Things we teach in EMS that are wrong

[BEorP]

I am curious to know about things that you were taught or that you know are still being taught that you now know to be wrong. I am not so much thinking of things like the benefits of spinal immobilization or other things that we do in the field, but more the medicine or physiology.

I remember being taught at one point that concussions involved a loss of consciousness but then had no long lasting effects. Certainly it isn't something that matters to our prehospital management of a traumatic injury, but I now know that there is often not a loss of consciousness and that there can be significant long lasting effects from concussions.

One that I am a bit embarrassed to have just sorted out recently is about oral hypoglycemics causing hypoglycemia. I remember having always been warned about the risk of recurrent hypoglycemia with patients who are taking oral medications for diabetes. Only recently did I learn that metformin is not known to cause hypoglycemia (though others certainly can).

Something that I unfortunately see being taught wrong, or maybe just not entirely correctly, is how CPAP is beneficial for COPD. If you are going to be in a position to treat a patient with CPAP for a COPD exacerbation, I expect a whole lot better than "it splints the airways open" when asked to describe the mechanism. Unfortunately, this is all that is taught sometimes because the instructors do not seem to know any better.

I'd love to hear what you now realize you were taught wrong or what you see being taught wrong to our future field providers.

[HellsBells]

The think the issue with concussions is not so much a lack of education, as a lack of general knowledge in the medical community. The impact (haha) of concussions, particularly repeated injury in sports, is just an emerging science at the moment.

[Bieber]

-Oxygen is beneficial to uncomplicated MI's.

-Diuretics should be given to acute CHF exacerbations (without labs to confirm a true fluid overload state, as oppose to incorrect fluid distribution).

-Pain management for abdominal pain is bad. Same for multi-systems trauma.

-Code blues should be transported.

-Narcan should be given to unconscious patients regardless of respiratory status.

-Some patients are too critical for pain management.

-Every patient should get a little bit of oxygen.

-Spinal immobilization is beneficial to patients with spinal fractures.

-Some medications and procedures "need" to be by physician order only.

-Intubation and PPV is beneficial to non-hypoxic code blues.

-The time saved by emergency traffic is clinically beneficial.

-Morphine is beneficial to CHF.

I'm sure there's more, but there's a little bit. And I'm not just talking about the procedures or treatments themselves, but the misunderstanding of the pathophysiology behind them that we were taught (or lack thereof).

Edited June 9, 2012 by Bieber

[BillKaneEMT]

Well crap. I know some of the things I was taught are incorrect and I just learned a new one. I just found http://acutecaretest...tion_beneficial when I googled part of your post Bieber. Naturally I'm surprised but I'm even more surprised they haven't done more extensive studies on this!

A systematic review of the literature revealed only two randomized clinical trials of oxygen therapy in myocardial infarction, involving a combined total of just 207 MI patients.

Ideally they should conduct a much larger study on this and if the numbers continue as it seems they will they need to change our protocols. I am a little hazy as to how the study would work though. Anyone ever taken part in this type of thing? I have the uneasy feeling that the family of any patient who dies during this sort of test will be suing like there's no tomorrow whether the patient got O2 or compressed air. If anyone has done this sort of study before, is it done by the hospital or EMS service on all their patients or do patients have to volunteer?

long edit:

Honestly it just seems as though learning something like that in a study would be widely publicized and maybe mentioned, at least once, in class. For our practical testing they demanded it go "Gloves on, scene safe?, Did anyone see what happened, Is that/Are you my only patient?, Partner, hold c-spine, Oxygen on." Then the call in, description, head to toe for trauma or call in, description, SAMPLE and so on for medical. Admittedly we were told things would be different when we started working (ain't that the truth) but in class they were adamant about giving high flow O2 to everyone except COPD patients for crying out loud.

I don't break out the nrb mask unless someone seems to legitimately need it but for the first week or so on the job I was pretty nervous about it. We got a new guy in last week, just got his cert, and he's got that edgy look in his eye that I recognize from the mirror when I started. We chatted the other day about how different things are compared to the classroom and it seemed to ease his mind somewhat. I dunno, I just feel that the class does a great job getting you ready to test and a "meh" job getting you prepared for the field. Even as it is I read something on here once a week or so that is contrary to what they teach us and, often, our protocols. Then of course I read up on it and it always seems to be correct. They should print this site's URL on the back of our certs. Well, time for me to get some sleep. Working an ALS shift tomorrow morning (yay!) which means I get to help one of our guys study for his nremt-p. Which is helpful for me too. Nighters all.

