At a recent EMS World Expo, a leading U.S. anesthetist and former paramedic was giving a lecture on the latest findings of several unrelated studies questioning the value of endotracheal intubation in the field. As we all well know, this hallowed skill of the paramedic has suffered in light of these studies showing worse outcomes. “Tomorrow morning,” he announced to the group, “I will wake up to an inbox of hate mail, and, quite possibly, another death threat.” No one seemed surprised. Indeed, I sensed from the packed house of muscle-bound paramedics that some in the audience may even be considering getting the guy’s e-mail address.
While the consensus in the EMS community on the subject of intubation right now is that the matter “requires further study,” recent findings have resulted in a highly emotional, almost hysterical response. Why this is the case can, in my view, be linked to a wider identity crisis faced by ambulance workers in high-income nations.
Until the mid-1970s, the skilled act of passing a tube through the vocal chords and into the trachea of an unconscious patient was the strict domain of experienced doctors. The birth of Anglo-American paramedic systems around this time was largely focused on gifting this procedure to ambulance personnel who were, until then, limited to very basic airway management and a bit of first aid. The development was greeted with hostility by plenty of doctors, and utter disdain from nurses. The job of “ambulance driver” had suddenly taken an unimaginable leap. And the new-found status symbol of this leap seemed to be endotracheal intubation.
The late-1970s and early- to mid-1980s represented a time of unprecedented skill acquisition for paramedics now focused on the idea of treating and stabilizing a patient at the scene before transport. Life depended on a little “stay and play” over simply “load and go.” This thinking has since been well-and-truly debunked. For most critical patients, with the exception of those in non-traumatic cardiac arrest who must be managed at the scene, immediate rapid transport with treatment en route is protocol. Back to the old ways, then. More than one study in recent years has revealed better patient outcomes in trauma cases when patients are taken to hospital in their own cars without delay. Only last year, retrospective analysis of data in the Pennsylvania Trauma Outcome Study found 90.4% of individuals taken to accredited trauma centers by EMS ambulance were twice as likely to die than 9.6% brought in by private vehicle. This was despite the fact that prehospital time for persons transported by EMS was substantially shorter than for those taken by private vehicle (66.2 vs. 245.5 minutes).
But what about the life-saving procedures and pharmacology paramedics can bring to the patient? Given you can reach the sick or injured in better time than they can reach the hospital in the back of their pickup, isn’t this a valid argument supporting advanced paramedic systems? The answer to this would be a resounding yes were it not for the increasing number of EMS procedures and medications found to be detrimental, or at least of lesser benefit than originally supposed. Be it rapid fluid replacement in traumatic exsanguination, atropine and adrenalin in cardiac arrest, high-flow oxygen for AMI or cervical collars and backboards, many of the medications and entrenched procedures we’ve been using for years are now discouraged in the face of new research or lack of any research at all.
No wonder many in EMS have been quietly wondering about the future of the profession. Regardless of the clinical knowledge we possess, the further our emergency interventions are reduced, the closer we come to resembling the humble ambulance drivers of yore. This is despite most of us practicing paramedics having anecdotal evidence of our benefit in critical cases. Successful life-saving may be less common than people assume, but we’ve all experienced instances where we can say with reasonable certainty that if not for our timely actions the patient would have died. Sadly, anecdotal evidence doesn’t count for much these days until backed up by empirical support from quantitative research.
A personal identity crisis is usually provoked when an individual’s current life does not meet the expectation they have about it. The EMS identity crisis is no different. At its heart is that widespread public perception that our core business is the saving of lives. Unsurprisingly, most of us became EMTs and paramedics with that same belief. These days, young recruits and graduates of prehospital university courses enter the profession by the hundreds, thirsting for such heroic resurrections. But in reality it is rare we can claim with absolute confidence that our interventions delivered the patient from death. Even in busy systems, on-road medics are lucky to get two or three cases like this a month. Indeed, for most of us, our core business is not the saving of lives at all. Herein, I argue, lies the answer to our disillusionment. Our value is not, as many believe, dependent on the “saves,” but on the rest.
Our value should be measured by the reassurance we provide people at critical moments when unexpected events threaten their lives. It should be measured by the slowness and gentleness with which we interact with the elderly. It should be measured by the empathy and hope we give a person when their mental health gives way. Our value is in our expert splinting of fractures, in the careful lifting and carrying of the injured, and administration of pain relief. Our value comes with other medication, too, drugs for opening airways or waking a diabetic with glucose. It comes from our courtesy, our problem-solving skills, our sense of humor. Above all, our very existence is a blanket of comfort for a population that knows if something ever goes wrong with their loved ones, we’re just a phone call away, ready to calmly manage an emergency.
An identity crisis is often a response to change that occurs without our choosing, a change that can make us feel insecure and lost. But embracing change is the key to avoiding identity crisis. In no area of healthcare is clinical practice static. While some of our long-cherished skills and medications may disappear, others will appear in their place. What is unlikely to ever change is the demand for what we do. And what we do is far more than a handful of obsolete skills and procedures. You never know—something as simple as making a patient laugh could be just the thing that saves their life.
Published on 28/8/14 as guest editorial in EMS WORLD MAGAZINE