Here is the bottom line, at the top of the page, they have too little education, do not understand science, and are too simple minded.
I was recently in a discussion with another doctor about using or adding anesthesiologists to emergency department resuscitation. It was an extremely good conversation, very civil, despite opposing ideas, and in the end, a very agreeable conclusion with each admitting that the other had some good points. But this was a conversation between physicians.
Enter in some cretin who is believed to be an EMT at some level. Yea I know that National Registry changed EMT-P to paramedic, but that is just lipstick on a pig. Paramedics are still trained like technicians. They still act like technicians, and worst of all, still think like technicians.
Right about now somebody chimes in with “our service…” and “not the people I know…” but I am just going to state the obvious for you. Your “service” is probably not as great as you think, because if it was, we would all know and have already have heard of it, because good services are so small in number anyone who has been around for 5 or more years knows them all.
The people you know are good… Ok, how many of them have even an associate’s education? The States that have made an associate’s degree the minimum as laudable, but they are few, if I count the 2 states I know of, 2 out of 50 is 4% of all states.
This is where somebody chimes in with a comment like “well we can give fentanyl and RSI. We have an advanced scope of practice.” Sad news friend, you have a medication you can administer and a technical procedure. That doesn’t make you advanced. Maybe you were even one of those services that “forced” your local hospital to institute the now questionable practice of hypothermia based on “science?” More sad news, you were duped.
The reason you do not succeed and are so easy to make a sucker out of is because you do not understand medical research. There is more to it than being able to read and convince yourself it is irrefutable data and no amount of opinion can dislodge it.
You should do yourself a favor and go read some of the many websites on science based medicine compared to “evidence based medicine.” One of the things they all talk about it the serious (fatal) flaw in EBM. You see it most often in the form of a clinical study. “treatment X was tried N times on Population Z, and compared to Y. our conclusion is…” (let me fill in the blank) A. More study is needed. B. Our hypothesis is confirmed. This is where unsuspecting EMS providers seize this published document as evidence and the answer to all mysteries. But in this attempt to use the scientific method to answer all riddles, (The same exact behavior of religious people who spout their deity knows and controls all without fail.) simple minded EMS folk don’t want to believe that this evidence is actually pretty circumstantial. I have yet to see an EMS provider pick up a study they like and try to reproduce it. Well, you know, it takes time and money and effort, and…Education!
You see, EBM is a system. Like any system, there are those who have mastered the ability to use that system. It may seem innocuous. That everyone has the best intentions. But what intentions are those? Sell a product? Get your name on a published paper? Publish a paper in order to get/use grant money? Make a new breakthrough discovery and save the world? Change medical practice to what you believe is correct?
Permit me to pose another question? If it was possible to create and publish a study that showed what to do or what was best for patients in every conceivable situation, why would we need healthcare providers at all? It is 2014, kid sick? Just get out your smart phone and google up some answers! The evidence is clear and incontrovertible. You could solve your kid’s sickness yourself, effectively and accurately. Drug companies would love it, they could massively slash their R&D budgets because they would almost never make a mistake. A simple clinical study easily would demonstrate the value of their medicine. No doctors or pharmacists injecting their villainous “expert opinion” in on the true and benevolent god of EBM.
But here is the heresy called the truth. All medical publications are based on expert opinion. How they start is an expert gets an idea, we call it a hypothesis. Said expert got this idea because they need to publish/sell something, or because they believe in their position. So they decide to create a study. (For our purposes we will assume that this expert has every benevolent intention and is not corrupt in any way, intentional bias is very easy to insert into a “study” and also very easy, but time consuming to disprove and is a criminal act in many places.) So, our expert needs to do a few things. 1. They need to convince somebody to pay for this research. It takes peoples time, you use consumable resources, etc. So you have to present your idea in such a way it seems like it matters. (Even if it is ketchup flow rates) Having competed against others seeking these same resources and having won, you now get to decide how you are going to study this topic. 1st, it must be possible to study. Meaning the technology and materials need to exist. 2nd, you must be able to measure it, if you cannot you must devise a way (this is more expert opinion) to extrapolate such data from something you can measure. 3rd, and probably most important to the critical care environment, you must be able to do it within ethical and legal limitations.
That’s right, no double blind random placebo controlled studies on the validity of CPR. No prospective treatment studies on unconscious people who cannot be advised on and consent to the risks. No deviating from “the standards” or “commonly accepted” modalities of care. Sometimes you can get a waiver, but it is easier to walk on water and part seas. Those waivers are extraordinarily rare. Nazi Germany is the closest anyone has come to unbiased human experimentation. Have a look at some of those studies (and the pictures). EMS exists in this environment; direct correlation studies are simply inconsequential, ethically impossible, or expertly extrapolated. Sure you can do a retrospective chart review study. But in terms of accuracy, precision, and conclusions, they don’t really provide much. Since one of the limits of these studies is documentation, a lot is assumed, missing, inconsistent, or just outright made up. (In very “reasonable ways” like filling in blank spots in your spread sheet with average values from those you have or asking your stat software to do it for you.)
