The Midlife Medic: Surfing the Paradigms

“Fifteen hundred years ago, everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and 15 minutes ago, you knew that humans were alone on this planet. Imagine what you’ll know tomorrow.”

—Agent K (Tommy Lee Jones), Men in Black

Every species comes to an evolutionary crossroads where they must either adapt or risk dying out. Paramedics are no different. The only constant in medicine is that there will be sick and injured patients to care for. It’s everything else that changes over time.

I don’t think like you do. I have treated the same exact patients you have, except I’ve had to approach the same diagnosis from a dozen different directions depending on the whim of the protocol or science of the day. We may come to the same answer to a question, but it will be by completely different routes.

I come from the age in EMS that is BC—before CPAP. You practice C-A-B, I came from A-B-C. Maybe your future students will learn B-C-A. Are you willing to invest yourself in the dynamic process that is medicine? Can you accept something new and work out of your comfort zone? That is not as easy as it sounds.

The idea of “that’s the way we’ve always done it” doesn’t always come from laziness. To learn a new treatment modality means giving up mastery of the old—it’s a scary place that often has older providers falling back on what they “know” as true. They are afraid.

I first noticed what a difference this made about 10 years ago. The patient was in significant respiratory distress. My partner had been a medic for the same amount of time I had. We had access to RSI; it was progressive and the newest thing on the block. The man struggled to breathe despite our interventions, and I said to my partner, “I think we’re going to have to RSI him.” His immediate response was, “Nah, if he doesn’t get better, I’ll just throw a nasal tube in him before we get there.”

The patient improved and did not reach the point of needing an advanced airway, but the quick and negative response to the RSI suggestion stuck with me. 

It did not make sense. Everything we’d been taught about RSI (then and now) indicates that while it has risks, anything we can do to decrease the physiological stress and aid the mechanical success of an intubation is what will give the patient the best outcome. Why would you rather nasally intubate, especially if you didn’t have to?

Nasal intubation is becoming a thing of EMS legend, but for a long time it was one of the few tools we had that allowed us to manage a conscious patient’s airway when they were in extremis. The only requirement was they had to still be breathing. Many places had no access to true sedation; the best you could offer was usually a conservative dose of morphine and hope it took the edge off. Often we would gently secure the wrists (so they wouldn’t reach for the tube and really mess things up) and insert a well-lubricated garden hose into the nostril of some frail elderly person.

Eye contact and coaching were critical to success: “Stick your tongue out if you can… Shhh, easy now. You won’t be able to talk… OK, cough for me. No, don’t move your head. Keep your eyes on me. Now, you breathe in and I will squeeze, and we will work on this together. In…out…in…out.”

It seems the stuff of Congressional sub-panel investigations, but I assure you it is the very real way we managed many airways BC. It’s a skill that was easily taught, but the finesse of working with conscious patients was where the true mastery came. Sometimes they would cry while you bagged them. If you could get the rhythm right, they would start to relax and trust you as they felt their distress ease. To keep them from fighting, I’ve kept my smiling Irish eyelock going with plenty of rheumy old eyes all the way to the ER. Any baby paramedic can nasally intubate, but it is the old masters who can nasally ventilate.

Those same old masters were afraid of RSI, and many still are. I would hear resistance to using it over and over again, and always from the seasoned people—never the newer paramedics who had had it integrated with their learning. I remember similar arguments to prehospital 12-lead acquisition, and that was just an ECG. When you’re working with someone senior who seems unsure of themselves, remember that it’s not always easy to switch gears.

Look, kid, I’ve given drugs they’ve only told you about in ACLS bedtime stories. I’ve changed mnemonics more times than your mom has posted your “first day of school” photo on Facebook. Every year I have to relearn something I once knew as an absolute truth. Learning is hard work, and relearning can be worse. Imagine what we’ll know tomorrow.

Let me buy you a cup of coffee. You show me how that ultrasound thing works, and I’ll show you a few tricks for your next pediatric code. Integrating generations of care is tricky stuff, but if evolution were easy, everyone would do it.

Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, AK. She spent the last 27 years serving as a paramedic, educator and supervisor in Newark, NJ. She is also a member of the EMS World editorial advisory board. Contact her at taloscar@gmail.com or www.taloscar.com.