Saved by the Basic EMT

“Paramedics save lives, EMTs save paramedics.”

We say it so often, it’s become a cliché in our profession. But phrases don’t get repeated often enough to become clichés without containing a kernel of truth. Actually, considering the current resuscitation literature, perhaps it is time for a new cliché—EMT’s save lives, paramedics just take the credit.

In the Ontario Prehospital Advanced Life Support (OPALS) study, to date the most extensive study ever conducted of the efficacy of prehospital ALS, researchers demonstrated that the addition of ALS interventions does not improve survival to hospital discharge when compared to the care provided by an AED-equipped EMT.¹ While the OPALS data did demonstrate reduction in morbidity in some of the patients treated with ALS—namely diabetics, respiratory emergencies and acute coronary syndromes—of all the interventions performed in cardiac arrest resuscitation, the only two proven to improve outcomes—early defibrillation and uninterrupted chest compressions—are BLS interventions.

Indeed, some studies seem to indicate endotracheal intubation, an intervention many paramedics identify as a defining part of their skill set, may even worsen outcomes,^2,3 particularly if we place a higher priority on it than uninterrupted chest compressions.⁴ However, a more recent study of 10,455 cases of adult out-of-hospital cardiac arrest patients compared outcomes between those who received successful supraglottic airway insertion or successful endotracheal intubation and found that an endotracheal intubation was associated with improved outcomes over supraglottic airway insertion. However, the authors also noted higher survival among patients not receiving any successful advanced airway placement efforts.⁵ It’s clear that uninterrupted chest compressions are of greater significance than intubation.

In recent years, CPAP has proven itself as one of the more effective tools in the prehospital arsenal. Most states consider it a BLS intervention, and perversely, its success at stabilizing CHF and pulmonary edema patients has resulted in even fewer opportunities for paramedics to perform endotracheal intubation.

Still, absence of evidence does not mean evidence of absence. There may yet be studies that demonstrate the value of the skills we perform as paramedics.⁶ Until that time comes, we must rely on the proven value of our BLS skills and, by extension, our EMT partners and colleagues. One experienced paramedic working in a tiered response system in New England describes himself as a “stand-back, big-picture, non-interventional paramedic” on EMS scenes, not because he is lazy, but because he recognizes most EMS calls need only the BLS interventions provided by the EMTs in his system, and of the few ALS interventions necessary, most can be performed en route to the emergency department. While paramedic school may provide you with the skills and knowledge to be a competent ALS provider, many programs fail at teaching effective leadership. While it would be nice if every newly minted paramedic were mentored by a seasoned paramedic partner, the reality is many are assigned an EMT partner and thrown to the wolves, barely competent to make their own decisions, much less direct the actions of another EMT. The remainder of this article will explore strategies to allow the new paramedic to make effective use of an EMT partner, including knowing how to recognize those times when the EMT might just save the paramedic.

Communication is Key

The hardest thing to work out with a new partner, and the one most crucial to a smoothly-run call, is scene choreography. The only way to make sure both members of the crew perform the right dance steps is through open communication, and the first step is to develop the habit of thinking out loud. Lay out your treatment plan on the way to the call. Brainstorm likely scenarios, and define what each of your roles will be. Plan what assessments and interventions you will do on the scene, and which you will do en route to the ED. Obviously, no plan survives first patient contact wholly intact, but at least you’ll have a starting point for care.

After the call, when it’s just you and your partner in the rig, critique it. Let your partners speak first, so that their impressions of the call will not be colored by their need for your approval. Ask them how they felt the call went, ask them what they felt they did well, and what they would improve. Then, offer your own observations. Most importantly, remember that the post-call critique is a learning tool, not an opportunity for you to vent your anger at your partner. Always remember—praise in public, criticize in private.

