As I was discharging the patient to rehab, she described the municipal EMS crew that had initially brought her from home with a fractured hip. “It took 20 minutes to get here,” she said, “and my house is only a mile down the road.”
Annoyed? Hardly. She couldn’t have been happier.
It’s well and good to be a really great driver. (In fact, if you ask me, it’s just about an essential skill.) Good drivers can push the efficiency of the “smooth vs. fast” curve, and this is important, because we want it both ways. But every now and then, you get a patient who simply needs to be transported at the distant, snowy left side of that balance. A patient who almost can’t be moved at all.
These are the patients with unfixated hip fractures. Or grim decubitus ulcers. Perhaps terrible, chronic back pain. Anybody who’s doing okay at rest, but experiences agony upon uncontrolled movement. Some of these are emergency patients, some are routine transfers, and a few of the latter may even be repeat customers while their problems gradually heal (or never do). Whoever they are, they’re patients you wish you could transport by either teleporter or hovercraft.
You touch them, and they scream. You move them, and they scream. You look at them vigorously, and they open their mouth to get ready to scream.
I can’t help you with extrication or getting them onto the stretcher; that’s your problem (or at least another post). But once you hit the road, there’s a solution. All it takes is patience. Here’s the formula:
Move to the rightmost lane.
Throw on your 4-way hazards.
Drive about 5 MPH.
Avoid every single bump.
Please understand what I’m saying here. I already know that you drive pretty well; you try to give your partner a great ride, and that usually means driving a little slower than you would in your personal vehicle. But for these patients, that’s still too rough. So you slow it down more, so you can pick a better path between cracks and potholes, and when you do hit a bump its effects are less dramatic. And that’s still too rough. So you slow, slow, slow it down. As slow as you need in order to completely negate the bumps, bounces, and turns. Your actual speed will depend on the quality of the road; on beautifully smooth, brand new city roads, you may be able to eke out 10, even 20 MPH. On particularly bad roads, with irregularities that look like speedbumps — or come to think of it, when you’re traversing actual speedbumps — you may literally be crawling along at about 1 MPH.
In most cases, you will probably find yourself driving with the brake pedal rather than the gas pedal. In other words, you’ll be lucky if your foot ever touches the accelerator; most of the time, you’ll “accelerate” by easing off the brake a bit more, and decelerate by pushing it harder. (Remember to ease in and out; in smooth driving, everything happens slowly!)
Obviously, this is only appropriate when you’re in no particular hurry. Critical patients need to move a little faster. Furthermore, your ability to execute this maneuver is somewhat dependent on how far you’re actually driving; the shorter the trip, the better, because a long trip taken at 1 MPH will end up lasting all week. The prototypical transport begging for the slow ride is the stable hip fracture from the nursing home, heading to the ED across town — not too far, but with nasty urban roads the whole way.
Other tips:
Other drivers will probably not be thrilled at this behavior. As long as there are multiple lanes, stay to the right, and they can go around. If you’re stuck on a one-lane road for a while, periodically try to pull aside and let vehicles pass.
Although it may seem smart to throw on your emergency lights, most drivers expect an ambulance running hot to be moving faster than traffic, not slower, so it generally causes more confusion than it’s worth.
At this speed, you have some real options for maneuvering. Mentally trace the double track that your wheels will describe on the ground ahead (remembering that your rear wheels may be slightly fatter, if you have “dualies” back there), and choose a route that places that path between the worst bumps. You can go left, you can go right, or you can straddle them.
When crossing a wide, straight barrier, such as a speed bump, railroad track, or the threshold of a ramp, try to “square up” first, striking it perpendicularly so you’ll make contact with left and right tires simultaneously. The back-and-forth rocking created by hitting it diagonally, resulting in asymmetrically bouncing across 1-2-3-4 wheels, is miserable no matter how small the actual bump.
Remember that the pain level of many unstable musculoskeletal injuries can be improved by smart, snug splinting. If you have time to drive like this, you probably have time to splint well — which may allow you to drive a little faster!
Although this may be obvious: paramedics, remember that you carry analgesics for a reason; Basics, remember that paramedics are available.
Pulling this off takes a little confidence, and a healthy dose of not giving a damn. And there will occasionally be roads or driving conditions that make it actually unsafe. But short of that, no matter how many stares you get, it’s a perfectly sensible maneuver, and one of the very best things you can do for these patients.
Update: Our friends at EMS 12 Lead have put together a “sister post” to this one, with further discussion and some additional clips. Check it out!
Although we’ve talked about the fundamentals of good CPR before (and then again), the fact remains that the first step of any resuscitation is recognizing the presence of cardiac arrest. In fact, failure to do this in a timely fashion is a common problem at all levels of healthcare: because these situations don’t happen often, we are reluctant to accept when they’re happening now. (Real emergencies don’t come heralded by a change in soundtrack.) The result is delays, often for many minutes, before anybody initiates CPR and attempts defibrillation. We can’t just point fingers at the bystanders and lay providers — it’s also the EMTs, the nurses, even the doctors doing this. “Is that a pulse?” we muse. “I think there’s a pulse. Here, come feel.”
It’s true that cardiac arrest, at least in the early stages, is often not easily distinguished from other maladies (such as unconsciousness due to seizure or drugs). A few clues may be immediately obvious, such as pallor of the skin if some time has passed, or if a bystander actually witnesses the patient suddenly collapse. However, in the end, the way to make this call quickly and reliably is to simply follow the algorithm. You’re not the first person to deal with this, and the American Heart Association has spent years simplifying the decision process — because the goal isn’t to eventually “figure it out,” the idea is to immediately recognize it and start lifesaving measures within seconds.
Is the patient responsive? (No; they appear unconscious, and make no response whatsoever to painful stimuli.) Are they breathing normally? (No; they’re not breathing, or merely performing agonal, “gasping” breaths.) Is there a carotid pulse? (No, no pulse is palpable within a few seconds.) That’s good enough for us. Start pushing on their chest and don’t stop unless it’s absolutely essential — and the only things that are absolutely essential are checking their cardiac rhythm (just a few seconds) and delivering a shock (less than a second).
We’re going to look at a number of examples of real-life cardiac arrest (or “codes” in the usual lingo). As a rule, the actual CPR that you’ll see here is of relatively poor quality. This is due to a number of factors, but primarily it’s because 1) Many of these clips are five, ten, or fifteen years old, from a time when CPR was taught and practiced differently; and 2) Even today, many people do not perform good CPR.
So: focus on the patients. Watch how they present, their breathing, their skin, their responses to the interventions. Watch the challenges that the providers face as far as managing the patient and the environment. Watch how their approaches differ by region, circumstance, or personal preference. But for the most part, do not do what they are doing. We’ll watch a couple examples of really good CPR at the end so you know what to strive for.
We’ve linked this before, and for good reason; it’s one of the best videos I know of a real code. This is older CPR, with less emphasis on compressions and more on ventilation, but otherwise fairly true to the textbook. Notice the early “activation” of EMS, and the brief pulse check. Notice how rather than trying to “one-man” the BVM, they take advantage of the many available hands, allowing one person to hold the mask and one to squeeze the bag. Notice how they quickly dry the chest for the AED without being obsessive about it. As for the compressions, nowadays we would like to see them faster and deeper, with fewer and briefer pauses.
In the patient, watch the spastic, gulping movements of the mouth and tongue; this is agonal breathing. Notice also the decorticate posturing of the upper body, suggesting neurological dysfunction. Finally, notice how (after the third round of CPR + defibrillation), he begins to breathe spontaneously, with obvious chest rise, and this is clearly different from the prior agonal respirations.
