Words By Mark Ward
Thinking back on it now, the entire myth of Santa Clause is hard to believe even as a little kid. Seriously, this bloke wearing snow gear in December with a small herd of magical reindeer has managed to not only pack enough toys for every kid on the “nice list”, but he has also manged to get around to every house on his list in one night. Not only that, but he has also never been shot sliding down some drunk farmer’s chimney or attacked by a west Sydney drug dealer’s rottweiler? And how quick does this guy have to work. This bloke hasn’t got time for a glass of milk and a cookie. He definitely hasn’t got time to be kissing mummy either. What type of lunatic writes a song about seeing mummy kissing Santa Clause? If that was me, I’d go straight in and tell dad that mum’s down stairs getting it on with some fat bloke dressed up like Santa. Christmas would be ruined.
As ridiculous as it is, I was still going to bed every Christmas Eve till I was fourteen with my stockings hanging over the mantel piece. Actually, I didn’t get into wearing stockings till I was much older and we didn’t have a fire place but you get the idea.
I saved my kids the pain and anguish of going through the same traumatic experience as I did over Santa. I just couldn’t do it. As soon as my daughter handed me a letter addressed to Santa with an iPad, Xbox and an 85-inch flatscreen TV on it, I just had to break the news to her. The conversation went something like, “Sweetheart, daddy is actually Santa. That weird fat guy with elves and reindeer doesn’t exist. Now go back to your room and rewrite that wish list and try to keep it under two hundred bucks”.
How gullible we can be? But looking back over two decades in the ambulance service and some of the lies I was told when I was a student almost makes Santa seem plausible. Here are the five biggest lies that I was told as a student paramedic. Some have been proven wrong by good medical research and others were just ridiculous lies from the start.
Lie 1. Everyone gets oxygen
Oxygen is one of those lies that was proven harmful in high doses by clinical research. The evidence was just too obvious to ignore. Back in the early 2000s, we would walk into a job, introduce ourselves, slap a mask on the patent, dial the flow metre to a level anywhere between 6 and 15 litres depending on how sick the patient looked, and then ask why we were called today. That’s just how we rolled back in the day. We treated every patient with oxygen and diesel whether they needed it or not. Those were the days when some cities around the world had oxygen bars. Forget walking in and buying a beer. All you do is sip on your skinny lactose free latte while wearing nasal prongs pumping out six litres a minute.
Funny thing is, a study printed in the British Medical Journal back in 1976 showed no benefit in routine oxygen for uncomplicated myocardial infraction. This was the gold standard double-blind control trial on a small cohort of only 43 patients however, the conclusion showed no evidence of oxygen being beneficial(1). That triggered a flood of research that continues to this very day. All of the research points to the same conclusion. Not only is there no benefit, in most cases it is actually harmful. So, if this was first discovered in 1976, then why were we still putting oxygen on everyone, especially cardiac patients, 30 years and hundreds of research papers later?
I have completed a lot of research into the way paramedics as well as people in general think over the years and this is not a surprise to me. One of the hardest things to change is our beliefs. They are linked to our behaviours and understanding of the world and can be challenging and even confronting to change. Imagine living in the days when Columbus was trying to make everyone believe that the world was round. For centuries we just assumed it was flat. How hard would it have been for that bloke to put a crew together for the first voyage? I wonder how confident he was himself. I’m sure he would have been telling his crew his reasons for believing the world is round but still sending a deck-hand up the crows nest with a telescope. “If you see the end of this thing, sing out and we will spin this ship around”.
Trees do a great job of supplying oxygen. Unfortunately, trees don’t supply a Wi-Fi signal, broadcast Netflix or anything else we consider important these days, so we continue to cut them down at a massive rate of knots. But until we run out of them, they will do the job just fine. It has taken many years and hundreds of studies before we changed our practice and these days, if I have to change an oxygen cylinder in the ambulance, I have to Google how it is done.
Lie 2. The Hospital is Just Around the Corner
How many students have had this scenario?
Student – “I might just pop a line in and give pain relief.”
Mentor – “What for?”
Student – “He’s in a lot of pain. I think he might have a penile fracture.
Mentor – “Nah, were almost at hospital anyway.”
I still see horribly painful injuries bought in by ambulance without pain relief. Isn’t it one of the fundamentals of pre-hospital care? Plus, the theory of being close to hospital is not a good one. Let’s assume that you are not “almost at hospital”. Let’s imagine that you are treating a patient at the front door of the hospital. How long do you think it takes for that patient to get pain relief from the hospital staff? Let’s compare paramedics giving pain relief and the ED giving pain relief.
Paramedic – Sets up and IV. Puts in an IV. Fills up an IV. Pain managed.
