Sunday, March 17, 2013

How to change things.

People who have read my previous blogs know that I am an advocate of EMS changing. I am a firm believer in EMS personnel becoming the true first line providers they should be. But good reader, I have met the enemy and he is us. We all know that competent medic that looks at new research and blows it off. He is the guy that has a great IV ratio but looked at 12 leads as unnecessary.  He is the guy that says that sounds nice but it will never happen. When it does happen he is shocked. Well that guy is part of the problem

Another problem is the medic that refuses to know anything more than the protocols. He has no desire to understand the pathology of the illnesses he treats. He looks at new advances as a pain because he has to change his routine. This is the guy that probably judges his skills as a medic based on scene time and being able to immobilize a patient so they can’t move.

So how do we change these people? One, engage them in conversation. When doing this, point out things that were commonly held truths in EMS that have been disproven. These guys are like you in that they want to help people. Point out that Performing 12 as well as 15 lead EKG’s and early activation of cath labs do not just save lives, they improve them. Ask them if they remember things like the Oral Screw, rotating tourniquets, and wide open IV’s. These people are your friends, colleagues, and mentors. Treat them as such.

To those of us in states that require EMS services to work with a resource hospital, learn to communicate with your Medical Director. These people probably have to deal with multiple services and can’t tailor their protocols to your service. Some services will actively oppose any change because it will cost the more than they are willing to spend. Your service might have medics that are so opposed to change that these Medical Directors are not willing to allow you more leeway. Look at it like this, if you can’t get all of your medics to perform a 12 lead, how can you expect to argue effectively for high dose nitroglycerine for CHF.

I am speaking from experience. I work as a supervisor for a service that is encountering many of these problems. When working to improve things and move from traditional paradigms to evidence based models people have to accept they can be wrong. This means me as well. I remember when Vasopressin and the new drug that is going to save everybody. It was the new thing, and I couldn’t wait to give it. I never did. Turns out that Vasopressin is no better than Epi and was packaged in a manner that discouraged its use. It turns out that there is no evidence that any antiarrhythmic drug has a positive effect on patients having a neurologically intact return of spontaneous circulation. Early BLS does though, and we should take that into consideration.

Now what I would like to see is a randomized trial of patients being intubated and ETCO2 capnography in place to see the effects on patient outcome. I know that in local experience it has improved the quality of CPR, but that is anecdotal evidence. We need several randomized studies in urban and rural locations. The studies need to be replicated for the new mechanical CPR devices as well. These things show promise, but we need to find out early if these things are good medicine or as another blogger calls it quackery.
I value your feedback,
Lone Medic