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Is there a difference between “street medicine” and “book medicine”?

Don’t let anyone convince you that sloppy techniques and shortcuts are a necessary byproduct of the prehospital environment

Holding up the BVM, I launched into my instruction about good BVM technique.

“Nobody in medicine should be able to hold a candle to an EMT on proper BVM technique! Since we have fewer tools than anyone else, we should be the masters of these tools.”

And with that, I began to demonstrate perfect BVM technique.

After watching my E-C hand technique, a student from the third row raised a confident hand. He was a volunteer for a local fire department and had seen the BVM used in the field a few times. He wanted to set the record straight on my insistence on good head position and a tight mask seal. I could see he was trying to reconcile the difference between the technique I was demonstrating and what he had witnessed in the field.

“Let’s face it, Steve, what we’re learning here is the book way to do it,” he said. “When we get out in the field we’re going to learn that there are a lot of differences between street medicine and book medicine.”

I stifled a cringe and took a deep breath. My mind raced to find a diplomatic way to say that I thought this observation was a bunch of hogwash.

“I know there are often differences between the medicine we learn in class and the medicine we practice in the field,” I explained. “But I only know one way to teach these skills and that’s the right way. We could call other techniques that don’t use proper positioning and good mask seal ‘street medicine,’ or we could just call them wrong.”

I smiled to temper the harshness of my reply and the student smiled back. The lesson continued.

Proponents of “street medicine” are everywhere

Recently an EMS1 reader replied to one of my articles with a familiar observation. “The problem isn’t level of experience, the problem is book-learned EMS for testing purposes versus real-life EMS for life-saving purposes,” the reader wrote.

I heard an instructor at FDIC offer a similar observation. “Today I get these book smart medics who can’t seem to manage to put their book smarts into practice,” the instructor said.

The implication is always the same. Somehow, the foundational skills and knowledge taught in the classroom or book are somehow inferior to the real-world practical learning that takes place in the field. Our requisite classroom learning is simply an annoying checkbox to endure until we can get out in the field and start practicing “real medicine” on the streets.

Practical Field Experience is important

I don’t want to undersell or devalue the importance of practical experience. Making the transition from the sterile environment of the classroom to the uncontrolled prehospital environment is difficult and loaded with critical learning that is essential to becoming a good caregiver.

There are also lessons that just cannot be imparted in the classroom environment. Until you’ve walked into a darkened home in the middle of the night, you can’t grasp the subtle importance of determining if the scene is safe. Until you’ve had a patient with crushing chest pain adamantly refuse your care, you won’t fully understand the importance of understanding the boundaries of the patient’s legal right to refuse care. Until the day that your 10-year-old patient says, “I don’t feel very good,” and then lapses into unconsciousness, the concept of strong physical assessment skills will only be academic.

These are just a few of the numerous learning experiences waiting for you during your transition from “book medicine” to “street medicine.” And they are all critically important. But notice that none of the learning experiences I just spoke about require you to contradict your book learning.

My beef with the “street medicine” crowd

My beef with the “street medicine” crowd is that, far too often, we use the concept of street medicine as an excuse for sloppy medicine. We rationalize that our deviations from proper technique and diligent attention to detail are just a byproduct of the prehospital environment.

We may have learned that a detailed head-to-toe assessment is indicated on an elderly fall victim, but in the real world, we just palpate the hips and put them back in bed. Maybe we were told that lung sounds are best auscultated on the patient’s posterior chest (under the clothing) and that you should remove your sunglasses when you speak to your patient, but in the field, those school book rules just aren’t practical. Nobody really does all that stuff, right?

When you hit the street, you quickly learn that the possible deviations from what you learned in the classroom are endless. Even the very best of us have some degree of guilt when it comes to straying from the ideal practices that we learned in that quiet, sterile environment. And the guiltiest among us are typically the same providers who talk loudest and most often about “real-world-medicine.”

Enough is enough

There is no division between the medicine that is taught in the classroom and the medicine that we practice in the field. There is only a division between the proper practice of medicine and the improper practice of medicine. There is a division between skills that are performed well and skills that are performed sloppily. There is a division between walking the path of diligent practice and taking shortcuts.

There are plenty of important lessons to learn when you enter the prehospital environment. Experience truly can be your most valuable teacher. But don’t ever let anyone convince you that sloppy techniques, shortcuts and plain old bad medicine are a necessary byproduct of the prehospital environment.

The only real difference between the classroom and the field is that in the classroom most of the standards are enforced by teachers and test proctors. In the field, often free from direct oversight or supervision, your standards are primarily your own. The degree to which you maintain or compromise the high standard that you were taught is completely up to you.

Steve Whitehead, NREMT-P, is a firefighter/paramedic with the South Metro Fire Rescue Authority in Colorado. He is a primary instructor for South Metro’s EMT program and a lifelong student of emergency medicine. Steve is the host of the One for the Road video training series.