You kneel beside Joe and ask, “So, would you like to go to the hospital?”
“No!” he vociferously replies — a theme that will be repeated often over the next few minutes.
You explain the risks — that given his anticoagulation (Coumadin), and given that he struck his head and seemingly lost consciousness, there is a non-trivial possibility of bleeding into or around his brain. That although he feels well now, it’s not impossible for such a problem to develop insidiously and not manifest with symptoms until it’s too late. That you can take him to the hospital of his choice, in total comfort, he can receive some quick tests, and if nothing is wrong he’ll be back home before he knows it.
Joe wants to hear none of this. He just came out of the hospital, enjoyed it not at all, and that was just the latest episode in a long series of hospitalizations. “They ruined my hip” on one occasion, he opines, and he’s already been fooled before by “home before he knows it.” No sir; he’s not going anywhere.
You try, your partner tries, the neighbors try, the proxy tries. No way, no how.
Well, okay. But this is not the sort of incident to just brush aside, and you’re well aware of the risk inherent to patients refusing transport, particularly in a risky circumstances like this. So you pick up your phone and hit your hotkey for medical control.
“Needletown Hospital; this is Dr. Scrubs. How can I help you?”
“Hi doc, this is Maverick from Poketown BLS 48. We’re on scene with a high risk refusal.”
You fill him in with the story. He asks a couple questions, then requests to speak with Joe, and finally talks to the proxy for a few minutes. When the phone gets back to you, Dr. Scrubs informs you that he really thinks Joe needs to go.
Well, okay. You dive back in, bolstered with a physician’s opinion, and attempt to get Joe on board the hospital train. He’s not having it. The whole entourage keeps hammering away at him, but he’s simply not budging.
You call back Dr. Scrubs, bringing him up to speed. “We’re making no headway here. He just doesn’t want to go.”
He asks to speak to Joe, and the sounds of his best MD magic come wafting over the speaker, but Joe just has less and less polite things to say, until finally he comes out with, “You’ll have to handcuff me before I’m going anywhere! And just go ahead and try it!” He hangs up on the doctor.
You call back. “I gotta tell you, doc, I don’t see us convincing this guy. If you tell me that we must take him, then I’ll take him, but I think we’d have to do violence to him and start a battle royale here. Is that what you want?”
Dr. Scrubs replies, “Well, I think he needs to be seen, and it sounds like his proxy does too. I’d like to hear your opinion.”
You pause, then carefully say, “I do not think that it would be inappropriate to leave him, although obviously it would be preferable if he came in. I don’t know that I’d make the same decision, but I might, and I don’t see the situation as so high-risk as to justify anything really extreme.”
“Head injury, on Coumadin, loss of consciousness, you don’t think he needs to be seen?”
“We obviously can’t clear him here. But he’s stone normal by our assessment from every angle, and he’s not going to be left alone.”
“Well, I don’t think that’s a great idea. And he wasn’t really able to logically explain to me the risks of his decision. Anyway, his proxy agrees, so I’m not sure if I see the problem.”
“Doc, the problem is that although he does have someone here who says she’s his health care proxy, by our assessment he is at this time totally oriented, competent, and exercising sound judgment. So I’m not really comfortable kidnapping him, unless you want to sign a Section [your state’s involuntary mental health process, for those who are a danger to themselves or others].”
“Sure, I’ll do that. I can fax it to your dispatch and to the receiving hospital.”
“So you want us to tackle him?”
“Do what you have to do.”
You hang up the phone and look around. Police have left the scene, but could be easily recalled. Joe sits before you, a 79-year-old in fair condition, but no Evander Holyfield.
It’s 9:00PM on a Wednesday, and you’re the tech on A48, a dual-EMT, transporting BLS ambulance. You are the 911 coverage for Poketown, a midsize urban area; ALS is available for intercept as needed. You carry fingerstick glucometry, activated charcoal, glucose, aspirin, and epinephrine.
You are just starting to yawn when a tone hums from the radio, and a voice declaims:
“Ambulance 8, take the response to 91 Eastbrook Rd. That’s priority 1 to 9-1 Eastbrook Road in Poketown, apartment 710, for the fall.”
You acknowledge, flip your lights on, and head that way. This is an apartment block in the middle of town that you know well.
You arrive to find Poketown Fire and Police already on scene. You load your bags into the stretcher, plus a backboard, and head into the elevators, which are so small you have to fold the cot to fit inside; you wonder how you’re going to fit the patient if you end up boarding them.
You arrive at the apartment to find an elderly man sitting in his wheelchair, accompanied by neighbors and friends, including a young woman who describes herself as his healthcare proxy. He greets you cheerfully, telling you that he’s Joe, 79 years old. He was walking around the apartment with his walker when he brushed against the refrigerator and fell backwards; his proxy tried to catch him but failed, and he hit the ground. He denies falling, then denies hitting his head, saying he landed on his butt, then finally agrees that he hit his butt then his head; his proxy, however, tells you he fell straight back like a board and struck the posterior of his head on the ground. She says his eyes rolled back for a few seconds and he seemed unconscious, after which he quickly came around and moved himself to his chair. She was alarmed and called 911 immediately after; the fall was about 15 minutes ago.
