Meditations On Being An EMS Cowboy

A few days back, a self-appointed EMS hall monitor took it upon himself to inform me of the damage I am doing to EMS with my little blog here.

Among other inaccurate, misinterpreted and generally just-don’t-get-it comments, he accused me of being an EMS cowboy, apparently because of the following statement, “A good paramedic knows when to deviate from protocol.”

I defend my statement. In this profession, our protocols, or Rules of Engagement if you prefer, are designed to provide a floor for medical care. The weakest paramedic, by following protocols, can at least provide the same minimum level of care as the strongest medic.

At least, that’s the theory. All too often, the protocols are written in such a way that the strongest medic is forced to lower his level of care to that of the weakest paramedic. The protocols provide a ceiling of care, rather than a floor. So it occasionally becomes necessary to decide, in the best interests of the patient, when to deviate from said protocol.

A good medic does this, often consulting with a medical control physician where necessary. A weak paramedic applies the protocol blindly, secure in the false knowledge that he has Done The Right Thing by following written orders. This serves neither the patient nor the profession of EMS. We have a responsibility to use common sense and a degree of discretion in the application of protocols which cannot address every eventuality.

People who think in concrete terms cannot grasp this concept. Abstract thinking and appreciation of nuance escape them, much like our EMS hall monitor. They get so caught up in the words that they fail to grasp the message. They think in the algorithmic terms so common to our profession, terms that, in my opinion, do a disservice to new medics and quash any critical thinking skills they may have.

If A, then B.

If X, then Y.

CPR, shock at 150 joules. Resume CPR.

Secure the airway.

Add a dash of vasopressin and a pinch of amiodarone. Knead with continuous chest compressions. Bake repeatedly at 150 joules and let cool in the ICU. Serves eight.

These recipes for care are nice tools for the weak of memory (myself included), but this profession requires a Thinking Cook. You have to recognize when you’re off the page. Many people simply cannot do this, and sadly enough, many of them have found careers in EMS.

So if I have the good sense to deviate from protocol where necessary, and to consult the Doc for permission NOT to do something, and that makes me a Cowboy…

…then Yee Hah. I’m proud of it. Personally, I prefer Bryan Bledsoe’s definition of EMS Cowboy much better than Recovering Paramedic’s. I think I fit Bryan’s definition better.

Until next time…

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