Editor鈥檚 note: Congress designated Oct. 28 as National First Responders Day in 2017. The day honors the paramedics, EMTS, firefighters, police officers and 911 operators who answer the call when a crisis arises, often putting their own lives on the line. Serving as a national day of gratitude, National First Responders Day pays tribute to their services to their communities and honors fallen first responders. Follow our ongoing coverage here: National First Responders Day.
鈥淭he better I do my job, the less exciting it is.鈥�
I had that epiphany over 10 years ago, when I noticed a couple of coworkers always seemed to be transporting their patients with lights and sirens or calling for police backup on every call.
鈥淪urely I can鈥檛 be getting only the boring calls, can I?鈥� I thought to myself, only to discover when I encountered those crews at the emergency department, their patients weren鈥檛 that bad.
Oh, they had everything done to them 鈥� non-rebreather masks pushed up on their foreheads, 12-lead ECG, IV fluids hanging, blood glucose readings at the ready 鈥� and stable vital signs.
Rock. Solid. Stable. Vital signs.
Somehow, I had become an ALS minimalist without realizing it. It was a weird paradox; the more confident I became in my skills and knowledge, the less likely I was to practice my skills (unless you consider not doing something unnecessarily a skill).
For many years now, my requirement for transporting with lights and sirens has had three elements:
- The patient has to be unstable
- The condition must be time-sensitive
- The treatment must be something I cannot provide and the ED can
If they don鈥檛 meet those three requirements, I don鈥檛 transport in emergent mode. The cardiac arrest patient I鈥檝e just resuscitated is better served by spending an extra few minutes on scene to stabilize their BP and rhythm and then transporting non-emergent, than by me rushing madly to the ED with a poorly packaged patient teetering on the brink of arresting again.
I wrote in a column years ago that I was more skilled at airway management than any previous point in my career, yet I was less likely to resort to invasive airway management than I had ever been. The more I knew, the less I did.
I graduated school as the cocky, know-it-all paramedic who judged myself by how many procedures I could perform on a patient or how deeply I could get into a treatment algorithm or protocol, rather than my patient鈥檚 outcome.
I think the first chink in the armor of overtreatment was reading the research on ventilator-associated pneumonia, prehospital CPAP and how much costlier and riskier the patient鈥檚 course of care became when I intubated someone, even if it was an easy tube.
Then I learned Dextrose 50% causes wild swings in a hypoglycemic patient鈥檚 blood sugar; causes phlebitis; and, God-forbid, severe tissue necrosis if the IV line extravasates. I discovered that a bolus of D5%W or D10%W achieves the Lazarus effect just as well without the risk of D50%.
Then I learned that ventricular antiarrhythmics were just selective cardiotoxins; they killed the arrhythmia just a little faster than they killed the patient.
I learned that a whole host of things I did as a medic were poorly supported by scientific evidence, and more than a few were harmful.
That started me on the path of being an EMS skeptic and questioning everything we do. If we want to know that EMS care does the patient any good, we have to be willing to closely examine our most cherished, long-held beliefs and discard them if they are proven to be untrue.
In short, I learned how to think critically.
Using your judgement
The Oxford English Dictionary defines critical thinking as, 鈥渢he objective analysis and evaluation of an issue in order to form a judgment.鈥�
There鈥檚 the key word: judgment.
Along the way, I learned when and when not to be aggressive. Many things we do most often aren鈥檛 proven to benefit the patient, and a few things we are reluctant to do should be pursued far more aggressively. So nowadays, I start IVs to administer medications or fluid I judge that the patient needs, not to pacify a triage nurse.
I make judgments that sometimes conflict with protocols 鈥� because protocols can鈥檛 address every eventuality 鈥� and when I do, I confer with a physician to cross-check my rationale. Most of the time, they agree.
鈥淗ey Doc, my patient has acute pulmonary edema and a blood pressure of over 160. How about me upping the Nitro dose to something that will do some good?鈥�
I judge that if the treatment I鈥檓 considering has more risk than reward for my patient, or if there is no proven benefit, the best course is to not do it.
Along the way of realizing that ALS care is often of questionable benefit, I learned to trust my EMT partners more, and expect them to perform their full scope of practice rather than be my driver and equipment sherpa.
I didn鈥檛 have the self-confidence to do nothing early in my career. It sounds strange saying that because I was so cocky, but I was afraid I鈥檇 miss something, so I hit the patient with everything but the kitchen sink. A lot of inexperienced paramedics do that, but I鈥檓 not sure that鈥檚 a bad thing.
I think it鈥檚 better to be aggressive than timid when you don鈥檛 have a lot of experience. Lots of patient care will teach you the fine art of clinical restraint, but when you鈥檙e new and inexperienced and unsure of yourself, you鈥檒l do the most harm by freezing up and doing nothing.
Some people look at a photo of a rig utterly trashed after an emergent call; trash and wrappers everywhere, pools of blood on the floor, and people who don鈥檛 know better think, 鈥淲ow, that must have been an exciting call!鈥�
People who do know better 鈥� and most of us have run very similar calls and trashed our rigs the same way 鈥� cluck to ourselves and think, 鈥淗ow sad that someone memorialized their 10 minutes of panic.鈥�
We look at the blood on the floor and think, 鈥淚f the patient was bleeding that badly, why didn鈥檛 you control it when you were on scene with room to work and a stable floor under your feet? Didn鈥檛 anyone ever teach you that it鈥檚 better to work smart than work hard?鈥�
We can鈥檛 always avoid stressful calls like that, but we can avoid creating them ourselves.
Never move faster than your brain can think
When you鈥檙e on that stressful call, with everyone hurrying about and bystanders screaming, 鈥淒on鈥檛 just stand there, do something!鈥� do the opposite: Don鈥檛 just do something, stand there. Never move faster than your brain can think. Take 10 seconds to survey the scene and take it all in, then act on what you鈥檝e seen. Professionals don鈥檛 run. We move with a purpose, but we don鈥檛 run.
Use the OODA Loop as your decision-making model, and utilize your partner to use the 鈥渆yes-in, eyes out鈥� strategy to running your calls; while one of you is task-focused and necessarily tunnel-visioned on correctly performing the task, the other is managing the scene. When both of you get task focused, things get missed and the scene runs you rather than you running the scene.
WATCH | Don鈥檛 let bias impact your decision making
鈥淭he better I do my job, the less exciting it is.鈥�
Slow and boring is good. It鈥檚 less stressful on the patient and the providers. The better you think, the better you do your job, and the less exciting it will be.