He presents as fluidly conversational, friendly, and fully oriented. He is slightly hard of hearing, speaks in a loud voice, and doesn’t always understand your questions the first time around, but he’s generally “with it” and remembers the full chain of events that led him here. He jokes around with you and the firefighters and offers to marry you to one of his daughters, who has “lots of money.” You tell him you wouldn’t know what to do with it.
Physically, he seems well, with no notable trauma. There is a small lump on his occiput which may or may not be baseline (hey, heads have funny shapes), but he denies any pain or tenderness there. He also denies pain or tenderness of the neck or back, and in fact denies everything, saying he’s just fine. A “lifeline” bracelet is present on his right wrist. His vitals show:
Skin: Slightly cool in the feet, some ecchymosis throughout, otherwise dry and unremarkable.
Pulse: Weak, slightly irregularly irregular radial pulses at 78
BP: 110/70
RR: 16 and unlabored
BGL: 124
Your physical exam notes no other gross trauma. His left pupil is large and abnormal in shape; he states that he has bilateral cataracts. His right pupil is round, slightly small, and somewhat reactive. His eyes track in all directions with no major nystagmus. His lungs are clear bilaterally. He demonstrates equal CSM in all extremities, and no facial droop, arm drift, or speech slurring. A full neuro exam notes no deficits. He denies chest pain, dyspnea, nausea/vomiting, general weakness or dizziness, peripheral weakness or parasthesias (numbness/tingling), or any other complaints. During your exam, he actually gets up and ambulates back and forth across the room with his walker, moving slowly but well with no major gait disturbances.
While you talk, your partner is examining the medication list provided by his proxy. It includes:
Digoxin
Metformin
Citalopam
Advair
Omeprazole
Coumadin
Ibuprofen
His full medical history is otherwise not readily available. He does state that he was just released from the hospital two days ago, after a 5-day stay for diverticulitis. He is allergic to morphine.
What is your general impression of this patient’s priority?
What do you think is going on? What are you worried could be going on?
What is your next step?
One of these days, we’ll have to do a comprehensive post on care and feeding of the multi-wheeled chariot we call the “waaambulance.” For the time being, however, here are a few morsels that most people don’t figure out until they’ve been in the business for a few months at least. These apply mainly to any Type II (van) or Type III (van cab with box module) ambulance based on the Ford chassis, although they may have some application to other vehicles as well.
If you turn the ignition key too far, it may get stuck slightly past the “on” position, in which case most of your vehicle electronics (FM radio, air conditioning, etc.) will not work. It’s not broken; just turn it backwards slightly.
In a similar vein, you may occasionally find that after switching off the power, your key is trapped in the ignition. Give the gearshift a wriggle while turning and pulling at the key. Jiggle the steering wheel too.
Lock yourself out? For shame. On many Type II (van) units, there’s an easy solution: unscrew your antenna (either the FM antenna or a stout two-way) and head to the back doors. The leftmost of the two lights above the license plate should be easily removable, and you can poke the antenna up into the gap and use it as a probe to “lift” the base of the locking post. Then open the sucker up and unlock the rest using the electronic switch (or just climb through to the cab). Of course, your service may also have installed an emergency unlock button somewhere hidden, but you should hopefully know about that…
The knob that you pull to activate the headlights has another function. If you twist it while it’s in the “on” position, it will adjust the brightness of your dashboard console (including the LCD radio display and the lights behind the dials); give this a try if your radio seems inexplicably dim. And if you turn it all the way to the left (it will click), it’ll usually activate the overhead light.
If you have a digital odometer, there should be a button beside it that cycles through your tripometers and resets them. If the ignition is off and you need to retrieve the odometer mileage for paperwork, you don’t need to turn the key; just press this button and the display will light.
If you have a “momentary” switch that disables the backup alarm (rather than one that can be switched off permanently), you can hold it down while shifting into reverse (you may have to shift left-handed) in order to avoid any beeping; this is a nice courtesy to avoid deafening your partner if they’re back there spotting you. Otherwise you’ll usually let out at least one beep before you can hit the switch. Once you’ve shifted you can let it go.
The newer gasoline vans have a third “cigarette lighter” charging port located inside the glove compartment.
Diesel vehicles can safely be fueled while the engine is running. There’s no need to shut down and kill the AC and everything else. I would not, however, try starting the engine while fueling it.
Editor’s note: this post was eventually expanded into a cover feature in the May 2012 edition of EMS World.
There’s a concept from psychology that’s recently made the jump to the world of popular science (that misty realm ruled over by a benevolent Malcolm Gladwell; Bill Nye is his jester) known as decision fatigue.
The idea is that human beings have a limited reserve of willpower. Willpower isn’t a physical substance, something stored in a sac in your abdomen, but nevertheless it’s a real quantity. Every time you’re forced to make a decision, especially important or consequential decisions, it drains a little of this resource. Certain restorative acts, like sleep or eating, can help restore it. But if you start running low, then you start losing the ability to make weighty or difficult choices — you tend to pick the easy option, the default answer, the path of least resistance. Rather than the big picture, the long term, you start seeing only the immediate payoff. That little mental push that lets you do the right thing… well, if you spend all day pushing, by 9:00 PM you just might be out of push.
This phenomenon may ring intuitively true, but understand that it’s not horoscopes or tarot cards — this is a real behavior exhibited by all or most people. This is something you do right now, whether it’s obvious or not.