(watch through 8:45) Despite the numerous pauses for commentary, this is also good. The initial compressions are rapid — a little too rapid, which is okay, but not deep enough, and if they were deeper they would likely be at a more reasonable rate. The second compressor goes deeper, but does not recoil fully at the top. The third (male) rescuer gives perhaps the best compressions, but notice his elbows — although pushing hard and deep, he allows his elbows to bend slightly each time. This is a very common error in otherwise skilled compressors, and is a good way to fatigue yourself quickly. Make a conscious effort to lock the elbows out completely, allowing you throw your full weight behind each compression rather than “pressing” with the arms. Notice also how frequently the rescuers stop compressions for one reason or another. Chest compressions need to build upon each other for several compressions before you’re producing anything like the coronary perfusion pressures you want to see; repeatedly stopping and starting sacrifices all your hard work.
In the patient, notice the pallor (paleness) of his skin, and the total lack of tone (limp flaccidity) of his body. Notice how he convulses with the shock, and how his chest rises and expands with ventilations. Finally, notice how his abdomen recoils outward in a seesaw manner with each downward compression of the chest.
(watch through 7:10) This is a chest pain patient that codes on camera. Despite the low image quality, notice how poorly he immediately presents; he is obviously fatigued, wan, and struggling with some sort of pain or other internal distress. Upon attempting to stand, he loses consciousness and demonstrates agonal respirations (listen to the heavy snoring). They ask if he has a history of seizures; a substantial number of cardiac arrests are initially mistaken for seizures, and may present with seizure-like activity (such as foaming of the mouth). There is obvious difficulty with compressions due to the high position of the stretcher. Bubba was very fortunate to arrest in the immediate presence of paramedics.
(watch through 3:43) Notice again the initial hesitation due to bystanders believing a seizure is occurring. These compressions have the kind of violent depth we want, although at about half the rate. Notice again the slight arm bend.
A chest pain patient who deteriorates into a full arrest while on camera for a UK documentary. Depicts a good portion of the code.
[Added 5/8/13 — ed.]
(watch until the credits)
ED footage of EMS bringing in a code. Shows the practice of “code surfing,” where a rescuer rides the stretcher to provide ongoing compressions during movement — a great idea if you can do it safely and effectively (it helps to use someone small!) Notice how fast some of the compressions are performed, but it’s tough to reach good depth at those rates, particularly when the arms aren’t held straight. Although the captions note that the patient had ROSC, it’s extremely unlikely that he survived to discharge; when patients are transported without achieving ROSC in the field, they almost never walk out of the hospital. Cardiac arrests are worked on scene; transport without a pulse is simply giving up, unless you have good reason to think there’s a reversible etiology of arrest that the hospital can address.
[Added 8/21/12 — ed.]
(watch through 12:05, or stay for some bystander interviews) Another near-drowning. Decent-looking compressions and a reasonable attempt to minimize interruptions, although notice the pauses for intubation and at various other times. Unknown outcome.
(watch through 2:25) This is a volunteer crew from AMR’s disaster response team in Haiti. There seems to be initial confusion about whether the patient is pulseless or merely apneic, hence the initial focus is on the airway; nowadays we would frown upon interrupting compressions for intubation, and the bagging after the tube has been placed is far too fast (every 6-8 seconds only, please). The teamwork is good, and return of spontaneous circulation (ROSC) is achieved after a few minutes. Notice the decision to defer a blood pressure measurement, since the patient has a strong radial pulse — an indicator of a decent pressure, if not an exact number. The patient does have fixed and dilated pupils, indicating a probable poor neurological status.
Keep watching only if desired; the patient is transported to the field hospital, where she rearrests, and the doctor there halts resuscitation efforts.
http://www.youtube.com/watch?v=0CimS2HZKyQ&t=1243
(watch through 23:50) This is a neonatal resuscitation immediately following a field delivery of twins; one infant is apneic following birth. BVM ventilations and compressions are performed, as well as an aborted attempt at intubation; however, in the end the neonatal fundamentals of warming, suctioning, stimulation, and supplemental oxygen end up effectively reviving the child.
[will not embed; click through to view video then return] Another infant resuscitation, this one in the ED. Excellent footage of compressions, ventilation, and the typical hubbub of a code, as well as an IO (intraosseous) line that infiltrates and the use of ultrasound to assess for cardiac function during PEA.
http://www.youtube.com/watch?v=oNv848sBbRY
CPR on a near-drowning. A fine example of the typical poor quality of bystander compressions; notice the negligible depth and general uncertainty about whether to intervene.
A collapse at a sporting event. There is no backstory available on this, so it may not be a true arrest, but if so it would be consistent with commotio cordis, when a blow to the chest (such as a punch) causes an arrhythmia (due to an R-on-T induced by the physical blow; this is the evil brother of a precordial thump, with the opposite effect). This type of arrest has extremely good prognosis for recovery if immediate CPR and defibrillation is performed, since there may be little to no underlying disease; it’s a healthy young patient who simply got whacked wrong.
http://www.youtube.com/watch?v=A-GM301zW1A&t=2
(watch through :38) Some brief miscellaneous footage of an arrest post-drowning, with a few pretty good compressions.
http://www.youtube.com/watch?v=bIYywQioAb8&t=5
(watch through :57) Another near-drowning. Nice compressions. Notice the pallor and lack of tone.
https://www.youtube.com/watch?v=sjoKuBTvxvU&t=61s
[Added 10/11/13 — ed.]
This is clearly an old video, although it’s not clear from what year. Regardless, it’s a great opportunity to list the things you’d do differently today. Since we know that the keys to a successful resuscitation are immediate, deep, fast, uninterrupted compressions, along with rapid defibrillation, do you think this patient had a good outcome? How many of the interventions they performed instead of that stuff are still recommended care? If you were on that scene, would you be an advocate (some might say a CPR Nazi) to ensure that things were done properly?
Finally, let’s look at a couple examples of really spot-on, perfect resuscitation. Since perfection is rare in life, and having a camera in the room is even rarer, these will be simulations.
Click here for a teaching video from the Austin/Travis County medical director’s office. It demonstrates their “pit crew” model, where each member has a designated role, and each action is carefully crafted to match the latest evidence for best practices to promote survival. Notice how compressions begin almost immediately, once the rescuers have noted a lack of responsiveness, breathing, and pulse — and compressions stop for almost nothing, no matter what else is happening. (I would call these compressions very good, but a bit fast and shallow.) Secondary tasks like bagging can happen in the background. This crew does stop compressions while the AED charges, while I personally prefer to compress during this interval (between analysis and shock); the longer you delay between last compression and delivery of the shock, the less chance of getting a pulse back.
(Watch from 2:45 onward) This is the model from Salt Lake City Fire, portraying a highly progressive model. Aside from the general concepts of “compression-centered” resuscitation and the pit crew model, they’re also eliminating pauses for rhythm analysis (using the “see-through” filter on the Zoll monitors, which removes CPR artifact) and even for defibrillation (shocking without taking hands off the chest, which has not been proven safe, but generally seems to be). In other words, there’s essentially no interruption in compressions until there’s evidence of a perfusing rhythm. Notice the compression technique, where knuckles remain against the chest to lock-in the hand position, but the heel of the palm comes off at the top, ensuring full recoil. Beautiful stuff.
There you have it, folks: what dead people look like, and what it looks like when we try to bring them back. Typically the process is chaotic, and we do our best, but often drop the ball on what’s important. Nobody’s perfect, but we can direct our focus toward the pieces that matter the most, and this lets us “streamline” our efforts away from the distractions and toward the critical elements. Recognize the problem early, compress hard, deep, and fast, and don’t stop for anything unless it’s defibrillation. Ain’t so hard, is it?