ED – Line up at the triage desk. Get triaged. Get ramped. Ask the nurse if your patient can have some pain relief. Nurse waiting for the doctor. We finally get to a bed and the entire process starts again. We hand over and the nurse starts from scratch. The poor patient has to go through all of those crazy questions again. “What brings you here today?” By the time the nurse confirms that the poor bugger has a ruptured tunica albuginea, our initial dose of pain relief would be starting to wear off.
This might surprise some paramedics but there isn’t a nurse waiting at the ambulance ramp with a syringe full of morphine. Surely, we have time to give some narcotics if required. I have been the patient a few times and I needed morphine on board just to answer all those questions. There is nothing worse than being in excruciating pain and having to answer the same questions over and over again. “How would you rate your pain?” Or the worst question I get asked is “who can we contact in case of an emergency?” What sort of question is that? Call another doctor. Call a few doctors if you can. Get a full retrieval team here if you have to.
Please don’t put your patients through that ordeal without any pain relief on board. There is no rush and giving pain relief is what we do. And as an added bonus, pain relief settles down the patients and can even make them a nicer person. I have read a lot of patient complaints about paramedics over the years and not one of the patients complaining was juiced up on fentanyl. Which is the perfect segue into my next lie.
Lie 3. Don’t ever use Narcan
We all learnt that waking up a heroin addict with Narcan makes them cranky because you have ruined their high. Not true.
Fentanyl is now a common drug on the streets and has taken up where heroin left off. Add a little black market Oxycontin and there is still a reasonable chance that paramedics are going to come across a narcotic overdose or two.
We used to go to a few good heroin overdoses back in the day and I have to say, all heroin addicts that I met on the job didn’t seem too scary. Skinny, weedy and sooky bunch that don’t seem to be too athletic, so I don’t know why we are scared about making them cranky. I’m six foot tall, 115kgs and can bench 6 heroin addicts so why are we worried about making them cranky. They should be worried about making me cranky. I can understand why they would be disappointed and perhaps even annoyed. Drugs are really, really expensive. That’s why whenever anyone offers me drugs, I always take them. There’s no way I could afford to buy my own.
While missing out on almost dying does make the average heroin addict upset, it is actually the hypoxic head that makes them cranky. The respiratory depression leads to acute hypoxia and a hypoxic head is a cranky head. A heroin addict that hasn’t taken a breath for 44 seconds is bound to be cranky. If it is safe and suitable to do so, wake them up after they have been ventilated for a few minutes. Reverse the hypoxia and they might be a lot more pleasant. Don’t expect a tip or a Christmas card but they won’t punch you in the nose either.
Interestingly, some of the more recent studies on naloxone reversal of narcotic overdose has found that the way the patient is spoken to before, during and after the administration of naloxone makes a massive difference to how aggressive they are(2). Being reassuring and positive in your communication as opposed to judgemental and negative can make a big difference. Slip in a little bag valve mask work as well and you may even make a new friend.
Lie 4. Pneumothorax will have Tracheal Deviation
When I first heard about tracheal deviation, it made sense. One lung has collapsed and the air filling that pleural space is now pushing the trachea over to one side. I could see that happening.
However, the plural space is a vacuum. It is at a slightly lower pressure than atmospheric pressure which is what creates the vacuum and causes the lungs to stick to the thoracic wall. A pneumothorax is when air is able to move into the plural space and a tension pneumothorax is when the air that has moved into this space has now caused the plural vacuum to fail. The plural space is now equal to or greater than atmospheric pressure. At this point, that lung is doing nothing and can only be inflated with positive pressure. This person is now officially sick.
The Journal of Clinical Diagnostic Reasoning printed an incredibly interesting case study of a pneumothorax with tracheal deviation. It was a 13yo female post RTC who was assessed and discharged after a chest Xray however, the patient had a pneumothorax that was missed. The patient re-presented a few hours later, and now had a tension pneumothorax with tracheal deviation. This girl was so sick by this stage that the lung was unable to be reinflated and an emergency thoracostomy was done which revealed a right main bronchus tear. The patient was sent to surgery to have the tear sutured closed and after a lengthy stay in hospital, she recovered.(3) This is obviously not something we can do on road and is a great example of how sick a patient with tracheal deviation is.
By the time we see this, the patient is way beyond a tension pneumothorax. In fact, it would be safe to assume that without a chest drain, the hypoxic patient now has so much thoracic pressure that venous return is now compromised as well. However, a chest Xray will see tracheal deviation but it will not be visible just by looking at the patient. Not until it is too late anyway. Delayed recognition of a pneumothorax has been linked to increasing mortality by between 31% and 91%.(4)
In my experience, hypoxic patients with reduced cardiac output tend to fall off the perch rapidly. Perhaps if we ever see tracheal deviation, we may need to give the needle decompression a miss and go straight to a finger thoracostomy. Following local clinical guidelines off course. Diagnosing a pneumothorax with tracheal deviation is like diagnosing pregnancy with a fully dilated cervix. Yes, that is a sign that you are definitely pregnant, but it would be nice to pick it up prior to this.