And this is very pertinent to those of us in EMS. Due to the nature of our work, we carry an unusually large burden of decisions. For the level of training and experience our job requires, we are granted a great deal of independent responsibility; in other industries, we would be working with a supervisor over our shoulder, a hands-on boss ensuring that we toe the line. Not so on the ambulance; we perform our duties on the road, alongside one partner, and typically have no direct oversight for the vast majority of our day. If you mess up badly enough, you’ll hear about it later; but to quote the luminary Peter Gibbons, “that will only make someone work just hard enough not to get fired.” We all know a few EMTs and paramedics who have learned all the hot spots, the danger zones, know exactly what they need to do (and what to avoid) in order to stay under the radar — and as long as they dance those steps, they can otherwise do, or skip doing, whatever the heck they want.
The point is, in this job you can do everything right. . . but only if you decide to.
Many of our decisions are small. When it comes down to it, even Old Man Lazybones, the 400-year-old medic who only wakes up to punch out and sometimes eat animal crackers, will generally mobilize for the cardiac arrest and the multiple stabbing. That stuff comes packaged with motivation. But what about all the little things in between? Do you change the stretcher linen between calls, or leave it? Do you sanitize that blood pressure cuff after using it on your “recent VRE” patient? Are you professional, caring, and thorough in your patient interviews, or are you starting to lapse into taxi driver mode? Do you document thoroughly, or cut a few corners? Is everything on the truck restocked for the next crew, or are you out the door? And so on, and so forth. There’s doing your very best, there’s just barely “not getting fired,” and there are many points in between, but no doubt, each time you’ll have to decide where you fall.
It’s tempting to say that what matters is simply the kind of person you are. The “good” EMT, the true professional, that guy will do the right thing. He’ll make the right choices. And the slacker, the hack, he’ll blow it off. And maybe that’s often true.
But the lesson of decision fatigue is that none of us is a saint, or an infallible machine. Every time we make one of those little decisions, every time we exert ourselves to do the right thing, we use up a little bit of our motivation. And after 8 hours, 12, 24 hours, five calls, ten calls, you’re going to start scraping the bottom of that well. The good medic will last longer, the hack won’t make it past lunchtime, but eventually, everyone starts cutting corners. Be honest with yourself, and you’ll see that it’s true. You can care, and you do care, but at some point, you’ll stop caring quite so much. In the long-term, we call it burnout, but in the short term we just call it “time to go home.”
One of the valuable observations from the research on decision fatigue is how the most successful subjects tended to cope with it. By and large, those with the best self-control didn’t survive by being the most stoic, just standing there and weathering a stream of decisions that would shake the best of us. Instead, what they did was set up their lives to minimize the drains on their self-control. They recognized that if they have to spend all day consciously choosing to do the right thing, eventually they’re going to start slacking. So whenever possible, they arrange their circumstances so that no decision needs to be made. When they grocery shop, they don’t just “buy what looks good,” because that’s a constant barrage of “cookies or carrots?” They go in with a list, and they buy what’s on the list, and that leaves no decisions to be made. And then, on the way home when they have to decide whether to yield for the slow-walking granny in the crosswalk, they aren’t already worn out from the battle of the cookies.
Good habits. Good habits will save us.
You can’t go through your shift constantly deciding to do the right thing. But you can create good habits, wherein you do the right thing automatically. This may sound like you’re creating work for yourself, but in fact it’s the opposite. “Work” is choosing to do it. Habits just happens. Waking up, brushing your teeth, driving to work, you don’t complain about having to do these, you just do ’em; they’re things you do, not things you decide to do. If every time you drop off a patient, you change the linen, then this stops being an “issue”; it’s just part of the call, part of your routine.
Setting up habits takes work, but maintaining them takes none, and you’ll quickly find that the type of EMT you are is defined by your habits as much as your decisions. Although I’m a huge proponent of good judgment, critical thinking, and wide leeway for field providers to make good decisions, the truth is that much of our work is routine. And the more of your routine you can manage by habit, the more willpower you free up for the tougher stuff. This doesn’t tie you down. It liberates you to think bigger, and aim higher.
I was never explicitly taught to write documentation in school. It fell into the “They’ll train you how they want it when you’re hired” category, and all we got was a rough idea that there were a few common formats for writing your narratives.
I’ve experimented with a few different models, including the typical SOAP, CHART, and chronological formats. I don’t want to rehash the basics of how these work, because you’ve probably either learned about them or you will. However, on a regular basis I get coworkers peering over my shoulder and commenting on my own somewhat unusual style, so I thought I’d share it for anyone looking for something new.
The biggest change in my own narratives came when I moved to a service that wrote their documentation on computers. I have poor handwriting, write slowly, and don’t enjoy it; however, I’m a fast and comfortable typist, so once we switched from pencil to keyboard my narratives improved substantially. One of the early changes I made was a conscious effort to remove 99% of the abbreviations and shorthand; when typing, it’s usually just as fast to write it out fully, and it makes everything much more readable. (If you ever think to yourself that “everyone knows what YEOIOCRIPIDRN means,” attend M&M rounds sometime and listen to a room full of fellow EMS professionals try to puzzle it out.)
