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Home > Topics > Health and Wellness
December 23, 2013
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The Art of EMS
by Steve Whitehead

Failure is effortless — good care is hard

Fixing our issues with medical incompetence doesn’t begin with a degree, it begins with changing our expectations of ourselves

By Steve Whitehead

From the stage, Dr. Atul Gawande sits in an armchair in comfortable repose and reads aloud to the mostly silent crowd. With his slight frame and soft-spoken demeanor, he makes no show of authority or presence. He commands the attention of the room with his reputation alone as he retells a story from his days as a young resident on an internal medicine rotation.

Dr. Gawande is a surgeon at Brigham and Women’s Hospital in Boston, but he’s better known as a popular author with a list of bestselling books. One of his favorite recurring topics is what the practice of medicine can teach us as about competence and performance. As he reads aloud from his current selection, he relates how the experience and conscientiousness of a senior resident allowed him to make a difficult diagnosis that would have been otherwise missed.

Closing the book, the doctor takes a deep breath and after a thoughtful moment observes, “In medicine, failure is easy. Failure ... is almost effortless.” Then he pauses while those words hang in the air, and the audience lets the observation sink in.

Failure is almost effortless.

The pain of poor care

Mulling over his words, my mind wandered to the noisy cabin of an H3 Sikorsky helicopter and a trauma patient enroute to the hospital, being cared for by an elite mountain rescue squad. I had been invited aboard to write a story about the team’s unique operation, and everything about them had impressed me greatly — except for that moment when the patient was secured to the treatment area. For all of their technical rescue skills, the team’s medical care was abysmal.

I thought about a paramedic friend of mine who had recently spent time riding along and photographing medical crews in the Middle East. He had been looking forward to seeing the street medicine of the highly trained and nationally recognized service. His opinion was succinct. “Nice guys, but their medicine sucks.”

One doesn’t need to travel overseas or fly in helicopters to track down poor medical care in the prehospital setting. It’s everywhere. None of this is news to ER staff, who witness daily the vast difference in care from one service to the next, and even among individual providers within the same organizations. EMS has its share of dirty little secrets, and this one is certainly up at the top of the list. Much of the care that we provide is simply substandard, even when our standards are low.

No easy solution for a hard problem

Solutions to this problem are predictable and often overly simplistic. The fix-it crowd clamors for higher educational standards, more clinical hours, stronger professional representation and rigorous quality assurance measures. None of these would hurt, but all of them overlook Dr. Gawande’s essential observation. The practice of medicine is hard. And failing to provide good care is far easier than rising to meet the challenge. Failure, as it turns out, is effortless.

I was thinking this over recently while teaching a class on sepsis in my home state of Colorado. A student asked about the physiologic mechanism behind hyperglycemia in septic shock. It was a great question, and I didn’t have a rock-solid answer.

Instead of dismissing the question as beyond the scope of our discussion and discreetly guiding the topic toward more comfortable waters, I dove in and asked if anyone could track down more definitive information. Several students started tapping away on their smartphones and keyboards and, in minutes, we had multiple sources with information about temporary insulin resistance in the presence of sepsis.

Question resolved.

In our modern world, at the height of the information age, no information is out of reach. No learning opportunity is denied us. Nothing prevents us from expanding our knowledge and our skills. The keys to the knowledge kingdom are not locked away. The road to improvement is open and available to all of us, but the road remains hard. The only real barrier is us.

Fixing our issues with medical incompetence doesn’t begin with a college degree program, or a new quality assurance system. It doesn’t begin with our education or our clinical rotations. It begins with us changing our own expectations of ourselves. It begins with the recognition that what we do each day is hard.

Difficult challenges, challenging solutions

We ask young, barely trained EMTs and paramedics in uncontrolled and sometimes hostile environments to make decisions that often challenge experienced physicians. We ask our personnel to perform physical assessments, complete medical histories, gather demographic data, implement interventions and reassess their results — all while moving toward the appropriate hospital. It is a job often completed inside the hospital in twice the time with triple the resources. And we do this with some of the least trained personnel in our industry.

