Why it’s not just about lights and sirens

“The better I do my job, the less exciting it is.”

I had that epiphany over 10 years ago, when I noticed a couple of coworkers always seemed to be transporting their patients with lights and sirens or calling for police backup on every call.

“Surely I can’t be getting only the boring calls, can I?” I thought to myself, only to discover when I encountered those crews at the emergency department, their patients weren’t that bad.

Oh, they had everything done to them – non-rebreather masks pushed up on their foreheads, 12-lead ECG, IV fluids hanging, blood glucose readings at the ready … and stable vital signs.

Rock. Solid. Stable. Vital signs.

Somehow, I had become an ALS minimalist without realizing it. It was a weird paradox; the more confident I became in my skills and knowledge, the less likely I was to practice my skills (unless you consider not doing something unnecessarily a skill).

For many years now, my requirement for transporting with lights and sirens has had three elements:

1. The patient has to be unstable
2. The condition must be time-sensitive
3. The treatment must be something I cannot provide and the ED can

If they don’t meet those three requirements, I don’t transport in emergent mode. The cardiac arrest patient I’ve just resuscitated is better served by spending an extra few minutes on scene to stabilize their BP and rhythm and then transporting non-emergent, than by me rushing madly to the ED with a poorly packaged patient teetering on the brink of arresting again.

I wrote in a column years ago that I was more skilled at airway management than any previous point in my career, yet I was less likely to resort to invasive airway management than I had ever been. The more I knew, the less I did.

I graduated school as the cocky, know-it-all paramedic who judged myself by how many procedures I could perform on a patient or how deeply I could get into a treatment algorithm or protocol, rather than my patient’s outcome.

I think the first chink in the armor of overtreatment was reading the research on ventilator-associated pneumonia, prehospital CPAP and how much costlier and riskier the patient’s course of care became when I intubated someone, even if it was an easy tube.

Then I learned Dextrose 50% causes wild swings in a hypoglycemic patient’s blood sugar; causes phlebitis; and, God-forbid, severe tissue necrosis if the IV line extravasates. I discovered that a bolus of D5%W or D10%W achieves the Lazarus effect just as well without the risk of D50%.

Then I learned that ventricular antiarrhythmics were just selective cardiotoxins; they killed the arrhythmia just a little faster than they killed the patient.

I learned that a whole host of things I did as a medic were poorly supported by scientific evidence, and more than a few were harmful.

That started me on the path of being an EMS skeptic and questioning everything we do. If we want to know that EMS care does the patient any good, we have to be willing to closely examine our most cherished, long-held beliefs and discard them if they are proven to be untrue.

In short, I learned how to think critically.

Using your judgement

The Oxford English Dictionary defines critical thinking as, “the objective analysis and evaluation of an issue in order to form a judgment.”

There’s the key word: judgment.

Along the way, I learned when and when not to be aggressive. Many things we do most often aren’t proven to benefit the patient, and a few things we are reluctant to do should be pursued far more aggressively. So nowadays, I start IVs to administer medications or fluid I judge that the patient needs, not to pacify a triage nurse.

I make judgments that sometimes conflict with protocols – because protocols can’t address every eventuality – and when I do, I confer with a physician to cross-check my rationale. Most of the time, they agree.

“Hey Doc, my patient has acute pulmonary edema and a blood pressure of over 160. How about me upping the Nitro dose to something that will do some good?”

I judge that if the treatment I’m considering has more risk than reward for my patient, or if there is no proven benefit, the best course is to not do it.

Along the way of realizing that ALS care is often of questionable benefit, I learned to trust my EMT partners more, and expect them to perform their full scope of practice rather than be my driver and equipment sherpa.

I didn’t have the self-confidence to do nothing early in my career. It sounds strange saying that because I was so cocky, but I was afraid I’d miss something, so I hit the patient with everything but the kitchen sink. A lot of inexperienced paramedics do that, but I’m not sure that’s a bad thing.

I think it’s better to be aggressive than timid when you don’t have a lot of experience. Lots of patient care will teach you the fine art of clinical restraint, but when you’re new and inexperienced and unsure of yourself, you’ll do the most harm by freezing up and doing nothing.

Some people look at a photo of a rig utterly trashed after an emergent call; trash and wrappers everywhere, pools of blood on the floor, and people who don’t know better think, “Wow, that must have been an exciting call!”

People who do know better – and most of us have run very similar calls and trashed our rigs the same way – cluck to ourselves and think, “How sad that someone memorialized their 10 minutes of panic.”

We look at the blood on the floor and think, “If the patient was bleeding that badly, why didn’t you control it when you were on scene with room to work and a stable floor under your feet? Didn’t anyone ever teach you that it’s better to work smart than work hard?”

We can’t always avoid stressful calls like that, but we can avoid creating them ourselves.

Never move faster than your brain can think

When you’re on that stressful call, with everyone hurrying about and bystanders screaming, “Don’t just stand there, do something!” do the opposite: Don’t just do something, stand there. Never move faster than your brain can think. Take 10 seconds to survey the scene and take it all in, then act on what you’ve seen. Professionals don’t run. We move with a purpose, but we don’t run.

Use the OODA Loop as your decision-making model, and utilize your partner to use the “eyes-in, eyes out” strategy to running your calls; while one of you is task-focused and necessarily tunnel-visioned on correctly performing the task, the other is managing the scene. When both of you get task focused, things get missed and the scene runs you rather than you running the scene.

WATCH | Don’t let bias impact your decision making

“The better I do my job, the less exciting it is.”

Slow and boring is good. It’s less stressful on the patient and the providers. The better you think, the better you do your job, and the less exciting it will be.