The goal with my narratives is to produce an easily readable, standalone document that tells the story of the call in a similar order to how I experienced it. Because our electronic PCR software includes separate sections to record details of the physical exam, vital signs, and so forth, I’m able to omit many of the nuts and bolts. What I do mention explicitly is all unusual findings, pertinent negatives, and whatever mundane details are necessary to knit the story together. One of the risks with the free-form chronological narrative is forgetting to include this or that assessment finding, but fortunately the ePCR prompts me for these things in other screens. Typically for EMS, documentation is one-half a record of patient care and one-half covering our butts; so although I try to minimize it, I also include some amount of standard butt-covering. This should be customized to what issues your own employer happens to care about. (I had one that insisted every patient be covered with two wool blankets in the winter; so, guess what ended up in the paperwork.)
I modeled my template on the discharge notes you find in hospital charts. I always found these to be pleasantly readable and professional; particularly if you start with the ED and admission note, read the hospital course, and finally the discharge summary, you have a great top-to-bottom view of what’s going on with the patient. I write chronologically, because it keeps the story understandable and because it allows me to show the order that things occurred, which is a central part of many calls; for example, we did X treatment, but then the patient began complaining of Y, so we changed things up to Z treatment — very different from if we’d known about Y from the beginning. However, I don’t adhere zealously to the timeline if it’s not especially relevant, so I’ll often group together assessment or treatment items for efficiency; as a result it’s often not too different from a loose SOAP or CHART format.
I’ll give three examples of hypothetical calls here: one routine transfer, one typical medical emergency, and one critical trauma call. This will seem wordy, but for many unremarkable calls the majority of the narrative can be written prior to arrival, simply leaving blanks for the bits you don’t know, then filling them in and fixing anything unexpected afterwards. (It’s helpful to understand how the actual PCR will print out once it’s completed and [in our case] faxed; this lets you know how it reads, what inserts where, and so on.)
Dispatched non-emergent to Waldorf Memorial Hospital (6 West) for discharge to Mumford Rehab.
Arrived on floor and met by staff, who provide paperwork/signature/report. Patient is Mr. Jeeves, a 73 yo male with hx of COPD and CHF, who presented with chest pain and dyspnea. He was found negative on cardiac enzymes with nonspecific ECG changes, admitted for further monitoring, and eventually underwent cardiac catheterization with no acute occlusions found. He is now stable and is being discharged to short-term rehab for gait training.
He is found in bed, alert and semi-Fowler’s, fully oriented with some general confusion, and denying acute complaints. There is some peripheral pallor, and non-pitting edema of the lower extremities. Vitals unremarkable, as noted above [note: in our ePCR, the vitals screen prints out above the narrative]. A locked IV is present in his left forearm.
He is transferred to our stretcher, secured with straps x5 and rails x2, and loaded onto A56. Transport routinely with monitoring en route. No changes in status during transport.
Arrived without incident, offloaded, and brought Mr. Jeeves to his room. He is transferred into bed and left in a low position, rails up, with his call button and belongings. His care and paperwork are transferred to staff.
Dispatched emergent to apartment in Malden for abdominal pain.
Arrived on scene to find Malden FD and PD with an adult female seated, alert. She is Ms. Bergerac, a 66 yo female with hx of NIDDM, who awoke 2 hours prior with general nausea, weakness, and abdominal pain. She describes the pain as 5/10, dull and diffuse, with a gradual onset over the past several days; she states the nausea has been ongoing over the same period, with the weakness new since this morning. She states she has been taking her normal meds, but has not eaten since yesterday due to the nausea. She denies vomiting, chest pain, dyspnea, headache, or parasthesias, and states she has felt normal with no unusual events up until several days ago. She denies any falls or other trauma.
She presents as fully oriented but slightly obtunded and slow to respond, and somewhat ill in appearance. Her pupils are midsize and PERL, and her lungs are clear and equal bilaterally. Abdomen is supple and non-tender with no visible discoloration, distention or mass. She is negative for arm drift, facial droop, or speech slurring, and demonstrates equal and unremarkable CSM x4. She is tachypneic, with an irregularly irregular radial pulse; her BGL is 46.
She is given 15g of oral glucose, which she tolerates well, and is transferred to our stairchair. She is brought outside, then transferred to our stretcher, where she is secured with straps x5 and rails x2. She is loaded onto A80 and transported non-emergent to House of God Medical Center with continuing assessment en route.
Repeat vitals note a BGL of 60 and minor increase in pulse. No other changes during transport.
Arrived without incident, offloaded, and brought Ms. Bergerac into the ED. She is transferred to a bed and left with rails up. Care transferred to RN with report.
Dispatched emergent to Denmark St. and Mulvaney Rd. in Waltham for an MVA.
Arrived with Waltham FD to find two vehicles in the center of the road. A small sedan has a heavily damaged back end with 2ft of compression; a midsize SUV is behind it with a broken windshield and crushed front left wheelwell. An adult male is found ambulatory, who states he was the driver of the sedan, with no apparent injury and denying any complaints. He states that he needs no care but wants his son evaluated, a teenaged male still in the front passenger seat, who also appears well and denies complaints. The father states they were struck from behind at unknown speed while stopped at a light. Both occupants endorse restraints, and there is no gross intrusion or airbag deployment. They are left in care of FD and a second unit is requested for further care.
