Call these lies, mantras, myths or misinformation, these pieces of EMS lore have been perpetuated in classrooms forever. It never hurts to occasionally clean out the closet so we thought we’d take a moment to share old—and even a few new—lies learned in EMT class.
1. Oxygen is the wonder drug
The AHA pretty quickly doused that fire for us. We may still use oxygen in some patients but the days of slamming everyone with 15 liters is gone. It makes me wonder when we stopped thinking of oxygen as a drug and started giving it out like candy. Maybe we never started. The current thinking on oxygenation is to give it when it is needed—and titrate it to adequate saturation levels. It also seems we have forgotten about just how much oxygen a nasal cannula can provide.
2. You can easily tell the difference between breathing patterns (biots, apneustic, cheyne-stokes)
We are taught all of these breathing patterns and that is probably ok. But expecting someone to recognize them—or spend the time to recognize them—in head injury is somewhat unrealistic. Face it, if you have a patient whose mental status is tanking, the BP is going through the roof and the pulse is dropping, does it really matter which brand of funky respirations they have? There is some good that can come from respirations, though. Elevated respirations are an early sign of shock and rapid, deep respirations (Kussmaul) often indicate a metabolic issue (think ketoacidosis, aspirin overdose).
3. Tracheal deviation is a reliable sign of tension pneumothorax
The part of the trachea that is palpable over the surpasternal notch is very proximal. For the trachea to deviate that much, the amount of pressure in the thoracic cavity is pretty extreme—and the patient is very critical. It is a late sign. You’ll likely see a lot of other signs and symptoms first.
4. EMS providers don’t diagnose
If this is true, then how do we know when to use the epinephrine auto-injector? For systems that are allowed to, how do we know when to give a neb treatment, CPAP or naloxone? We may not have all the diagnostic capabilities of a hospital (labs, radiology) but as our toolbox grows we must be confident in the condition we are treating. Call it “field diagnosis” or “presumptive diagnosis” if you must. But it is diagnosis.
5. A radial pulse equals a BP of 80 systolic
This came from ATLS and was meant as a method of rough approximation. EMS took it and carved it into stone as fact. What is the real message? If there is a radial pulse, it is better than if there isn’t. No radial pulse (or a very weak radial pulse) with a carotid pulse—especially with other ominous symptoms—is bad for your patient. That is the real message.
6. All patients with a given condition present the same
Oh how we memorized those lists of signs and symptoms in the book. In our mind, our patient would look just like that—and the signs and symptoms would appear in just that order. Our first few real calls changed that pretty quickly.
7. You can hear muffled heart sounds in a moving ambulance
We are lucky to hear a blood pressure in the ambulance—and our stethoscope is right over the artery. Beck’s Triad (cardiac tamponade) isn’t found in every patient (some sources say only about half)—and muffled heart sounds certainly can’t be heard in a moving ambulance.
8. “A little” altered mental status isn’t a big deal
This is a good saying—if it isn’t YOUR altered mental status. The brain is particularly intolerant to reduced glucose and oxygen. When these items are in short supply, the mental status changes. Don’t forget stroke and sepsis where altered mental status is often a presenting sign. Any altered mental status is significant.
9. You must only suction for 15 seconds
This is a great rule when your patient vomits a little. Not so much when they are spewing out liquid like the big fountain in park. Where did 15 seconds come from? I’m guessing the ICU where there were intubated patients. You could suction, ventilate and suction again. BVMing a couple of potatoes and a pint of beer into the lungs is MORE fatal than an extra ten seconds of hypoxia to suction properly.
10. You perform your patient history using SAMPLE
Assessment is a thinking process. Using rote mnemonics isn’t part of a thinking process. Mnemonics are designed to help you remember things when you forget. They are not designed to be the main tool for assessment. You begin a history with your patient, you create a dialogue—a flow—you assess body systems strategically. At the end, when you sit back you think, “Did I forget anything?” This is when SAMPLE (or any mnemonic) fits in.
This one just in… Now number 11:
11. Everyone with trauma needs a backboard
This is our latest addition to the list. Everyone used to get a backboard as a “precaution.” Sadly, that precaution is profoundly uncomfortable and can even cause harm. While not yet rolled out in all protocols, the new trend is to do a solid spinal assessment and use the backboard less. Much less.