Sincere thanks to James Oz (Melclin) for assistance with compiling these video clips.
Although these things are connected, they aren’t the same.
Some of the most common advice a new EMT might hear is to be more confident. And it’s justified: the typical new guy looks and behaves like a scared bunny, and it’s perceivable by everyone around him. You can’t be an effective field provider that way. Other responders won’t take you seriously, patients will decide they’re better off taking the bus, and other medical personnel will mentally delete your input. You won’t make the right decisions, because you won’t have the confidence to commit to them. Plus, your shifts will be nerve-wracking, and your hair may fall out. No good.
Oddly enough, though, this isn’t the worst-case scenario. Worse still is this: you’re supremely confident… even though you’re clueless.
Confidence is a statement. It says to the world, “Don’t worry, I know what I’m doing.” In response, they grant you further responsibility. “If this guy knows what he’s doing, then let him handle it,” they think.
If you project that message, yet are making things up as you go along, you’re telling a lie. You will be given responsibility, only to err terribly. You were trusted according to your level of confidence, but didn’t deserve it; your confidence exceeded your actual competence.
So, you need both. We want EMTs on the ambulance with the ability to assess, treat, and transport sick people. And we want them to demonstrate that they have that ability, by their words, body language, and appearance.
The good news is that confidence tends to grow from competence, which how it should be. As you learn the ropes, you become more comfortable, smoother in your actions, and more certain of your conclusions. Rest assured, you’ll broadcast this difference to everyone around you.
So where’s the problem? The problem arises when there’s an imbalance between the two qualities. Some people are just naturally “nervous-looking” or withdrawn; they may be entirely competent, but you wouldn’t know it by looking at them. These are the folks who need a slap on the ass, and to be told to throw their chest out, strut a little, and say it like they mean it. Even generally mousy people can usually learn to develop a “patient face,” a professional, commanding persona they wear during calls. (Think of your favorite medic… now think of his “medic voice.” Talk about heavy artillery.)
Conversely, some people are either overly confident in their abilities, or have simply been taught to fake it until they make it. (“A commander can be wrong,” as Arthur C. Clarke once wrote, “but never uncertain.”) In fact, some of the most difficult partners to work with fall into this category — the “newish” guy who can perform the everyday basics of the job, but whose cockiness swelled far beyond his actual knowledge, to the extent that he can no longer be educated or corrected. He knows it all, so he’s done learning. These folks need to be taken down a peg, because while ignorance is temporary, wrongness can last forever. If they’re simply afraid to admit when they’re unsure, it helps to reassure them that nobody has it all figured out yet, this is a team sport, and asking for help is much better than dropping the ball.
In the end, the goal should be supreme confidence, clearly palpable to those around you, yet directly built upon a foundation of clinical competence. If you’re good enough, you don’t have to put on a show; you can even hide your moves a little, because they’re going to come out anyway, and a certain amount of humility is professionally appropriate. (Plus, you won’t have to act like a douche all the time.) If you know your stuff but come up short in confidence, that’s your cue to start strutting a little more. And if you lack both, then start by developing quiet competence — not ignorant cockiness.
Bringing order to chaos. It’s hard to suggest a more important skill for an EMT.
Emergencies are chaotic. Heck, even non-emergent “emergencies” are chaotic. The nature of working in the field is that most situations are uncontrolled. Part of our job is to bring some order to it all, sort the raw junk into categories, discard most of the detritus, and loosely mold the whole ball of wax into something the emergency department can recognize. Call us chaos translators. This is important stuff; it’s why the House of God declared, “At a cardiac arrest, the first procedure is to take your own pulse”; and it’s why we walk rather than run, and talk rather than shout.
The thing is, it’s not just those of us on the provider side that need this. Oftentimes patients need it too. Imagine: every other day of your life, you’re walking around without acute distress, in control of your situation and knowing what to expect. Today, something you didn’t anticipate and can’t understand has ambushed you — a broken leg, a stabbing chest pain — and you don’t know how to handle that. So you called 911 to make some sense of it all.
Most ailments are side effects of other problems: the fear of going mad, the anxiety of being so alone among so many, the shortness of breath that always occurs after glimpsing your own death. Calling 911 is a fast and free way to be shown an order in the world much stronger than your own disorder. Within minutes, someone will show up at your door and ask you if you need help, someone who has witnessed so many worse cases than your own and will gladly tell you this. When your angst pail is full, he’ll try and empty it. (Bringing Out the Dead)
With some patients, this is more true than with others. With some patients, there may be little to no underlying complaint; there is mainly just panic, a crashing wave of anxiety, a psychological anaphylactic reaction to a world that is suddenly too much for them. Particularly in those cases, but to a certain extent with everybody, bringing that patient to a place of calm may be exactly what they need. I have transported patients to the hospital who clearly and unequivocally were merely hoping to go somewhere that things made sense.
The burned-out medic likes to park himself behind the stretcher, zip his lip, and allow things to burn out on their own. This may sound merciless, but there is a certain wisdom to it.
We are very good in this business at escalating the level of alarm. Eight minutes after you hang up the phone, suddenly sirens are echoing down your street, heavy boots are echoing in your hall, and five burly men are crowding into your bathroom. We have wires, we have tubes, we have many, many questions. What a mess. So sometimes, once we’ve finished ratcheting everything up, it behooves us to pause, step back, and make a conscious effort to turn down the volume.
Take the stimuli of the environment, of the situation, and dial it way back. One of our best tools is to simply get the patient away from the scene — the heart of the chaos — and into the back of the ambulance, where we’re in control. It’s quiet, it’s comfortable, and there is less to look at. Move slowly, consider dimming the lights, and whenever possible avoid transporting with lights and sirens. Demonstrate calm, relaxed confidence, as if there’s truly nothing to be excited about. Some patients with drug reactions, or some developmental or psychological disorders (such as autism spectrum), may be absolutely unmanageable unless you can reduce their level of stimulation. Just put a proverbial pillow over their senses.
If you’re stuck on scene, try to filter out the environment a little. If bystanders or other responders (such as fire and police) are milling around, either clear out unnecessary personnel or at least ask them to leave the room for a bit. Make sure only one person is asking questions, and explain everything you do before you do it.
There’s a human connection here, and if you can master it, you can create an eye of calm even as sheet metal is being ripped apart around you. Look directly into your patient’s eyes, and speak to them calmly, quietly, and directly. Take their hand. Use their name, and make sure they know yours. Narrate what’s going on as it occurs, describe what they can expect next, and try to anticipate their emotional responses (surprise, fear, confusion). If they start to lose their anchor, bring them back; their world for now should consist only of themselves and you. To achieve this you need to be capable of creating a real connection; it is their focus on you that will help them to block out everything else. Done correctly, they may not want you to leave their side once you arrive at the hospital; you’re their lifeline, and it may feel like you’re abandoning them. Try to convince them that the worst is over, and they’ve arrived somewhere that’s safe, structured, and prepared to make things right. They’ve “made it.”
Applying these ideas isn’t always simple, and learning to recognize how much each patient needs the volume turned down requires experience. But just remember that no matter who they are, no matter what their complaint, most people didn’t call 911 because they wanted things more chaotic. Try to be a carrier of calm.
On this most auspicious of Sundays, EMS Basics is one year old!
A year ago exactly, I threw this site into the EMS 2.0 blender <head>-first, giving me something to engage my brain between dialysis runs and hopefully teaching a few new and new-at-heart EMTs which way is up. Since then, we’ve made 81 posts on a variety of vaguely educational topics, and over 30,000 people have landed on our digital shores.
