Comfort in Change

One of the things that amazes me about this field is how tightly we hold on to our beliefs.  It does not matter if it has to do with oxygen management or medication administration, or even C-Spine.  People always seem to revert back to how they were taught the first time that they learned something presumably because it is uncomfortable.  Maybe it is time to get comfortable with being uncomfortable.  Make it is time to make change a way of life.

It has been my experience that people seem to base a lot of decisions that they make off of one negative experience in their career over a more frequent positive one.  We balk at giving pain medications to some patients because we believe that they are lying to us thanks to that one addict that we feel pulled a fast one on us in the early days in our career.  Or we put the nitro aside on an inferior MI because this one time a medic that you met told you about a medic that they knew who dumped the pressure on a patient who then coded on them.  The truth is though that the person in pain, regardless of their background, could benefit from that fentanyl, and chances are, that person having the MI will maintain their pressure and could greatly benefit from the treatment that you are so reluctant to give them.

Or take response times as another example.  Despite evidence to the contrary, and despite studies that have been conducted, there is little correlation between response times and mortality in a majority of the emergencies that we as EMS providers respond to.  I happen to know of one rather large service that despite having an excellent ROSC rate they see a lower percentage of CPR saves in the more densely populated section of their service area with considerably lower response times than they do in the more suburban or rural areas.  While the difference in miniscule, it is further proof that despite the fact that somebody gets on scene more quickly than in other areas, speed alone does not constitute more lives saved.

I have always found the concept of changes in CPR care to be the perfect illustration of the evidence over anecdote argument.  The change from ABC to CAB resulting in the deprioritization of the ET tube has probably been the most prominent.  I cannot tell you how many times I heard, “I’ve been tubing people for years.  I know how important is.  I need to get this tube.”  Or the importance of working a code on scene.  People in my old system were so bent on rushing a dead person out the door so that they could deliver a dead person to the hospital that it took a while for them to see that working a person on scene worked.  They started to realize it worked not because of evidence but because they saw it happen.  They saw a ROSC because of the prioritization of compressions.

EMTs and paramedics hate being uncomfortable.  Give them a new piece of gear to use, or a new technique that works better than what they were doing before and watch how long it takes most to actually adopt it.  Now that oxygen administration is not as important, watch a see how many people still roll into the emergency room with a room air oxygen saturation of 98% on a nasal cannula.  The evidence is there.  Oxygen is not the “chicken soup of the medical world” anymore but it is this old crutch that many of us have been leaning on for the last fifteen or twenty years.  Some is good, more must be better.  That’s what our experience and the anecdotes of what we see and hear tell us, but science tells us otherwise.  Seeing might be believing for a lot of people, but reading it in a study needs to be a close second.

Ultimately what we need to do is start to get comfortable with the changes in the care that we deliver that will inevitably happen.  Much like what we did fifteen years ago, what we do today might not be the gold standard tomorrow.  If that was the case we would all have bite sticks in our back pockets and fifteen antiarrythmics in our drug bags.  It turns out that elephants don’t like big mud puddles sometimes, and oxygen might not be as magical as we once thought it was.

Leave a Reply

Your email address will not be published. Required fields are marked *