One more post about glucometry is pending, but for now, something lighter.
Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).
In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.
A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.
With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.
THE LAWS OF EMS
Help your patient in any way you can.
Be nice to everybody. It’s your job.
If you can’t save their life, make their day a little better.
Protect your partner.
Have a reason for everything you do.
Leave the patient better off than when they met you.
It should get calmer when you show up.
Good habits make doing the right thing easy.
Tomorrow, nothing will remain but your documentation.
Everything’s a bigger deal to the person on the stretcher.
But that’s just me. What laws do you believe in?
Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.
So we want to know how much glucose is in our blood. How can we determine this?
Most modern systems involve a handheld electronic meter, which accepts disposable test strips. The general method:
Insert a strip into the meter; this usually turns it on automatically, and the screen will indicate when it’s ready for a sample.
Clean the patient’s fingertip with an alcohol swab.
Using an automatic lancet (a spring-loaded needle), prick their finger-tip, drawing out a droplet of blood. You may need to push or massage the skin toward the puncture site in order to “milk” blood out, particularly if there’s poor circulation.
[Optional] Many services recommend wiping away the first drop of blood and drawing out a second for your sample.
Once you have a sizable, “hanging” drop of blood, apply it directly to the sample site on the test strip. It will wick inside and be absorbed.
The meter will usually display some kind of count-down. Once it’s finished analyzing, it will show the blood glucose concentration (BGL) in mg/dL or mmol/L.
Apply a band-aid to the site, and dispose of the test strip, lancet, and other bloody bits as appropriate.
What magic happens when you apply blood to the strip? There are a few methods.
(Skip this paragraph if chemistry wasn’t your favorite class.) As a general rule, the glucose in the sample is broken down by an enzyme (often glucose oxidase, or a version of glucose dehydrogenase). This reaction is proportional to the glucose concentration, and can be visualized by the accumulation of an indicator; the more glucose that reacts, the more color develops, and this is measured by a photometric transmission sensor. Alternately, in most current sensors, a more modern and somewhat more robust electrochemical method is used; here glucose is selectively oxidized, and electrons are pulled across a mediator to an electrode, which measures the current generated — either average, peak, or total depending on the type of analysis.
Results
Across the US, blood glucose is measured in the units mg/dL (milligrams per deciliter). In much of the rest of the world, the unit is mmol/L (millimoles per liter). This means that if your paramedic buddy from the UK is telling you about a diabetic he treated, the numbers may seem peculiarly low. Since we’re mostly Yanks here, we’ll be working in mg/dL, but if you ever need to convert to mmol/L, you can simply divide it by 18 (or multiply by 18 to get from mmol/L back to mg/dL).
Much like vital signs, textbook ranges for “normal” blood glucose levels vary. A loose range for practical purposes would be around 70–140, although ideally we should be under 100 most of the time, and routinely testing over 125 is not a great indicator for your health. Numbers will be elevated after eating, but non-diabetics still shouldn’t break 200 or so.
Although we’ll talk more about clinical interpretation later, in general it’s safe to say that the lower the number, the more each point matters. The difference between 70 to 50 can be profound, while the difference between 200 and 180 may be totally undetectable.
Accuracy and Precision
Glucometers have evolved through quite a few generations by now, and they continue to improve in robustness and reliability. Most diabetics use them regularly to track their sugar and thereby guide their diet and medications.
How accurate are they? Depends on who you ask. The American Diabetes Association says that at a minimum, they should give readings within 15% of the true value, and ideally manufacturers should shoot for an error of under 5%, at all concentrations. But percentages can be a confusing way to measure it, because as we observed, a 15% difference at a sugar of 500 (a possible range of 425–575) may mean little, while a 15% difference at a sugar of 60 (a range from 59, which is low, to 69, which is about normal) can be rather important. So the FDA says this instead: 95% of the time, for values below 100, meters should be within 20 points of the true value, while for values above 100, they only need to be within 20 percent.
Whatever the case, every meter varies, but generally they can be relied upon to fall within about 15% of reality, as long as no user errors or confounding factors (we’ll talk about those) are present.
Blood Source
Traditionally, capillary blood for glucometry is taken from the fingertips. This is painful, so most modern glucometers have been evaluated to determine their accuracy when blood is drawn from alternate sites. Any location with lean, vascular muscle close to the surface (i.e. not too much fat overlying, which you may not be able to penetrate with a lancet) can be usable — the forearm is the most common site. The research has shown that this practice is generally fairly accurate for routine purposes, but the danger is that BGL from the forearm lags behind that from the fingertips. It takes longer for these readings to approach reality — about 30 minutes, in fact, before you’ll read the same from the forearm as you’d read at the fingertip, and until then the numbers may be radically wrong (for instance, a reading of 145 when it’s really 50). So glucometer manufacturers recommend that diabetics always use the fingertip when there’s any question of hypoglycemia, when they’ve recently eaten, or any time when it’s important to have the most current and accurate figure. Obviously, this is always important for EMS, so we should generally stick to fingers.