What all that means is that your all knowing all powerful Evidence Based study isn’t really all knowing or all powerful. That big giant hole is filled in by, wait for it… Expert opinion.
This is where I will talk about another major issue with EBM in general. The peer review and consensus. In my )expert)opinion peer review is absolutely a must for any study. It needs to start during the study, to look for unintentional bias and perhaps keep excitement under control and force you to constantly re-verify your findings. But when submitting for publication, your experiment is not repeated, some “experts” look over the work, make sure there are no glaring errors, and often ask you to answer a question, soften the language of your conclusions, or add or delete something they believe is important. Once you do this, you are published.
The system of EBM is easily corrupted by the exact same trick creationists use to insert the idea of intelligent design as scientifically credible for more “reasonable” purposes. Teach the controversy! You see, if I do not like something you have to say, I can immediately give credibility to my position, by demanding evidence from you. In many cases the evidence does not exist, and as we have seen here, because of things like ethics and the publication requirements, may never exist. Simply, if you cannot produce a published study, you must be wrong or your position has no credibility. On one of the SBM websites, this was very well illustrated by an example the author (I forget who, but it was all his/her idea) parodied called “stick in the eye to cure blindness treatment.” Many years ago, the (correction)BMJ published a similar example claiming “There is no randomly controlled, double blinded, evidence that parachutes work.” It is all simply expert opinion. If you track it down, it is quite funny to read.
Science based medicine in a nutshell. The long and short of it is, in order for a study to have credibility, in order to nullify the giant flaw in the EBM system, the basic science, biology, chemistry, physics, etc. must be viable. If these basic elements are unaccounted for or a study does not account for them, then that study is suspect.
I’ll tell you, as a researcher, this prospect is painful. You have to track down and read all kinds of publications totally unrelated to your specialty or research. A personal example is when I had to prove a molecule could physically fit through the space between glomerular cells. Eventually, I was able to establish this basic fact with credible research, but it took time and was definitely not fun.
Ask a homeopath to do something like that with eye of toad or whatever they are selling today. Does the molecule actually fit where it supposedly works? Do the chemical properties of the atoms permit bonding to their target? This is the basic science that proves the value of an evidence based study. It is why clinical studies without it are garbage, even if they enroll ½ the population of the entire earth and come out with numbers needed to treat and harm. It has to be accounted for at every level of measurement too. Not just atomically, or molecular receptor cite, as well as other basics like transport, volume of distribution, etc.
Most EMS providers simply don’t have the education, time, or resources to check that sort of stuff. They read a study, and assume this evidence has been met. Here is a hint, after I take the time and effort to research all that stuff, I write about it and cite it in the publication as evidence, so if you are not reading about it in the publication in front of you, it is because it has not been done.
EMS providers, especially ones who call themselves “advocates of evidence based medicine” really latch onto clinical studies. They are on every website demanding you cite proof that parachutes work in order to give credibility to their pathetic positions for stick in the eye treatment. They believe so desperately and completely in the all-knowing, all powerful deity of the published study, that they label anyone who does not share their acceptance of the one true faith as uninformed, unscientific, biased, and simply an unsubstantiated opinion. Yet they haven’t the education, resources, or experience, in research perhaps other than retrospective studies or reviews of research. (Among the lowest levels of publication, just above case report) They create websites and blogs (which are not peer reviewed) to pontificate their opinions citing this incomplete “research” and the masses of EMS buy into this dogma and call it “evidence” as clear to see, read, and accept as fact as the King James Bible or the Quran.
No critical care provider will ever be able in the Western and even Modern World to ethically and legally conduct definitive studies to treatments or diagnostics. All of that information is “expertly extrapolated.” EMS providers are simply not expert enough to do it. So you will repeat the cycle of backboards, fluid boluses, etc. with treatments and procedures that will one day ultimately be disproven because our knowledge of basic and clinical science changes with time. The “expert opinions” that brought you those treatments actually used EMB and studies to come up with them. They were not sitting around drawing on bar napkins when they decided a fractured spine should be stabilized. They had actual patients and created studies. Based on this “evidence” they instituted what they could demonstrate was best, based on what they knew. Today’s EMS providers vilify these people as just making shit up. (Expert opinion) Some of these people are still alive today. You can talk to them. Meet them. Ask them what evidence they used. They will tell you and show you. They are not meat headed villains. They spent their lives caring for people, not selling snake oil. 10 or 20 years from now, the evidence we create will be written off as expert opinion, unless we check our basic science credibility and publish studies based on it rather than random clinical trials. The dogma you buy into today based on “evidence” will one day be vilified and ridiculed as expert opinion. You can “teach the controversy” and demand evidence all you like. But you will never have the true answers.
Because of all of this, US EMS providers, and in fact many providers at all levels around the world, will never be more than sheep, singing the choruses created by the experts with more knowledge, while indisputably believing in their evidence, and labeling as a heretic anyone who cannot prove another god exists.
It is sort of ironic they use the same methods to attempt to discredit others that homeopaths and creationists use to discredit them. “Where is your evidence God did not create the earth in 6 days? You cannot cite one study as proof!”
EMS providers really sound that stupid when they do it too.