With the new year upon us I began to ponder what really constitutes a “High Performance EMS” and came up with several criteria. I started this discussion by posting on “Response Time” and now want to bring in a second topic.
Part 2: Effective Care
While being effective in our care of patients should be an automatic criteria, I believe there is still plenty to say on the topic. The American Heart Association re-evaluates its approach routinely to cardiac care every two years. How often do we truly examine our practices in the “out-of-hospital” emergency care profession where we know that patient demand and provider skills are constantly changing? In the past several months, I have seen articles challenging standard practices toward intubation and c-spine immobilization – basic tenets of our practice – but how many agencies have made any significant investigation toward change in these protocols? For its part, The Army Awards Follow-On Contract for Autonomous Airway Management to Energid Technologies to create robots that can perform endotracheal intubation. Before we answer the question of whether robots or people are better at ETI, shouldn’t we answer the question regarding efficacy of the practice for the patient or refine the scope of practice regarding it? Similarly, other detailed questions are being raised like Is the 6-12-12 adenosine approach always correct? Is the closest facility really the best facility and who is allowed to make the call of an appropriate destination when EMS strategy change gets heart patients faster care? Is public perception or even financial reimbursement a more important driver? Please don’t think I am just being cynical, I believe that the return of the tourniquet is a good example of evidence-based practice in practice. While we don’t want to see protocols change like fashions, we need to avoid viewing them as sacred writings as well.
This next point may need to a separate topic altogether, but as an example of considering all parties involved, lets look critically at a new protocol that has been introduced at many agencies including the service where I work. For cardiac patients requiring CPR, it is now to be done on-scene for at least twenty minutes or until ROSC. If resuscitation attempts are ended, the body is left. Just last night, I departed a scene of the cardiac arrest of a mother leaving her cyanotic body in the home with her husband and 5 yo daughter. I admit that I was relieved not to have to transport, but I was equally mortified to leave the grieving family in that way. Perhaps there isn’t always a good answer, but do we communicate the reasoning behind the decision or just the alteration of the protocol itself?
In my mind, EMS personnel are consummate professionals. But how does the system view these providers of emergency care? I was involved in a serious debate recently over whether EMTs are qualified to place the pads for 12-lead ECGs to be transmitted for interpretation at a receiving facility. I was surprised to find that there was any serious question. Are we more concerned over maintaining a strict division of labor skills for the benefit of the provider even over the needs of a patient? Think of the combined experience out there. There are many innovative EMS personnel, who out of necessity (or extreme practice) create better “mouse traps” such as the REEL Splint or WauKboard for example. Paramedics, EMTs, and even Medical First Responders must not be viewed simply as automatons that can only repeat protocol standards, but capable of some judgement within the limitations of their qualifications and skill level. But whether it is the fault of EMS personnel who attempt to skate by with minimal effort or the cautious medical director who sees the wide disparity in knowledge (or more accurately “wisdom”) in the staff, many good professionals are being short changed. It is our responsibility, whether an EMR or MD, to teach and even police, “our own”. We must hold each other up to the standards we want to examined by and to guide our profession.
You are required to bring about the next generation of EMS, the so-called EMS 2.0 revolution by your actions. EMS World recently published a article to help you move in that direction in their Quality Corner: How to Make Better EMS Providers. Don’t view “professional” as a title, but as a calling to service in always providing “effective care.”