The Tale of Two Horses

I am fascinated by the Critical Care/HEMS FOAMed community. The amount of information and experience that is shared is invaluable. In a very short period of time, you can expand your clinical knowledge, make great friends, benefit from the experience of others, and propel your career to “new heights” you hadn’t thought possible. Unfortunately, I have noticed a few things in my observations of the community. In the many conversations and debates I’ve participated in or watched from a distance, it has become very apparent that we love to beat a dead horse. Very “spirited” debates will rage on and on about what is the absolute best drug or practice; often among contenders that are evenly matched. Another thing I’ve noticed is the seeming exclusivity of the community. “HEMS, high-performing EMS, and teaching hospital associated professionals only, please.” Everyone else, bless their hearts, is a horse that certainly can’t be led to water nor made to drink, and it’s our job to fix their mistakes. I believe they can be led, that they can drink, and that the FOAMED community should do the leading, instead of the beating.

My introduction to FOAMed came when I took a CCEMTP course hosted by CareFlite in Dallas several years ago. This was immediately followed by a FlightBridgeEd FP-C prep course. I was a ground Paramedic at the time, pursuing my first Flight Paramedic position, and very new to Critical Care. I still am, in my honest opinion. I had always been passionate about good medicine and best practices, and I was exceedingly curious about “what lay beyond” my limited interactions with my patients. Over a three week period, my mind exploded with all the new information. There were fascinating lectures, intriguing books, challenging skill stations, and a collegiate cadaver lab; as well as conversations and networking with in-hospital and pre-hospital Critical Care clinicians. My learning, in regards to standard 911 ALS Paramedicine, had grown stagnant, and now I had a whole new world to explore; to satiate my curiosity. Not only that, but I was introduced to the FOAMed community; full of podcasts, blogs, forums and groups – Oh my! I quickly became an addict; losing myself in all this new information and taking it all in as fast as I could.

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I imagine many in the FOAMed community feel as I do, and have had similar experiences. I feel at home among my peers in HEMS/Critical Care. I love networking with people, sharing information, having in-depth and thought-provoking discussions. But as I participate more in the FOAMED community and transport sicker and sicker patients, I can’t help but feel troubled. I’m concerned that while our community has grown and expanded the knowledge of those within, that there are still so many on the outside. Those on the outside are unaware of the existence of this wealth of information available and of the potential benefits to their patients.

EMCrit had a great blog post and podcast back in 2014 following Dr. Simon Carley’s presentation at SMACC entitled “What to Believe and When to Change.” If you haven’t listened to/read it, I highly encourage you to do so. One of the highlights of the discussion for me was the “adoption life cycle”, and how it demonstrated different groups of clinicians in relation to the points when they change their practice in response to new evidence:

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Personally, I feel that I now fall under the Early Majority category along with many in the FOAMed community. Many of the content creators that I follow, with admitted fanboy reverence, are in the Early Adopters category – Save a few real innovators. They’ve taken the time to analyze and interpret the data, apply it to their practice, and provide more easily digestible information and recommendations to those that follow. The early majority is a very safe zone, where we are adopting best practices after a sufficient amount of evidence and industry experience has deemed that practice to be beneficial and safe. This is where I feel the majority of us in the FOAMed community belong; a happy medium for both patient and clinician. The only problem is that the graphic is not an accurate representation of the overall clinician population, as well as the number of patients seen. The categories are spot on, but when you look at the overall population of Paramedics, Nurses, and Physicians in Emergency Medicine and Critical Care, I feel that it would be much more accurately represented by a linear line than a bell curve.

Here in lies the crux of my dilemma. The best example to demonstrate this is the recent debate between Tyler Christifulli of FOAMfrat and Eric Bauer of FlightBridgeEd about “Volume vs. Pressure” in ventilator management. I love these discussions. The initial debate at FAST18 and the follow-ups by each participant, as well as the analysis by Chris Meeks over at Mind Body Medic, have all been phenomenal. They’ve given me, as part of the early majority, much to consider about the optimum management for my patients on a ventilator. That being said, much of the debate centered on what I feel are the finer points of ventilator management which are reserved for those of us in the Early Majority category and above. All that discussion and effort is akin to a teacher focusing their attention on improving the grades of that one straight-A student in the class, the Early Majority, and getting them from a 95% up to a 99. Is this bad? Absolutely not! We should strive as individual clinicians to provide the best care we can for our patients. But maybe more of our effort as a community should be focused on bringing the Late Majority and the Laggards up to speed. Perhaps focusing on the rest of the class with a C-average would do more for patient outcomes, instead of beating the proverbial dead horse.

