The Diesel Bolus

My name is Scott, and I’ve made mistakes. There. I said it.

The medical world is one where we strive for perfection. That seems to be multiplied ten fold in the world of EMS. We expect ourselves to be perfect. We expect ourselves to be better than nurses and sometimes doctors as we stand back and watch residents and attendings make mistakes that we feel we are immune to making. We can point them out or cite the newest evidence but for some reason when it comes to our own industry, we are prohibited from pointing out those same mistakes.

Some think that in the absence of protocol or knowledge, a good ol’ diesel bolus is the answer and should continue to be the answer when reeducation and more training would be far more appropriate. “Do no harm” is significantly different from “no harm was done” and we need to realize that. Just because nothing bad happened does not mean that something good happened.

The key to success in this field is learning from the things that don’t quite go as well as they should have. When I hit the streets fifteen and a half years ago I was terrified. I made a lot of mistakes, and when things were not going well my partner’s foot had better be getting heavy. Through the course of my career, I have grown and I’d like to think today that I’m a better paramedic. In all of the intricacies of medicine that I learned, and all of the journal articles I have read the biggest lesson that I have learned is humility and the ability to admit when I was wrong.

When things do not go well, the first question that I ask myself, or someone who takes my patient over is “what could I have done better?” how could I have improved my patient’s outcome?

Which brings me to my ultimate point in this post. The internet has been on fire lately after a Virginia volunteer fire department was cited for transporting a pediatric seizure patient in the cab of the fire engine instead of providing care and assessment and waiting for a responding ambulance to arrive. How could we possibly condemn these responders if there was not a negative outcome to the call? The kid is fine. They did what they felt was best and administered their own diesel bolus.

The Virginia State EMS Office, however disagreed with the QA/QI consortium of Facebook and mandated that the department make a number of changes. As far as I have read, there has been nothing done to the responders who were on the call, and that is fine. You cannot cite those who do not understand what they were dealing with, however education should be the focus.

I am a firm believer that medicine and operations need to have a line drawn between them. If somebody makes a medical mistake, they should be given the opportunity to learn from that mistake and prevent it from happening again in the future. If they willfully repeat that mistake again though, is that negligent? One of the responders from this incident said that if faced with the same situation, he would make the decision again, and that is what I have a problem with.

Paramedics are not perfect. We make mistakes, and we probably make them more than we admit. We operate in a vacuum, and we fix what we have to with the tools that we are given and we do it all with a little more than a year’s worth of training. When you compare that to the disciplines we frequently compare ourselves to that’s not all that much schooling for the amount of responsibility that we shoulder when we hit the street. This is why continuing education is so important. This is why the QA/QI process and those events that might not go as well as we’d expect them to are so important. We need to be the ones that look inward at our own industry and the care that we provide. We need to understand that in most cases a diesel bolus is not the right course of action for our patients. Normally, or at least in my experiences, we fall back on the diesel bolus because we lack the knowledge that we need to deal with the medical emergency in front of us.

There are some out there that feel that we have enough training, or even in some cases too much training. They think that just knowing when to put oxygen on, and how much oxygen to put on is all that is important, and there is no reason to know why we should put oxygen on them. This case in Virginia is the latest example of the need to understand the “why” of medicine. We carry the word technician in our name but we need to look at ourselves as clinicians and we need to be clinicians, like it or not.

We are the bridge between the community and the next level of care, we are not just a means of access for it and until we admit that to ourselves, we are going to have to continue to make excuses for falling back on a panicked response and a heavy foot.