An adult male is found in the driver’s seat of the SUV, slumped to the right against his seatbelt. He groans to painful stimulus but does not rouse. His skin is pale and cool, respirations are slow and irregular at 8/min, and radial pulse is thready and regular at 124. Breath sounds are grossly clear and equal. Oxygen is provided at 15LPM by NRB. An open abrasion is present on his left forehead, with blood found on the left upright support. There is no other obvious external trauma. A frontal airbag is deployed. There is starring of the windshield, seemingly from the airbag, and no other interior damage. ALS is requested.
The patient is manually stabilized and a C-collar is applied; he is rapidly extricated, exposed, and fully immobilized to a long spine board. He is placed on our stretcher and secured with straps x5 and rails x2, then loaded onto A104. (A11 arrives and assumes care of the other patients; see their runsheet for further.) Transport emergently to Intergalactic Trauma Center with continuing assessment en route.
Bleeding from the head wound is minor. There is diagonal bruising of the chest consistent with seatbelt trauma, and no other major bleeding or deformity. The trachea is midline and there is no appreciable JVD. Chest rise is equal bilaterally, the ribs are stable, and the abdomen is supple and without distension. Vitals note a BP of 184/100, HR 80, and increasingly shallow respirations at 6/min. A grossly dilated right pupil is also noted to develop en route. An OPA is inserted and well-tolerated. Ventilations are assisted by BVM with mild hyperventilation at a rate of 20/min.
P4 intercepts at this time and assumes dual-medic care.
[Documentation note: See PCR 121512 for full patient demographics, billing, and ALS care en route.]
Let’s just get it out of the way. As a Basic EMT, and to a slightly lesser but still very similar extent as a Paramedic, you are typically viewed as unskilled rank-and-file. You are more like the kid flipping burgers at Burger King than a nurse or a doctor. This is a consequence of supply vs. demand, low barriers to entry in this business, and minimal labor and political representation. I don’t think it’s right, but it is the way it is.
(Note: those working for fire departments and other public services may find that this information does not apply. If that describes you, I applaud you for your good fortune. But for the thousands employed with private services, read on.)
This is a difficult and personal subject for me. I’ve been employed with several ambulance providers, and I’ve been fired from more than one. There were various reasons, but in the end, there was one overarching reason, which is that I didn’t understand how to be the kind of EMT that employers wanted. The lessons that follow may not apply everywhere, but based on my experiences with numerous companies in two different geographical areas, they are generally more true than not, and if you’re newly entering this industry in a field position, they’re worth holding close to your heart.
First, understand that, as we noted, you are not a high-value employee. In fact, you are essentially a low-wage service worker, and you are largely interchangeable with anyone who holds the same certification. Moreover, the job market is currently Bad, and even when it was better, there were people out there who would do this job for free; in other words, even though demand for your skills is still reasonable, supply is very high. Although your service needs a certain number of EMTs and/or paramedics, and although they may perform some amount of screening or testing to find the best candidates (better employers will do more of this), as a general rule there is a limitless supply of people standing behind you, all holding the same card. And your company is just as willing to pay them instead of you.
Second, your employer is in the business of making money. Just like BK needs someone to flip their burgers, ambulance companies need someone to drive and tech their ambulances, so you are a necessary part of their business model. But you are far from unique or irreplaceable. Since it’s not very difficult to hire an EMT, it’s never very difficult to fire one and hire another. So if you ever become more trouble to keep around than you’re worth, you’re inching towards termination.
Third, and most importantly, the money is in the money. A principled and respectable private service will try to drive their financial success through clinical excellence, but whether they do or not, their financial success remains the bottom line. Your Lifepaks and MDTs may or may not get upgraded, but the marketing and PR is never in question. So if by your actions, inaction, or even by association you’re ever involved with something that jeopardizes your company’s revenue stream, you’re absolutely begging them to reconsider taking their chances on a fresh hire.
So, do you want to keep this job, be it briefly or for a long career? (Whether you should be taking advice from me is a fair question, but at least you’re hearing it from experience at the wrong end of every error.) Job stability in this field depends on three skills, and you don’t need them all. Pick any two and you’ll do okay. You might even sneak by with just one. But when the day comes that you don’t have any to protect you, your days are numbered.
1. Protect the Money
You can kill patients, break equipment, curse like a sailor, and drive rigs off cliffs, but if you can avoid impacting your employer’s bottom line, you’ll probably be fine.
Billing is big. Try your hardest to help generate billable runs, because getting paid for your calls is how money is made, and consistently interfering with this will bring you the wrong sort of attention. Whatever documentation hoops they ask you to jump through, as long as they’re not unethical or detrimental to patient care, just do it.
Furthermore, your company’s continued existence is predicated on maintaining certain contracts that it holds with cities, counties, hospitals, and other facilities. These contracts give your company the right to transport some or all of their patients, and that can mean many calls and many dollars per year. If you look unprofessional to someone important, piss off a staff member, or make a clinical error that comes to the wrong person’s attention, you are making the Powers That Be at that organization wonder if they shouldn’t be handing their patients and dollars to a different ambulance company. And that is numero uno on the list of ways to lose your job. Don’t think that the facts will save you, and don’t think that they’ll be reasonable or go to bat for you, because if being able to say “the people responsible have been terminated” is good for business, then nothing else will matter.
