If you talk to people in EMS eventually the discussion turns to skills. How many intubations, how many IVs, electrical therapy, needle decompression of the chest…

The list goes on and on. Paramedics generally, but not always, like when a new skill is added. Under “not always” 12 Lead EKGs seemed to lead the list. A lot of people, both in the field and in the hospital, were dubious about the need for doing this in the field. Early on that even included your faithful author. Eventually we all learned that doing that, along with the mundane skill of giving patients with Acute Coronary Syndrome were not only easy, but vastly beneficial to patients. Pick any “new” skill, CPAP, Intraosseous infusion, ventilators. Each new skill, often referred to as a “toy” was usually met with delete. We could do another skill. Yay!

Of course the flip side of this is “taking away” a skill. Often this is expressed in the tone of a petulant child complaining that one if his toys has been taken away by mean old parents.

The past several years have seen a lot of change in EMS. Much of that change involves abandoning old technology or skills that we now know not only aren’t beneficial, but are in fact harmful.

When I was first an EMT, 40 or so years ago, Oxygen was a stable of treatment. Not only because we thought it was beneficial to most patients, but because it was one of the few “advanced” treatments we had. Oxygen, the more the better. In the early 1990s it reached the point of ridiculousness when we were instructed that field providers were too dumb to decide if a patient needed a little, a little more, or a lot of Oxygen. So, everyone got Oxygen whether they needed it or not. Many of us knew that this was foolish, as were the lower end of the medical school graduates who seemed to be behind this move.

Eventually this silliness subsided, but not because the doctors behind it got smarter. No, other doctors who apparently stayed awake in school did studies that started to demonstrate that not only did high concentration Oxygen not help most patients, but it usually did more harm than good.

So, the protocols were changed as organizations such as the American Heart Association and others published guidelines recommending limiting the use of Oxygen in cardiac emergencies and stroke. Everything we had learned since the start of EMS was suddenly turned on it’s head.

The push back was significant as people fought hard to retain a skill that they had used for a long time. It seemed that using the skill was more important than the science that suggested that it was harming patients. Science be damned, I want to give Oxygen.

Eventually science won out, but it wasn’t easy.

The use of spinal immobilization is going through a similar transition now. After years of complaints from patients, in hospital providers, and some field providers, science has taken a look at the process of spinal immobilization in the field. This includes the techniques, the equipment, anatomy and physiology, and the real world effects on patients.

The results are not good for a skill that we’ve been using since the 1970s. It sucks. It doesn’t help, doesn’t reduce spinal cord injury, causes other injuries, is just shy of torture for elderly people and not so good for the rest of us.

Slowly at first, but ever increasingly, systems across the nation are starting to change their protocols to limit and in a few cases almost entirely eliminate the practice.

How do you think that’s going over with field providers? Field providers who are now being relieved of the need to perform a usually unnecessary procedure about which the majority of patients complained.

Not well as it turns out. A lot, way too many, field providers are inextricably wedded to the notion that immobilizing patients on a slab of plywood is a life (or movement) saving procedure. These fossils of EMS don’t care about the science, they are more interested in maintaining the status quo. It’s about them, not the patients.

Those are two BLS level skills that a lot of paramedics seem to think define what they do. Because, as I said at the start, EMS is defined by what we do, not necessarily what we know.

For the past dozen years or so pre hospital intubation has been studied and in some cases under attack. Some of those studies were well designed, but many weren’t. They focused solely on pre hospital intubation, which seemed like a direct attack on paramedic’s ability to perform the skill. “What makes pre hospital intubation so much more dangerous and less effective than in hospital intubation?” we asked. Answers varied, but they were not particularly convincing to us. Some systems in fact did away with intubation for the medics, but most didn’t. Our most sacrosanct skill was safe, at least for now.

In the meantime military experience in Iraq and Afghanistan showed that patients intubated before going to the operating room did poorly in relationship to patients who were intubated in the operating room immediately before surgery began. Military surgeons and anesthesiologists developed a protocol that the patient would be prepped for surgery and then rapidly intubated almost as the surgeons started cutting.

At about the same time, research was showing that patients in cardiac arrest didn’t suffer if bystanders did compression only CPR. In fact, they seemed to do about as well as those who did get ventilated. Out of this came the AHA guidelines for Compression Only CPR for lay people doing CPR. Patients still survived because as it turns out compressions are the important part of CPR as the body retains sufficient Oxygen reserves for about eight minutes after cardiac arrest.

At the same time research was being done to develop what is known as “Cardio Cerebral Resuscitation” or CCR. A key component, maybe the key component of CCR is not ventilating or intubating the patient for the first eight minutes of resuscitation. Systems that have adopted this approach have seen significant improvements in resuscitation and discharge to survival with little or no neurological injury. That’s pretty cool.

Would any of my readers like to render a guess as to what is the most difficult part of getting providers, especially advanced providers, to accept and adopt CCR?

If you guessed anything other than getting them to understand that intubation is harmful early on in the resuscitation, you’d be wrong.

Resistance may be futile, but it’s also vigorous.

It is not just EMS that is seeing these changes. Here is a good article about the dangers of intubation in the Emergency Department.

 Post-Intubation Hemodynamic Collapse in the Critically Ill Patient

A snippet,

Venous return and intrathoracic pressure. Venous return (VR) is the second critical element of cardiopulmonary physiology, determining cardiac preload and, thus, cardiac output. Simply described, VR is proportional to the difference between extrathoracic and intrathoracic pressure (ITP) — venous blood returning from the venules in the tissue beds must overcome ITP in order to return to the right heart. During spontaneous respirations, ITP is either negative or zero at its peak. However, intubation and positive pressure ventilation (PPV) affect return of venous blood to the heart in several ways.

When patients are placed on PPV, intrathoracic pressure increases above zero, which in turn impedes venous return. This phenomenon may not become clinically relevant in a healthy patient who has plenty of room on the Frank-Starling curve. But in patients whose preload was barely adequate prior to PPV, the decrease in VR and preload may lead to a significant decrease in end-diastolic filling pressure and cardiac output. Furthermore, elevations in ITP are also exacerbated by gas trapping; inadequate attention to ventilator settings for patients intubated with obstructive lung disease (e.g., COPD or asthma) may lead to drastic rises in ITP and critical loss of VR.

Which brings me to the point of this post.

If EMS is going to ever be recognized as a profession (or even a trade) and not a skill set, paramedics are going to have to start being more interested in the science behind what we do, understand the rationale for providing or withholding drugs, treatments, and procedures, and start recognizing that what we do is far less important than what we know. While it’s important to be competent and capable providing those things, it’s far more important to be able to discuss the why behind what we are doing and understand when we shouldn’t be doing it.

That’s only part of the story, but it explains a large part of why and how intubation can harm an already critically ill or injured patient. I recommend that my readers who are providers, or even just interested, read the entire article.

There’s going to be more of this sort of thing in the next few years. Even though I’m not actively providing care in the field, I work with and teach those who do. Which is why I stay current on the state of the science in EMS. Or as current as I can because the science it evolving rapidly.

Science doesn’t stand still, it is rarely “settled”. More and more it seems that improving patient care requires us to discard outdated knowledge and skills that have no been proven to be useless or worse harmful.

Sadly too many people in EMS are all too happy to stay mired in what worked well in years gone by and have no interest in advancing their knowledge.

Like the dinosaurs of pre history, paramedics who can’t adapt and evolve are doomed to become extinct.