On the other hand, in many areas it’s common for paramedics to start IVs and then use a drop of blood from the catheter’s flash chamber for glucometry. Briefly, like so:
A used catheter (needle inside)
The rubber stopper behind the flash chamber
Press on the rubber until a usable drop of blood comes out the end
This method works, saves you the trouble of lancing a finger, and spares the patient some extra pain. But it’s usually considered technically incorrect, because the blood in the catheter is venous, whereas glucometers are calibrated for capillary blood. See, since venous blood has already given up glucose to the tissues whereas capillary blood is still in the process of doing so, venous BGL is lower than from capillary sources — usually about 5–10 mg/dL. (If by chance you have a source of arterial blood, then that should be higher still.) However, after eating, particularly carb-rich foods, capillary sugar may be as much as 25% higher than venous, because of the extra glucose sequestered in the muscular tissue. (Stockpiling this fuel is why marathon runners like to “carbo load” before events.)
With that said, I’m going to make a controversial recommendation: in most cases, whenever it’s available, venous blood should be used instead of capillary blood. If someone has started an IV, then you should be using that instead of a fingerstick. Why? Despite the small and usually predictable difference, in sick people, it’s actually a more accurate result.
In sick people, circulation is often impaired; this is particularly true in situations like shock, sepsis, and the mother of all shock states, cardiac arrest. When perfusion is poor, the first thing we lose is the peripheral circulation, and it doesn’t get more peripheral than the capillaries of the fingertips. What does this mean? It means that in many acute patients, when it’s important to have accurate diagnostics, capillary blood sugars can be utterly, totally inaccurate. Since blood is no longer moving actively through the periphery, it tends to “pool” there stagnantly, letting the tissues chew through its glucose supply without resupplying it. This results in a falsely depressed capillary BGL even when the venous BGL is normal. Conversely, it’s also possible that in poor circulation, the distal capillaries are the “last to hear” about a drop in sugar, resulting in a falsely elevated BGL. But high or low — usually low — it’s not reliable. Anybody with impaired circulation should get a venous glucose if there’s a chance of it affecting care. (And if there’s no chance of it affecting care, then why do it?) By the way, this includes impaired local circulation, such as patients with PVD. Not that a diabetic would ever have PVD…
(Edited 6/12/12: A few commenters have pointed out that the practice of drawing blood samples from used IV catheters can present a safety risk; although modern safety catheters usually retract or obscure the needle, this is not a fail-proof mechanism, and pushing on the plunger can potentially lead to an accidental stick. We should all be sensible about this sort of thing, so be cautious and give a moment of serious thought to the conditions, equipment, and your technique before trying such a move — and of course be aware of any policies your service has on the subject.)
Coding and Calibration
The important business during glucometry is taking place in the test strip, where the actual chemical reaction occurs. Since this is a rather minute organic event, individual test strips tend to vary a little in their performance.
Traditionally, this is handled by lot coding. Each batch of strips (they come in packs of so-many) would usually include an electronic coding strip, which looks like a regular test strip, with some extra electronics attached. You insert it into the meter, and it automatically calibrates it for the current lot. If your device works this way, it is essential that you code your meter for the lot you’re using, and do not mix your strips with those from other lots; your results can be off by over 30% due to using the wrong code. However, many current glucometers no longer require coding, either by automatically self-calibrating using information in the strip itself, or by controlling manufacturing tolerances so that all strips are the same. Read the manual or check your policy!
Now, is a rose a rose, or are there different BGLs out there? Really, there are two that matter. When we prick the finger and sample capillary blood, we’re measuring the glucose concentration in whole blood — the raw, unmodified stuff running through your veins. We could also take that blood, centrifuge out all the big cells (particularly red blood cells), and measure the glucose in the plasma that remains. This latter method is how it’s done in the laboratory, and this is the gold standard for this type of test. (In the handheld glucometer, the test strip usually uses a filter to either absorb or lyse the red cells, but their presence still affects the measured concentration.)
Why does this matter? Only because whole blood BGL differs slightly from plasma BGL. Since the number is a concentration, and the presence of hemoglobin slightly dilutes the blood, plasma values are typically 5-15% higher than than whole blood values. In most of us it’ll be about 11%, but the exact difference depends on how much space your red blood cells are filling up, aka your hematocrit, so that estimate only works for people with a normal “crit” (around 45). The higher your crit, the larger the difference (and the levels of other circulating lipids and proteins can be relevant as well). The good news? In order to make home BGL readings comparable to laboratory readings, most glucometers report results as a “plasma equivalent,” either by assuming a normal crit and performing a quick mathematical adjustment, or by actually measuring the hematocrit. Some meters can be set to display either whole-blood or plasma equivalents, and ideally we should know which we’re looking at, but plasma is usually the default.
Ketones?
We know that when hyperglycemia becomes severe, the body often develops high levels of ketones in the blood and urine. (These are involved in a secondary metabolism that cells can use as an alternative to directly consuming glucose.) Lots of ketones in a diabetic is a corroborating sign of a highly elevated sugar, and suggests deterioration to diabetic ketoacidosis, a dangerous state involving a deranged pH.
