EMS 2.0: Critical Thinking in Prehospital Training

By Kelly Grayson

Stop me if you've heard this one:

"Heck, you go to any ER and watch the nurses. They need orders to administer oxygen, for pity's sake! We can do assessments, defibrillate, pace, cardiovert, give meds, needle chests, cric people… heck, we can even intubate! So why don’t they let us work in the ER and pay us like nurses? I mean, we can do more than they can anyway…"

If you've been an EMT long enough, chances are you've heard a similar statement from one of your colleagues. Perhaps it was a youngster with barely a year's experience, or perhaps it was a grizzled veteran with that same year of experience, repeated 20 times.

Either way, we should know better.

EMS is unique among the health care professions in that we have this peculiar tendency to define ourselves by a skill set rather than a unique body of knowledge. You don't see nurses or doctors doing it, but ask anyone in our profession, "What is an EMT?" and likely as not they'll answer not with what they know, but what they can do.

Perhaps it's understandable, given the physical nature of pre-hospital care, but defining ourselves by the patch we wear and our particular skill set limits the growth of our profession. It sets us apart from other health care professions at a time when we need, more than ever, to integrate ourselves into the allied health community. At a time when our entire health care system in this country stands on the cusp of a radical overhaul, the last thing EMS needs to be is what it has always been: an afterthought, the forgotten stepchild clamoring for a seat at the table with the grownups.

This point has been driven home to me over the past several weeks as I've followed various discussions on internet EMS forums and blogs. One EMS blogger has been engaged in a spirited debate on Paramedicine 101 over his series of posts, "Why Medics Can't Intubate."

The blogger, a gleeful gadfly who calls himself Rogue Medic, opined that not only are paramedics woefully inadequate at providing one of our core skills – endotracheal intubation – but that in the vast majority of cases requiring airway management, endotracheal intubation is usually unnecessary. He asserts that paramedics' poor intubation skills can be traced to three root causes: inadequate initial clinical experience, absentee medical directors, and all-paramedic EMS systems and the inevitable skill dilution resulting from dividing a finite number of procedures among a large pool of ALS providers. And unlike his opponents in the debate, he can defend his position with numerous citations.

While Rogue Medic poked the EMS establishment with a sharp stick on his blog, another debate raged on an EMS list server over paramedic-initiated refusals. Opponents of the concept pointed out that most EMS systems that instituted such programs eventually found them unworkable and fraught with legal liability. "Even ER doctors often wrestle with the decision to admit someone to the hospital," they said. "So what makes you think that medics can do it reliably?"

Proponents of the practice countered that many — perhaps even a majority — of our patients do not need Emergency Department care, much less ambulance transport. In a health care system staggering under the weight of uncompensated care and expensive Emergency Department visits, they saw EMS providers as the logical choice to screen most of those non-emergent patients and direct them to more appropriate avenues for seeking medical care.

"We've got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!" they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.

All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools. Major U.S. cities have EMS systems whose medics cannot reliably wield a laryngoscope, or whose EKG interpretation skills are limited to reading the machine interpretation printed on the strip. Every few months, we see a news report of someone mistakenly pronounced dead by the EMS crews on scene.

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal. Some, like Rogue Medic, would say that inadequacy in initial education is the rule and not the exception. With the implementation of the National EMS Educational Standards, hopefully that inadequacy will be addressed, but to add significantly to our skill set is going to require a corresponding increase in our knowledge base. That is a task that will require more than an augmentation of existing programs; it will require a wholesale overhaul of the way we educate EMTs in this country.

Some of you may argue that things aren't that bad. You may know of EMS educational programs that excel at turning out capable EMTs. You may know of individual medics with the chops to not only get the toughest tubes, but the discretion to know when a tube isn't necessary. And they may even have the diagnostic acumen to safely triage non-emergent patients and screen out those not in need of EMS transport.

But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it's not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.

It's when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we'll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.

Only then are we going to be more than a patch and a skill set.

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