What it Looks Like: Agonal Respirations (because of support from my friend David Hiltz at the Facebook HEARTSafe page [which I help coadministrate, but have never “self-linked!”], but also because people like good visuals; the What it Looks Like series remains this site’s most popular)
All in all, it’s been a great year from my side of things, and I hope you’ve have gleaned something of value as well. It’s a truism that the best way to learn is to teach, but I can personally attest that even if nobody in the world had clicked in this site, it would still have taught one person a great deal — me. The research that goes into every post, and the actual act of developing and writing it, has made me a far better provider, never mind educator.
As we round this milestone, I want to call attention to a few shadowy figures behind the curtains. This site would not exist without the work of Dave Konig (The Social Medic), who runs the entire EMS Blogs network. Dave is a hard-working, incredibly selfless enabler and supporter who is now directly or indirectly responsible for the voices of over 20 EMS bloggers reaching the public eye, including some of the very best. He does this for no real pay (ad revenue comes back to us authors), minimal recognition (he’s out there plugging our sites, not his), and presumably no reward except the desire to help further the community. But today, for once, we should drag his butt out into the spotlight. Because although he didn’t invent the EMS blog, he’s done more to promote it than anybody else.
I also want to mention Tom Bouthillet. Tom has been a driving force in bringing the art and science of ECG interpretation back into the forefront of modern emergency care, and his website is one of the best resources available for anybody who makes clinical decisions using the electrocardiogram. It’s true that he’s been well-recognized for many of these efforts, including most recently a web series at FRN.com (go check it out!). However, he’s more than just an ECG wizard. (He also makes a wicked cherries jubilee…) As I hope this site demonstrates, I’m a real believer in the power of the web to educate and elevate those of us working in medicine. The key attributes that make such distributed training possible are: it’s free; it brings world-class experts directly to your screen; and it allows interaction and discussion that pools our collective resources. EMS 12 Lead and Tom’s other projects are an absolutely shining example of how this can work, and although he would not admit it even with thumbscrews applied, he has been a true role model to me. If I can reach half as many people in half as profound a way, I would consider this site an overwhelming success, but even my meager achievements wouldn’t be possible without his example.
Finally, I’d like to point a finger at David Hiltz of the AHA and HEARTSafe. David is an example for everyone who claims to serve the public with his utterly tireless, shameless, unflagging devotion to improving survival from sudden cardiac arrest. In any cause célèbre, there are those who dip their toes in, look for the easy gains, and jump ship when things get rough; but the people who watch them come and eventually see them go are the ones who get the real work done. If there’s one thing that’s true about cardiac arrest, it’s that most of the aces have already been played, the silver bullets deployed, and everything from here forward is going to be a slog. There’s little glamour or reward in that grind, and we should acknowledge the efforts of those pushing the millstones, because twenty years from now, it’s the fruits of their labor that we’ll be enjoying. Most of all, though, David is a generous and earnest supporter of small fry like myself, and I owe him a great deal for his help and guidance.
I hope to see you all in another year. Remember that if you have any questions, requests, or suggestions, my door is always open via blog comments or email. In particular, I love to hear what type of material you like to see — although I can get a certain sense from site traffic and links, it’s not always obvious, and what seems valuable to me may not be interesting to you. So stay in touch (the Facebook page is an easy way, and we share other interesting tidbits there too), and don’t go far — more good stuff is just around the corner.
It’s not very exciting, which is one reason we don’t seem very impressed by it in EMS. Also, I have a theory that most prehospital providers (probably most people in general, with the possible exception of those who have taken a microbiology course and seen gross things) don’t really, on a visceral level, believe in germs.
Whatever the reason, we really drop the ball on this one. Walk into your nearest Mega-Lifegiving Medical Center, where the best and brightest are using the latest and greatest methods to save lives every day, and look at the hand sanitizer mounted to every wall. Look at the giant signs reminding everyone to clean their hands, cover their nose with their elbow, and lock themselves into an airtight bubble if they think they’ve got the flu. Watch nurses exit patient rooms wearing full-body gowns, eyeshields, respirators, and gloves. Then watch the ambulance crew wander in wearing week-old uniforms, touch everything, scoop up the patient like a sack of potatoes, heave him onto a suspiciously gray and drippy stretcher, and do just about everything but lick the doorknobs.
Admittedly, one difference between us is that the hospital makes its money in part based on metrics that include the number of nosocomial (healthcare-acquired) infections it sees. But maybe that’s a good thing. If our billing started depending on how many patients we infected, suddenly we might start believing in germs. Just a prediction.
Why should we care about universal precautions? For one thing, to stay alive. Not long ago I transferred a nurse between facilities. She was being admitted to a medical floor for a massive MRSA-colonized abscess on her cheek; it had been surgically incised and drained, and she was now beginning a course of antibiotics and further care. The cause? She’d idly scratched her face one day at work.
For some reason, I find this argument unconvincing to many of us EMTs and medics. I suspect that, as usual, we consider ourselves immortal. Whatever the case, if you find it compelling, go with it, but otherwise, try its mirror image: precautions keep your patients alive.
You may be a romping, stomping, deathless badass. You’re 18, you take your vitamins, and you’ve never been sick in your life. Staph tells stories about you to scare its children. But your patient is elderly, takes immuno-suppressant drugs, and has leukemia coming out of his ears. How’s his immune system? Do you want to find out?
He’s the reason that the hospitals have become so paranoid about cross-contamination — because this guy is right across the hall from a guy infected with Ultra-Virulent Pan-Resistant Skin Melting Brain Bleeding Disease, and it’s very, very easy for staff to touch one of them, then touch the other. Or touch the doorknob, which someone else touches, who then touches… etc. This is why hospitals are such dangerous places for sick people.
That’s why I’m not particularly paranoid about germs in my everyday life, but I try to bring a little paranoia to work with me. Because our patients may pass through many medical hands, but most of those hands are now climbing aboard the sanitation train. Yet the system is only as good as the weakest link, and especially when it comes to interfacility transfers, EMS may very well be that link. We wear the same uniform from patient to patient (if not from day to day), we don’t always replace linen or clean the stretcher, and equipment — never mind the ambulance itself — gets decontaminated far less often than after every call.
And perhaps, due to the nature of our work, some of this is necessary. We work in a more difficult and less controlled environment than the ICU, and maybe we can’t maintain exactly the same standards. (This argument is less convincing when it comes to non-emergent, routine transfer work, though — particularly when a patient’s infectious status is already known.) However, there are some things we can do that are easy, routine, and when introduced into our habits, create essentially no added work.
Number one is hand hygiene.
Whenever possible, I wash my hands after every call. It’s no burden. If I’ve delivered a patient to a hospital or other facility, I simply find the restroom (which I probably want anyway, because my bladder is the size of a grape) and wash. Many times a sink may even be available in the patient’s room.
The proliferation of waterless hand sanitizers, usually alcohol-based foams or gels, has given us an alternative to this. When there aren’t any sinks, it’s the only way. But I don’t like ’em. They leave a residue that’s palpable, and which smells — and if you’re planning on eating anything, tastes — foul. They are also, in many cases, literally less effective. Although alcohol and similar agents kill most microorganisms, they don’t kill all of them (Clostridium difficile and the norovirus being notable exceptions), and like all contact sanitizers, they disinfect but do not clean. Any gross dirt, grease, or other contaminants on your hands (and this includes particles that are “macro”-sized but still too small to see) can cover or encase microbes, preventing antiseptics from reaching them. Unlike contact sanitizers, washing with soap and water is an essentially mechanical process: you are physically rinsing contaminants away from your skin and down the drain. (All that the soap does is “lubricate” hydrophobic particles to make them easier to rinse off.) Some soaps now are “antibacterial,” meaning they contain a germ-killing substance as well, but it’s not clear that these do any better of a job for routine purposes, and they may contribute to drug resistant strains. (They do, however, leave a microstatic coating on your hands afterwards, which helps to keep things clean a little longer.) Either way, most soap in healthcare facilities does contain an antimicrobial agent. In any case, I use the waterless sanitizers only when soap and water aren’t available.
