The Harm of Rituals in EMS

Over at Gomerville, it seems that Buck Feris has a life back and will be writing more often. In Remove the Rituals From Your Care, he writes about many of the ways that superstitions/rituals get in the way of doing a good job, many of the ways rituals endanger our patients.

I guess I never had a chance to develop these handicaps. Things such as setting the IV kit up just so, only using the one true type of needle, and all sorts of other ways of believing that if it isn't just the right way, I can't do it. That is just another example of all of the BS non-science nonsense I continually criticize on this blog.

My preceptor's partner, back when I was a student, would be leaning over the patient's shoulder, in the moving ambulance, holding the IV catheter backwards, while I was sitting next to the patient with everything as close to ideal as it gets in EMS. He would have the IV before I would. In too many cases, he would get the IV, while I would just create a little biohazard site. Sometimes not so little.

When you are dealing with that kind of setting, what excuse can you possibly come up with for bad performance? He was working on the same patient. In the same ambulance. Standing in a much less comfortable position. With a worse view of the vein he was sticking. Holding the catheter backwards. Et cetera. Still he was faster and better than I was, in spite of all of those handicaps.

There were 2 things that were potential excuses. He was sticking the right arm most of the time. Since most people are right handed, that is their most used arm and will have better circulation, which means healthier veins. The other is that sometimes it was distracting and difficult not to watch. And I did learn a lot from watching him stick people. Neither is a legitimate excuse.

He didn't make any excuses, when he couldn't get an IV. On the few occasions, when I would get the IV, but he would miss, he would compliment me on my ability and still not make any excuses. That is professionalism. It isn't about the ego, but about taking care of the patient.

Well, what do people do wrong?

Everything.

Does it matter what brand IV catheter you use? No. At least not after you get comfortable with each brand. The only way to get comfortable with them, before your boss decides that as of yesterday, we are switching to the ACME laser guided hydraulic catheters, is to look for opportunities to use things you never used before.

Also -

We insist on contaminating the site after we have cleaned the site.

This is just world class stupid.

Why bother to clean the site if you are going to make it dirty again?

If you have an excuse, do not bother to answer. If you think it is a good excuse, you have no idea of what you are talking about.

OK. Maybe you do know what you are talking about. But rather than put your answer in the comments and risk looking stupid, do this. Try explaining it to a trauma surgeon. They are easy going people, who take a win some, lose some approach to patient care. Give it a shot.

Explain to the trauma surgeon that your finger is clean, or that your glove is clean. I'll wait.

And if you think that a trauma surgeon is really worried that you are going to kill his/her patient with the bacteria that you do not realize are there, just because you can't see them and you consider ignorance of biology to be a virtue, you are also wrong. The trauma patient will receive a gram of cefazolin (Ancef) in the trauma room. A little bacteria from an incompetent IV start is not going to make much difference. The reason trauma surgeon will not be happy, because you are advocating doing something that is flat out wrong. And did I mention stupid?

All of this applies to the relatively stable patient, In the case of an unstable patient, cleanliness is much less important. Keeping the patient from dying is what is important.

Back around 1850, Dr. Ignaz Semmelweis was working in Vienna. He tried to get doctors to was their hands, because they were killing their patients. The doctors refused to listen, because they did not believe in germs. 160 years later and paramedics are making essentially the same argument. Only it isn't the same argument, because the doctors did not have the benefit of all of the science that demonstrates the germ theory. All of the imaging capabilities to see these different germs that are everywhere, even on things that are clean.

We are demonstrating that we are stupid. We cannot be taught. The germ theory was confirmed a little over a decade later, almost 150 years ago. We still have not learned. It isn't just EMS. You will see the same stupidity in the hospital, but we should be better.

It is as if we want to have big tattoos on our foreheads saying - Stupid, and proud of it!

Competent people do not need excuses.

We need to accept our limitations, but work to minimize them. We need to stop creating limitations. Science/skill vs. superstition/ritual? If you want to go with the superstition/ritual, we need to play poker. Maybe I won't convince you, but I will at least be getting paid for my time.

If you think that I am being unfair in using the word stupid too much, then there is only one smart thing to do. Prove me wrong. change your behavior. Improve your skills. Improve the care you deliver to patients. If you change your behavior, then you are not stupid, because stupid people do not learn. I don't mind being wrong. I've been wrong before. I'll be wrong again.

Prove me wrong. I double dog dare you.


As for doing everything just so, I always think of the beginning of this scene. Especially when the patient has huge veins. It is good to develop skill with your non-dominant hand, assuming that you have more than one hand. Instead we seem to prefer to make excuses. No, this is not a scene from My Left Foot.





I'm going to do him left handed. . . . It's the only way I can be satisfied.

First rule of EMS. Everything in EMS can be connected to either The Princess Bride or Monty Python and the Holy Grail.

If you haven't already, go read Remove the Rituals From Your Care. Buck presents things a bit differently.


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