You’re Part of a Team

There is no Monro-Kellie doctrine for EMS crews. There is no finite knowledge base to be split between you and your partner. Just because you have a shiny new paramedic patch doesn’t mean the EMT-Basic on the truck suddenly became stupid overnight. Try to remember that they have more to contribute to patient care other than being a personal pack mule, and they might just save you from making a fool of yourself one day.

Also remember that the paramedic patch on your arm doesn’t buy you any respect. To your partners, even the EMTs, you’re still the same marginally competent goober you were last week. If you want respect, earn it, and the best way to do that is to practice the Golden Rule—treat your EMT partner as you’d want your paramedic partner to treat you.

The Vast Majority of the Job is BLS Care

Assessments, patient history and interventions—most of what you do on a scene is BLS. That makes the EMT’s role on a scene just as important as the paramedic’s. Divide the tasks on scene according to your own skill levels, and pay your partner the compliment of expecting him to do his job without you micromanaging every aspect of it.

Airway Management is a Team Sport

Airway management always begins with the least invasive BLS interventions. Often, BLS is as far as you need to go to effectively manage an airway, and many states also allow EMTs to insert highly effective supraglottic airways. If that is the case in your system, allow your partner to handle the BLS aspects of the airway management, reserving yourself for those interventions only a paramedic can perform.

Teach your partner to set up your laryngoscope with your preferred blade. Teach her how to set up and check an endotracheal tube or supraglottic airway prior to insertion. Teach all the methods for confirming tube placement and properly securing a tube. On those calls where you feel that even if you were an octopus you wouldn’t have enough arms, another trained set of hands can literally be a lifesaver.

Having a trained EMT partner apply the BURP maneuver can improve a laryngoscopic view by at least one grade,^7,8 and may make the difference between a successful intubation and a failed one.

Teach your partner the importance of adequate pre-oxygenation. A simple nasal cannula at 15 lpm applied by your partner in addition to BVM ventilation can buy you many more minutes to secure an airway without fear of the patient becoming hypoxic during the attempt.^9,10

Experience Doesn’t Have to Be Your Own to Be Valuable

One of the perceived benefits of running dual-paramedic ambulances is the ability for medics to bounce ideas off each other, to get another medic’s perspective on an unusual presentation or vague set of symptoms. Such input can be invaluable.

Keep in mind, however, that your partner doesn’t have to be a paramedic to provide that input. Your most common mistakes as a new paramedic will not be medical treatment errors, they will be failures of leadership and scene management. The tendency of the new paramedic to focus on ALS assessments and interventions at the expense of neglecting BLS can be mitigated by a strong EMT partner. The more you empower your partners by valuing their experience and seeking their input, the less likely you will be to make those mistakes.

And just perhaps, your EMT partner may indeed save you, the paramedic.

References

1. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. New England Journal of Medicine, 2004; 351(7): 647–656.

2. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA, 2000; 283: 783–790.

3. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: Where are we? Ann Emerg Med., 2006; 47: 532–541.

4. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med., 2009 Nov; 54(5): 645–652.

5. Wang, et al. Endotracheal intubation versus supraglottic airway insertion in out-of hospital cardiac arrest. Resuscitation, 2012; 83(9): 1061–1066.

6. Colwell CB, Cusick JM, Hawkes AP, et al. A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region. Prehosp Emerg Care,2009 Jul–Sep; 13(3): 304–10.

7. Takahata O, Kubota M, Mamiya K, et al. The efficacy of the “BURP” maneuver during a difficult laryngoscopy. Anesthesia & Analgesia, Feb 1997; 84(2): 419–421.

8. Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by optimal external laryngeal manipulation. Journal of Clinical Anesthesia, 1996 Mar; 8(2): 136–40.

9. Weingart SD. Preoxygenation, reoxygenation and delayed sequence intubation in the emergency department. J Emerg Med., 2010 Apr 7.

10. Levitan R. NO DESAT! (Nasal Oxygen During Efforts Securing A Tube). Emergency Physicians Monthly, www.epmonthly.com/archives/features/no-desat-/.