There are handheld meters that can measure ketone levels, but simple glucometers can’t. However, many models have a feature where, if BGL is found to be over a certain level (often around 300), an indicator will light up with a warning like: ketones?
This is not indicating that ketone bodies are present, which the meter can’t know, but is merely a reminder that at these glucose levels, we should consider the possibility of their presence. Which, as clinical wizards, we already knew, so it doesn’t tell us much. (In fact, it’s more intended for patients, who may have the specialized strips with which to measure their ketone levels.)
Takeaway points:
Glucometry can vary by around 15% even when it’s working correctly.
Use venous blood (e.g. from an IV) rather than capillary blood (from a fingerstick) whenever possible.
If using capillary blood, use a finger rather than alternate sites like the forearm.
If your meter needs coding, make sure you do it.
Remember that many conditions (such as shock, PVD, and a recent meal) can alter capillary BGL, and some (such as anemia or hyperlipidemia) can even alter a venous reading.
Ordinary glucometers don’t measure ketones.
Tune in next time for a discussion of more clinical phenomena that can influence blood glucose readings, as well as interpreting and applying the results in real patients.
Editor’s note: Remember that although we often don’t cite specific references for our figures and data, if you ever want to know what studies or evidence we’re using to support our claims… just ask! We’re happy to oblige. This applies to all of our posts, but may be particularly germane for this one, where some specific and possibly controversial points have been made.
Glucometry — i.e. bedside measurement of blood glucose levels, usually from a capillary finger-stick — is an ALS skill almost everywhere, and in some systems it’s available to BLS providers as well. Even in places where it isn’t technically permitted for BLS, it’s often still widely allowed on a “wink and nod” basis, especially on mixed-staffing units where the paramedic has better things to do than apply droplets to test strips.
In other words, it’s something we do. Moreover, it’s something very valuable that we do. I work in a system that allows BLS glucometry along with various other “extras,” and if I had to give up all of it (nebulized albuterol, nasal naloxone, and more) to keep the glucometer, I’d do it in a heartbeat. It serves an invaluable and often irreplaceable role in patient assessment, and it’s used often, not sometimes.
As with any tool, though (such as pulse oximetry), intelligently using the device requires understanding how it works, how its results should be clinically applied, and when it fails. Unfortunately, this is rarely taught in depth, beyond perhaps a brief “How’s how you press the buttons” in-service. So let’s talk about glucometry. And talking about glucometry means starting with glucose.
Glucose Physiology
Practically speaking, glucose is the fuel of human life.
What’s a fuel? Imagine I’m starting a campfire. I build a pile of wood, I light it with a match, and it begins to merrily burn. As any firefighter (or Boy Scout) knows, a fire needs certain things. It won’t burn without a supply of oxygen. It won’t light without a heat source. And, of course, it needs something to actually burn — a fuel.
Although humans have a few different metabolic processes that allow us to survive in difficult circumstances, for the most part, we work the same way as the campfire, except our fuel isn’t wood: it’s glucose. We make a pile of glucose, mix it with oxygen, “light” it with some excess energy, and we’re rewarded with an outpouring of energy far greater than we put in. It’s called aerobic respiration, and almost all of the energy we need to live (sing, dance, hunt the mammoth, think about cellular metabolism, buy cheeseburgers) is generated in this way.
Glucose comes from food; in other words, we eat it. Glucose itself is a very simple sugar, and generally, we don’t literally spoon glucose into our mouths; instead, we eat more complex foods (like cheeseburgers), and our bodies break them down or transform them — either directly into glucose for immediate use, or into a form we can store (like fat), which can be readily broken down to burn later.
Remember, folks: the basic “fire” of life burns glucose and oxygen. We know that without oxygen, we quickly die. For the exact same reason, without glucose — we die. This is not optional stuff, and the only reason we survive longer without cheeseburgers than without air is because our bodies can store substantial amounts of fuel for later use, whereas we can only retain a few minute’s worth of oxygen. (We can also generate some energy through anaerobic metabolism, an “oxygenless fire,” but only very little; it’s a short-term reserve that burns out fast.) Every cell in the body therefore needs a constant supply of fuel to keep its machinery running, and this is supplied by glucose circulating in the bloodstream. Since this stuff is so important, our bodies are very good at monitoring the amount of circulating glucose, replenishing it from reserves when it’s low, and dumping it off when it’s high.
One of the main ways that this fine-tuning is done is using a hormone called insulin. Glucose needs to enter cells in order to be burned, but we want tight control on how much of it enters at any given time (since we need to keep enough circulating for the rest of the cells), so access is managed by a “lock-and-key” mechanism. To pass into most cells, glucose needs to “unlock the door” using an insulin “key.” Without insulin, we can have all the glucose in the world circulating through the blood, but it won’t be able to enter the cells hungry for it, any more than you can get into your house to feed your cat if you’ve lost your keys.
Diabetes
Now, let’s say that I have glucose in my blood. And I’m releasing insulin to let it access my cells. But my cells aren’t listening. It’s like somebody changed all the locks on me; we still have the key, but suddenly, it’s no longer opening the doors.