Proper handwashing isn’t hard, but since it requires mechanically washing each portion of skin, it helps to have a system or you can easily miss spots. If you’re scrubbing in for surgery or a similar sterile procedure, you’ll need a much more stringent method than I use — but you’re not going to practice that ten times a day. So I use an approach that hits essentially the whole hand with as few steps as possible. Once you have the basic pieces in place, you can then do it fast for a routine wash, or spend much longer on each surface if you know that your hands are funky.
Here’s how I like to wash. It may seem elaborate or awkward at first, but with a little practice it’ll become second nature.
The same method can be used with waterless sanitizer. In the past, frequent washing tended to dry out your skin and lead to cracks (great windows for infection), but nowadays most soap in the hospitals contains moisturizer to prevent this.
A few points to remember:
Washing is a mechanical process! Mere contact with soap doesn’t clean anything. If you didn’t rub an area of skin at least briefly, you didn’t clean it.
Use warm water. Cold is a less effective solvent, and hot abuses your hands.
If you’re also using the bathroom, consider washing before and after to avoid contaminating your… important areas.
Drying with a towel is part of washing: it helps physically clean the hands, and wet hands are microbe-magnets.
Although I don’t religiously practice the turn-off-the-water-with-the-towel technique, if you know that your hands were grossly contaminated, it’s a good idea; remember that whatever was on your hands before you washed is probably now on the knob.
In an ideal world, we probably wouldn’t wear watches. In the real world, just try to be aware that it’s a great shelter for contaminants, and find a way to clean it (watch and band) regularly.
Cops are gruff and authoritative. Librarians are helpful and a bit bookish. When a plumber bends over you can see his crack.
We’re all sophisticated and modernized folks here, so we understand that stereotypes aren’t true. Moreover, their broad, unthinking application can lead to many errors and evils.
Still, there’s often a certain amount of truth to them, or at least a systematic error behind them, and it can be worthwhile to ponder on this kernel. Why, for instance, do we associate certain personalities and affects — certain demeanors — with certain professions?
There are doctors of every shade out there, but what do you typically expect when you meet one? Probably his shoes are tied (and even polished) and he looks well-groomed. He shakes your hand and looks you in the eye. He listens carefully, expresses himself clearly, and generally presents the image of a serious and dedicated professional.
Nurses? Again, there are more varieties here than at any Baskin-Robbins, but we find that some traits are common. A bit hurried and no-nonsense, you might say, and a little feisty. Yet deep down, they’re caregivers at heart. And they wear comfortable shoes, and they dig free coffee.
My point is, we have these stereotypes because to a certain extent, the jobs dictate, demand, and develop certain types of behavior. The physician spent twelve years working towards this job title, a large portion of which was spent either trying to get himself accepted somewhere important or being instructed on how he should look, talk, and think. The nurses, they spend eight hours a day walking quickly from bed to bed, playing middleman between the vagaries of difficult patients, difficult doctors, and difficult bureaucracies. Imagine how you’d behave.
So, once we’ve put in enough time that we’re walking the walk and talking the talk, how do we behave in EMS?
Mostly, we behave with a kind of breezy insouciance. One part humor, one part world-weariness, one part quiet competence (if not outright cocky arrogance), and a large dash of sarcasm and cynicism (which we hopefully remember to switch off when we meet patients). We strive to be the kind of people whose panic-o-meter has no readings higher than Hmm…
We are unflappable; we’ve seen it all, done it all, and the only thing crazier than the stories we hear in the crew room are the ones we try to top them with. We are generally unimpressed. We haven’t run toward or away from anything since high school gym class. We happily eat our lunch after cleaning brain matter from our boots.
The prototypical paramedic rocks out to Journey en route to the call; he jokes with the patient and reassures them with casual self-assuredness; he easily improvises an IV using a cocktail straw and large safety pin; he’s businesslike and to-the-point with bystanders; and he flirts with the receiving nurse at the hospital. A hundred years ago he could have gotten away with wearing a cape and a sword; a hundred years from now he’ll probably own a jetpack. He is not quite a god, but he does understand if you got them confused.
As always, there are variations. But this is the basic mold of our kind.
Why are we this way? And is it a good thing?
In EMS, we do our work fast, and cut shallow. Most of our patient interactions last under an hour in total, which doesn’t leave much time for either nonsense or space-filling. Yet we also work with high-acuity, high-risk pathologies — heart attacks, major trauma, and so forth — that need to be quickly found, explicated, and managed. In the chaotic prehospital environment, our patient, our scene, and our course of care is often muddled with obstacles and red herrings; in order to function, we have to cultivate powerful and aggressive pattern filters that allow us to isolate the essential elements of a situation and pursue the key decision-points like an unshakable bloodhound.
The attitude also protects us, and perhaps it protects our patients. By skimming over the surface of every call and every patient, we never get dragged too deeply into the mud. As they say, it’s not our emergency, and if we acted like each emergency was a freak-out, we wouldn’t last very long. If we treat it like a laundry run, we can remain ready and in service for the next one. And the patients? They get the reassuring sensation of being cared for by someone who projects the message: “I’ve treated six people sicker than you already, and I haven’t even had my coffee yet.”
So is this a good thing? It clearly has benefits. But it has its negatives as well.
When we try to imagine behaving in the field like that well-tempered physician behaves at the bedside, the very idea seems bizarre to us. A swashbuckling air seems central to who we are; could we still bang through a full patient interview and physical exam in 120 seconds otherwise? Could we still concoct the same weird and wonderful solutions for our problems? C’mon, we couldn’t do this stuff by speaking slowly and wearing a cardigan.
And maybe there’s truth to that. But it’s also true that we lose something when we go this route. We lose a degree of professionalism, which affects our perception in the eyes of colleagues, patients, and the public. We lose the ability to form a certain type of bond with the patient, based upon a certain type of trust and respect; we gain a different sort of bond, but the loss is still real. And maybe, by standing too far back from the action and poking it with our toe, we also lose some of the compassion and humanity that make this job worth doing at all.
So I don’t have any prescriptions, and I’m not suggesting that we make an industry-wide effort to change our culture. But these are things worth thinking about, because automatic or implicit behaviors are the hardest to recognize, and the fact that we all do something doesn’t mean it’s the best thing.
As a reward for bearing with me on the very, very, very, very, very long journey through shock, let’s turn to a somewhat lighter topic. This is a perennial favorite on the online EMS haunts: what do ya carry in your pockets during your shift?
Personally, I’m of the belief that everyone on the ambulance should have at least a few essential items:
Gloves — a more or less essential tool, even if you don’t always wear them you should always be prepared to, and there’s nothing worse than needing to hunt down a pair when things are moving quickly. Sometimes I’m surprised at how many you can go through on a single call. I keep a handful in one pocket and a single lonely pair in another, so I have a “ready” set that can be easily grabbed without having to peel them off from the wad. Remember to restock your supply when the call is done.
