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To withhold or not withhold EMS treatment: That is the question

Expand your knowledge of EMS care beyond rote memorization and you’ll soon realize that you are rarely withholding care

Actually, the real question is, "Is withhold even the word we should be using?"

Merriam-Webster defines withhold as, "to refrain from granting, giving, or allowing."

In medical applications, it is implicit that withholding is to "refrain from granting, giving, or allowing" a needed and indicated medication, procedure or intervention.

Administer oxygen and other treatments when they are indicated. (Photo/Greg Friese)
Administer oxygen and other treatments when they are indicated. (Photo/Greg Friese)

Not doing something because it isn’t indicated isn’t withholding anything. It’s simply practicing good medicine. Imagine this conversation:

"Sir, I’d like to apply this synchronized shock to your chest at 100 Joules."

"I dunno, does that hurt?"

"Considerably, yes."

"Do I need it?"

"Not at the moment, no. But you do have a history of ventricular tachycardia, and it may come back between here and the emergency department. I’d rather be safe than sorry."

"In that case, hell no."

"But your wife called, said your heart was racing again."

"My wife is a sales clerk, not a doctor. She panicked and called 911. I’m not having a repeat of my v-tach."

"But I’d like to shock you anyway, just in case. Besides, it’s synchronized. Unlikely to kill you."

If that conversation sounds a bit ludicrous to you, then imagine similar conversations many of us engage in every single day when we justify high-flow oxygen or spinal immobilization.

I see 'withhold' in comment threads on clinical scenarios, even in headlines on EMS1’s Facebook page: "Your patient has ischemic chest pain, a 12-lead ECG that looks like he may soon be eating his salads from the roots up, normal vital signs and a room-air oxygen saturation of 98 percent. Would you withhold oxygen for this patient?"

Um, no, I wouldn’t withhold oxygen. Withholding implies I’m denying him something he needs that could potentially benefit his condition. I’m just not going to give it because it isn’t indicated.

Ditto for the guy walking around at the scene of a motor vehicle collision complaining of neck pain. I’m not going to withhold a cervical collar and long spine board. I’m just not going to apply a device far more likely to cause harm than good.

If my pediatric patient with the broken wrist is deathly afraid of needles, I’m not going to stick him with one if my only reason is to avoid getting snide looks and catty comments from the ED nurses for not getting a line.

My self-esteem can handle their disapproval, and I’m confident enough in my skills to know that if I needed a line quickly, I could get one.

I’ll give the kid fentanyl intranasally and make his ambulance ride less scary and uncomfortable. I’m not withholding vascular access, I’m simply administering medication in the most appropriate route for the patient and deferring a painful procedure until it can be done, if needed, under better conditions.

While all this focus on a word may seem like we’re quibbling over semantics, I’d say it has much broader implications as to how we define ourselves, the job we do and the worth of our interventions. I’ve said before that EMS, as a profession, has wrongly defined itself by a patch and skill set, rather than by a unique body of knowledge. We measure our worth not by what we know, but by what we do.

And that’s just wrong.

Reason and restraint

When we measure our effectiveness by how much stuff we do to a patient, then withhold smacks of shoddy care, as if we haven’t done all we could: "Darn it, I didn’t get to the fourth-line drug in the protocol. I’m such a failure."

If we instead defined ourselves by what we know, then not doing something takes on an entirely different meaning. Very often, the most important interventions are the ones we don’t perform: "I rock. I turned that crashing CHF’er around without intubating him. Go Team Me!"

Voltaire once said, "The art of medicine consists of amusing the patient while nature cures the disease."

Wise man, Voltaire. Even in the 1700s he knew that a physician’s most valuable tools were reason and restraint.

So rather than give high-flow oxygen because "it can’t hurt," start focusing on knowing more about physiology. You’ll soon learn that high-flow oxygen is not a benign drug. It’s a potent vasoconstrictor, reducing coronary artery flow by upwards of 30 percent. It worsens neurological outcomes in stroke. There’s good evidence that it doesn’t do normoxic trauma patients any good, either. Even the crashing pulmonary edema patient that you put on CPAP might be able to do without oxygen. The pressure is the important thing and that CPAP can be just as effective powered by compressed air.

Instead of doing a standing takedown of your ambulatory wreck victim, or escorting him over to your cot and laying him down on the long plastic torture device, learn more about the indications for prehospital spinal motion restriction. A five-minute Google search and a little light reading will demonstrate that those indications are damned few and ambulatory patients aren’t among them.

Become a student of your profession, expand your knowledge beyond that of rote memorization of protocols and algorithms and you’ll soon realize that the only thing you’ll ever have to withhold is the urge to express your disdain of those EMTs who still practice monkey-see, monkey-do medicine.

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