But We’ve Always Done It . . .

Over the years we all come upon our own method of doing things. Whether it be our particular order of Primary survey to methods of writing a report. We’ve developed these based on what we feel is the best for our patients. So embroiled are we in our habits that we pass them on to new medical care candidates.  But some of these practices are not based upon science and have no real benefit to our patients.

As more of us teach, more opinions are passed onto the next generation. We are a field based upon research and science and therefore should return to what is proven when educating.

I had explained to a class once that as I teach I can only teach certain ways of doing things, similar to when we learned the alphabet. We learned that the order was ABC . . . and that B always comes before C. But after understanding this alphabet someone can rearrange the order to create something beautiful like “I have a dream!” While there are many alphabets out there, we cannot add letters on a whim and expect that others must use these letters in the future.

Let’s cover some misconceptions.

Long boarding based solely on the mechanism of action. Many years ago, we would immobilize people based upon sound clinical judgement that included assessment AND MOI. Later we started to think that the next generations were not smart enough to use judgement and taught that we should immobilize patients regardless of their presentation.  I have written an article a few months ago To Board or Not to Board regarding LSB’s and the fact that there has never been a study to show their efficacy.

Oxygen is needed by everyone. We teach that a little oxygen is good, a lot is better. It’s suggested that apply oxygen again based on the Nature of Illness, not sound clinical judgement. We have tools that allow us to determine just how well the patient is breathing. Pulse Oxymetry and End Tital CO2 can help us determine if the patient’s respiratory rate is sufficient and that there is perfusion happening at the cells. The patient has similar tools within the body and will increase or decrease ventilations to ensure proper cellular respiration. If the patient is maintaining an alert LOC and not guppy breathing, they likely don’t need oxygen. When they do, 2-4 liters is generally sufficient.

In cardiac arrest, it’s the drugs that save people. The truth is that all of the advanced care that we provide is simply there to support or benefit GREAT basic life support. Great compressions will circulate the blood and benefit the patient more than the drugs. Don’t get me wrong, the drugs are beneficial, but should not replace great mechanical skills.

An arrested patient needs oxygen to the cells, ventilate more. We have plenty of oxygen bound to our hemoglobin, we simply need to circulate it to cells that need it. Over bagging simply increases intrathoracic pressure, reducing blood flow (in an already compromised system).

Stopping compressions to breathe. Many of us have been to a campground with a water pump. During the first few pumps, nothing happens as we need to prime the pump. When we stop, we need to start over by priming. The heart works the same way, studies show it takes approximately 10 compressions to prime the pump. If we stop to breathe, we have to re-prime the heart, losing a full 1/3 of our compressions. Until we can secure the airway, compressions only will benefit the patient more(see above). We should try for an advanced airway soon so that we can continue to provide compressions without interruption.

A trained medic can replace a doctor. Many times we have family members or neighbors that ask our opinion on medical care or the need for more. They assume that we provide definitive care. A good medic realizes that the best outcome from every situation involves us bringing our patient to the doctor. We cannot diagnose over the telephone and do not have the tools (or sometimes experience) to be able to make a good judgement. Point these people to their doctor.

We don’t need to know that. Many are so stuck on their scope of practice that they feel that anything outside what they learned in a book, or in our class years ago should be ignored. Sticking our head in the sand will not benefit our patients. We should ALWAYS be learning. Using the same alphabet demonstration from before, we should always be looking for new words to spell using the same alphabet.

Next week, I’d like to cover some more. We should be based on sound clinical experimentation and judgement, not because we’ve always done it that way. We can do better than simply rehashing misconceptions.

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