As a followup, I'd like to point out the last paragraph of the article;
Less is more when it comes to prehospital care, Dr. Davidson said. “A heavy foot
on the gas pedal and only a few interventions, such as defibrillation, are what
lead to better outcomes,” he said
Does a "heavy foot" on the gas pedal (which I interpret to mean rapid, emergent transport) really lead to better outcomes?
Maybe. The research in certain areas like hemmorhagic shock, STEMI, and ischemic CVA seems to indicate that time to definitive treatment (like surgery and lactate clearance, PCI, or tPA administration) is associated with improved patient outcomes. However, the flip side to that coin is that if you're going to die or be seriously injured in EMS, the odds are that you'll be in the patient compartment, unrestrained, driving with lights and sirens. How do we judiciously balance the risks to ourselves and our patients with the benefits to the patient?
Now, for the second part of that statement, do we have proof that only a few interventions lead to better outcomes?
The wording is tricky, and maybe I'm reading it wrong, but I disagree with that statement as it's printed. I agree with Dr. Davidson that only a few interventions have good evidence that they improve patient outcomes. However, I interpret his statement to mean that, conversely, all the other interventions we routinely perform don't improve patient outcomes. And the simple answer is that we just don't know.
This is dangerous; not only to our patients, but to the profession of EMS as we know it.
EMS has become entrenched in dogma; that may have been acceptable when the profession began, but it's not any longer. While we look forward at new treatments and therapies, we need to also look back at what we currently do; to validate that it does, in fact, make a difference or at least doesn't compromise other care.
But.
"No evidence" doesn't mean "no benefit". It just means "no evidence". It identifies an area that needs validation, not necessarily revision or deletion. To equate the two means a diminution of potentially significant therapies, procedures, and even entire scopes of practice. If we have no evidence that 90% of ALS treatments improve patient outcome, does that automatically mean that 90% of the ALS scope of practice should disappear?
I hope not. "No evidence" in many cases means that no research has been done. Let's change that! Whether or not we temporarily suspend a therapy until we can prove its' benefit or lack of harm is a decision left to others besides me (although I have my opinions), but we need to put a halt to the automatic association of "no evidence" with "bad" while we generate evidence. We need to be open to change, but also not change arbitrarily. It's a tough balancing act, because most of us naturally fear uncertainty, but it's the way it is. We have to be constantly asking "why?"; but more importantly, we need to also always be seeking the answer.
How can we call ourselves medical professionals if we don't?
I have these thoughts when it comes to reasons medical directors do a bad job:
ReplyDeleteMedical directors dont get paid enough to justify putting in the time. I can see this as a valid excuse, but not much more than that... If you are a physician and are being asked to provide a service for which you feel you are not getting paid enough,, quit. I dont mean that in a mean way. I dont volunteer my services as a paramedic and I wouldnt expect a physician to do it either. The public (and even some EMS people) seem to think that EMS should be provided for free. I dont understand that logic. People need to pay EMS providers (EMTs Paramedics, MDs) what they are worth. Thats never going to happen when you have people willing to work for next to nothing or for free.
Physicians generally do not understand the environments we operate in. Thats a cliche saying but its not completely irrelevant. Medications and healthcare concepts do not change just because they are outside the hospital Paramedics need to hold themselves to a higher standard and earn the respect of the physicians
I am fortunate to work at a service that our medical director worked as a paramedic while getting him MD. In some instances, he understands why we don't "stay and play", while our quality assurance officer questions why we didnt do proceedures on scene...
ReplyDeleteParamedics that have some seasons under their belt seem to have more of a load and go attitude and do en route.
Just shows that there will always be different levels of care and opinions.
I talked a little bit with John Karduck, MD of the National Association of EMS Educators about this topic at a recent workshop. His view was that the new establishment of an EMS specialty in the US would help abolish the taboo (in the US, at least) that doctors belong in hospitals. Also, more and more physicians with EMS backgrounds are entering the MD workforce. These are positive steps, in that there will hopefully be more medical directors with internal motivation to be a great EMS medical director. However, I still think that it's incumbent on the EMS service to pony up and provide some external motivation as well :)
ReplyDelete