Say Goodbye to Always and Never

By Dan Limmer

A student in the Facebook EMT/Paramedic study group recently asked this question:

If a patient is unconscious, is it [the sequence] always C-A-B?”

Embrace the maybeI can see why a student would ask that. It’s December, they’re preparing for the NREMT, and they want to get some key facts squared away in their mind. The problem here isn’t that they want to clarify the C-A-B versus A-B-C issue—the problem is that they believe there’s an always and a never in EMS.

From their early days in education, students’ minds are conditioned to believe there is a right or wrong answer to most questions. Students bring this philosophy into their EMT courses knowing there will be a challenging exam at the end. They have no or minimal field experience and no frame of reference to apply to their classroom learning. The traditional “lecture” style of education with facts and PowerPoints does nothing to help critical application.

To prevent the always/never mentality in the classroom:

  • Use cases and other dynamic learning exercises whenever possible.
  • Don’t play into into it when a student asks a question that requires an always or never answer. Respond with criteria instead of facts. Offer multiple brief scenarios or situations that show students there are different ways to apply the same material.
  • Encourage situations in which students may have differing opinions or answers to questions, and facilitate discussion of them.
  • Model critical thinking and avoid using always/never yourself.

Here is the answer I posted in the Facebook study group. It shows various scenarios and also cautions the student against the always/never approach.

I think the real issue here is the word “always” in the initial question. The answer to that is no, it isn’t always. The best thing we can do is recognize that there is no black/white and embrace the “maybe.”

If you have an adult patent who is unresponsive, likely from a medical condition, and doesn’t move as you walk up, the AHA in the 2015 guidelines acknowledges that you can do a pulse and breathing check simultaneously. Poor color, no movement or breathing, no pulse (or not sure but no breathing)—compress. No breaths first.

If you have a child patient, where respiratory problems are often a more likely cause, you have some discretion to look to A/B first but don’t delay C if there is no pulse. Ditto for an adult who was pulled from the water in a drowning scenario.

If you have a trauma train wreck with spurting arterial bleeding and respiratory failure, stop the bleeding first because it is likely to kill the patient before the respiratory failure will (and with a TK it is quicker to fix).

These differences are commonly asked on the NREMT and used in practice. When people bomb the cardiology and resuscitation part of the NREMT it is often because they don’t understand resuscitation. Reading your cardiac chapter and taking a CPR course isn’t enough. You need to know how to think, choreograph and know what to do NEXT when given a scenario.

I’ll end as I started. There is no “always” in practice and the NREMT.

Never say never—that’s always a good rule.