker. While I cannot discuss the specifics, the process each time was conducted by professionals, including mental-health practitioners, paramedics trained as CISM counselors, and religious personnel. Their ability to work together within their particular fields resulted in healing for each participant. As far as the sciences are concerned, none of the personnel who voluntarily attended these sessions have left their professions as a result of traumatic stress disorders.

Bledsoe needs to understand that we treat human beings. Along with that come emotions, stress and grief—these cannot be measured by the sciences. We treat anatomical and physiological issues by the sciences—nitro and aspirin for ischemia, Versed and Valium to sedate, oxygen for hypoxia, etc. We treat stress disorders by discussing them with understanding and caring coworkers and professionals. The sooner EMS realizes the difference, the higher our employee retention will become. Give me a caring, competent paramedic over a scientific doctor anytime.

Donald W. Messer, EMT-P, ERT, SRT-II
Haywood Co. Rescue Squad
Blue Ridge Papers Emergency Response Team

Bryan E. Bledsoe, DO, FACEP, EMT-P, replies: Thanks for the letter. The CISM discussion generated quite an emotional response. I will respond to several points raised in your letter, and please understand that I mean no disrespect. All I am trying to do is to get people to question what they are doing in EMS and why they are doing it.

I have nearly 60 scientific papers in my CISM file. Of these, there is not a single paper of any scientific validity that shows CISM helps. In fact, as previously stated, the vast majority of reputable scientific evidence has shown that CISM is ineffective at best and, in some cases, actually harmful. Your example of the three CISM sessions you attended over the past 14 years is just an anecdote. Can you honestly say that the people who were debriefed would not have gotten better without the CISM? Just because people were perceived to be better after a session does not mean the session caused the improvement. This phenomenon is referred to as the regressive fallacy, and is a common feature of pseudoscience. The only way to demonstrate that CISM works would be to compare similar groups—one that received CISM and one that did not—using objective measures. If CISM helped, then such a study should clearly demonstrate this. However, every time this format (called a randomized controlled trial) has been tried, CISM did not show any improvement in stress symptoms and, in fact, made stress symptoms worse for certain parts of the population.

The use of the randomized controlled trial has been the standard in psychology for nearly 60 years. As far as using something other than science to test the efficacy of psychology, what other tests or measures would you use? If one of the goals of CISM is to reduce stress and prevent post-traumatic stress disorder (PTSD), would you not expect objective measures of stress symptoms to decline with CISM? In fact, with CISM, in many studies, stress symptoms actually increased. So if we cannot prove CISM works, then why use it? There is no evidence to show that CISM is more effective than simply talking to your colleagues at the station after the call. As far as we know, CISM is no more effective than sitting in a circle, holding hands and singing Kumbaya. All may make us feel good, but which one really helps? If none of these is more effective than the other, why choose the one (CISM) that has been shown to be harmful?

Numerous reputable organizations have dropped CISM, and there are scientific papers being published that warn systems and companies not to provide CISM, as it might result in getting sued for using a technique that has been shown to be ineffective and possibly harmful.

For a comprehensive discussion of CISM and the issues mentioned herein, please read the recent paper by McNally, Bryant and Ehlers (available free online at www.psychologicalscience.org/journals/pspi/). Don't simply take my word for it—research the material yourself and draw your own conclusions.

Your point about not being able to quantify everything in EMS is well-taken. I discussed this in the Mythology column when I contrasted the "art" and "science" of EMS and medicine. However, when we can quantify something through science, I believe it is our duty to do so. Otherwise, we will end up with a litany of EMS practices that continue only because EMS providers "like them" or "feel they work." This will restrict the growth of EMS as a bona fide profession.