Sox Education

You’re probably expecting something about EMS in this space. We’ll get to that. First let’s talk about sox, or socks, if you’re not a fan of Red or White. I’m sporting a pair of brown ones right now because socks are something I was taught to wear even on steamy summer days, when they’re about as welcome as toques. (Memo to readers in southern North America: A toque is a Canadian sock for the head. My friend Sandy from Ontario assures me Canadians also wear socks on their feet.)

The Lovely Helen and I disagree on the importance of fresh socks. She complains I monopolize our washing machine, not to mention her discretionary time, by changing my socks daily. “Did you just dump your sock drawer into the laundry basket because you thought I didn’t have enough work?” she’s been known to ask. (Yes, she does the wash—her choice, I swear.) So I’ve been thinking: Maybe I don’t have to change my socks every day just because I’ve always done so.

You see where this is headed? Slavish devotion to custom doesn’t necessarily produce the best outcomes; good enough, perhaps, but why settle for the acceptable when you can chase the exceptional?

I’ve heard medics characterize their jobs as routine. They say they diagnose patients from doorways, treat, transport and never look back. They tell me their ambulances are extensions of ERs; that the biggest difference between doctors and paramedics is income. They pride themselves on their independence—tolerating, but not needing, oversight.

I say these are signs of apathy, not expertise.

Yet I so wanted to be that kind of medic. I imagined arriving on scene with nothing more than a penlight, sensing sickness behind my patient’s rheumy eyes, then declaring “pneumonia” while awestruck junior crew members merely confirmed my diagnosis with their clumsy analytics. Oh, the inevitability of it all.

I assumed the path to paramedic omnipotence began with mastery of the curriculum. If a disease had a protocol, I was all over it. That ruled in the classroom; not so much in the field. As I look back on my earliest mistakes, I think most of them were caused by lack of imagination—by my determination to fit presenting problems into contrived cases that ended as predictably as they’d begun. Rigid adherence to hypotheticals didn’t leave room for the variability of real-world conditions, such as multiple complaints and causes.

Knowing when not to act is as important as mastering any treatment algorithm. In Taigman’s Advanced Cardiology, the author recounts the making of a “cardiac cripple” through needless, protocol-driven administration of bradycardia meds. Contrary to classroom imperatives, parroting “atropine” for heart rates below 60 can be more dangerous than doing nothing at all.

My wife survived another instance of what we sometimes call “cookbook medicine”:

The only thing Helen hates more than hospitals is…I can’t think of anything. Being in a hospital for her is like me being on a roller coaster: terror tempered by hysteria. As Helen awaited discharge—anxious and in pain—after major surgery last summer, a physician noticed her blood pressure was up. Ya think? The attending told Helen hospital rules required her to stay until her BP came down and ordered Lopressor.

Helen was panicky when she called me to rescue her. I broke laws driving to that hospital. I bet I would have qualified for Lopressor too.

My wife needed peace of mind, not beta blockers. Any policy that said otherwise clearly was inappropriate. To blithely follow such directives is neither efficient nor therapeutic; it’s foolish. I think any medical professional who allows habit and complacency to override common sense should find another line of work.

I think most of us find a middle ground between anarchy and doing everything by the book. At an organizational level, that means a willingness to adopt policies that would have been labeled heresy two decades ago, like BLS Narcan, limited O₂ and delayed intubation. No one expects EMS agencies to invent the next standard of care; just to get permission to follow the latest evidentiary wisdom before books are written about it.

Individual providers are certified to exercise judgment by keeping current on the potential consequences of bad decisions. Bi- or triennial expiration dates acknowledge the role of new research in shaping prehospital practices. I’m afraid caregivers who scoff at refreshers and other continuing education as time-wasters, and who feel experience alone should be a ticket to recertification, will be the last to recognize flawed methods.

It’s summer in Nashville. Should be a good day to go without socks.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.