Fast, Functional & First-Rate

     I first heard the phrase "hindsight is 20/20" many years ago. I'll admit it took a while, but eventually I grasped the meaning of the incredibly simple truth: that it is easy to have perfect vision when looking backward at a past event. What woulda-coulda-shoulda been done to alter an outcome is simple to identify. While frequently used with regard to sporting events, "hindsight is 20/20" certainly applies to many aspects of life, including our work in the realm of prehospital medicine.

     As I consider my last 35 years in EMS, I think about the particular common denominators among the many exceptional EMSers I've had the privilege to work with. This month in BTB, I'd like to look at the three elements of prehospital medicine that I believe separate the average from the excellent in our profession.

Fast
     For critical trauma patients, or those with evolving AMIs, time is of the essence. Our ability to provide patient care quickly and efficiently may well be the difference between life and death. Time wasted in the field cannot be recovered and only serves to further complicate the efforts of the ED staff to do their jobs.

     The master EMS provider has his skill set developed and refined to a pseudo-instinctive level. These are lessons taught by repetition, which, over time, develop into muscle memory and, in turn, allow our skills to simply "happen." Endotracheal intubation, starting an IV, splinting a dislocated shoulder, immobilizing a patient on a long spine board, etc., with time and practice become mentally effortless events. Make no mistake here: High-end performance takes an incredible commitment of time and energy to practice, polish and hone your skills. Equally important, keep in mind that it is not acceptable for EMS providers to be fast and sloppy. Saving time at the expense of quality medicine is a bad trade-off, to say the least.

     As an added plus of getting your skill set mastered, when you don't have to spend brain time thinking about how to perform a given skill, you can focus on continually assessing and communicating therapeutically with your patient.

Functional
     There isn't a patient on this planet who cares one iota about how much you know if you can't provide the care they need. In the end, all of our educational preparation and skill training must produce a clinician who can take care of people. In regard to true functionality, adapt, improvise and overcome becomes the mantra of the high-end EMS provider.

     I once watched the pilot bulb fall off an endotracheal tube after my partner had intubated a patient and was inflating the cuff. Rather than pull the tube and risk what is often a more difficult second intubation, he reached over and grabbed an 21-gauge needle out of the drug box, put it on the end of the syringe and inserted it into the tube where a moment ago the pilot bulb had been attached. He pushed 6 ccs of air, clamped off the tube with a hemostat and withdrew the needle. Problem solved; crisis averted. In another case, when the ankle hitch failed on a traction splint, the medic used a triangular bandage to perform the required function. These are just two examples where I've seen incredibly creative problem-solving, each in its own way representing state-of-the-art field medicine functionality.

First-rate
     The two most fundamental challenges of prehospital medicine have not changed since the first transport of injured soldiers under Napoleon's command in Chief Surgeon Dominique Jean Larrey's "flying ambulances."

     Back then, just as today, prehospital work was performed in dynamic, unstable and unpredictable environments with limited physical and technical resources. In spite of those formidable challenges, we are still expected to provide quality care. Not once during my career have I heard a patient say, "Oh, I see there are only two of you, and since we aren't in the controlled environment of the hospital setting, please feel free to provide substandard care."

     In spite of the challenges we face on a call-by-call basis, the bottom line is that our patients still expect and deserve top quality medicine. Because of those previously mentioned challenges, we have to work just a little bit harder to make certain that the quality of our medicine doesn't suffer.

Conclusion
     As Tom Peters so eloquently wrote in his landmark publication, In Search of Excellence, "Excellence comes from a voluntary commitment." Too often, life comes packaged as "low-bid," "bare minimum," "lowest passing score" or "acceptable." Those providers who choose to invest time and energy in the pursuit of excellence do so of their own volition.

     Fast, functional and first-rate represent for me the trifecta of prehospital medicine. They are the pinnacles of performance that we should all strive to achieve. Believe me, your patients will benefit in terms of reduced mortality and morbidity.

     Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.