Everything you Know about EMS is WRONG, WRONG, WRONG


That’s maybe a slight exaggeration. Not everything we know in EMS is wrong, just a lot of it.

I was having a very pleasant email exchange with some friends from around the country. All of us are, or were, engaged in EMS at some level and for varying lengths of time.

These are people who are not only close friends, they are people whose opinions I respect in most things, including EMS. I don’t always agree with them, nor they with me. Still, if they say something, especially if it’s something I disagree with, I check me facts carefully.

The topic du jour the other day was mythology in EMS. These are things that many of us learned when we were new EMTs, even before we were paramedics. In a couple of cases, even before there WERE paramedics. As I said, my friends have been around the block a time or two.

We compiled a nice list which they agreed to let me turn in to a blog post.

If nothing else, I hope to start people thinking about their EMS assumptions and maybe even generate some comments and debate.

It certainly started a lively debate among our cohort. Some we agree with, some we disagreed with. Most of these have no, absolutely no, science behind them. Still they are things that and probably are, taught to new EMTs and paramedics in case and out in the field.

Here’s the list,

If you transport your pre-eclamptic patient with lights and sirens, she will have a seizure and die!

Closely akin to this is that if you use the siren when transporting a MI patient, the sudden sound will put them into VF.

If your patient has a neck laceration, even a small one, you must use an occlusive dressing or he’ll get an air embolism that will kill him!

Rib fractures and flail chests must be splinted with IV bags or something to keep the ribs from moving. Every time the patient takes a breath those rib ends will rip through lung tissue. Bind them up!

Epinephrine is a good drug to use in cardiac arrest.

Note that the science on this is less than clear. It might actually help very early on in the process. Other than that, probably not.

The more drugs we throw at cardiac arrest patients, the better the outcomes will be.

As above.

A Medical dispatch can determine which calls are most important and triage them.

I’d be happy if they could get the address right and figure out if there is danger to the responding crews.

If we arrive in 8 minutes and 59 seconds, the patient will live.

This is a myth that is based on response times to fires, not medical calls. For some reason it became a “national standard” even though the truth is that most calls could be responded to in hours and¬† it would make no difference. The problem being as above, that we don’t know which are which.

IVs save the lives of trauma patients.

Placing the IV (if you can do it in a moving ambulance) is probably beneficial, but running in lots of fluids is harmful.

Atropine and atrovent will cause anaphylaxis in people with peanut allergies. Morphine will cause anaphylaxis in people allergic to sulfonamides.¬†Systolic BP can be predicted by radial, femoral, and carotid pulses. Here’s a study (small though) that debunks that. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27481/ Transporting a patient against his will constitutes either kidnapping or false imprisonment.

EMTs don’t diagnose (Shudder the VERY THOUGHT)

Helicopter EMS is the ultimate mode of transport (and I might add SAVES LIVES! [Is it the diesel fumes or the vibrations? More work needs to be done.]

Helicopter EMS has it’s place, especially if you are in a remote area, but it’s over used in surburban or urban areas.

We must stop even if we are not on duty, and especially if we have any sort of EMS or medical sticker on our vehicle

Pulse oximetry is the 4th vital sign (I though temperature was)

Tourniquets are a last resort and will cause loss of the limb if applied.

This is finally dying what will hopefully be for the last time. It seems to be cyclic.

If you are close to a hospital, doing a 12-lead is a waste of time.

NTG is contraindicated for all patients with suspected right ventricular infarcts.

All wide complex tachycardias are Ventricular Tachycardia.

I think the real number is about 65%, but the point is valid. Don’t assume anything when it comes to cardiology.

Glasgow Coma Score is a useful tool for EMS and ED providers.

Even the people who developed it have stopped using it. Which doesn’t keep us from using it. Sigh.

Traction splints help to limit bleeding in femur fractures.

Mechanism of injury is a reliable indicator of the extent of injury.

Trendelenburg is beneficial to patients in shock.

Every ambulance should be staffed with at least one paramedic.

Suction for no more than 15 seconds.

What if there is 25 seconds worth of vomit in the airway? Bag the patient and give them aspiration!

Closely related, You must intubate within 30 seconds or the patient becomes hypoxic.

That might have been a useful guideline before we had pulse oximetry or ETCO2. Maybe.

Well, that’s my list. At least for now.

Have at it.


    • LOL! That came up in the discussion, but only in passing because all of us were in total agreement on the stupidity of back boarding the way it was done until very recently. Finally doctors are starting to actually look at the data and change the protocols.

  1. You already know how I feel about EMS Dispatch in general, and EMD in particular. In my agency, we take people who are field qualified (theoretically, anyway), put them in the comm center (where they don’t want to be), and then tell them they aren’t allowed to use their field experience, but must use an EMD system that was designed for people with no medical knowledge.

    Conversely, the various EMD systems are nothing more than a CYA mechanism. The more “popular” one is held up as a “standard”, but only because it was the first one (and it’s creator claimed it to be the standard). It’s way more complicated than it needs to be and the terminology is unnecessary. The system my agency uses was created by a standards-setting organization (APCO) and allows customization to an agency’s needs (the “standard” system doesn’t).

    Ultimately, however, an EMD system is useless, if there’s no QA/QI process regarding event location verification to begin with.

  2. It is probably closer to 80% of all WCT’s are VT, but the prevalence changes based on age and medical history. Prior MI? ICD? Older than 60? Jack that number up. Usually the problem is the reverse, where paramedics believe 65%+ of all WCT’s are *not* VT. I’ve never understood the fetish with giving Ca-channel blockers to WCT’s…but some paramedics seem to believe that letting just one supraventricular rhythm skirt by is like giving morphine to a “drug seeker” (a never event, right?).

    In your undifferentiated regular WCT, the vast majority will be VT, the next largest chunk (15-20%) will be AVNRT with aberrancy, and a small minority will be antidromic AVRT, atrial flutter, and a smattering of even more exotic variants (AT with aberrancy, JT with aberrancy, bundle-branch reentrant tachycardia, etc).

    • Way back, the number given to us during a class was 65% of WCT is Ventricular. The exact percentage probably matters far less than NOT given a Calcium Channel blocker to it. I’d probably opt for Amiodarone before any other drug, but that’s just me. I’d much rather let a SVT slip by than risk killing the patient.

      Thanks for the comments.

  3. I’m a pretty green responder, so I’d love to know- what’s up with the GCS not being valuable? It’s asked for in all my patient care reports and I was taught it was useful for a few really important things in the field, including making the decision of whether to hyperventilate a patient with a TBI, and also just giving the physicians a map of a brain-injured patient’s progress from the time of the event.

    • In short, it’s not always consistent between people performing it and it has little or no prognositic value. AVPU is probably more reliable.
      A few points to keep in mind.
      1) Half of what we learn in EMT or paramedic school is wrong. The hard part is figuring out which half.
      2) Much of what we do has no scientific basis.
      3) Bad teaching persists because text books are about five years behind the state of the art.

      Question everything that you’ve been taught.

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