Why would this happen? There are various reasons, including genetics, certain medications, and a few diseases. But often, a key factor is habituation. If we keep our glucose levels elevated all the time (say, by eating a lot of rapidly-digested sugars), then our insulin levels will also be elevated all the time, and eventually, the insulin receptors on the cell membranes will say: “Boy, it seems like there’s a ton of this stuff around; I must be too sensitive to it. I’ll start ignoring some of it.” This is called insulin resistance, and it can range from mild (only some receptors of some cells are a little resistant) to severe (most cells are practically ignoring insulin). Unfortunately, this problem tends to exacerbate itself, because when our control centers see that releasing insulin isn’t lowering the circulating blood glucose as much as it should, we release more insulin, which encourages further insulin resistance… and so on.
The result of this is that more glucose tends to remain in our blood than we need: hyperglycemia. This isn’t a good thing; all that extra sugar zooming through our veins has a habit of piling up in the wrong places, which leads to strokes, heart attacks, pulmonary embolisms, DVTs, peripheral vascular disease, kidney failure, and more. It sucks, and it’s called type II diabetes mellitus. (Mellitus refers to sugar, and it distinguishes DM from diabetes insipidus, a totally unrelated disease.)
On the other hand, what if we can’t make insulin at all? Usually, this happens when our body’s immune system attacks the emitters that produce insulin, for unclear but unfortunate reasons. It usually begins when we’re young, and although it can be precipitated by various triggers, it generally happens more or less on its own. Whatever the case, if we can’t produce insulin, we’ve lost the key, and glucose can’t enter our cells. Without glucose, the fire doesn’t burn, and we die. It’s called type I diabetes mellitus, and without treatment, it’s always fatal.
Nowadays, type I diabetics survive by taking exogenous insulin — since they can’t make their own, we synthesize it for them, and they simply inject it. (They still make their own insulin, so most type II diabetics don’t need to inject the stuff; they manage their blood sugar through careful control of how much they eat. In some cases, however, particularly in the elderly or anyone who is less able to tightly manage their diet, type IIs will also use insulin to help adjust their levels.) How do they know how much to take?
There are ways to estimate insulin doses by, for instance, measuring how much food you’re eating, or from past experience. However, it’s also incredibly easy to misdose. Insulin is a powerful, powerful drug, and a small change in dose can mean the difference between bringing you to a normal, healthy blood sugar, and sucking every last glucose molecule out of your blood until you’re dangerously low — hypoglycemic.
Although hyperglycemia is unhealthy in the long run, and massive hyperglycemia can be an acute danger, even brief periods of modest hypoglycemia can be deadly, so it’s something to avoid. As a rule, the problem in diabetes is too much sugar, not too little, so left on their own, almost no diabetic would become hypoglycemic. However, since all type I and some type II diabetics take exogenous insulin, hypoglycemia happens all the time due to overdosing. In other words, we do it to ourselves — or to our patients — accidentally. (Even when type IIs don’t take insulin, they almost always take other drugs that help mitigate glucose levels or sensitize their insulin receptors, and some of these meds can also cause hypoglycemia.) Getting it right isn’t as easy as it sounds, because numerous factors can cause changes in your blood glucose and/or your insulin sensitivity; for instance, exercise depletes glucose (the hotter fire needs that fuel), so if you hit the gym and forget to eat more or to reduce your dose to compensate, you can easily deplete your available sugar and collapse.
The best way to get the right insulin dose is to accurately track your current blood sugar, and nowadays, this is done easily and quickly using a hand-held glucometer. Tune in next time, and we’ll talk about how they work and how to use them.
About a month ago I was solicited over email by a marketing agent working on behalf of Shoes for Crews, a designer and vendor of its own line of work shoes and boots. They offered me a free pair of their boots — my choice — in exchange for a review on this site.
I was, at the time, extremely reluctant and uncertain about this. I have very little to offer as a blogger and “authority,” and the small service I do provide is largely predicated upon my credibility; in other words, I may not know much, but I try to be as honest, impartial, and accurate with the small amount of information that I do provide. Taking free swag in exchange for kind words seems like a slippery slope at best. It’s more important to me to be able to, in the future, recommend a specific product because it’s worked well for me — without anybody wondering if I’m getting a kick-back for it — than to benefit from occasional free goodies.
I eventually agreed under the clear and explicit terms that I would write exactly what I thought, with no prevarication or white-washing. If I liked the boots, I’d say that; if I had reservations, I’d share them; and if I thought they had no role in EMS, then I’d say that too, and in that case their marketing effort would be counter-productive. They agreed to this, which I suppose was a calculated gamble.
So here’s the review. I doubt that this company will be sending me more boots, whether or not they appreciate this post, but in the future the same type of situation may arise, so I’m very eager to hear any opinions — positive or negative — on this practice. Does it leave a bad taste in your mouth, and make you less inclined to run your eye over our next volume on drug interactions or pulsus paradoxus? Or do you find this sort of thing useful?
