The devil is in the details...or is it?

I recently had some comments from instructors and students about material in one of my books. I researched the answers, consulted with Ed Dickinson, our medical editor and replied to the queries. I always enjoy and appreciate these comments.

It was after I replied that I began thinking about a bigger picture. Let me explain.

The first comment was in reference to how many weeks a woman is pregnant. One source said 37 - 40 weeks while another was 38 - 42. Which was correct? The answer: pregnancies are "scheduled" to last 40 weeks from the first day of the last menstrual period (LMP) until birth. Some babies come early, some come late. A (very) few are born on the due date. Not an exact science. We use the 38 - 42 week numbers to reflect this fact.

The next question was in reference to flail chest. The book states a flail chest is 2 ribs broken in two or more places. The reader asked if it should be three or more ribs broken in two or more places. Good question.

This is what the trauma sources say:

• Lippincott trauma manual says 2 or more in two or more places
• Tintinalli and Rosen say three or more in two or more places
• The Mattox trauma book says "severe thoracic injury causing paradoxical motion of chest wall segments has been termed a flail chest."
• emedicine.com says three ribs broken in two or more places
• trauma.org says two ribs broken in two or more places
• PHTLS 4th says two or more adjacent ribs in two or more places

That's about as clear as mud isn't it?

The last questions is: Why do we say that we can suction for no longer than 15 seconds? Another good question. The most likely answer is that the longer we suction the more hypoxic the patient gets and someone thought 15 seconds was a good guideline.

But the real questions is: What happens if a patient vomits for 20...or 30 seconds?

These three issues actually leave me with a larger concern. How do we get our students and practitioners to think critically when we present (and test) very concrete facts? Lets look at the three questions again from a field perspective:

Pregnancy - the EMT asks how far along the patient in apparent labor is. 24 weeks (holy crap) 36 weeks (early but do-able) 42 weeks (really uncomfortable overdue mom).

Flail chest - is the segment unstable and interfering with breathing? Do we care--or even have the time to count--how many ribs are broken?

Suction - This patient won't stop puking. If I keep suctioning he's hypoxic. If I don't suction and start bagging I push the yuk down his throat and he dies in the ICU later from aspiration pneumonia. (The point: some patients die despite our best efforts to save them.)

These questions from instructors and students are real and necessary. There is an urgency to know these facts because they may be on exams. No one suctions or treats a flail chest unless they get the EMT card.

Do we need the 15 second and two/three rib rule or can we be more practically oriented? Do students and new EMTs need concrete rules or can they apply concepts and consequences under pressure?

Can we test without these exact numbers? Are they necessary facts or traditions that holds us back from better clinical thinking?

Enough for today. Add a comment to tell me what you think.

First draft of EMS education standards released

The long-awaited first draft of the EMS education standards has been released. These standards--both the content and the format of the standards themselves--will have a profound influence on EMS and EMS education.

EMS Education Standards

There are several questions with links to submit comments online. I like that. Some of the questions and issues:

Can EMS education be competency-based (rather than based strictly on hours)?

Is an EMT class that is estimated to run 166 - 198 hours too much (as proposed it includes NIMS, CPR and HazMat orientation)?

Should EMTs have a greater knowledge of anatomy, physiology and pathophysiology in order to better understand assessment, disease processes and traumatic conditions?

Are the education standards and brief outline of content enough (as opposed to providing a detailed lesson plan)? Will publishers fill this in? (I believe we do that now anyway.)

And more...

Check it out. Offer comments.

More to follow on this important topic...

Does a fire chief need a degree?

The position of fire chief is open in St. Paul, MN. The city of St. Paul lists qualifications for the new chief: bachelor's degree required, master's degree preferred. Only one person in the St. Paul FD meets these qualifications.

Does a fire chief need a degree?

The union has asked the city to lower the requirements so the job is in reach for in-house candidates. Currently only 1 is eligible. The city counters that thousands of unqualified people may apply if the bachelor's degree requirement is lifted.



The bigger issue: those in the emergency services need more education. The lack of education comes easily. Not all employers require degrees in their new hires. Some require degrees for promotion. The young person lands a career job. Bennies, retirement. He or she knows a degree is important--but now it is not a priority. Then the lure of overtime and the demands of a family continue the pull away from education. (Note: I speak from experience!)

Until an injury puts a person back on the job market. Or a provider retires at 45 and suddenly has no other skills or education. Or, as is the case in St. Paul, a promotional opportunity comes up. In all these cases its too late to start now.

Yes, emergency service providers have difficult schedules. Employers should step up to the plate with some scheduling concessions to make education easier. But with the quality, legitimately accredited distance education institutions out there, is there really an excuse for not pursuing a degree?

Take a look at:
Excelsior College
Empire State College

Both of these reputable, accredited schools provide distance education and mechanisms for evaluation of training and life experience toward college credit. And almost all local and state schools have some sort of option such as this.

Learning through photos

The students in our Wednesday evening EMT-I class participated in a photo shoot for EMS Magazine. After I sent an email asking for students to come to class in uniform--and for some prepared to bare their chests for the sake of education--the photoshoot began.

We shot a sequence for a CE article on thoracic injuries and an article on intraosseous infusion. Marc Minkler, who instructs the class, served as technical advisor and author of the article on IOs.

The students saw a shoot, learned procedures like trauma assessment and how to do IOs, and spent some time outside. Time outside is always a popular thing.