Lie 5. No one reads the paperwork
The fifth lie I was told as a student is one that drives me crazy. No one reads the paperwork. This is just wrong. The paperwork is read and read on more than one occasion. My partner is an emergency nurse and has read thousands of ambulance report forms. From the triage nurse, to the treatment nurse, to the emergency physician all the way to the ward nurse, the paperwork is read. Not every word but it is used as part of the patient records.
I know some paramedics that are great at paperwork and others, like myself, who are average at paperwork. I also see paperwork that is treated very differently to the patient. My partner tells me that when she would be on triage, she would get a hand over by the paramedics, then the paperwork would read completely different to what she was just told during the handover.
The strangest paperwork I ever read was by a crew that upset the patient’s wife with their poor attitude so the wife told the paramedics that she wasn’t happy and would make a complaint. Therefore, the paramedics wrote a report on the wife and very little was written about the patient.
Paramedics are notoriously poor at documentation. I have worked in an ED where I have written up the assessment of my patients and it is vastly different and more detailed than my paramedic paperwork. As it should be. Paramedics are not discharging a patient with a management plan or admitting a patient to a ward. Having said that, what we do document is just the basics. And that is fine, but we need to document the basics very well.
Let’s look at a potential spinal injury as an example. We do that very well. We are trained to look after potential spinal injuries from day one of paramedic school. We know the NEXUS criteria. Some of us still know the Canadian C Spine Rules. That’s the one where all patients over 65 years old get a collar. We all know how to do a thorough neurological examination. In most cases, paramedics are more than capable of ruling out C Spine injury on the vast majority of patients we collar. Problem is, we don’t document it. I was able to find on old study on exactly this issue. The study reported that “Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings.” (5)
What I take home from that is we just have to write down the entire examination if it is relevant. And if your patient is in a collar, then a detailed neuro would be nice to have on the ambulance report. However, if your patient is presenting with a STEMI, a detailed neuro exam isn’t import but a typical back pain would need a full neurological exam. I would like to add that it doesn’t have to be full of fancy medical terms. Just make it easy to read and relatable. Doctors do this all the time so why shouldn’t paramedics? Doctors don’t say, “Mr Ward, we have just found a 13mm pheochromocytoma on your right adrenal gland”. No, they say “Mr Ward, we found a grape sized growth near your kidney that we have to remove”. Same thing. Both make sense to me but my dad would have no idea what the first one is and I would still have to clarify the second explanation to him as well. Doctors measure everything in fruit and veg. Grape, pea, apple and the big one, grapefruit. That’s terminal. You want to hear them say grape but never grape-fruit.
Keep it simple, make sure the relevant information is detailed and don’t ever think that no one will ever read the paperwork. The nurse, doctor, judge, defence lawyer or coroner may be reading it one day so make sure you only write down the facts.
So that’s it folks, my five top lies I was told as a student. They were factually wrong, professional stupid and downright rubbish. In conclusion, lies suck. Follow the evidence and if you are unsure, don’t repeat it, clarify it before you continue the endless cycle of clinical lies.
References
1. Rawles JM, Kenmure AC. Controlled trial of oxygen in uncomplicated myocardial infarction. Br Med J. 1976 May 8;1(6018):1121-3. doi: 10.1136/bmj.1.6018.1121. PMID: 773507; PMCID: PMC1639993.
2. Neale J, Kalk NJ, Parkin S, Brown C, Brandt L, Campbell ANC, Castillo F, Jones JD, Strang J, Comer SD. Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis. J Subst Abuse Treat. 2020 Oct;117:108099. doi: 10.1016/j.jsat.2020.108099. Epub 2020 Aug 5. PMID: 32811629; PMCID: PMC7491601.
3. Gupta A, Rattan A, Kumar S, Rathi V. Delayed Tension Pneumothorax - Identification and Treatment in Traumatic Bronchial Injury: An Interesting Presentation. J Clin Diagn Res. 2017 Sep;11(9):PD12-PD13. doi: 10.7860/JCDR/2017/27859.10642. Epub 2017 Sep 1. PMID: 29207778; PMCID: PMC5713800.
4. Inocencio M, Childs J, Chilstrom ML, Berona K. Ultrasound Findings in Tension Pneumothorax: A Case Report. J Emerg Med. 2017 Jun;52(6):e217-e220. doi: 10.1016/j.jemermed.2017.02.008. Epub 2017 Mar 23. PMID: 28342574.
5. Pennardt AM, Zehner WJ Jr. Paramedic documentation of indicators for cervical spine injury. Prehosp Disaster Med. 1994 Jan-Mar;9(1):40-3. doi: 10.1017/s1049023x00040826. PMID: 10155488.