None of this is said with the motivation to let us off the proverbial hook. Instead, I bring it up as a reminder that our job is difficult. Failure will always be the most tempting option, especially when it is so common and apparently acceptable.

We could simply take the hard-nosed approach. We could raise the bar of competence high and demand the heads of all those who fail to meet our exacting standards. But I fear that we would be left with a lot of empty ambulances and unanswered calls for help.

Raising the bar will be an important part of our solution. But another critical and less comfortable component will be the recognition of how frequently we stand in our own way. It is often our nature to choose the path of least resistance. We don’t consciously choose the path of failure. The most tempting thing about it is that it requires no thought at all. We simply wake up, put on our uniform and go to work.

It is effortless.

About the author

Steve Whitehead, NREMT-P, is a firefighter/paramedic with the South Metro Fire Rescue Authority in Colo. and the creator of blog The EMT Spot. He is a primary instructor for South Metro's EMT program and a lifelong student of emergency medicine. Reach him through his blog at steve@theemtspot.com or at Steve.Whitehead@EMS1.com.
Comments
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EMSEduCast EMSEduCast Wednesday, January 08, 2014 5:18:47 AM "In our modern world, at the height of the information age, no information is out of reach. No learning opportunity is denied us. Nothing prevents us from expanding our knowledge and our skills. "
J.t. Cantrell J.t. Cantrell Wednesday, January 08, 2014 10:47:32 AM While we do have the capability to access various data sites do we, when we need it most, have the time to do it ? All of us would love to have photographic memories and instant recall but is that a realistic expectation ? When someone is "dying all over you" it seems that rapid basic interventions will buy you some time but unless you have a long transport do you actually get to use a lot of the more technical medical practices. We still have a lot of scoop and swoop runs and if you do transfers.......well enough said. One thing I did learn from training in multiple fields, the broader your scope of knowledge the thinner it becomes. Granted there are some very exceptional individuals in fire, police and EMS who are good at many things but a lot of us aren't blessed with that ability. The more you desire to know the greater the need to study and review and inevitably you wind up losing some of your knowledge. You are only human and the last time I looked we do not have the ability to use all of our brain. Failure is effortless, yes but even a genius has bad days every now and then. It is a shame that a patient must sometimes pay the price.
Clint Hogan Clint Hogan Wednesday, January 08, 2014 11:13:40 AM Well said!
Rita Cranford Atkinson Rita Cranford Atkinson Wednesday, January 08, 2014 11:22:56 AM JT I admire you. Even using your own time and money to attend classes to enhance your knowledge and then use it to teach firefighters and EMT skills to save lives. I hope that I never need your services but I am confident that I would be in the best hands. Thanks for your service!
Steve Whitehead Steve Whitehead Wednesday, January 08, 2014 3:41:06 PM Thanks for the comment. A few observations I would make. The example of looking up the question in a classroom wasn't meant to imply that we should be typing on our smart phone in the middle of patient care. The thing that was great about that moment was that there were caregivers who were asking questions and wondering why and then seeking out the information. (And finding it easily.) I didn’t know what caused hyperglycemia in sepsis that day but I do now. And I don’t believe that some other vital bit of information now slipped from my brain because I put that piece of information in. We took the time to explore and be curious and now we’re all smarter about sepsis. We should all be this way. The information age gives us the ability to be curious and explore and learn and we often ignore it. Second. When I speak of caregivers who lack competence, I’m not talking about failing to demonstrate photographic memories and instant recall. I’m talking about the ability to do a solid head-to-toe assessment. Take lung sounds. Palpate an aching abdomen. Take accurate vital signs. Form a basic differential diagnosis and choose acceptable interventions. Then give a coherent and thoughtful hand-off report. Bad caregivers don’t fail because they lack photographic memories. They fail because they lack the basic skills of medicine. And they fail because they don’t care about getting better. And they fail because they make excuses instead of choosing to learn. They fail because it’s effortless.
