In my system the paramedics perform a function that we call “clinical supervision”. That is, on a call one of the responsibilities of the paramedics is to make sure that the BLS crew performs their role correctly. It’s been this way since I started here and I fully expect (and hope) that it will continue this way when I am just the name of some guy who used to work here. This role has never been formalized, which is both good and bad. Still, everyone from the medical director on down the chain of command knows and expects us to do this. The reason for this is simple. On an ALS call, it is the paramedics, not the EMTs who “own” the call. If anything goes wrong, even if the it’s the BLS crew who screwed up, the paramedics are the ones who have to answer for it. IV gets pulled out because the EMT tripped over the line? Paramedic owns that. Same if, God forbid, an endotracheal tube gets yanked because the EMT did something ham handed. It’s expected that the paramedics on the call will be the ones with the ‘splaining to do.

Since it’s informal exactly how we approach this responsibility varies widely. Back when dinosaurs roamed the earth, some of the medics were a bit, uh more direct than we are these days. I remember going home more than once with my butt hurting from a figurative ass kicking at the hands of a paramedic because I had in fact done something dumb. As General Patton said, “When I want something to stick, I give it to them loud and dirty.”

Today, we mostly take the “kinder, gentler” approach while celebrating diversity and all that crap. I tend to do my correction after the call is over, unless it’s something that immediately effects patient care. I also do more explaining than was normal in the past, teaching as well as correcting. Well, correcting is part of teaching.

I told you that, so I could tell you this.

A few weeks back we responded to a call with one of our better BLS crews. Sharp guys, they try to do the right thing. I forget the details, but the patient was a hypotensive. Not, “Oh my Lord, he’s got no blood pressure!” hypotension, but low none the less. As they had been taught in EMT school, and not untaught ever since, they put the patient in Trendelenburg position, which entails lying the patient flat and then elevating his legs. Technically, Trendelenburg entails lying the patient flat and then tipping them so that the feet are higher than the head, but we generally don’t do that. There are a couple of problems with Trendelenburg. The first is that it has never, ever, been shown to improve patient survival, or even raise blood pressure (the intended effect) enough to make a difference. The second is that when you position a patient like that, it places pressure on their diaphragm and makes it harder for the patient to breath. If the patient is overweight, which some are, it makes breathing even that much more difficult. Breathing, for those keeping score, rates very high on the good list in medicine.

The first thing I did when we met the BLS crew was look at the patient in Trendelenburg and direct them (remember, clinical supervision) to place the patient’s legs flat and sit him up just a bit. This put him in a more physiologically correct position which eased his work of breathing. Which amazingly enough improved his mental status. Imagine that! I mentioned in passing to the EMTs what I wrote in the previous paragraph about the uselessness of Trendelenburg. One of them gave me a bit of a look, not quite eye rolling, but well on it’s way. Still, he complied with my directions and didn’t say anything about it. We completed the call and it joined about 100,000 others that I have done and promptly forgot.

Until tonight, that is. We did a call with the same BLS crew and while we were working up the patient, who was not hypotensive, one of the EMTs told me that he had looked up what I said about Trendelenburg. Seems he was a bit peeved that I had told him to do something that was counter to “what everyone knows” in EMS. So he did some research on line with an eye towards having some sort of pithy rejoinder next time he saw me. Only one thing stood in his way. He discovered that I had been exactly correct in what I said. Which is what he told me, with a somewhat amazed tone in his voice. Imagine that, a paramedic who actually knows something not in the text books. Will wonders never cease?

Oh, we had a call with another BLS crew this very shift where I ended up doing the exact same clinical correction. I wonder if they’ll do some research too?

If my blog buddies who are trying to get EMS 2.0 off the ground do succeed one of the first things that I hope they do is fix BLS education so that it’s based on science and not war stories from the time of the War Between the States. Trendelenburg, traction splints, the irrational fear of using tourniquets to stop life threatening bleeding all live on in EMS because no one has taken the time to destroy the myths that promote them. Everyone seems intent on destroying myths of ACLS, but the myths of BLS do far more harm every year and no one is paying attention.

Why you’d think that medicine, even pre hospital medicine, is supposed to be based on science or something. What an idea.