The Science Of It All

A few years ago we had a paramedic that worked for us that used to refer to himself as a “Purple Box Paramedic.” His idea of care was pretty simple—he saw bradycardia on the ECG, open a purple box. Asystole? Open the tan box. Low blood sugar? Open the big blue box. For him, patient care wasn’t about clinical assessments or diagnosing, it was a matter of looking at the monitor or vital signs and opening the appropriately colored box. Wash, rinse, and repeat.

Some would argue that that’s what we do. That’s what protocols dictate we do. Find the protocol that the patient fits into and open the appropriately colored boxes. I would argue that you’re not doing enough for your patient. After reading the article on JEMS that Peter Canning recommended (EMS 12-lead ECGs after ROSC?), I noticed a comment by an anonymous poster. I’ll paraphrase: “what’s the point? It won’t change our treatment.”

I don’t want to belabor the argument (and there was a big list of objections), but the first thing I thought of after reading the comment was: Purple Box Paramedic. 12-lead ECG didn’t fit into his/her protocol for post-arrest treatment, so why bother with it? Because, as the science is starting to show, it’s probably a good idea. And as a follow up commentator stated, “if it doesn't change what I do within the next 5 minutes then I guess it has no value at all, right?” (the sarcasm is implied). In addition to the science of it all, we have to be willing to think past the purple box and think about he long term continuation of care.

I like to browse JEMS and other literature and try to keep up to date on how EMS is evolving. In some ways, I know that I can be a little quick to jump on the bandwagon. I’ll sometimes read an article, think that’s it’s the greatest thing since sliced bread, and want to implement it the next day, regardless of how “new” or “unproven” the concept may be. But this comes from being aware of something about myself as medic: I like to know why I’m doing something. If I’m informed about the science behind it, I’m more likely to 1) perform the assessment/intervention/whatever, 2) have greater confidence in my ability to perform it, and 3) have greater confidence in the potential outcome.

As an example, I recently helped recertify our volunteer firefighters/first responders at Seaside on their CPR cards. In addition to the standard stuff (“push hard and fast; 100 times a minute; think of ‘Stayin’ Alive’”) I also gave them a brief lecture on coronary perfusion pressure and why it’s so important that we get our rate and ratios right. I kept it simple, not because they wouldn’t have understood a long lecture, but because the concept can be kept simple. And I could tell by looking at them that they were getting it, I could see the light bulbs turning on. In fact, I had numerous firefighters tell me that it was the first time that they every really “got it.” And this is the same stuff we’ve been teaching for almost 5 years now.

I’m a strong believer in the science of it all. I went to a subpar paramedic school and came out with a less-than-stellar education. I’ve done a lot of research and studying on my own and still try to learn new things every single shift.

Here’s another example. One of the headline articles on JEMS right now is The Disappearing Endotrachael Tube. Research nationwide is beginning to show that prehospital intubation by EMTs is a poorly performed skill with a significantly high (relatively) failure rate and an alarming trend towards higher rates of mortality. I read this and I think about how I want to be able to perform the skill proficiently with an eye towards long term patient survivability. Now I couple this with everything that I’ve learned about quantitative capnography, and I begin to think of intubation from a perspective of performing the skill when appropriate with an eye towards the overall patient outcome, and in turn, I have more confidence in my decision to intubate when determined appropriate.

So much of what we do in EMS is based upon habit, anecdotal evidence, and presumption. We need to be open minded about emerging research, changing trends, and evolving treatments. If we want to be taken more seriously as a profession, then we need to be willing to get behind the science of it all. It’s also so important for us to understand that we’re part of a greater health care team and that everything we do will have an effect, whether positive or negative, on the remainder of the patient’s care in hospital.

And as the NAEMT Code of Ethics for EMTs reads: “The Emergency Medical Technician shall maintain professional competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team.”

Something to ponder the next time the question is asked, “but will it change the way we treat them?"