Tales of the Street

It was a pleasant, warm afternoon, early spring maybe. My partner and I were dispatched to a

motorcycle vs. car accident downtown. Fire and police units were on scene when we arrived. A

motorcycle had run into the left front fender of a sedan at about a 90 degree angle. The

motorcyclist and his passenger were thrown onto the hood of the car. Glancing at the damage to

both vehicles as I approached, it appeared to have been a low-speed impact.

The motorcycle driver was a male in his 30s. He was walking around the scene with an obvious

wrist fracture. My patient, his passenger, was a female in her 30s. She was sitting on the ground.

A firefighter was kneeling behind her, supporting her back. She was conscious, alert and

oriented. I got a brief report from the firefighter. He said he couldn't get her to lie down. There

was no loss of consciousness. She was complaining of shortness of breath and lower back pain.

I knelt down for my initial assessment.

Her skin was warm and dry, pupils equal and reactive to light, pulse and respirations a little fast,

but regular. She complained that she was having some trouble breathing. Her lung sounds were

clear and equal bilaterally. I asked her why she wouldn't lie down. She told me that when she

tried, she became more short of breath, and it hurt her lower back. She told me she was two

months pregnant.

The only finding on my head to toe exam was lower back pain. When we tried to lay her down on

the backboard, she would cry out in pain and tell me she couldn't breathe. She became

increasingly anxious. I decided to immobilize her in position. I wanted to avoid increasing her

anxiety and dyspnea. I certainly wanted to avoid causing any damage by forcing her to lie flat.

We placed a cervical collar. When the cot was brought over, I positioned the head of the cot and

rolled up blankets to maintain her as close to the position in which she was sitting as I could sort

of a left-lateral-recumbent-semi-Fowlers. I recruited two additional firefighters, and we lifted her

with a blanket, as a unit, in position, onto the cot. I padded around her with blankets and towels,

and in addition to the cot straps, I stretched several lines of tape across her to hold her in place.

The other patient sat on the bench seat, and off we went to the hospital. We transferred patient

care, and then I went to the report room to do paperwork.

My partner, whom I didn't know very well, came into the report room. He was almost foaming at

the mouth. "You're dangerous!" he yelled at me. Huh? What are you talking about? "You're

dangerous!" he repeated, "I'm never working with you again" and stormed out. "Huh? Say

what?"

I followed him outside and asked him again what he was talking about. He ranted about my not

putting the patient on a backboard, and standard of care, and how I, a paramedic instructor,

could do something so heinous, and how dangerous I was. I would like to say that I chuckled and

told him to stick it where the sun don't shine, but in fact I was mortified. I was not used to being

screamed at by a patient, perhaps, but not a partner. (Well, there was that time back in Elyria ...

but that's another story). And, of course, I prided myself on patient care and was startled and hurt

by his accusation.

Even when I finally got him calmed down a bit, no rationale was acceptable to him. He didn't care

about developing standards for spinal immobilization, about "first, do no harm," about the

studies of respiratory compromise and iatrogenic injury secondary to backboard use or any

other argument I raised. Moreover, he couldn't explain why "reducing" a possible spinal fracture

or dislocation by forcing a patient onto a backboard was acceptable, when doing the same to,

say, a possible humerus fracture was not. To him, the issue was black and white: MVC + MOI =

BB , no ifs, ands, buts or exceptions. In my attempt to exonerate myself, I ended up having to

write a three-page single-spaced footnoted treatise on exceptions to long spine board

immobilization for our medical director.

Mercifully, we had the opportunity to move back home to Indiana shortly thereafter. One of the

first things my new medical director asked me was (and I paraphrase) "Guy, can you research

ways we can start cutting down on the unnecessary, harmful, and expensive immobilization of all

these patients on backboards that are clogging up my ER?" You can imagine how delighted I

was and, within a year, we had adopted a variation of the progressive Maine protocols for spinal

ruleout in the field, protocols that have become the standard of care in much of the nation. I also

continued my research on the subject of spinal immobilization. I should actually thank my old

buddy Johnny Dangerous the experience of meeting face to face with blind, even zealous

adherence to protocol in the face of common sense led me to eventually write, with Dr. Amir

Vokshoor, "Primum Non Nocere First, Do No Harm: The Importance of Neutral Spinal Alignment

for Patients of All Sizes" in March 2006 JEMS.

But I'll never forget the closed-mindedness of that otherwise intelligent and competent, if

immature, paramedic. He had worked within the same system for his entire career, a system

that considered itself the best of the best, unquestioned in its methods. He viewed wearing their

colors as the pinnacle of paramedic achievement. Even when confronted with evidence that

there might be another way of doing things, his certitude and self-righteousness could only

produce "you're dangerous, you violated the standard of care." Certain that it was their way or

the highway, this service engaged in practices that in most systems would be considered

unacceptable, if not illegal.

The only compliment I ever received during my time on that job was when, tired of being ragged

for my "grandmotherly" driving, I let my ego get the better of good judgment, and I dredged up my

old New York City cab driver bag of tricks to prove that I could drive just as fast and just as

recklessly as any of their ambulance jockeys. "Hey, you really can drive," my partner admitted. It

was the system's practice to transport every patient "lights and sirens" to the hospital ("we gotta

keep units in service" they said "yeah, dead or alive," I thought). Once I requested my partner not

start driving to the hospital before I could obtain vital signs on a stable patient. He yelled back, "a

real paramedic gets vitals en route." Patients seen as system abusers were themselves

regularly abused. Heroin O.D.? Narcan hot-shot, no I.V. Lights with no siren? No problem. Seat

belts? Optional. It was the Wild West in the Northeast with an attitude of infallibility and selfrighteous

superiority that persisted even after a pedestrian was killed by one of their careening

ambulances.

In EMS, as in every other discipline, we have to guard against the prejudices that quickly

develop within a closed mind, whether that mind is individual or collective. We need to guard

against prejudices that render us incapable of accepting the "other" whether that other is a

different kind of person or a different way of thinking as being anything but "dangerous." It's one

thing to pay lip-service to receptivity to new ideas it's another to actually be receptive. It's one

thing to acknowledge the value of evidence-based medicine it's another to actually abandon

enshrined practices as a result.

First Published June 27, 2007, jems.com