Play the game. If you’re asked to wash the truck with a toothbrush, wear a tie and a monocle, and give all of your patients free backrubs, just do it. Play the game, or someone else will.
2. Be Liked
They never taught you this in school (and school was where you’d have found many of us just before we became EMTs), but if the right people like you, nearly anything is possible. If not…
You don’t have to be universally popular, but you should not be “that guy,” because when push comes to shove, somebody with an office and a salary is going to have to decide whether you should keep working here, and if they never liked you to begin with you’re not going to have any armor.
Here’s the big, big secret. You may think that life should be fair, or at least employment should, and if you do your job and don’t screw up too big, there’s no grounds to fire you. In other jobs, you might be right. But we just saw that you hold no sway in these parts, cowboy. Moreover, in most places you were hired under a contract that included the words “at will,” which means they can get rid of you for no reason at all. (Wholly legal? Maybe, maybe not, but most of us won’t be bringing any lawsuits, because it’s a lot of trouble and being “the dude who sued” is not great for your future employability.) So here’s the way it really works: they can terminate anyone, or they can keep anyone. It all depends on what they want to do.
If you’re well-liked by the people who have a say, then you can screw up, and it will be water under the bridge. It may be documented and recorded, or it may simply be swept aside, but nothing will come of it. On the other hand, if you’re someone they’d rather no longer worked there, then you don’t even need to screw up to find your way to the chopping block. Because the fact is, nobody is perfect; even if you think you’re a company man, in the 40+ hours you punch each week, they can find a violation here, an error there, a complaint, a concern. If you ever start getting called to the deck for driving 26 in a 25 MPH zone or parting your hair left instead of right, update your resume, because this is known as “building a paper trail.” (If you’re lucky, maybe they have no problem with you yet, and they’re just preparing a case for the future. Some places are optimistic like that.)
3. Stay Under the Radar
This is the master key of maintaining your employment. Many people lack one or both of the previous virtues, but still keep their job for 10 years because they’ve got this one down pat.
If you’re hired today, and starting tomorrow nobody ever hears your name again, then your job is safe. Your name has to cross someone’s desk before they can tie you a noose. So if you’re ever going to screw up, just make sure that it’s never in a way that draws attention.
EMS is rife with uniformed men and women who show up, clock in, work their hours, and go home. They may be interesting people or boring ones, smart or dumb, up-and-coming or cheerfully stagnant. They may be loved or hated by their coworkers. They may even give bad care, write bad documentation, and draw ire in every ED they enter. But so long as it’s never the kind of thing to make anybody complain to the supervisors, then they’ll do just fine.
On the flip side, they might be a Super EMT, aces in every category, but if their name and face are constantly attracting the eye of the bosses, then they’re at best one or two steps from seeking new employment. Because being a bother is not a good virtue if you’re not valuable.
Truth be told, if you’re wise, then you’ll probably stay off the radar even for the most harmless reasons. No attention is good attention, not even asking to change a shift or replace a shirt, and while some of that is obviously necessary it should certainly be minimized. It’s a fine, fine art you’ve mastered when you’re hired as a new medic, and five years later nobody upstairs knows you beyond a vague sense that might work there.
There you have it. The big three.
You will notice that nowhere in the above list do I include clinical competence. For a long time, I believed that if you were a good EMT, that was enough to keep you safe — and if you were an exceptional EMT, that would even make up for a few things. This couldn’t be further from the truth. Possibly in a few cases, such as if you assist with training and continuing education, your knowledge and skills can be a feather in your cap. But as a rule, nobody in charge knows or cares about how good you are. You’re just one of the many EMT-Bs or EMT-Ps from the big group of identical licenses on the payroll. So if you think that being the fastest intubator in the West will protect you from violations of the Big Three, then you are sadly mistaken.
Indeed, this is yet another reason (you know, beyond the basic moral ones) to treat your patients and facility staff with respect and compassion. By and large, they don’t know if you’re any good at medicine — the patient in particular — but they know if you were a dickhead, and dickheads are the people they call and complain about. You can nearly kill someone, but if you smile, hand them a warmed blanket, and shake their hand, they’ll go away thinking you were the nicest young man they ever met. For all the great ideas on kindness and empathy in our favorite EMS book, Thom Dick’s People Care, it’s worth noting that its subtitle is not “How to Get into Heaven,” but “Career-friendly Practices for Professional Caregivers.” Career-friendly indeed.
It may sound like I’ve become a terrible cynic, but in truth, I think I’ve just come to understand the basic realities of the field we work in. We may wish the world were different, but we may also wish for a pet unicorn and world peace; things are the way they are, and the truth is that you should be able to maintain a long and successful career, providing the most outstanding care you can offer, if you simply learn how to stay employable.
One of the most common drugs we encounter in the field are various forms of anticoagulant and antiplatelet medications. These are relevant to our care both in their therapeutic role as well as in their adverse reactions and potential for harm.
Unfortunately, coagulation is a miserably complex process, and it has to be understood at least generally in order to understand these drugs. In the hope of making this less confusing, rather than throw a wall of text at you, the worker gnomes at EMS Basics have put together an illustrated video. View this, then read on — the drugs won’t make any sense if you don’t start with the physiology.
This form of teaching is a new frontier here, so any input or feedback is welcome. Due to both personal and technical failings, it didn’t turn out exactly how I’d hoped, but hopefully things will continue to improve in the future.