Paper — something to write on. Although I find that I write down less the more experienced I become, this is still a non-negotiable tool. I’ve carried a variety of small pads, but nowadays prefer a stack of 3×5 index cards held together with a binder clip — they work better when you’re writing something to hand to someone else, which I often am (noting vitals to give to my partner, for instance). Cards are also useful for holding open the latch on self-locking doors, leaving notes, and various other miscellaneous tasks.
Pen — ’nuff said. Even if your service has gone mostly digital, an EMT without a pen is like a knight without a sword. Also useful for poking blood samples from catheters for glucometry, testing sharp peripheral sensation, and stabbing zombies in the eyeball.
Watch — admittedly not usually stored in the pockets unless you’re Mr. Monopoly. Other than mundane needs like determining when you get to go home, without a working timepiece you can’t properly take vital signs. (Pulling out your cell phone here is only one step better than recording your signs via x-ray “vital vision.”) Something durable, light, and cheap is recommended, but anything that counts seconds will work.
That covers the absolute essentials. But there are a few other items that I’d place just barely behind essential, including:
Flashlight — some sort of small but bright penlight usually works well. This isn’t a clinical penlight for examining pupils — you’d probably burn their jelly right out — but something bright enough for searching a night-time scene, finding things you’ve dropped, and otherwise navigating the darker areas of life. Quite essential on certain shifts and valuable at all times; I recommend something water resistant, with a clip. I like the Streamlight Stylus Pro.
Shears — for all those things in the world that need cutting, a pair of standard trauma shears can’t be beat. Aside from stripping clothes off your patients, with a firm grip these can cut anything including the horizon — seatbelts, wayward tubing, tape, whatever. They also come in handy for wedging into doors, holding open fuel handles, reflex testing, and chucking at angry geese.
Knife — most people seem to carry one, and there’s always one guy who asks “why? shears work better.” Shears do work better for most cutting, but a knife works better for prying, poking, scraping, or levering, and that’s typically how it gets called into use. In almost no case will a knife be useful (or appropriate) in a clinical role, but it seems to be continually called into use for the daily minutiae of EMS — opening packages, fixing equipment, and so on. An affordable but quality folding knife with a clip and a lock is a good choice, and I’m a believer in half-serrated blades — that way you have a smooth edge for prying or slicing, but also an aggressive edge to start cuts in tough materials. I use a Spyderco Delica, an old classic.
Phone — perhaps it shouldn’t be, but nowadays a good cellphone seems almost irreplaceable. I use mine to speak with dispatch or supervisors when the radio isn’t appropriate, to call medical control, occasionally to give ED entry notifications… to note door codes and other tidbits… it has a GPS when needed, and useful reference apps like Epocrates (which includes cool tools like a pill identifier)… you can Google to check drugs names or disorders you’re unfamiliar with… real-time language translators are available… the list goes on. See the DroidMedic for ideas on using these little multitaskers.
Stethoscope — most folks seem to own one, but they don’t always have it on them. If there’s one truism to this job, it’s that the times when the poop hits the fan are never the times you’d expect it to, so try and be prepared. Your service probably provides cheap scopes, which tend to be loud but poor at filtering out background noise, making them less than useful in a busy scene or ambulance. For better or for worse, a stethoscope is also something of an identifier for the medical professional, and can do much to convince the public that you Know Things. Littmann is the most famous and popular brand, but you can probably spend less on others if you know what you’re getting. If it’s not in your pocket you’ll probably forget it when you need it, so I like a model that’s fairly light and can lay flat; I use a Littmann Master Classic II, which has no bell (which tends to be difficult to use in the chaotic prehospital environment anyway) and as a result has a very low-profile head. Mine’s in the most obnoxious baby blue I could find and my name’s all over it, in an attempt to discourage light-fingered coworkers.
Finally, there are the things that aren’t particularly vital, but come in handy if you’re willing to stick them in a pocket somewhere.
Penlight — a standard assessment tool. Probably available in your bags or cabinets but it’s convenient to have one immediately available.
Extra pen — because pens disappear. I also like to carry a permanent marker for things like labeling unmarked BP cuff bags (put on a bit of tape and write on that — is it an infant cuff? adult cuff? a bunch of OPAs?), marking pulse points, and the like.
There have been other things I carried in the past, but nowadays this about makes up my pocket milieu, and seems to strike a good balance of utility vs. clanking like the Tin Man. (Some people like to store stuff on their belt, but I tend to find that a little silly.) I have a work bag with other junk in it, but that’s a topic for another day.
Anyone have other items they find terribly useful? The variety on this issue seems nearly limitless.
Although it may not be immediately relevant to most of us prehospital folks, the ongoing battle for supremacy in the world of IV fluids is a fascinating topic that’s worth following. We know that blood is the good stuff, but we remain interested in concocting an artificial fluid that can replace volume and mitigate the shock response — maybe even carry oxygen or support clotting — yet remain logistically feasible for everyday use. The current contenders are:
Normal Saline (aka NS)
Probably the most common fluid used today, this is nothing more than sterile water with .9% NaCL (table salt) dissolved in it. This amount of solute more or less approximates the concentration of our body’s water, which makes normal saline “isotonic”: its tonicity is approximately equal to our cells, making its osmotic pressure very low. In other words, it’s basically the same raw liquid we already have circulating, so its volume of distribution — the amount of saline that will leave the intravascular space, once we drip it in there — is relatively low.
That doesn’t mean we don’t lose a lot, though. Once it’s had a chance to settle out, quite a bit of infused saline will end up in the interstitial space. Typically this distribution will be in the ballpark of 1:3–1:4 — in other words, if we give a liter of saline, within an hour or so only about 250–300ml will remain in the intravascular space. Sicker people (who have problems like increased capillary permeability) have even higher volumes of distribution.
The benefits of normal saline: it’s very cheap. It’s very stable, lasting approximately forever on the shelf, and has minimal storage requirements. It’s compatible with every patient and every med. It’s easy to administer (any access will do, preferably large-bore).
The downsides: it carries no oxygen, impedes clotting, promotes inflammation, produces acidosis (called a hyperchloremic acidosis, since it’s secondary to the chloride content), and generally does absolutely nothing for you except increase the intravascular volume, and it does only an okay job at that.
Lactated Ringer’s (aka Ringer’s Lactate)
This stuff is basically normal saline with some extras. Like NS, it’s isotonic, so the volume of distribution is the same. But in order to mitigate the acidosis produced by NS, it’s got lactate added. Lactate converts to sodium bicarbonate in the blood, and bicarb is a strong base, so Ringer’s essentially comes “buffered” — it should have less impact on the pH. This is good, and large volumes of this stuff have a more benign effect than large volumes of saline. (Ringer’s also includes some other electrolytes, such as potassium and calcium, bringing it closer to the composition of blood serum.)
The downsides: for many prehospital services, the main “downside” is that they don’t want to stock multiple types of fluid, so once they’ve stacked NS on the shelves they’re done. Ringer’s is not as appropriate for general use, since it’s incompatible with some medications and contraindicated in some patients. There is also an old belief that it’s incompatible with blood products — that is, if you hang a bag of PRBCs on your Ringer’s line, the calcium in the Ringer’s will stimulate the coagulation cascade (PRBCs are usually stored by adding citrate, which prevents clotting by binding up calcium) and create emboli. This is now generally understood to be false.
Hypertonic solutions
Now we get into the more interesting stuff.
Remember we agreed that normal saline and Lactated Ringer’s are isotonic? What if we use a fluid that is hypertonic? This would mean that the fluid has a higher tonicity (more dissolved stuff) than our cells. Since the golden rule of osmosis is that water moves toward the space with the higher concentration of dissolved solids, adding hypertonic fluids to the blood — and hence making the blood hypertonic — will cause fluid to move from the intracellular into the intravascular space.