The Company
Shoes for Crews is not a new company, although they’re new to me; they’ve been around for several decades now. Their claim to fame seems to be their slip-resistant soles, which use a patented tread-pattern and material to allow high traction in dangerous environments like wet floors or oil splatters. Their line runs from slip-ons to high-top firefighting boots, and the general theme is similar to Red Wings — basically footwear for working folks who are on their feet all day and need both comfort and protection.
Lately they seem to have been making a marketing blitz, possibly due to enlisting the help of the service that contacted me, and I’ve been seeing their ads everywhere. I even received a memo from HR at my job offering a company discount for their products. The social media angle has been aggressive (via Facebook, Twitter, and obviously blogs like this), and on some level I have to admire it. After all, it’s clearly working.
In my experience, boots for EMS fall into about three ranges. There’s the low-end range, ballpark of $40 or so, which is mainly low-cut shoes you find at Walmart or other generic retailers, intended for waiters and entry-level jobs. They can look good and seem somewhat serviceable for brief periods, but invariably they fall apart, sometimes catastrophically, after a few months. After that, there’s the mid-range, around $100, where the bulk of workhorse EMS and police boots fall — Bates, 5.11, Rocky, etc. These are good boots that wear well and last, perhaps, from 1–4 years depending on care and your tolerance for their final appearance. (All of my own boots have been this type.) Finally, there’s the high-end lines — Haix, Danner, and others — usually in the $200 range. These should last approximately forever, are built from high-end materials with scrupulous manufacturing, and ideally add an extra level of comfort.
Shoes for Crews seems to sit on the low end of the mid-range category. Many of their boots are in the $70–$80 territory, which is a pretty affordable boot if you’ll wear it for a solid few years.
The Boots
As I flipped through their collection, my first impression was that there weren’t too many styles that seemed suited for EMS. Typically our uniforms require black footwear that will take a polish, and I like a side-zip for easy ins and outs.
The models that seemed most appropriate included the Ranger; the Yukon; the Expedition; the Empire; and the Legionnaire. (None, sadly, included a zipper. Maybe next year.) Eventually, I settled on the Maverick, a recent release.
Here they are new out of the box:
First impression: well-built, good looking all-leather boots. They are relatively low-cut, but they are clearly boots and not shoes; here’s a comparison next to my 5.11 ATACs.
They do have a white-threaded stitching, adding a bit of accent against the black; however, it is barely noticeable and I doubt would run afoul of anybody’s uniform policies. After a few polishes it will probably fade completely.
The lacing system is a typical hiking-boot style, with hooks instead of D-rings for the top two pairs. This is supposed to make it easier to get your foot in and out, but to me it just adds to the lacing process and makes donning and removing them a bit of a chore. I also noticed a couple of the hooks get bent outward during regular use; they bent back easily, but it may be a common issue. Although I didn’t try it, I wonder if you could use a pair of pliers to fold them tightly in around the lace, converting them into semi-permanent lace-retaining tubes instead of open hooks.
Here’s the slip-resistant soles after some wear:
Slip resistance, although undoubtedly positive, is not exactly something I lay awake at night worrying about. However, I admit that these soles felt good, with solid traction on all surfaces including soapy washfloors and the occasional grease patch. They seemed to do well on loose soil as well, although I didn’t do much off-roading in them. They are also, for any aspiring ninjas, very quiet.
The uppers are all leather, without any nylon or mixed surfaces. Although it takes longer to polish, I prefer this look to a two-tone or “patchy” style; one does wonder how well it breathes in the heat, but I had little trouble on some reasonably hot days. They felt decent in the cold as well (it’s been a rollercoaster month), so for moderately extreme temperature ranges I’d give them a thumbs up.
The product page makes the fairly strong claim of “waterproof.” Many boots say water resistant and some say waterproof, but within the low and middle price ranges this usually means some kind of external treatment or half-hearted membrane that lasts a year or two at the most. I saw no mention of a Gore-Tex or similar liner on mine, so that may be the case here as well. However, they do have a gusseted tongue, and on moderately rainy days, as well as a leisurely test session of soaking them in several inches of bathwater, I noticed not one drop of moisture penetration.
This is how they look after about a month of use (every shift at work plus many days off):
So they’re reasonably durable. The leather is actually somewhat soft, so I have some concern for how it’ll hold up in the long-term; you notice one small cut already on the left boot. I gave them one quick shine when I first received them, and that’s held up well. The particular style at the edges also seems to help prevent scuffing the toe. The included laces do seem pretty frail, already looking a little scruffly after a month, and I’ve read reviews that others have had similar experiences; laces are easily replaceable, of course.
These have a composite toe, which I found quite light compared to steel toes I’ve used in the past. Combined with the lower cut, they’re overall not heavy boots, although obviously heavier than a soft-toed variant. The good news is that the toe is very roomy and never felt confining, which is something I’ve always experienced with safety toes; the box is built quite high, which is actually noticeable from the outside, giving a bit of a square, blocky look.
