It’s Time to Do Away With Steps

By Dan Limmer

I recently posted a multiple choice question on bleeding control. It was a challenging situation in which the student would actually use a tourniquet first (the severe bleeding was from a deformed joint). I received quite a few questions about whether the answer I provided was the “NREMT-approved” answer.

While it’s worth noting that the NREMT doesn’t set clinical guidelines, there are several bigger issues here. The initial one is whether direct pressure should be used first. I say no. Pressure on a deformed joint can damage nerves and blood vessels as well as cause tremendous pain. For those who would argue this, picture yourself splinting the joint to “prevent movement” after you just mangled it with direct pressure.

Another big issue is the perception that the NREMT and practice are different. They are not—they’re one and the same. Although clinical opinions may differ somewhat, an approach that’s wrong on the street is also wrong on the NREMT. By trying to get our students to provide the “correct” answer every time in class, we’re actually hurting their chances of passing the NREMT—and limiting their thinking on the street.

My solution actually lies outside the comfort zone of many educators and providers. If we were to eliminate steps and instead create criteria, we would eliminate the artificial wall between learning and thinking.

So, instead of teaching steps for bleeding control, we should instead teach criteria like these:

1. Do no harm. If this isn’t possible, then do the least harm you can, but always act in the patient’s best interests. (This would be the first criterion for everything throughout the EMT course.)
2. Don’t let the patient bleed to death. With severe bleeding (or when more minor bleeding is combined with existing shock or bleeding in other places), hemorrhage must be stopped quickly by the most appropriate means.
3. In general, use the techniques of bleeding control (direct pressure, hemostatic agents and tourniquet) starting with the least invasive first, and always in a manner consistent with the patient’s overall clinical picture.
4. Consider modifying your care for the bleeding patient when circumstances of concern include multiple patients, multiple critical situations in the same patient, the location of the bleeding, other injuries to the same areas of the body and more.

A bleeding control class would go like this:

1. Teach and practice different bleeding control techniques without regard to order of use. Explain how each technique works and when it is best used (e.g., hemostatic agents for the torso, tourniquets for extremities).
2. Present the criteria for applying the skills.
3. Use scenarios to reinforce application of the criteria in decision making.

Before you say We can’t do this, think about how we approach splinting. We routinely say that any splint is acceptable that doesn’t excessively move the injury site, that immobilizes the bone ends and adjacent joints, and that maintains pulses. In effect, these are criteria. We admit that there is a wide variety of conditions in which the EMT may find an extremity, and that it requires judgment and creativity to splint properly. We even say that there are times the patient is so critical we don’t even try to immobilize the bones—we just put the patient on a spine board.

So why are we so inflexible when it comes to bleeding control and our ABCs? It’s time to change our rigid thinking and replace it with criteria that work for us and our patients.

You can find an introductory post on criteria-based education from earlier this year here.