Why would this be good? Well, for one thing, it yields an awesome volume of distribution. Compared to the isotonics, distribution is actually reversed; we end up with more than we put in, not less. Infusing a liter of a typical hypertonic can yield an eventual volume increase of nearly 8 liters.
Isn’t it bad to suck fluid out of our cells? It would seem like it. However, for short-term use (such as emergency trauma care), the effects of this generally seem to be benign. In fact, there is some evidence that using hypertonic solutions may attenuate the inflammatory response associated with fluid administration — perhaps just because we don’t need to give as much of it.
So far, there’s insufficient evidence for the routine use of hypertonic fluids in the civilian world. So far, the research suggests that they’re “at least” as good as the isotonics. The military is another story, though; they love this stuff, because it’s light. Whether or not they should be doing that, in order for a combat medic to dump 4 liters of saline into someone, he’d have to carry 4 liters of liquid on his back — alongside absolutely everything else he’s going to need. Much better to bring some easily-portable 250ml bags of a hypertonic. It’s like an expand-o-fluid.
There are various hypertonics out there, including high-concentration salines (such as 3.0% — call it abnormal saline if you want to be cute) and others. So far nothing’s really landed on top, although mannitol is often used to suck fluid from the brain and cause “shrinkage” during cerebral edema.
Colloids
Saline is a crystalloid fluid because it’s water with small ions dissolved in it. The sodium (Na) and the chloride (Cl) are not like particles of sand, swirling around in there but too small to see — they’re fully dissolved and dissociated.
Colloids are different. A colloid is a large molecule, something too big to easily cross cellular membranes. These don’t dissolve in the same way; they’re more like ice cubes rattling around in your glass. Blood itself is a colloid, since it contains big molecules like red blood cells.
“If blood is colloidal,” the wags say, “why not try giving colloidal fluids?” Well, all right then.
One big benefit of this would be the volume of distribution. Since the colloidal solids can’t easily escape across the membranes, they remain in the intravascular space and hence keep the oncotic pressure high.
But they’re usually expensive. And tend to be more complicated (in indications and contraindications) than crystalloids. And can be more finicky to store. And for the most part, have been shown to be no better than crystalloids. Oh well.
Artificial oxygen-carrying colloids
Well, here’s a neat idea. Maybe an arbitrary colloid isn’t much good, but can we make one that mimics blood — can we come up with a fluid that actually binds and carries oxygen in the same sort of way as our red blood cells? If we could create such a thing, and if it were broadly compatible and not too expensive and had a reasonable shelf-life, it would be the next best thing to using blood and a major breakthrough.
We have created such things, either wholly artificial or derived from purified (usually cadaverous) blood samples. You can store them for ages, although they’re not particularly cheap, being new, on-patent drugs. So far they all seem to have little to no benefit in outcome — and often an increased rate of complications like heart attacks. Hmm. The search continues. (The trick may be to come up with something that shares more of blood’s qualities, such as positive-feedback binding, and maybe even some clotting goodness. We’ll see.)
Hypotonic fluids
Like half-normal saline! Good stuff, right? Wait, no. That would have a god-awful volume of distribution. Excellent, you’re paying attention.
Blood Products
You really werepaying attention! Full circle we come. Although blood is not all things to everybody, and has its own negatives and caveats, at the present date if you lose blood the best replacement is blood. Of some kind.
Of what kind remains a bit of a mystery. Men in white coats continue to play with different mixtures of red cells, and plasma, and platelets, and even various concentrates and precipitates of specific clotting factors. One of the latest miracle additions is tranexamic acid, which antagonizes natural thrombolytics (remember plasmin?) and seems to reduce bleeding. There are also cool devices, used mainly during surgery, that “salvage” your own lost blood, rinse it off, and give it right back to you, which obviously simplifies some things.
Of note is an approach to transfusion developed by the anaesthesiologists at Shock Trauma in Baltimore. They like to give PRBCs and plasma until you reach a reasonably permissive pressure. Then they bolus some opiate goodness (fentanyl is nicely controllable). This puts a brake in the patient’s compensatory catecholamine response — their clamped-down veins and arteries relax a little. Which drops the pressure again. So they give some more fluid. Which raises the pressure again. Then they give more fentanyl. Repeat repeat repeat. The end result? A well-resuscitated patient — with a nice pressure — but with a relaxed, normal vasculature — and a normal volume. It’s not hard to fill up a severely compensating patient; their pipes are tiny. But it’s also not as good as filling them up to a normal perfusing volume. Neat idea. (Plus, pain management or sedation for surgery is no problem with that much fentanyl on board!)
Best of all, of course, is simply not to lose the blood to begin with. Tourniquets have really made a resurgence, and many feel that at this date, nobody with reasonably timely medical care should ever die from an extremity injury — not if you can slap a tourniquet somewhere proximal and cinch it down until the bleeding stops. The military has led the way with this, as with the use of hemostatic agents — powders you sprinkle on (or, nowadays, often come pre-embedded in a dressing) which help chemically promote clotting when combined with direct pressure.
Okay, so where does all of this leave us?
We’re not sure. Despite decades of research into this topic, best practices remain uncertain. But the following are probably true:
Extremes are probably to be avoided. Too much or too little of anything is rarely good.
If there is any benefit for non-oxygen-bearing, non-clotting fluids in hemorrhagic resuscitation, it is likely limited to a supplemental or temporizing role.
Further evidence may or may not demonstrate a benefit from hypertonic solutions.
A really usable “instead of blood” fluid remains the holy grail, and is not yet available.
and most of all…
There are significant negatives associated with any fluid administration, so in order to produce real improvements in survival, any benefit must be substantial enough to outweigh this basic harm.
Thanks to everyone who stayed with us through this lengthy chat about shock! I want to give particular thanks to Dr. Jeffrey Guy, whose teachings were instrumental in forming the core of my own material.
To wrap up our story on shock, let’s discuss how to recognize it.
We all have some idea what shock looks like. Like many pathologies, its loudest early markers are actually indirect — we’ll often recognize the body’s reactions to shock rather than the shock itself.
Although there are a few ways to classify the stages of shock, let’s just use three categories here.
Early or Insignificant
Shock that is very early or minimal in effect may have no particular manifestations. One situation where significant or late shock may also be “hidden” is in the elderly patient, or anyone with significant comorbidities; if their body’s ability to mobilize its compensatory mechanisms is poor, then the red flags won’t be as obvious. This doesn’t mean the shock isn’t as bad; in fact, it means that it’s worse, because their body can’t do as much to mitigate it.
The way to recognize shock at this stage is from the history. If we see an obvious bullet hole in the patient’s chest, and three liters of blood pooling on the ground beside him, then it doesn’t matter how the patient presents otherwise; we’re going to assume that shock is a concern. Blood volume is proportional to bodyweight, but for a typical adult, a fair rule of thumb is to assume about 5-7 liters of total volume. (Not sure what a liter looks like? The bags of saline the medics usually carry are a liter; so are those Nalgene water bottles many people drink from. “Party size” soda bottles are two liters.) Losing more than a liter or two rapidly is difficult to compensate for.
Remember, of course, that blood can also be lost internally, and aside from the occasional pelvic fracture or hemothorax, the best environment for this is the abdomen. Always examine and palpate the abdomen of the trauma patient, looking for rigidity, tenderness, or distention. Remember also that the GI tract is a great place to lose blood; be sure to ask your medical patients about blood or “coffee grounds” (old blood) in the vomit or stool.