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Mike Verkest of the Second Shift podcast has said many times, “If you’ve seen one EMS system, you’ve seen one EMS system.” There is some truth to this thought. The same could be said for hospitals. There are unique differences to each EMS system and each hospital, but there are many similarities due to industry standards and practices that transcend the geography of Emergency Medicine and Critical Care. There is some truth to the adage of “stereotypes are based on reality.” The phrases in HEMS, “scene call with four walls” and “rescue vs. physician”, are common dark humor quips that are relatable. We have all run those calls with considerable frequency. We look at our partner and know that we’re thinking the same thing they are. In our heads, we are applying palm to face. We wonder how the Doc didn’t know this, or how the Medic could screw that up, or “What was the Nurse thinking?” when all they had to do is GTS (Google that s#!^)! Ironically enough, most of us might have made the same mistakes not long before, simply because we didn’t know any better.

I have seen very few patients in my short HEMS career where the differences in Pressure vs. Volume played a significant role in their care. Inversely, I cannot count how many patients I have treated who weren’t even on the most basic of lung protective ventilator settings, hours into their care. Not to mention, all the mismanaged airways both inside and pre-hospital, inadequate pain management and sedation, ineffective use of vasoactive medications, and inappropriate volume resuscitation. I make my living mostly by stopping what is harming my patients and starting what helps. I’m certainly no miracle worker, and these are just the patients that I am fortunate enough to see. Yes, of course this is anecdotal evidence, but these are common experiences among our community. This means there is at least some truth to it. How many more patients never see clinicians of the Early Majority and higher during their care? How many of those outcomes could we improve?

Chris Meeks ends each of his Mind Body Medic podcasts by saying “Do the best you can, for as many people as you can.” This is where I feel the real promise of FOAMed lies. As a Paramedic working the streets before I went down this fascinating path, I admit I was a part of the Late Majority or even a Laggard. Not because I was stubborn and resistant to change, but because I didn’t know what I didn’t know. This is where the majority of us fall before we “see the light” of FOAMed, and this is where the majority of patient contact happens. Coincidentally, this is where I believe the greatest positive impact on patient outcomes can occur.

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This is the tale of the second horse. When I was lead to water and made to drink, I reflected on my many patients who had received sub-optimal care simply because I didn’t know any better. It was humbling to be sure, and my ego took a big hit, but it motivated me to change and become better. So here is the question that I pose to the community: How do we bring more of those horses, the Late Adopters and the Laggards, to the sweet, refreshing FOAMed water? And once we get them there, how do we get those stubborn few to drink? I don’t have the answer, and I have had limited success in trying to do so. Thanks to FOAMed, I know the best practices for treating my patients. So, what are the best practices for treating my peers?


About the Author

AdamT_bnw

After serving as a U.S. Marine Infantryman and fighting in Iraq, Adam Tresidder returned home in 2007 to pursue a career in EMS. His broad view of EMS comes after working as a Firefighter, Emergency Department Technician, and Paramedic. He now serves as a Critical Care Flight Paramedic, recently returned to military service to pursue the same role with the Army National Guard. Adam is passionate about training and education, and has also been a preceptor and instructor in numerous roles and disciplines. As a strong advocate for increasing the quality of both initial and continuing education, he feels strongly that by expanding educational offerings for Nurses and Paramedics, we can improve patient outcomes and empower clinicians.


Carley, S. (n.d.). What to believe and when to change.

Lecture presented at SMACC Gold in Australia, Sydney. Retrieved September 01, 2018, from http://www.stemlynsblog.org/believe-change-st-emlyns-smacc/

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