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Monday, July 11, 2011

Current state of the art in emergency care education and why it is flawed.

The title may seem a little dramatic to some and to some extent that is intentional.
We'll start with the beginning.
I am currently doing pre-requisite classes to enter into a Paramedic program with the ultimate goal of an Associate's Degree in Emergency Medicine. During this program, I have noticed several rather annoying and to some extent disturbing flaws with the curriculum. The textbooks that we are required to use are filled with glaring flaws. Downright inaccurate information, some of which appears to have been pulled out of thin air. Fabricated from whole cloth.
These are flaws that not only the authors should have known better than to put on paper, but that somehow also escaped the oversight of a rather large group of editors, all of whom should also know better. And in some cases, these mistakes are some that if not nipped in the bud by the instructors could ultimately cause a patient to lose their life.
 To wit, in the 7th edition of the Pre-Hospital Trauma Life Support textbook, one of the most glaring errors was in the way they demonstrated, in a pictorial, how to administer a tourniquet using an Israeli Trauma Dressing, colloquially known as an "Izzy-D". The pictorial was an excellent demonstration of how to apply a pressure dressing. However, if applied in the manner shown you would not only not be able to achieve occlusion of the vessels, in attempting to get enough constriction, you would likely also damage the dressing and thus prevent it from working even as a pressure dressing.
That one may be the most grievous of errors and could quite likely result in a patient losing their life.
The others that I have found are more innocuous but to some extent demonstrate a lack of understanding of even basic concepts when it comes to biology and pathophysiology.
For instance, in my EMT-Basic textbook, in a section about metabolic emergencies, it was stated quite clearly that without insulin the brain cannot make use of glucose and will quickly starve. This is a patent falsehood, as the brain is one of the only organs that CAN utilize glucose without insulin being present.
Another error that demonstrates a lack of understanding of the biological processes involved is in the 7th edition PHTLS textbook. In the section about the pathophysiology of shock, the book goes over cellular metabolism, notably aerobic and anaerobic metabolism and the differences between the two.
It is when it comes to anaerobic metabolism that their explanation turns into fantasy, as they state that anaerobic metabolism utilizes stored bodyfat as the energy source.
Again, patently untrue. Anybody with even an introductory class in biology could tell you that this is entirely wrong. Anaerobic metabolism in humans uses a process referred to as homolactic fermentation, where the cells ferment pyruvate into lactic acid in a redox reaction. It is significantly less efficient than oxidative phosphorylation, producing only 2 molecules of ATP per molecule of glucose, instead of the roughly 34-36 molecules produced by the oxidative process. The lactic acid would, in ideal conditions, be removed from the blood by the liver, however, the process of removal in the liver requires oxygen which is absent when the body is in shock and thus it builds up in the blood, leading to metabolic acidosis, which eventually leads to a cascade of system failures throughout the body as shock becomes irreversible.
Nowhere in this process is stored body fat used as an energy source! The idea is preposterous!

These are just a few examples of glaring errors that are present throughout these textbooks and frankly, I could go on at even greater length. These errors are then also sometimes exacerbated by instructors who seem to have forgotten a great many things. It worries me, as both a medic and as a possible "customer" of the Emergency Care system, that so many completely wrong things are being taught. It is my firm conviction that the standards should be raised drastically, both for textbooks, but also for EMTs in general, both instructors and students.

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