Fluid enters and leaves the body continuously, and any disruption in this should be recognized. If a patient complains “I haven’t been able to eat or drink anything in two days,” they’re telling you that they haven’t taken in any fluid for 48 hours. If they tell you they’ve been vomiting or experiencing profuse diarrhea, that’s fluid leaving their body in significant volumes. What about the man who just ran a marathon and sweated out a gallon? Did he drink a gallon to replace it?
Compensated Shock
Significant shock will result in the body attempting to compensate for the low blood volume. Much of this work is done by the sympathetic system, and there are two primary effects: vasoconstriction and cardiac stimulation.
By constricting the blood vessels, we can maintain a reasonable blood pressure and adequate flow even with a smaller circulating volume. We normally vasoconstrict in the periphery — particularly the outer extremities and skin — “stealing” blood from those less-important tissues and retaining it in the vital core. This causes pallor (paleness) and coolness of the external skin. The sympathetic stimulation may also cause diaphoresis (sweating), which is not compensatory, but simply a side effect of the adrenergic release.
The heart also kicks into overdrive, trying to keep the remaining volume moving faster to make up for the loss. It beats faster (chronotropy) and harder (inotropy), resulting in tachycardia. Note that patients who use beta blockers (such as metoprolol) may not be able to muster much, if any, compensatory tachycardia.
A narrowing pulse pressure (the difference between the systolic and diastolic numbers) may be noted; since the diastolic reflects baseline pressure and the systolic reflects the added pressure created by the pumping of the heart, a narrow pulse pressure suggests that cardiac output is diminishing (due to loss of preload), and that more and more of the pressure we’re seeing is simply produced by shrinking the vasculature.
Tachypnea (rapid respirations) are also typically seen. In some cases, this may be due to emotional excitement, and there is also a longstanding belief that it reflects the body’s attempts to “blow off” carbon dioxide and reduce the acidosis created by anaerobic metabolism. (Interestingly, lactate — a byproduct of anaerobic metabolism — can be measured by lab tests, and is also a sign of shock, particularly useful in sepsis.) Additionally, it ensures that all remaining blood has the greatest possible oxygenation. However, it is also plausible that this tachypnea serves to assist the circulatory system: by creating negative pressure in the thorax (the “suction” you make in your chest whenever you inhale) and positive pressure in the abdomen (due to the diaphragm dropping down), you “milk” the vena cava upward during inspiration, improving venous return to the heart and allowing greater cardiac output. This “bellows” effect helps the heart fill more and expel more with each beat.
The more functional the patient’s body is — such as the young, strong, healthy victim — the more effective these compensatory systems will be. Hence the old truism that pediatric patients “fall off a cliff” — they may look great even up through quite profound levels of shock, due to their excellent ability to compensate, then when they finally run out of room they’re already so far in the hole that they become rapidly unhinged. It’s great that these people can compensate well, but it does mean we need to have a high index of suspicion, looking closely for signs of compensation (such as tachycardia) rather than outright signs of shock — because by the time the latter appears, it may be very late indeed.
Patients in compensated shock may become orthostatic; their bodies are capable of perfusing well in more horizontal postures, but when gravity pulls their remaining blood away from the core, this added challenge makes the hypovolemia noticeable. Less acute shock due to causes like dehydration may result in dry skin (particularly the mucus membranes; try examining the inside of the lower eyelid) with poor turgor (pinch a “tent” out of their skin and release it; does it snap back quickly or sluggishly?), and potentially with complaints of thirst. Urine output will usually be minimal. Generally, the more gradually the hypovolemia sets in, the more gradually it can be safely corrected; it’s the sudden, acute losses from causes like bleeding that we’re most worried about.
Decompensated Shock
As shock continues, compensatory systems will struggle harder and harder to maintain perfusion and pressure. Eventually they will fail; further vasoconstriction will reduce rather than improve organ perfusion, beating the heart faster will expel less rather than more blood, and the blood pressure will start to drop.
The hallmark of this stage of shock is the normal functioning of the body beginning to fail. The measured blood pressure will decrease and eventually become unobtainable. Pulses will weaken until they cannot be palpated. As perfusion to the brain decreases, the patient’s mental status will deteriorate. Heart rate and respirations, previously rapid, will begin to slow as the body loses the ability to drive them; like a government office that can’t pay its workers, the regulatory systems that should be fighting the problem begin to shutter their own operations. As the heart continues to “brady down,” eventually it may lose coherence (ventricular fibrillation), or keep stoically trying to contract until the last, but lose all effective output due to the lack of available blood (PEA). Cardiac arrest ensues, with dismal chances for resuscitation.
Alternative Forms of Shock
Although we have focused so far on hypovolemic shock, particularly of traumatic etiology, there are other possibilities. A wide range of shock types exist, but speaking broadly, there are only two other categories important to us: distributive, and cardiogenic/obstructive.
Distributive shocks include anaphylactic, septic, and neurogenic. The essential difference here is that rather than any loss of fluid, the vasculature has simply expanded. Rather than squeezing down on the blood volume to maintain an appropriate pressure, the veins and arteries have gone “slack,” and control of the circulating volume has been lost; it’s simply puddled, like standing water in a sewer pipe. (Depending on the type of shock there may also be some true fluid losses due to edema and third-spacing.) Imagine tying your shoes: in order to stay securely on your feet, the laces need to be pulled snugly (not too tight, not too loose). If the knot comes undone and the laces lose their tension, the shoe will likely slip right off. Your foot hasn’t gotten smaller, but the shoe needs to be hugging it properly to stay in place, and it’s no longer doing its job.
The hallmark of distributive shock is hyperemic (flush or highly perfused) rather than constricted peripheral circulation. The visible skin is warm (or hot) and pink (or red), and the patient may be profoundly orthostatic. Septic shock is associated with infection; anaphylactic with an allergic trigger; and neurogenic with an injury to the spinal cord.
Cardiogenic and obstructive shocks are a different story. In this case, there’s nothing wrong with the circulating volume, or with the vasculature it flows within; instead, there’s a problem with the pump. Cardiogenic shock typically refers to situations like a post-MI heart that’s no longer pumping effectively. Obstructive shock refers to the special cases of pericardial tamponade, massive pulmonary embolism, or tension pneumothorax: physical forces are preventing the heart from expanding or blood from entering it, and hence (despite an otherwise functional myocardium) it’s unable to pump anything out. In either case, we can expect a clinical picture generally similar to hypovolemic shock, but likely with cardiac irregularities — such as ischemic changes or loss of QRS amplitude on the ECG, irregularity or slowing of the pulse, or changes in heart tone (such as muffling) upon auscultation. Pulsus paradoxus (a drop in blood pressure — usually detected by the strength of the palpable pulses — during the inspiratory phase of breathing), electrical alternans (alternating QRS amplitudes on the ECG), and jugular vein distention also may be present in the case of tamponade or severe tension pneumothorax.
In sum, remember these general points:
The history and clinical context should be enough to make you suspect shock even without other signs or symptoms.
The faster the onset, the more urgent the situation; acute shock needs acute care.
Look both for signs of compensation (such as tachycardia) and for signs of decompensation (such as falling blood pressure). However, remember that due to confounding factors (such as particularly effective or ineffective compensatory ability, or pharmacological beta blockade), any or all of these may be absent.
Distributive shocks are mainly characterized by well-perfused peripheral skin; cardiogenic/obstructive shocks are characterized by cardiac irregularities.
Interested parties can stay tuned for a brief appendix discussing fluid choices for resuscitation — otherwise, this journey through shock is finally finished!