How about comfort? These are actually quite comfortable boots. Partly it’s because of the low cut (which makes driving particularly easy), but mainly they just feel like boots designed for humans to wear, unlike many uniform boots which seem primarily intended as ornate buttcaps for bipedal robots. They are quite rigid, with a steel shank and more arch support than I’ve ever had in a boot, and the feel of the heel and overall “stance” against the ground is very stable and comfortable. I feel better lifting in these than in my current boots, extremely stable while stair-chairing, and I could almost certainly wear these to the gym to squat, press, and deadlift without any difficulty. The collar is heavily padded, and although it took a few days before it stopped feeling noticeably stiff against my ankle (the only real break-in), after that it’s been perfect. The insoles are replaceable, too, if you have your own orthotics.
My two biggest gripes, in the end, are these:
The low cut. Every pair of uniform paints I’ve ever received has been (at least after a wash) laughably short, barely reaching my instep while standing and “flooding” embarrassingly whenever I bend my leg. As a result, wearing a low-rise boot like this makes the gap extremely noticeable; my pants almost don’t reach my boots even while standing. With properly-fitted pants, it wouldn’t be as bad, but I still feel that a medium-rise boot is a more professional look.
No zipper. I tried to adjust to this, but particularly on overnight shifts, it’s a deal-breaker; having to lace and tie these every time I pull them on, and reverse the process to get them off (even just to rest my feet for a bit) is like switching from a cotton T-shirt to a corset. It’s enough to make me wonder if I could buy a center-zip panel like Haix makes and lace it into the front, but I doubt it would fit.
Final Thoughts
So with all of that said and done, what are my take-away impressions of these boots?
They are generally well-thought-out work boots, very appropriate for their primary market (for instance, warehouse personnel, contractors, or repairmen), and with an overall pretty good quality. They are obviously not specifically aimed at the EMS/fire/police market, but there are not too many gaps (targeted “EMS boots” are usually bizarrely overbuilt, anyway), and the main difference seems to be one of feel. My quibbles with them are enough that they won’t be replacing my existing boots, but I will wear them occasionally, and in fact they make decent-looking off-duty shoes (my girlfriend approves). Moreover, I know many field staff who don’t mind, or even prefer, low-cut and zipperless uniform boots, and for them I do recommend the product. The value is good, and if you can find some sort of discount (and they seem to be falling from trees), all the better.
I’d love to hear from anybody else who’s tried these, or better yet, one of the other Shoes for Crews models; I’d suspect that many of them are pretty similar in the overall feel, but there may be some important distinctions.
Best of all, SfC has provided me with a coupon code for one more free pair of any of their products to give away to one of you lucky folks. EMS Basics isn’t exactly The Price Is Right, and we don’t do a lot of contests, but here’s what I’d like to do: if you’re interested in a free pair of boots, post to the comments below describing:
What boots you currently wear, and what you like/dislike about them
What features are important to you in a pair of uniform boots
Our apologies for the lack of updates while we battle technical difficulties here at EMSB HQ. Here’s a few quick tips to tide you over until the next meaty helping of knowledge.
Still learning your way around that temperamental home-away-from-home we call the ambulance? Try these ideas for making life easier. As always, they apply foremost to the Ford diesel chassis, but may work elsewhere as well.
If your stretcher mount is misadjusted, you may have trouble getting the side-rail to “release” and lock home when you insert the stretcher. Whether it’s too tight or too loose, try the following maneuvers, in this order: pull back (toward you); stand on the step and lift it directly up; sit on the leftmost side of the bench seat, place your feet on the lower deck of the stretcher base (this is the rail upon which the wheels are mounted, not the upper rail that holds the mattress), and use your legs to firmly press it into the side bracket. Do not, except in utter extremis, solve this problem by “slamming” the stretcher against the wall.
If your backboards don’t fit their slot snugly, they tend to bang around at every turn. Try folding a large towel or two into a thin strip (6″–12″), rolling it tightly so that it forms the thickest possible pad, then stuffing it into the void so that everything’s held snug. (You can stuff anything in there, but you need something pretty substantial and the rolled towel seems to work best.)
If you have a module power switch in the cab, but no remote switch for the patient compartment heat/AC, get in the habit of leaving the thermostat switched on in the back, blasting whatever air is appropriate for the weather. Then to save the battery, kill the module power whenever you shut off the engine. That way, you can pre-heat or cool the passenger compartment while on your way to a call by just throwing the switch up front.
If you’re not feeling up to shutting your door to the cab, you can usually get it to close by shoving it outward hard and letting it “bounce” off the hinge and recoil shut. In fact, you may be able to bounce the passenger-side door closed (if you’re at the wheel and an absent-minded partner leaves it open) by tapping the gas and then hitting the brake. A caveat: I have yet to hear the opinion of fleet maintenance on this practice.
If it’s a truly scorching day, park in the deepest shade you can find, set the high idle (usually by locking the parking break), and prop open the hood to help ventilate. (The hood will often stay open without use of the support rod if you lift it all the way up and rest it against the windshield.) Remember that “Max A/C” recirculates the interior air, making it increasingly cold, while “Norm A/C” will continuously introduce fresh air.