Now that we understand the process, we should talk about the drugs.
There are two major categories here: anticoagulants and antiplatelets. Antiplatelet drugs inhibit the initial step of platelet aggregation and adhesion, where they collect at the wound site in activated form and create a loose plug. Anticoagulants have no effect on this, but instead interfere with the production of fibrin, and therefore prevent a solid clot from growing.
As a general rule, the anticoagulants are rather more clinically significant, as far as their effects on bleeding.
Anticoagulants
First off, to be clear: tPA (tissue plasminogen activator) is not an anticoagulant of any shade. It is a thrombolytic; it attacks and degrades existing clots, dissolving their fibrin bonds. It has no role as a protective agent, and would be far too hazardous in such a role anyway; even its emergency use for acute events like ischemic stroke always requires careful weighing of benefit vs. risk — because the risks are significant.
With that said, there are two main anticoagulants we see frequently in the field.
Warfarin (Coumadin)
Coumadin is an old drug with an interesting backstory; one of its original uses was for rat poison. It’s given orally.
Nowadays, it’s mainly used for chronic anticoagulation of patients at high risk for embolic events. For instance, if you’re in atrial fibrillation at baseline, the blood in your atria isn’t being pumped downstream effectively, and tends to pool. We saw that brisk movement of the blood is one of the main ways we prevent clotting; A-fib is therefore a risk factor for hazardous clots. So when possible, these patients are covered by Coumadin or similar drugs.
The mechanism is interesting. Recall that for the activation of several factors, primarily in the extrinsic and common pathways (including thrombin and Xa), Vitamin K needs to be present. (For some factors, Vitamin K is also needed for the initial production of their inactive forms.) The process looks like this: in order for the factors to be activated, a second background process must also occur, where Vitamin K is changed into a form called Vitamin K epoxide. Once this is done, Vitamin K epoxide can be cycled back into Vitamin K, allowing it to be reused again for the next activation.
Coumadin prevents this second step. It allows the inital activation and conversion, but it blocks Vitamin K epoxide from being recycled to Vitamin K. So over time, as you use up available Vitamin K, it doesn’t get replaced, and you end up with less and less of it available. Less available Vitamin K means less activation of thrombin and its precursors, which means less fibrin, which means less clotting.
Obviously this process takes time. Since Coumadin has no effect on the active factors already present, if we start you on Coumadin today, it won’t have any effect for several days. We need to wait for currently circulating factors to degrade. So for newly anticoagulated patients, a more fast-acting drug is usually used to cover this loading period; heparin is common.
Other than its widespread use, warfarin is also famous for frequent misdosing. It has a narrow therapeutic index, where it’s very easy to give too much or too little, and depending on diet and other drugs, the appropriate dose can change daily. It therefore requires regular monitoring of the patient’s actual anticoagulation, which is done through a test called the prothrombin time (PT). This is a lab test that measures clotting time with an emphasis on the extrinsic and common pathways, and gives a result in seconds. Due to different PT tests available, a standardized result has been devised called the INR (or International Normalized Ratio). This is essentially a ratio of your clotting time over the standard clotting time; a normal result is therefore close to 1.0. Obviously, anticoagulated patients should have a longer clotting time, so 2.0–3.0 is more typical. Much higher than this puts one at high risk of bleeding — into the GI tract, into the lungs, into the nose and mouth, and if trauma occurs, the chance of significant bleeding is magnified. A too-low INR, of course, simply removes the benefits of protective anticoagulation.
In the event of overdoses that need reversal, patients can receive supplemental Vitamin K, as well as plasma (or concentrates) to replace the missing factors directly.
Heparin
Heparin is another old drug. It’s actually a biological substance naturally present in the blood, one of the body’s own anticoagulants, and when extracted for pharmacological use it’s derived from sources like pig intestines. Lovely. You can’t take it orally, so as a rule it’s given by IV.
Compared to warfarin, heparin has a more direct mechanism. Recall that one of the antagonistic factors that works to deactivate thrombin (as well as a few other factors) is antithrombin. Heparin, when taken in therapeutic doses, multiplies the effects of antithrombin by several thousand times. It therefore deactivates far more factors, which are then unable to produce fibrin. Thrombin and factor Xa are two of the factors most affected.
You can already imagine that heparin will probably work much faster than Coumadin. Aside from being given intravenously, it’s not simply stopping the influx of new Vitamin K and waiting for the old factors to degrade; it’s actually going in and deactivating them directly. In fact, heparin takes effect within half an hour or so. However, its half-life is short, so it’s often given as a continuous drip. Obviously, its usage is typically for acute events, such as acute coronary syndromes, or the bridging to Coumadin we mentioned.
However, there is another version of heparin that’s available. To briefly describe the chemical structure of heparin, it’s a polysaccharide, or a repeating chain. When we cook this stuff from pig parts, we end up with a collection of heparin chains in widely varying lengths. The problem is that only chains of a relatively long length will deactivate thrombin. So depending on the actual size of our heparin molecules, unaltered heparin — known as unfractionated heparin — can be fairly unpredictable in its effectiveness as an anticoagulant.
