The Cult of Mechanism
A funny thing happened on the way to writing this column; an event that led to the delayed submission of said column, thus depriving legions (okay, seven) of my dedicated readers the opportunity to read my disjointed scribblings for an extended period of time.
I wrecked my motorcycle on the way to work.
I’m sure you’re probably wondering, “What was he thinking? Surely a paramedic would know how dangerous those things are!”
And the answer is, yes I know how dangerous they are, and I choose to ride anyway. I’m one of those dedicated paramedics for whom merely checking the “organ donor” box on my driver’s license isn’t enough — I also engage in such pursuits as to make the act more than just a theoretical possibility.
Hey, I’m a giver. That’s what I do.
Anyway, when I was busy decorating a couple hundred feet of asphalt with strips of my hide and spatters of blood like a Jackson Pollock mural, I had an epiphany. They say that in your time of greatest crisis, that your life flashes before your eyes and you are gifted with one fleeting moment of utter clarity before shuffling off the old mortal coil. In my moment of utter clarity, one thought flashed through my mind:
Lord, please forgive me for all the people I’ve spinally immobilized needlessly over the years.
Okay, so maybe that wasn’t exactly what ran through my mind, but my thoughts while cartwheeling across the pavement like an ungainly rag doll aren’t fit for print in a public forum.
But afterwards, as I was forced by circumstances to run my own wreck scene until the police and ambulance arrived, I had time to reflect on the value of mechanism of injury as a diagnostic tool. Is it really all that important a consideration? The only answer I could come up with was, "Not very."
Consider that, in my case, all the ingredients for disaster were there: a motorcycle, a car, highway speeds, and a remote scene. I was 20 minutes from a trauma center, and the length of my keister-to-pavement interface was greater than a football field.
The only things missing were the injuries.
For calls like mine, my employer typically dispatches an ambulance and a helicopter, and quite often the fire department and local first responder agencies. That is reasonable and prudent.
What is not reasonable and prudent is actually utilizing all those resources if the actual injuries prove to be somewhat less than the MOI would indicate. For my broken toe and severely bruised leg — and a rather impressive case of road rash — I could have had no less than 10 trained emergency responders rushing to my aid in expensive vehicles, all at considerable risk to their own lives and safety. The treatment protocols would have required large-bore IV access, high flow oxygen, and spinal immobilization. None of that was necessary.
So I borrowed a cellular phone from a bystander, called the 911 center back, and had them cancel the helicopter, fire department and additional first responders - all dispatched, might I add, based solely on protocol and mechanism of injury - and bring the ambulance down to a non-emergency response. And when the ambulance arrived, I refused everything but the ride I needed to the ER. If the ER had been busier when we arrived, I’d have gladly waited my turn in the lobby instead of the trauma room to which I was taken.
Folks, somewhere along the line we’ve developed an entire belief system based upon mechanism of injury. What started as a useful conceptual tool to aid medical responders in predicting where injuries might be — and thus, guiding their assessments — has morphed into the assessment.
We dispatch resources based solely upon it. We triage people to certain hospitals and activate trauma teams based upon little more than magic words like “rollover” or “ejection” or “high speed.” We teach EMT students to evaluate it and pay attention to it. And all that is fine. Prudence demands it.
But we have reached the point where many of us allow mechanism to dictate our treatment. We strap people to hard, uncomfortable boards based upon it. We start IVs because the mechanism demands it, not because of the patient’s hemodynamic status. And if the wreck looked particularly impressive and we’ve got the time, we’ll even throw in a second IV free of charge.
We have reached the point where many of us allow mechanism to dictate our treatment. We strap people to hard, uncomfortable boards based upon it.
We even let it dictate our mode of transport. We send patients with minor injuries on risky and expensive helicopter flights - often when a ground ambulance would have been faster — only to see the victim discharged home from the ER a few hours later.
We allow it to seduce impressionable EMT students into believing that it is more important than their assessment findings. It is easier, after all, to memorize a list of “bad things” from the DOT curriculum than to use critical thinking skills and a thorough assessment to choose the proper course of care for our patients.
I can understand the reasoning behind it. In Bryan Bledsoe’s EMS1 column, he points out that a number of EMTs in one system are proving themselves incapable of using sound judgment when it comes to utilizing a spinal clearance algorithm. Bryan points out that the hospital’s trauma outreach coordinator had determined that virtually all of the 13.5 percent of spinal injury patients that the EMS system had failed to immobilize, met exam criteria requiring immobilization.
It also warrants mentioning that, of the NEXUS exam criteria upon which most pre-hospital spinal clearance algorithms are based, none of those criteria involve mechanism of injury. The state of Maine, pioneers in implementing a statewide pre-hospital spinal clearance algorithm, no longer uses mechanism of injury as a criterion for immobilization because it is so unreliable. It is clear that the assessment is the key. There is a growing body of research that bears this out.1
It’s clear that we’ve got to educate our providers better, but we’re not going to improve the state of EMS practice and education by reinforcing the belief that we can accurately predict injury based solely upon the forces involved. It’s a false God we’ve been worshipping and we ought to sacrifice less time to it.
When I was in EMT school, when we read the words of Nancy Caroline hand-written on papyrus leaves, we were taught two phrases: mechanism of injury and index of suspicion. The first phrase was supposed to have some bearing on the second and that was the way we approached patient assessment. The mechanism of injury increased your index of suspicion for certain findings, and you assessed accordingly.
During my convalescence and recovery, I had plenty of time to think about it, and I believe that’s still sound advice.
But bear in mind that the key word in the second phrase is suspicion, not certainty.
1 Boyle MJ, Smith EC, Archer F. Is mechanism of injury alone a useful predictor of major trauma? Injury, 2008 Sep;39(9):986-92. Epub 2008 Jul 31.
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