From the “off” position, turn the ignition key backward (towards you) rather than forward to activate the “accessories” mode. This activates the FM radio, windows, etc. but will automatically shut off power before your battery runs dangerously low; that way you can sit there with power without running the engine. However, test this to see if your two-way radios will remain on in this mode; I’ve seen it work both ways.
Look around the passenger compartment, particularly on the rear doors. Are there any speakers visible? If so, you can probably pipe music back here from the FM radio in the cab, a great way to keep patients entertained if they’re game. Just like in your car, the radio should have settings to adjust the balance, which controls how much volume comes through the left vs. the right speakers, and the fade, which controls how much volume comes through the front vs. the rear speakers. Normally, it will be faded all the way forward; just adjust it into the middle to pump your jam through the speakers in both compartments. Try asking what genre they prefer, and for bonus points, plug in your iPod for a fully DJ-able experience. Just remember to fade everything forward again at the end of the call, or you’ll inadvertently subject all your future patients to your Taylor Swift Experience.
Run your seatbelt adjuster (there should be a slider where it attaches to the wall) all the way up to the top, keep it buckled, and the belt will make a pretty decent pillow for your cheek.
Eventually, we all reach EMS satori — I’m referring, of course, to the realization that most of our job doesn’t involve saving lives, or performing any high-level, acute medical interventions. Once we understand this, the question becomes: what does our job consist of?
One good answer among many is the management of psychological rather than physical injury. Can we help the person, even when there’s little need to help the body? We sure can, and it seems like after all the hours we spent studying airway management, we should spend at least a little time developing this other skill. If we’re going to surrender our identity as ET tube samurai, we’d better become experts at dropping mental balms.
It may not be rocket science, but there is certainly a right and a wrong way to help. One good source of ideas for doing it the right way is called psychological first aid.
Psychological first aid, or PFA, is a system developed jointly by the National Child Traumatic Stress Network and the National Center for PTSD. It’s meant to be a psychological counterpart to medical first aid — not a replacement for long-term professional therapy, but merely a method for addressing the immediate, acute mental stress response following crisis. It’s largely aimed at post-disaster scenarios, such as the victims of hurricanes and mass casualty incidents, and it’s become the preferred methodology for American Red Cross personnel. However, it also has valuable concepts that we can use every day on the ambulance, to help us care for both patients and any of their family or friends who are struggling.
This sort of thing may come naturally to some people, but PFA rolls it together into a standalone curriculum that can be transmitted to any professional, particularly those of us who don’t specialize in mental health. It’s also evidence-based: there is research behind most of its interventions, and the science tells us that it generally works. (Contrast this to CISM, which many feel is baseless at best and counterproductive at worst.)
Classes are available; check with your local Red Cross for more information. But here are some of the concepts:
General ideas
Take your cues from the patient. If they want to talk, listen. If they don’t, don’t force them.
You’re here as support and to listen, not as Dear Abby; limit your input and resist the urge to offer advice. Be sparing with relating personal anecdotes or “war stories,” even if they seem germane; it’s the patient’s crisis, not yours.
Cater your approach to the patient’s age and culture. Children in particular will need a different style than adolescents and adults. When approaching children, make contact with parents first, and understand that both parties will probably need to be attended to.
Reassure them that their emotions and reactions, no matter what they may be, are understandable and acceptable, not pathological.
Use language that’s clear, simple, and personal, avoiding medical terminology or jargon.
Understand your own role and limitations, and be ready to bring in better-trained specialists.
Avoid these types of remarks:
I know how you feel.
It was probably for the best.
She is better off now.
It was his time to go.
Let’s talk about something else.
You should work towards getting over this.
You are strong enough to deal with this.
You should be glad she passed quickly.
That which doesn’t kill us makes us stronger.
You’ll feel better soon.
You did everything you could.
You need to grieve.
You need to relax.
It’s good that you are alive.
It’s good that no one else died.
Major Goals
1. Contact and Engagement
As you go about the business of the call, make sure that you’re orienting yourself as somebody who’s willing and able to help. From the initial patient contact all the way until you shake hands and part ways, you should be presenting yourself as a compassionate professional; all it takes is one slip of the tongue or roll of the eyes to betray that you’d rather be back at quarters finishing your burrito.
2. Safety and Comfort
Obviously, you should ensure that you are both physically safe, and that immediate medical concerns are managed; this also includes the recognition of patients who could harm themselves or others (like you).
If you’re still at a scene or in the ED where upsetting things are happening (such as a resuscitation), try to move somewhere more quiet and controlled. Keep them physically comfortable, with blankets, a chair, food or water, etc. Remove them from anyone who is themselves panicked or emotionally distressed, but do help to put them in contact with social support, such as friends, family, or clergy.
Try to give people active, familiar things to do, rather than sitting there passively being overwhelmed. Anything, even minor tasks (“here, hold this”), that involve them with their own care or the care of their loved one is beneficial; perhaps they can make some phone calls or locate insurance information.