Even very short chains, however, will deactivate factor Xa, and since Xa is a necessary precursor for thrombin, this has the same effect. So if we can produce an artificial product that only includes short heparin chains, then it will mostly affect Xa rather than thrombin, and its effects will be more predictable. This is called low molecular weight heparin, and it has several advantages. It’s easier to manage, it requires less close monitoring, and it has a longer half-life. In fact, it can be given once a day by subcutaneous injection; for instance, post-operative patients can be taught to inject themselves and sent home with the ability to manage their own anticoagulation. Most of these LMWHs end in -arin: enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep) are common. Fondaparinux (Arixtra) is also used; although technically not a LMWH, it’s very similar in all respects.
Heparin can be monitored by testing the partial thromboplastin time (PTT), which focuses on the intrinsic and common pathways. LWMH can, if necessary, be monitored by testing levels of factor Xa. Overdose leads to bleeding complications, and in a few cases heparin can induce a disorder called heparin-induced thrombocytopenia (HIT), causing a paradoxically elevated chance of clotting. Super-therapeutic levels can be reversed by protamine sulfate, which binds to heparin and prevents its utilization.
Dabigatran (Pradaxa)
A few brief words on this relatively new drug, only made available over the past year or so.
Dabigatran is an anticoagulant from a wholly different class known as direct thrombin inhibitors. Unlike the somewhat roundabout pathways of warfarin and heparin, these drugs inhibit thrombin directly, and may therefore be somewhat more predictable and easily managed.
In the case of dabigatran, it’s being marketed as a replacement for Coumadin. Although supposedly just as effective for chronic anticoagulation, its claim to fame is that it requires no monitoring of INR, which would be a huge burden lifted from patients and caregivers.
Still very new, it remains to be seen how widely it will be adopted. The main concerns about it are: 1. Cost, and 2. Reversal. Unlike warfarin, which in the case of hazardous events (the proverbial bonk-to-the-head with an epidural bleed) can be readily reversed by Vitamin K and fresh frozen plasma, there is no easy or clear method of reversing dabigatran. Some ideas are out there, but clinical experience remains scarce at this point. In any case, this drug isn’t too common yet, but you may start to see it more often.
Antiplatelets
Aspirin
Aspirin is probably in your medicine cabinet somewhere. It has widespread uses from analgesia to antipyretic effects, but also plays a role in platelet adhesion. It’s taken orally, although IV aspirin does exist, and is used both for chronic risk-reduction and acute treatment of coronary syndromes. This stuff is good enough that nearly everybody you know with wrinkles on their face probably takes it every day.
As platelets are activated and degranulate, one of the chemicals they release is thromboxane A2. It has several effects, including vasoconstriction of the immediate area and stimulating further platelet activation. However, it also promotes platelet adhesion by a pretty neat mechanism.
Remember fibrinogen? The inactive precursor of fibrin? Unlike some of the other inactive factors, this one has its own chance to be the star of the show. Fibrinogen can form a bond between activated platelets, attaching at their glycoprotein IIB/IIIA receptors and creating a link. This isn’t anywhere near as strong as a fibrin bond, but it’s enough to make platelets stick together and clump. Thromboxane activates glycoprotein IIB/IIIA receptors and allows the formation of these fibrinogen bridges.
Aspirin inhibits thromboxane release. Fewer fibrinogen bonds are formed, and less platelets adhere. Coagulation itself proceeds unimpeded, but there are fewer platelets in the clot to be married by fibrin.
Due to the widespread effects of aspirin, overdose is a complex subject. Altered mental status, neurological and cardiovascular signs, sensory disturbances (blurred vision or ringing of the ears), and GI problems are all possible. However, there are typically no obvious bleeding abnormalities. Treatment of acute toxicity can include attempts to limit the dosage (such as gastric lavage and activated charcoal), bicarb, supportive care, and if necessary hemodialysis.
Glycoprotein IIB/IIIA inhibitors
This mouthful of a name is another class of drugs from the antiplatelet family. They’re typically not used chronically like aspirin; one reason is because they’re given intravenously, with oral forms rarely seen. (Another reason is because they’re simply stronger drugs). We see these most often used during and after known coronary “events,” such as a STEMI, NSTEMI, or a coronary catheterization, at which times they can help prevent reocclusions.
Their mechanism is similar to aspirin. As we saw, fibrinogen binding to glycoprotein IIB/IIIA receptors helps bind together platelets and allows them to adhere and aggregate. GBIIB/IIIA inhibitors block these receptors by competitive binding, and hence prevent the fibrinogen bonds.
We rarely see these in the field, but common ones include: abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat). Adverse effects mainly involve bleeding.
Thienopyridines
Although there are a few drugs in this class, by far the most common is clopidogrel (Plavix). Think of these as an alternative, somewhat more powerful aspirin; they work similarly, have similar effects, and are used for similar purposes. Like aspirin, some people use it chronically and it can be given in acute events as well. It can “stack” with aspirin for a synergistic effect, or be used in its place for those who cannot tolerate aspirin.
Once again, the mechanism will sound familiar. One of the pathways that activates glycoprotein IIB/IIIA receptors requires the binding of adenosine diphosphate, or ADP. (ADP is more famous as the product of ATP once energy is released, but it has its fingers in a lot of cellular pies.) The thienopyridines block ADP binding and hence discourage platelet aggregation. Prasugrel (Effient) is another drug in this class.
Adverse effects generally involve bleeding diatheses.