Edited June 9, 2012 by BillKaneEMT

[ERDoc]

Classes/text books generally lag 5-7 years behind the current literature. In EMS, where there is no emphasis on keeping up to date on the literature is generally 10 years behind the curve, but hey, that's the way we've always done it, so why change now?

[Kiwiology]

I was not formally taught any of the above. When I did the Paramedic (ICO) modules it was suggested that frusemide in CHF may have a benefit as may morphine in pulmonary edema but both should be used with caution because of possible negative effects, both have now been withdrawn (as of 2011)

I do not think things that are "wrong" are taught (although having seen the above .. I dno) but that certainly not enough is being taught.

[DwayneEMTP]

That patient advocacy is gospel, unless it will get you jammed up, and then you should cover your ass instead.

That no one ever dies in my ambulance.

That a PCR should be succinct to the extreme to disallow a lot of stuff to be used against me in court five or ten years from now.

That I should never, ever lie to a patient.

That ammonia vials are a good way to check responsiveness.

That I should ALWAYS follow my protocols, (In reference to confounding comorbidities)

That there are 'normal' vital signs across patient populations and pathologies.

That I should avoid O2 in COPDers or they'll stop breathing.

That I should never reduce a compound fracture (Not sure what the correct term for this is now) as the contaminated bone ends will cause massive infection.

That an alert and oriented 'recovered' hypoglycemic is competent to refuse transport after a tuna sandwich but without a significant support system at home.

That a good medic can spot drug seekers and should deny them narcotics so as not to bury the system in the losers that he's encouraged.

That hypertension is bad, always, and should be managed if symptoms are present. (This one is near and dear to my heart as I once treated a dizzy, hypertensive patient, neg Cin stroke scale, very proud of my progressive interventions to be told by the ER doc afterwards that she was a compensating stroke. No harm done I was told.)

That chest pain resolved by nitro is verification of a cardiac etiology.

That nitro has a nasty habit of critically dumping people's blood pressure.

That equal and reactive, or unequal and sluggish pupils give me way more information than they actually do.

[Kiwiology]

That I should never reduce a compound fracture (Not sure what the correct term for this is now) as the contaminated bone ends will cause massive infection.

You were right mate, it is a compound fracture

Sorry tho, we are all out of Wiley Gutrot the moonshine brewin' hillbilly's authentic homebrew grain alcohol so you'll have to have a gold star instead, I really am sorry I knew you would have rather had some of ole Wiley's finest

I will bring some to our BBQ, which was are having at AK's house to avoid damaging our friendship by me befouling your carpet

[systemet]

A few others that come to mind:

* The heuristic that a radial pulse = SBP >90, brachial > 80, femoral > 70, carotid > 60, etc.

* That antiarrhythmics are beneficial in cardiac arrest

* That high dose, escalating dose, huge amounts of epinephrine in a bag, or the regular 1mg epinephrine q 5 min, actually helps my cardiac arrest patients.

* That the point of a code is to ram as many drugs with confusing infusion rates into the patient as rapidly as possible.

* That it's ok to just walk in, ram in the laryngoscope, get the tube quickly, then start CPR

* That CPR isn't important

* High volume fluid resuscitation, e.g. 20 ml/kg repeated a couple of times, is good in hypotensive trauma.

* That thiamine is useful.

* All trauma GCS <= 8 intubate

* That every intubation should be with paralytics

* But, also that paralytics should be avoided at all costs unless there's trismus

* Pacing asystole

* Atropine, bretylium, procainamide, in cardiac arrest

* That a 12-lead can rule out AMI

* That 12-leads are pointless prehospitally

* That EMS will never give thrombolysis

* That capnography is useless

* Sadly, that EMS can't affect acid-base status with overaggressive ventilation in a short transport

* That helicopters are necessarily superior to ground or fixed wing

* That paramedic self-governance is a panacea to everything that's wrong in EMS

* That people in pain are tachycardic

* That paramedics should try and distinguish fakers from patients in real pain, based on socioeconomic factors.

* That you can say something nice and poetic to the family to make them suddenly feel better.

* That EMS is always acute / emergent care.

* That nurses are stupid.

* That paramedics are like physicians.

[Kiwiology]

* That every intubation should be with paralytics

Unless the patient is in cardiac arrest, it should!

Edited June 9, 2012 by Kiwiology