Share whatever information you have regarding what’s currently happening, including what’s happening to others affected, and what can be expected next (do use judgment on how much they want/need to hear at this stage, though). But don’t lie, guess, form unfounded predictions, or make promises beyond your control (“they’ll/you’ll be just fine”). Consider a broad interrogatory like “Is there anything else you’d like to know?”
Kids may appreciate something like a teddy bear, and you can use it as a proxy for their own care, for instance: “Remember that she needs to drink lots of water and eat three meals a day — and you can do that too.” Also, children especially are sensitive to alarming sights and sounds; try to shelter them from unnecessary stimuli.
3. Stabilization (if needed)
As we’ve talked about before, anyone experiencing an acute, uncontrolled emotional response needs to be stabilized and grounded before much else can be done. Be on the lookout for things like: glassy-eyed or vacant stares; aimless wandering or unresponsiveness; uncontrolled crying, hyperventilating, shaking, or rocking; or frantic, illogical, even potentially dangerous behavior such as perseverating on simple tasks (continuously searching for a pair of glasses) or walking thoughtlessly through traffic. Remember that reactions may ebb and flow in surges.
Rather than broad reassurances — “stay calm” — try to determine their specific concerns, even if not entirely rational, and help address them. If completely adrift, patients may be assisted in “grounding” by deep breathing and asking them to describe where they are or concrete aspects of their surroundings (I see a table, I see a clipboard).
Consider both giving them some brief privacy (do tell them when you’ll be back), and remaining present and available yet non-intrusive, such as sitting nearby while you finish paperwork.
4. Information Gathering: Current Needs and Concerns
Determine the specific problems and needs of the patient. Individual responses may be flavored by their own psychological backdrop (such as depression or anxiety), history of similar incidents (a prior MVA or death in the family), or other unpredictable elements (they can’t stand the waiting room music). In some cases, the need for referral to a specialist may become obvious here, such as uncontrolled schizophrenia or major stressors in the setting of known PTSD and a history of self-harm; don’t try to “wing it” in complex psychiatric cases.
Follow their lead, and don’t press for details — a CISD-type debriefing can come later, if appropriate. Listen actively and openly. Look for expressions of emotion in their remarks, then make clarifying comments such as: “It sounds like you’re being really hard on yourself about what happened” or “It seems like you feel that you could have done more.” No matter what, don’t judge.
5. Practical Assistance
Assist the patient with any practical issues, which may be dominating (or over-dominating) their attention. Offer to notify friends or family, arrange for needed support, or obtain information about their care. Larger needs (such as questions about the costs of treatment) may be beyond your immediate power to address, but you can often take the first step, such as notifying hospital staff of their concerns. At the very least, provide whatever information you can and discuss a plan for resolving the problem. Even small measures like a warm blanket can have both practical and psychological benefit.
Remember that, although you may not be the most knowledgable or appropriate resource for many concerns, as an EMS provider you may be the only person who has the time and ability to address them. If you don’t make that phone call or find them a glass of water, it may be a long time until anybody else does; and it may not seem like a priority to find someone to move their car, but imagine how much better they’ll feel after it gets ticketed and towed.
6. Connection with Social Supports
Make an effort to enlist the patient’s support structure. In some cases, the first step may be to actually ask some version of, “Do you have a support network?” Some patients, such as the elderly or homeless, may not, and may need to rely particularly on institutional support, such as social workers.
When multiple individuals are in a group, such as family members at a scene or in the waiting room, ask if they have any questions or requests; this can provide a jumping-off point for further communication.
Make particular effort to bring children together with their parents or caregivers, and try not to separate them unnecessarily. Consider engaging children with simple activities, such as tic-tac-toe, “air hockey” (wad up paper and try to blow it across a table into the opposing person’s “goal”; this also promotes deep breathing), or the scribble game (one person scribbles on a paper, and the other tries to make it into something coherent).
7. Information on Coping
This step focuses on describing common stress reactions so that individuals will be more equipped to manage them. It is probably best left to more specialized professionals, since our own training is usually limited here.
8. Linkage with Collaborative Services
Help pass the patient along to existing resources, either by providing contact information or through direct referral. Most hospitals will have phone numbers or extensions for mental health, social work, counseling, and other services, and there are hotlines available for individuals not in care at a facility. (It’s worth having this sort of thing in your phone or on a cheat sheet, so that it’s available when you need it.)
When bringing in other aid, and even when making routine hand-offs to ED staff and the like, try to smooth the transition of care. Patients often feel as if they are passing through the hands of an endless series of personnel, with each one demanding to hear their story (and probably take their vital signs). Make an effort to give full, complete reports, and to establish your credibility through word and deed so that receiving staff feel less of a need to do it all over again; in particular, try to communicate whatever concerns or emotional state the patient is currently experiencing, so that the job of managing it can be seamlessly turned over. Introduce the new “helper” (for instance, the RN) directly to the patient, and let them know that they’ll be taking care of them; don’t just disappear, or they may feel abandoned.
Further information can be downloaded here from the National Center for PTSD.
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.
