“Half of what is taught in medical school is wrong, but nobody knows which half.” ~ Lucy Hornstein, MD
Everyone knows that the wise bartender never discusses politics, sports or religion with his customers. There’s just too much potential for conflict there. Most EMS bloggers and writers follow the same rules, for the same reasons.
I am not one of those writers.
I’m going to throw a little religion at y’all, and talk about what we believe, and why. I’m going to talk about dogma in medicine, and use religion to make my point.
I’m not going to evangelize to you about evidence-based medicine. Other people preach that better than I, and when it comes right down to it, I’m still a believer in some things, even if they have never been proven in a randomized, double-blinded controlled trial. The British Medical Journal made that point several years ago in this study:
I think even the most ardent supporter of evidence-based medicine would agree that it would suck to be in the control group of a study to see if parachutes actually worked. I’d also like to point out that it doesn’t require a parachute to skydive. It only requires a parachute to skydive twice.
But the efficacy of many of the things we do in EMS is not so intuitively obvious, and some of the things that we thought were intuitively obvious have persisted long enough that, when finally subjected to scientific scrutiny, we reject any evidence to the contrary.
Those things have become dogma.
The dictionary defines dogma as “a point of view or tenet put forth as authoritative without adequate grounds.”
It’s something we’re expected to take on faith, and altogether too many of us do just that. We don’t question, we just accept it as fact.
And it’s easy to do, because at the heart of dogma in medicine is our desire to help our patients. It sounds good. The theory was plausible. The motivation was admirable. The goal was reachable. The lie was easy to believe, because every good lie contains a kernel of truth.
Although, “lie” may be too harsh a word, one that smacks of deliberate falsehoods. Perhaps we’d do better by labeling them “misconceptions,” but the damage can be just as real.
And you know, dogma may sometimes serve a greater good. The dictionary also defines dogma as “a doctrine or body of doctrines concerning faith or morals formally stated and authoritatively proclaimed by a church.”
When it comes right down to it, some things you just believe, despite the lack of scientific proof. As the noted philosopher Hub McCann said in Secondhand Lions:
“Sometimes the things that may or may not be true are the things a man needs to believe in the most; that people are basically good, that honor, courage and virtue mean everything, that power and money… money and power… mean nothing, that good always triumphs over evil, and that true love never dies . Doesn’t matter if it’s true or not. A man should believe in those things… because those are the things worth believing in.”
Wise man, that Hub McCann.
He captures the essence of faith perfectly. When it drives us to love and serve our fellow man, it can be a wonderful thing. When it separates us, turns us against each other, makes us treat women like chattel or gays like second-class citizens, or fly planes into buildings, we have perverted faith into something obscene. We’ve placed more value on the wording of our moral code than on its intent.
And when that happens, it’s time to abandon the dogma – medical or religious.
Far too few of us question what we’re told in class, or critically examine the theory behind our practice. Far too many of us have invested our treatment protocols or algorithms with the power of faith. Far too many dubiously beneficial treatments persist as supposed standard of care for far too long, merely because we’re afraid of lawyers. Far too many fervently believe in a treatment because they’ve seen it work with their own eyes.
There’s a reason eyewitness testimony is so easily discredited; because people are fallible. Ask a prosecutor which he’d rather have: eyewitness testimony, or forensic evidence. By the same token, ask a defense attorney what he’d rather have to defend a malpractice case, an expert opinion backed up by organizational inertia and conjecture, or an expert opinion based upon scientific studies.
I’ll bet a mint-condition pair of MAST pants that they’ll both pick the science.
When I was a starry-eyed EMT student, I took what my instructors said on faith. After all, they were paramedics, and I wasn’t. They had worked in the field, and I hadn’t. They were teaching from a textbook written by doctors, people at the pinnacle of medical knowledge. They had to know what they were doing, right?
Turns out that, just like Dr. Hornstein’s medical school professors, half of what Richard Pace and Randal Howard taught me was wrong. It just took me years to figure out which half. That was years spent, at the very least, doing my patients no good, and quite possibly doing them harm.
It’s not that my teachers were stupid. What they taught was considered solid twenty years ago, but as it was subjected to scientific scrutiny, much of it fell apart.
They taught me that MAST pants auto-transfused two units of blood from the legs to the trunk.
They taught me to replace every milliliter of blood lost with three milliliters of isotonic crystalloid.
They taught me direct pressure and elevation was far better options than tourniquets for arterial extremity bleeding.
They taught me that antiarrhythmics were important for converting VF. I even memorized the sequence in which to give those selective cardiotoxins, and the indications for suppression of PVCs.
They taught me that even a millimeter of neck movement of a patient with an unstable cervical spine fracture might induce paralysis.
They taught me that the Golden Hour was an absolute, and that my portion of it was the Platinum Ten Minutes.
They taught me A-B-C, with all the immutability of something written on stone tablets. To do chest compressions while ignoring breathing altogether? Unthinkable.
But the most useful thing they passed along to me in training was what they didn’t do. They didn’t discourage me from questioning them, and they didn’t require one specific approach to a problem. They taught me that as our knowledge expands, the more we realize how little knowledge we actually have.
In short, they let me keep a flexible mind. That alone has served me better in my career than anything written in a textbook. It allowed me to become a medic with twenty years of experience instead of a medic with one year of experience, repeated twenty times.
Accept nothing we have been taught at face value, most especially those things that we feel to be true. If our profession is to advance, we need to identify the things we do well, the things we don’t do well, and recognize the lies we have been telling ourselves.
It’s not necessary to completely abandon our faith in EMS.
But it is our professional obligation to question it.
