A Culture of Silence Is A Two-Way Street, Dr. Baehren

In the latest American College of Emergency Physicians News, Dr. David Baehren writes about how paramedics have become less receptive to negative feedback since 9/11.  You can read his article, Culture of Silence, here.

Skip Kirkwood wrote a response that appears on Mike Ward’s Firegeezer.  Skip describes issues with data exchange, bad protocols, and feedback loops much more eloquently than I could, and highly recommend reading it.

Here is my response:

First, Dr. Baehren implies that EMS providers have developed a hero complex since 9/11.

Firefighters and EMS providers walked a bit taller and felt even better about what they did for a living.

He then bravely sticks his neck out (his words) by jumping to the conclusion that…

What I have found, over the past decade, is that people in the EMS system tend to bristle at negative feedback and even find ways to turn it back on the person who is trying to be helpful. Suddenly the person trying to be the good guy is the bad guy.

So let me get this straight. Starting on 9/11 the group of paramedics he interacts with at his hospital south of Toledo have become more and more resistant to his friendly criticism.   Since that fateful day 11 years ago, the movement has grown  and can be generalized to paramedics across the whole country.  He even writes that the change is so subtle, that most people don’t notice it.

I was not a paramedic yet on 9/11.  Half of my coworkers did not graduate from high school yet on 9/11.   None of us “feel better” about what we do since that day because we didn’t do it then.  I learned in statistics that correlation does not equal causation.   Perhaps his logic, or his approach, is flawed.

Although we are colleagues and we should always be collegial, paramedics are in a subservient role, and it is our job to oversee their performance. The tail does not wag the dog.

Friendly criticism is a lot different from overseeing performance.  Is he a medical director?  Has he ever done a ride along?  Does he know what their protocols and policies are? As Skip pointed out, the best course of action would be for him to consult the physician’s medical director.  Perhaps the paramedics in his service work under some outdated protocols.

And about that subserviant role.  That reminds me of an airway disaster I watched take place at an academic, level 1 trauma center.  The 250 pound gentleman on Coumadin had been struck in the head several times with a baseball bat.  We found him lying prone on the floor of his small row house with agonal respirations.  Over the next 40 minutes we were able to keep his sats at 95% and end-tidal in the 40’s with continuous bagging, suctioning, and pulling out broken teeth on the way to the trauma center.

RSI was attempted in the trauma bay.  During a long intubation attempt with a video laryngoscope, his sats dropped into the 50’s and his tachycardia turned into a bradycardia.  The attempt was abandoned, but his sats and heart rate stayed in the toilet with bagging.  Panic ensued.  Orders were shouted.  But the plane stayed in a nose dive.

I gently suggested that they try applying a nasal cannula at 15 liters.  The flustered trauma attending shouted something at me that was not nice in response.  Apparently squeezing the bag harder and faster and yelling “get his sats up!” was a better idea.  So far this had only accomplished making a bloody mess.  I left before watching the plane finish its descent.

I first read about high flow oxygen two years earlier in Emergency Physicians Monthly about how that can maintain an apneic patient’s sats for over 20 minutes.   It has since been validated with peer-review research, and is now part of the Difficult Airway Course curriculum. I have used it to successfully rescue the sats of patients that were difficult to ventilate.  But none of the physicians in the room were open to an idea from a paramedic.  Maybe I shouldn’t say anything next time either.

The line from administration usually goes something like, “Hey dummkopf, don’t aggravate EMS. They bring a lot of admissions to us.” Translation – forget medical oversight, we don’t want the gravy train (bus) going elsewhere.

Gravy train, eh? You know there’s a perception that America’s emergency departments are expensive glorified drunk tanks and primary care clinics.  I read a lot of Tweets from advocacy groups disputing that.  I know that’s not true.  I also know that the airway disaster I described is an isolated case, and that countless lives are saved every day in emergency departments.  Same with EMS.

Despite stating that most of the time we do a good job, his piece makes EMS look like a group of well meaning simple-folk who botch airways and abuse corpses.  I work for one of several services in the country with a 40%+ V-fib survival rate, a regional STEMI system based on paramedic ECG interpretation – not transmission, and a validated, EMS/hospital  integrated sepsis care  system.  That only happened because we have physicians active in EMS, who promote EMS, and who try to make EMS better.

Dr Baerhen, we want to be better.  We need the help of physicians to do that.  Complaining about EMS people not welcoming  friendly criticism, and then taking cheap shots in your association newletter only sets us back.


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