Elizabeth Miller Elizabeth Miller Thursday, January 09, 2014 6:54:01 AM Thank you Steve. Last year my heart broke when I quit an EMS that refused to perform basic assessment and treatment. I couldn't find one member who even cared to improve, even amongst the trainees. Your articles give me hope that I will someday find a team who is as eager to learn and excel as I am!
Julia Harris Julia Harris Saturday, January 11, 2014 8:47:16 AM Thank you for always encouraging me to think. My agency is doing a recert class on AMLS next week; and I'll be willing to bet I'm the only one going back through the book now, just because I need to. I'm one of the geeks that goes to classes on my own time and dime. I'm still a para-pup and know that there is so much more to learn and incorporate in my skill set. One of the reasons that I find this career so rewarding is that I'm never in danger of knowing it all or being bored!! I love to learn and this is an exciting and challenging place to do that, where I know that my efforts may lead to saving a life. Doesn't get any better than that.
Nita Jones Nita Jones Saturday, January 11, 2014 6:41:50 PM This is great, Lizabeth. We know how dedicated and intelligent you are and I hope you know how proud we are of you. I know you give
Nita Jones Nita Jones Saturday, January 11, 2014 6:41:50 PM This is great, Lizabeth. We know how dedicated and intelligent you are and I hope you know how proud we are of you. I know you give
Nita Jones Nita Jones Saturday, January 11, 2014 6:41:50 PM This is great, Lizabeth. We know how dedicated and intelligent you are and I hope you know how proud we are of you. I know you give
Skip Kirkwood Skip Kirkwood Sunday, January 12, 2014 8:10:01 AM The job is difficult - make no mistake about it. I will freely admit to being one of those who believe the solution is in greater educational standards - as a barrier to those who are too lazy to do the job well. My thought is two-pronged: first, keep out those looking for an "easy entry" job. Second, keeping those out will cause the compensation of those remaining, and those to come, rise. Thus we will attract and keep a better quality of people. Why do the SEALS spend so much time training by running with telephone poles or with boats on their head? Are those skills that they will use in performing the "real job" Nope. They are tests to see who has the character they are looking for - those who won't quit, no matter what. We in EMS should devise some tests to weed out those who will "do the minimum necessary" when nobody is looking. This "lazy" thing is a character flaw - every patient deserves our very best.
J Dale Johnson J Dale Johnson Sunday, January 12, 2014 9:56:58 AM Chief, I have to agree with you that the first step is raising the education bar but I am afraid that is an uphill battle at best as there are too many entities that have a vested interest in keeping the educational standards where they are. With that said, I can see some of the aforementioned ‘character building/determination exercises’ as beneficial. I cannot relate to the SEALs training, but I can relate to some of the exercises from US Army basic and advanced training. Not all of what we did was ‘related to the job’, but it was essential to assessing whether or not you had the determination needed for the task(s) at hand. Sadly, I think a lot of the tasks and tests that could be devised to measure determination and ‘build character’ would be struck down by most HR departments.
Cristie Stone Cristie Stone Sunday, January 12, 2014 10:32:45 AM We all as EMS professionals and volunteers have a duty to provide the best care possible. We should challenge ourselves to learn more and to apply those skills with competence. We all have a time when we doubt our own training and skills in certain situations. I have worked with some people and have met others with other agencies that have a serious lack of self confidence in their training and skills. This has lead to sub standard patient care and that can not be okay with anyone. We all need to realize that we have a life of someone in our hands and they are depending on us and our training to help them. We should strive to give them the best care possible and continue to build on our training and knowledge. We have to require more of ourselves and help those that need help with skills and help them boost their confidence in their training. My personal saying for me is : SUB-STANDARD PATIENT CARE IS UNACCEPTABLE AND I WILL DO ALL I CAN WITH MY KNOWLEDGE AND TRAINING THAT I AM ALLOWED TO DO. More EMS folks need to say the same.
Steve Whitehead Steve Whitehead Sunday, January 26, 2014 5:03:02 AM Sometimes we have to just move on Elizabeth. Good for you for knowing when an organization wasn't going to help you grow as a provider. You can influence culture, but you can't change culture. Keep searching.

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