Today's Cure . . . T o m o r r o w ' s Poison . . .

O N E OF THE FATHERS of modern cl inical medicine, Sir Wil l iam Osier, legend has it, once r emarked to a g radua t - ing class t ha t 50% of w h a t he t augh t was incorrect and he unfor tunate ly was unable to t e l l the g radua te s which 50% that was. Tha t l i t t le story, if any th ing , test if ies to the di- lemma of modern medicine and its re la ted fields. W h a t is today's cure may be tomorrow's poison, and we as prac- t i t ioners of the a r t mus t be cons tan t ly at work upda t ing our knowledge and keeping ab reas t of the changing scene in cl inical medicine.

In p e r h a p s no o t h e r f ie ld is c o n t i n u i n g e d u c a t i o n so r e l e v a n t as in emergency medicine. Only r ecen t ly has much a t t en t ion been given to immedia te care and we are only now beg inn ing to ga in the exper ience neces- sary to provide bet ter care to our pat ients . As our re- search efforts and knowledge in emergency medic ine in- crease, the necessi ty for r e t r a i n ing and cont inu ing ed- ucation become more crucial.

Our paraprofess ional col leagues are not exempt t~om this need a n d the e f for t s by S k e l t o n and M c S w a i n (JACEP, October 1977, pp 436-438) to document sk i l l de- ter iora t ion among mobile in tens ive care pa ramedics are much admired and appreciated. While the i r survey does not discuss possible var iables such as p r imary t r a i n i n g and s tandards of re tes t ing, it nonetheless confirms much of wha t many of us involved in these programs have ob- served.

Sys tems of mobile intensive care have been viewed as a signif icant advance in emergency medicine. Not only can they improve the qua l i ty of immedia te care in the pre- hospital phase, but the h igher s t andard of care in the s treets tends to influence emergency t r e a t m e n t in the hospital .

S t a n d a r d s of educa t ion , r e s p o n s i b i l i t i e s and even equipment differ in the many programs th roughou t the country. The var ia t ion in these sys tems is made al l the more a l a rming by the f indings in Skel ton and McSwain 's paper, such as the s t r ik ing f inding t ha t the '%asic skil ls" de ter iora ted "rapidly, a lmost to the point of incompetence ...". Often the most i m p o r t a n t '~basics" of emergency care can be forgotten amid the wires, tubes and elec- trodes of "advanced" care. Any sys tem tha t '~assumes" thei r personnel are ski l led in basic emergency medicine and does not provide for ski l l de ter iora t ion is bound to have difficulty m a i n t a i n i n g m i n i m u m s tandards .

The conclusions d rawn from the Kansas f indings are far - reaching and very impor t an t to those of us in teres ted in th is field of emergency medicine. It is inc reas ing ly clear t ha t we mus t adopt the philosophy t h a t r e t r a i n ing or cont inuing educat ion of personnel is an in tegra l pa r t of any sound educa t iona l program. No sys tem of prehos- p i ta l care is complete unless i t offers sound p r i m a r y and cont inuing educat ion programs.

The f inding in the Skel ton and McSwain s tudy t ha t EMT-paramedics ~' . . . were confident of the i r knowledge and felt no rea l need to continue the i r educat ion . . . " is not unexpected and points o u t another aspect of continu- ing educat ion p rograms in prehospi ta l emergency care. A solid r e t r a in ing p rogram may fail due to lack of in te res t if par t ic ipa t ion is voluntary . An effective '~preventive" approach to ski l l de te r iora t ion in the ambulance service mus t be compulsory. Legis la t ion t ha t out l ines de ta i l s of a mobile in tensive care p rog ram must, as well, de l inea te requ i rements for cer t i f icat ion and recer t i f icat ion th rough cont inual r e t r a in ing and educat ion of personnel .

A la rger quest ion t ha t mus t be addressed is the re- sponsibi l i ty of emergency physic ians to assure the qual- i ty of such prehospi ta l care programs. Emergency physi- cians mus t embrace th is field as an in tegra l pa r t of the special ty of emergency medicine, and we mus t involve ourselves in a l l aspects of these programs - - t r a i n i n g s tandards , recer t i f ica t ion requirements , legis la t ion and s tandards of appropr ia te field care.

The Amer ican College of Emergency Phys ic ians is a logical body to provide guidel ines for s t andards in the field of prehospi ta l emergency care. One migh t envisage a sect ion of the College wi th dut ies inc luding the de- velopment of s t andards for p r imary and cont inu ing edu- cat ion of prehospi ta l care personnel . It migh t serve to "endorse" p rograms which fulfil l the s tandards set by the Col lege , f u n c t i o n i n g in m u c h the s a m e w a y as t he Liaison Resident Endor semen t CommLttee.

The need for a closer involvement by emergency physi- c ians in the p rograms of prehospi ta l care in th is country is evident . I t is incumbent upon us to fill this need by offering assert ive, competent leadership t ha t wil l benefi t our pa ramedica l col leagues and our pat ients .

Ronald D. Stewart, MD

(Dr. Stewart is an emergency physician at the Los Angeles County University of Southern California Medi- cal Center.)

J ~ P 6:12 (Dec) i977 571/73