The anti-axiom axiom

While EMS education and protocols are important, experience proves that every situation is different and nuanced


“One axiom to rule them all, one axiom to find them. One axiom to bring them all, and in the wrongness, bind them.” — Shamelessly paraphrased from Sauron, “Lord of the Rings”

The dictionary defines an axiom as “a self-evident truth that requires no proof,” or “a universally accepted principle or rule.” I was taught quite a few axioms as a young medic:

  • GCS less than 8, intubate.
  • Hold your breath when you intubate. When you need to take a breath, so does your patient.
  • BLS before ALS.
  • Never give pain medication to undifferentiated abdominal pain.
  • You can never go wrong by administering oxygen.
  • Never suction for longer than 10-15 seconds.
  • Anything over 150 is SVT.
  • Never pass a slower vehicle on the right during an emergency response.
Twenty-five years in, I have come to realize that there are very few absolutes in emergency medicine. (Photo/City of Royal Oak)
Twenty-five years in, I have come to realize that there are very few absolutes in emergency medicine. (Photo/City of Royal Oak)

Emergency medicine is always evolving

Twenty-five years in, I have come to realize that there are very few absolutes in emergency medicine, and the only real axiom that has stood the test of time is, “Always leave your patient in better shape than when you found them.”

That is, if you can.

Sometimes, our patients deteriorate despite our best efforts. And, occasionally, they deteriorate because of our best efforts. From hyperventilating head injury patients, sublingual procardia for stroke patients and high-flow oxygen for MI and stroke patients; to rushing an intubation because we were taught we had only 30 seconds, immobilizing trauma patients, pouring IV fluids into our trauma patients;  or because we insisted on passing on the left when the right lane was the safer option. This mindless devotion to axioms often causes more harm to our patients than doing nothing at all.

What spurred this musing was a recent encounter with a young paramedic who had apparently graduated from the Memorize and Regurgitate a Bunch of Rules Without Understanding Them Paramedic Academy. He was confident – cocky, even – and able to spout axioms at will. He reminded me of, well … me, 25 years ago. I remember what it was like to be absolutely confident that I knew everything there was to know about EMS, because I had memorized all the rules, too.

Educating rookie paramedics when it comes to EMS rules

It started because I stepped over a patient. I needed to get to the patient’s left arm to start an IV, and she was positioned in such a way as to make that impossible without moving the patient or stepping over her. And, since I didn’t want to move the little old lady with a hip fracture without adequate analgesia, I stepped over her.

After the call, in the truck, he observed, “I was taught never to step over a patient.” There was an unmistakable hint of judgement in his voice.

I replied, pleasantly, “Unless, of course, you have no other choice,” while mentally congratulating myself on my diplomacy, tact and self-restraint. Those online interpersonal communication courses have really been paying off.

“You. Never. Step. Over. A. Patient.” He repeated, as if talking to a slow child.

“That approach may work in school, but real life is rarely that cut and dried,” I replied, gritting my teeth because he was forcing me to be That Old Paramedic Guy. “Experience will teach you when those rules don’t apply.”

“So, what you mean is, after a few years, I’ll get lazy, too.”

My response was brief, to-the-point and left no room for doubt as to my position on the issue, and his level of education and critical thinking. I also made a mental note that I need to stop putting off those 200-level diplomacy courses.

Needless to say, the rest of the shift was frustrating for both of us. He’d pronounce one of his articles of faith, carefully memorized in paramedic class, and I’d reply with, “Well, actually … ” Changes in paramedic education had given him a different set of absolutes than I was given, but he hadn’t learned yet to distrust those absolutes.

Best treatment practices change with the circumstances and experience

In school, I was taught many axioms of emergency care, but there was always the caveat that “this is the best treatment as we understand it now.” I don’t think Randal Howard or Ray Ezell ever mentioned the words “research” or “evidence-based medicine” in my paramedic class, but they had both been doing the job long enough to see changes in the way they practiced. They knew that medical treatment evolves with greater understanding, and so they encouraged in us the most valuable trait of a good paramedic – a flexible mind.

It’s understandable, when you’re a rookie, to give those axioms more credence than you should. When you’re a new medic, what you were taught in school and what’s in your protocols is still very much your bible of good EMS care. But, as you grow and learn, you begin to appreciate nuance and recognize how frequently it is that uncertainty rules the call. You realize that there are some situations not governed by any axiom you’ve ever learned, and some situations you’ll encounter are actually worsened by following the axiom. And, if you’re learning anything from your experiences, you’re growing from that novice practitioner to an experienced practitioner and, hopefully, one day, an expert practitioner.

One day, you wake up and realize you’re more Gandalf than Sauron, and you’re saying things like, “You must understand, rookie, that I would use this axiom to do good. But, through me, it would wield a power too great and terrible to imagine.”

Or, in my case, “Well, actually … ” I’m no wise wizard, and my witty aphorisms run heavily to poop jokes and dirty limericks.

New and older paramedics can learn from each other

If you’re a young medic, keep that in mind. Your instructors can teach you to the best of their abilities and the most current medical theory – if you’re lucky enough to be in a good program – but, the street has a way of challenging even the best-educated medics. If you were taught well, there will be few absolute contradictions between the classroom and the street, and a flexible mind will ease your growth from novice rule-follower to expert.

And if you’re an old, grizzled paramedic, try to remember what it was like as a rookie, when the protocols were still the bible, and the confidence that a good medic needed could lead you to do stupid things. And, when you pass on that hard-won wisdom, take a look inward at how much of it is experience and growth, and how much of it is complacency and laziness.

I’d tell you that a good mentor always passes on the former, and never the latter … but we’ve already learned how I feel about absolutes.

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