Licensed Texas attorney. Licensed Texas paramedic. Unlicensed BBQ critic.

One of the old saws of EMS that continually is repeated like a mantra is “GCS less than 8, intubate.”  Much like other EMS myths such as backboarding every patient, withholding pain medications for abdominal pain, and the always popular “treat the patient and not the monitor,” the idea that every patient with altered mental status requires advanced airway management is a complete fallacy.

While I don’t have studies to back my assertion (and really, that’s more the forte and bailiwick of my friend Rogue Medic), I can say that I had a significantly altered patient today who was maintaing their own airway quite well.  In fact, the patient’s patent airway was the best part of her clinical presentation.  And even with a fifty plus minute transport to a comprehensive facility, she continued to breathe well on her own and maintain her own airway.

The Glasgow Coma Scale was originally developed to measure the neurological status of patients with head injuries.   The measurements and decision-making processes associated with treating a head injury are significantly different from treating a patient whose mental status is altered due to a metabolic crisis.  Intubation is as much about maintaining an acid/base balance as it is about maintaining a patent airway.  Waveform capnography is a huge help, but for the metabolic/medical patient, they may well need to be on a  ventilator where settings can be tweaked and adjusted.  In other words, intubating a medical patient may well be a procedure that should wait until lab values are obtained and the patient can go on a ventilator.

It’s way past time to embrace clinical decision making rather than rote memorization of protocols and old wives’ tales passed down from crew to crew.  It’s definitely time to base the paramedic’s identity on knowledge and clinical judgment rather than continually clinging to certain skill sets.  And for the medical patient, I think clinging to the Glasgow Coma Scale to measure the patient’s neurological status is the equivalent of using a screwdriver to put nails in wood.

I have many friends in the medical field.  Most are in the EMS world, whether paramedics or EMTs.  Several are physicians.  And more than a few are nurses.   What I continue to see are people in EMS thinking that they can easily transition to nursing and nurses who think that EMS providers are “ambulance drivers.”

In my opinion, I think a lot of it stems from ignorance.  Not stupidity.  Ignorance.  As the old saying goes, ignorance can be fixed.  Stupidity is forever.  For me, I first noticed this ignorance during my EMT clinicals and later during my paramedic clinicals.  I vividly remember the labor and delivery nursing staff excluding me from any role whatsoever.  I was told, “All you need to know is to bring them here.”   Sorry, that’s not always an option when my current EMS gig means I’m at least thirty minutes from a hospital.   I also remember an ICU nurse asking me what antibioitics we carry on our ambulance, but then acted surprised that paramedics had protocols (AKA standing orders) for airway management.  The current educational paradigm for both professions means that nursing students don’t get any exposure to the prehospital care setting and that EMS students get plenty of time in the hospital.   And yes, I believe that nurses in the acute care setting (ICU, emergency deparment, etc.) need a couple of shifts on the ambulance as well.

Here’s the thing.  Nursing and EMS do overlap to some extent, but they aren’t the same thing.  EMS providers have a unique skill set in being able (at least in theory) to rapidly assess patients outside of a hospital (or clinic) setting and provide certain immediate interventions.  Nurses have a greater understanding of the disease processes, pharmacology, and the long-term aspects of patient care, but typically act only after receiving orders from a physician.  In other words, a paramedic/RN combo could enhance one’s practice in either direction.

In fact, I’d assert that a paramedic with nursing knowledge might be the perfect candidate for community paramedicine roles that involve less urgent or chronic conditions.   And similarly, a RN with paramedic knowledge would be perfect for the current trend of in-hospital “rapid response teams” that assess and intervene with patients before they crash.

Let’s quit trying to find shortcuts for paramedics to become nurses and for nurses to become paramedics and start recognizing that the two professions complement each other rather than being a total overlap.