Dumb Questions

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Way, way, back when I was in EMT school, there was always that one guy. The one guy who asked questions that were dumb, but actually needed some sort of answer. For some reason, the question always seemed to revolve around CPR. On one occasion the question was “If a person is trapped in a car and in cardiac arrest, how do we do CPR until the fire department can get them out?” My instructor would patiently explain that you couldn’t, at least not effectively. Further the instructor would explain that a person trapped in a car and in cardiac arrest was pretty much dead. Now this was back in the days when ACLS, such as it was, made no clear distinction between traumatic and medical cardiac arrests. So, the uncertainty of the student was somewhat understandable. What was really annoying though was the persistence of the questioner. The “Yeah, but…?” could have dragged on for hours if the instructor had not stopped it.

In a similar vein the other day I received an email from a friend of mine who has been an EMT instructor for a number of years. She asked my opinion about a question one of her students had asked in class recently. Well, she wasn’t looking for an opinion as much as a technically correct answer. What she GOT was an opinion. She got some possibly technically correct answers from some other friends of ours.

The question was this. “If I’m treating a trauma patient, is is okay to use blood coming from a wound to check his blood glucose level?”

Blink. (As Lawdog would write)

What. The. Actual. Fuck?, as I would say, not being the scribe that Lawdog is. Who, BTW has a book available on Kindle at Amazon. Buy it, read it, laugh. A lot.

Back to our topic.

Here is my actual answer to my friend,

If someone is bleeding, the last fucking priority is getting a fucking blood glucose level. 
This insane obsession with getting a BGL on every patient is stupid. In fact, I'd say that unless the patient has altered mental status
there is no reason to waste time doing one. It is not some magic indicator of anything. 

EMS instructors of all levels do their students a great disservice teaching them how to do a skill, but not when. 
The same goes for O2 Sats, as well as the indiscriminate use of inhaled Beta agonists. 

Just another reason why EMS is not considered a profession and never will be.

Seriously, why don’t people understand that in trauma, airway, bleeding control, and transport are the priorities, not looking for zebras that don’t exist. I don’t recall ever being asked for a blood glucose level in a trauma patient I transported. I don’t ever remember hearing from anyone that I should have done a blood glucose level on the shooting victim I brought in who needed surgery to save his life.

It seems that we give EMTs (and some paramedics) equipment and teach them how to use it, but not when to use it. Let’s say our BLS provider does a blood glucose on a person who was just run over by a vehicle. The blood glucose level comes back at 68 mg/dl. The protocol says that if the blood glucose level is less than 70 mg/dl it should be treated. Should our EMT stop applying a tourniquet to open a tube of glucose paste? Should he (or she) call for an ALS unit if one is not already dispatched? What if the patient has stopped breathing? Which is the priority?

I can drill a student all day long on anatomy and physiology, the physiology of trauma, the importance of maintaining an airway, and everything else in EMS. What I can’t do is teach them how to apply all of that. Yes, I know it’s the affective domain of learning, but I call it common sense.

Years ago, I worked part time for a hospital based intercept system. We didn’t have an ambulance, so we depended on those of the towns to which we responded. One of those services had a number of paramedics, however had been unable to obtain the needed authorization to run as an ALS service. One day we responded to a call for a cardiac arrest. On arrival, we found the Paramedic working at the Intermediate level busy trying to intubate the patient. Her partner was busy doing chest compressions. No one had even touched their AED. I asked the Paramedic why she hadn’t used the AED. Her answer was “Airway, airway, airway” in a tone of voice that indicated that I should know better.

I applied our monitor, saw that the patient was in a shockable rhythm, and, uh, shocked the patient. To no avail because all that happened was that the patient went into Asystole and later expired.

A complaint was lodged. Against me by the paramedic. I was “rude” and “interfered” with her attempt to intubate the patient. When I discussed it with my very understanding service director he told me that knew I was right, would do nothing about her complaint, but that he knew if he complained about the paramedic, nothing would happen.

This woman had memorized a trite phrase about airway control, but had not the common sense to understand that defibrillation was the important first step for cardiac arrest patients.

How do you teach that? How do you teach an EMT that worrying about a blood glucose when a patient is bleeding to death in front of you is not the proper approach?

Is there a magic methodology that I’m just not seeing here?

I don’t consider myself a good classroom lecturer, especially given the material that is in the Power Point presentations that accompany may BLS text books. I do consider myself a good practical instructor. I can sit and discuss things like why we shouldn’t be pigeon holed into only looking at things that the text books cover. I think my experience is pretty helpful in teaching how EMS is practiced in the field. Yet, I still can’t teach the thought process (if there is a process) that allows an EMT or paramedic to recognize a sick patient and then treat that person appropriately. Why can many good paramedics and EMTs walk into a room and know what is wrong with them just by looking at the patient? Can that be taught?

More importantly, can that be taught in the classroom since most EMT programs have no field observation or experience requirement? Even most paramedic field internships seem to be skill, not assessment focused.

I don’t know of any other field where a person can take a minimal hour class, pass a written and “psychomotor skills” exam which is mostly static, get a card that says they are certified, and go out and practice.

Maybe that’s what is really holding back EMS, and not some sort of college degree requirement.

 

2 COMMENTS

  1. Agreed. As an EMT, BLS, ACLS, PALS instructor. It amazes me how little some students actually ‘learn’ and then go out and know it all.
    We strive to teach them ‘enough’ to pass the written and skills tests in the time we are allotted. So we can move onto the next class.
    The more students the more dollars, right?
    As you stated we cannot ‘teach’ students how to recognize a seriously ill or injured patient. We teach them what to look for, called signs and symptoms or some such thing, using our many mnemonics, acronyms etc.

    Then send them out and hope the figure it out.

    • Don’t even start me on mnemonics! When I’m teaching documentation classes, I make it a point to tell the students (who are already out in the field) not to use “DCAP-BTLS_, because other than in EMS, it’s not used at all. Very few in the ED, and probably no one else anywhere in the hospital is going to know what they are talking about.

      It’s like when we used to do scenarios. Every student would parrot “BSI. Is the scene safe?” I’d throw in a “No, the scene isn’t safe, there is a guy shooting at your patient.” Most of the time, they’d just continue walking towards the patient, so I’d just stop the scenario and tell them that they were dead.”

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