Today something came across my facebook page that has been debated and talked about in EMS for ages untold.
“Should family members be permitted to ride in the back with family members, even when they are in critical condition?”
I must admit many of my mentors in my career were/are some of the most outstanding providers the world has ever known, and I have learned a lot from them.
The arguments, like many in EMS, have not changed in decades. “It is unsafe”, “they might get in the way…”, I’ve heard them all.
I would like to share some observations?
EMS only has a handful of life saving skills and they are all very simple, An AED or manual defibrillator, an epi pen, and on rare occurrences, a self-inflating bag valve mask, some hemorrhage control techniques, and CPR. Past that, you basically got nothing… All of the IV drugs, tubes, etc. are largely useless, many completely lacking in any scientific evidence. Take for example, epinephrine, aka adrenaline; when I was writing my PhD dissertation, I traced its use back to the early 1600s. The first scientific study I found on it was in 1899. To this day, there is no convincing evidence it works, and a growing body of evidence that it worsens outcomes. Yet it still remains in all the major arrest guidelines. A drug studied for more than 100 years and nobody can prove it works… Is that one of your “life-saving skills”? Forgive me, but is rather weak…
I was part of the era of fluid boluses with whatever crystalloid you could muster, 3 liters of it.. to start… In the attempt to “normalize” blood pressure I have seen blood the consistency of Kool-Aid pour out of patients. I have seen chemically induced pulses that have worn out seconds after the medications were stopped. With every refining of guidelines and modern studies, I am faced with the reality that many of the patients I “saved” or “helped save” are probably alive inspite of my efforts, not because of them. We know for certain the most effective way to help the most common cause of cardiac arrest is CPR and defibrillation. That’s it… All of the resuscitation guidelines are based on sudden cardiac arrest in its most common etiology, v-fib secondary to an MI, roughly 70 percent. But v-fib is only 1 of the 10 potentially lethal side effects of MI and all the drugs and shit don’t work at all for the other 9!
Saving lives… The average mortality for ICU patients in the world is ~40%. When intensivists talk to each other, they often ask or even boast about this measure. “We only have a 30% mortality rate!” That’s almost 1 in 3 (~33%). Some centers even worse. (Often for reasons beyond control, like the population served, system issues, logistics, and money).
I have spoken at great length, around the world, of the feebleness of non-academic medical centers and the level of “life-saving” care they don’t have. Every provider I know has stories of hospitals to crawl past in an emergency, certain death awaits at those centers. Even providers who work in those places recognize their utter lack of ability to help. (But it won’t stop them from sending your unrecoverable and dying body on a $20,000+ helicopter or plane ride.)
The circle of care…
Most providers, me included, get into what we do with the desire to help people. I didn’t say I wanted to “treat pathologies.” We then talk about start our education with a list of skills we must prioritize, perform, and master.
It is overwhelming, it really is. Not only do we have to be able to properly perform our skills, treatments, and guidelines, we have to figure out how we fit in to the whole picture of a situation where somebody is dying or could die. Since we were called to the place or people brought the afflicted to us, it is a very public event, under the watchful eye of our peers, family, bystanders, and even the media.
We believe in our hearts our treatments work. After all, if they didn’t why would they be given so much importance in school?
But the more I learn and continue to learn and profess, our guidelines and formulas are basically useless to all but a very small percent of patients, usually <10% for treatments we perform on everyone! We will perform our witchcraft on patients whether it helps or not! If they fit into our numbers game great! If not, too bad so sad…
Many providers and even systems never move past this point.
For many reasons they continue to go through the motions, even perfecting those motions and holding them up as unassailable. There are only a few paths that leads down. 1. They mindlessly perform their job, not caring about their effectiveness or people 2. They quit, take up drugs and alcohol, and all other manner of destructive behavior. 3. They recognize that being humane, caring, and empathetic, is the most important part of what they are doing.
This 3rd group are the ones who made it. They are the old-timers, the sages, they have mastered their art and understand their role within it. Look up to these people. Follow their lead. They will demonstrate to you how to “help people.” Their skills are beyond refute. They are comfortable with what they are doing and are eager to teach as well as well as have anyone watch them at any time (occasional personal bad days excepted).
If you are not at this level yet, I wish you luck on your way to it.
The reason you don’t see a lot of “old timers” in various emergency and critical environments is because not everyone makes it that far and your chances of not are far greater than your chances to.
If you want more details, my friend Russ wrote this book. He was one of the ones who made it. He explains it much better than I do, and as I was reviewing it pre-publishing, I read almost every page thinking “that was me!” I get nothing from it, but it’s worth every penny, even if you are an old-timer simply recognizing you are not alone.
One of my all-time favorite movies quotes. Mostly because I identify with it a lot, and nobody could ask for a better delivery from a greater actor.
So, in closing, let the family ride in the back of your rig. Let them stand in as you try to help your most sick patients. Explain what is happening, what you are doing, and why. Be the master of your art, so capable you can operate unhindered by others. You may not be able to stop somebody from dying, but honestly, if I am at the end of my days, I’d much rather be in the presence and feel the touch of somebody I care about in my last moments than I would put my faith in the pitiful guidelines and machinations of resuscitation medicine. I suspect many others feel the same. Don’t take that moment away from others, because you can never give that opportunity back and it is far more powerful and lasting than your little bit of hocus pokus.