What If You Do? What If You Don’t?

OK, I will admit it; as a medic I struggled with being a creature of habit. Like many EMS providers, I established a comfort zone that I liked to work in. I knew what gear I wanted to take in to calls, and what I wanted to leave in the rig. I had a favorite laryngoscope blade that I used on probably 95% of my tubes. The list of habits goes on.

That raises the question: Are there risks in becoming too habitual? I think that the answer is a resounding yes when it comes to clinical decision-making. The simple fact remains that every call, to some degree, is unique to itself. Though one can make a strong argument that a standard approach to certain problems has benefits, i.e., consistency of practice, one of the problems this creates is the bell curve of medicine. Those patients lucky enough to be inside the curve get treated well, while those to the left or the right of the curve are, unfortunately, not treated as well.

Another issue that comes into play is that of risk/benefit assessment. Without question there are risks that come with certain interventions, and while we may “know” these risks do we actually put them into a dynamic thought process? I believe that there are significant patient care benefits to be had by asking yourself two questions: What happens if I make this choice? What happens if I don’t make this choice? Let’s look at how this might work out in the real world of EMSland. For example, let’s examine IV therapy:

First question: Is this a “want” or a “need” IV?

If it’s just a “want” IV you may give it one try, and if unsuccessful, just shrug your shoulders and move forward with patient care. On the other hand, if it’s a “need” IV, and you have medications that need to be given IV push, you may try two or three times–or even more.

Second question: What’s the risk of starting this IV in the field setting?

Over the years, a number of studies have shown that a properly started field IV has no higher rate of complications that one started in-house. That being said, the fact remains that when you start an IV, there is always a chance that the hole you created while inserting the catheter may well be the one wherein some pathogen enters your patient. Again, as you look at patient care outcomes specifically in regard to trauma patients, if they survive the first couple of days and then succumb what commonly takes them out of the gene pool? Along with ARDS or MODS, the third part of that fatal trifecta is infection. Even though it may be a million to one occurrence that the pathogen sneaked in that little hole, if your patient happens to be the “one,” that’s all it takes to make a million to one event what it is.

Third question: Should I stay on scene to start the IV?

For the sake of discussion, let’s say that you have a seriously injured patient and you have a Level II trauma center 10 minutes away. Though I have never seen literature that indicates that an IV in and of itself is a lifesaving intervention, common sense dictates that the cardiovascular system needs to remain uncompromised, and we all understand the outcome when you run out of fluid. As such, you opt to stay on scene, but because of the patient’s condition it takes you two sticks to get the job done. By the time you get the line started and secured, five minutes have ticked away as a result of the choice you made. Yet you still remain 10 minutes away from definitive care—surgery to stop the leaks permanently and blood replacement to refill the container.

In this case the choice to sit and stick increased the time to get the patient to a real solution to their problems by 50%. In the case of survivability, you may have just wasted the time that might easily separate a survivor from a fatality.
The example used above represents just a few of the many choices that you make everyday on behalf of your patients. Should I institute full spinal motion restriction or opt for rapid extrication? Should I treat the shortness of breath problem now or wait until I get the patient in the rig? Should I chemically convert that atrial fibrillation, or should I move on to the Edison medicine and electrically solve the problem? Should I attempt to assist the patient’s respirations or should I paralyze them, secure their airway with an ET tube and take over ventilations for them?

In order to optimize your patient care decisions, I believe in taking the time to think through your plan and carefully evaluate both the upside to performing a given intervention, as well as the downside. If you only look at one side of the equation, you have put all your eggs in one basket. And as shown in the example above, that can clearly impact patient care. Avoid that situation by asking and answering those two simple questions: What if I do? What if I don’t?

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 the EMS World editorial advisory board.