Talking Green

There’s a secret behind this job.

You go to work. You run the calls: the boring, the exciting, the obnoxious, the weird. Occasionally, the terrible. You see, you do, you move on. Like everything else, it runs off our backs. Like rain off a tin roof.

At least, that’s what we tell ourselves. But there’s a secret.

The secret is that hidden beneath the uniformed cowboy swagger of no-problem, we-got-this, no-big-deal, a thick vein of psychological stress is flowing. You don’t see it in your coworkers, because they hide it away. When it reaches you, you do the same, because it’s not okay to show it. Our professional image is unflappability, and you can’t be unflappable if you let things get to you. So we push it under the rug.

Until one of us takes their own life.

PTSD, depression, anxiety, substance abuse, and yes, suicide, are a fact of life in EMS. But we never talked about it. At least, not until a few of our colleagues were brave enough to start shining light upon the problem, in an effort called the Code Green Campaign.

Code Green collects anonymous confessions from our brothers and sisters who can’t speak them out loud, reports the (all too frequent) suicides, collates the research exploring first responder mental health, and performs outreach to build awareness.

Explore their website for more information about their basic mission. After that, come back, because I asked them to unpack a few of the subtleties behind this problem and how they’re trying to solve it.

Question: While most first responders agree with the need for the Code Green Campaign, most of us haven’t actually done anything about it. You did. How and why did it first come about? What was the impetus and how did the early days take shape?

Answer: In March of 2014 one of my co-workers died of suicide. After his death I was talking about it with a group of friends, and we realized that even though we worked for different agencies in different states, we all knew someone that had died of suicide or had a serious attempt. We knew that this couldn’t be a coincidence, so I started looking into it further. I couldn’t find a lot of data, but what I did find told me that this was a much bigger problem than anyone realized.

Once we established that there was, in fact, a mental health problem, as well as a stigma problem, we started discussing what could be done — particularly about the stigma. It occurred to us that if there was one thing first responders like doing, it is sitting around telling stories. We thought that if we could come up with a way for first responders to share the stories of their own mental health problems, other people could read them and realize they weren’t the only ones struggling. We started collecting the stories and posting them on social media every Monday, Wednesday, and Friday. Things blew up from there.

In the early days things moved fast. My co-worker died on March 12th, and on March 16th we came up with the story sharing idea. We came up with our name a couple days later, and I think it was by March 23rd that we had our Facebook page up and running and stories being shared.

Q: Let’s get down to the elephant in the room. Why is this a problem for us? Why do EMS providers seem to be at higher risk for mental health issues in general, and for suicide in particular, compared to bakers, librarians, and schoolteachers?

A: I’m going to preface this answer with the warning that this is a lot of supposition, extrapolation, and educated guesswork. PTSD has most extensively been studied in the military population, so that is the best info we have. This is also a simplified answer, since the long answer would probably beat a doctoral dissertation in length.

We are frequently exposed to known risk factors for PTSD, such as seeing people hurt or dead, feeling helplessness or fear, having poor social support after a traumatic event, and having extra stress outside of work (marital, financial, etc).
We are poorly prepared for the realities of the job. Yes, we’re warned that we’ll see blood and guts and gore, but we’re not told that we are going to feel helpless on a regular basis, or that we’ll be scared we hurt a patient or made them worse. We’re not taught about how different this job can be from normal jobs, and how hard it can be for spouses and other family members to understand what we go through.
Aside from stressful calls, we’re exposed to higher rates of assault, vehicle crashes, and workplace injuries than many fields, which can add to the trauma.
We seem to have higher rates of depression, anxiety, and substance abuse, although it is unclear why.
We work in a very macho field and we’re supposed to be the helpers, not the ones that need help. There have also been reports of people being suspended or fired after admitting they have a problem. That combination helps create a huge stigma against admitting any sort psychological problem and asking for help.
We have more knowledge about lethal means of suicide.

Q: Okay, so let’s contrast EMS against some similar fields. Other first responders like fire and police, or medical personnel like doctors and nurses, all seem share most of the qualities you listed. Are they in the same boat? Or is there anything that puts us at greater risk compared to them?

A: Other first responders like fire and police are in the same boat. In fact, we don’t separate EMS numbers from fire service numbers because the employee base is so entwined. There are almost no fire departments out there who don’t do any EMS at all, so it is tough for us to draw a line as to who counts as EMS and who doesn’t. Just because an agency doesn’t transport doesn’t mean their employees/volunteers aren’t exposed to the same trauma. If you can’t draw the line at transport versus non-transport, where do you draw it? In the long run, it becomes almost impossible to separate people out. With police officers it is easier, but their suicide rate is on par with Fire/EMS. I believe that in 2014 there were over 140 reported police suicides.

As far as other medical professionals go, we do know that doctors do have a high rate of suicide, to the tune of 46 per every 100,000 (for first responders we’re looking at about 30 per 100,000). We don’t know what the suicide rate is for nurses, PAs, or NPs, but we wouldn’t be surprised to learn it is also high.

This is purely supposition on my part, but I do think we are particularly susceptible, because EMS is less developed than other medical fields. Nurses and doctors have well-established professional organizations representing them at the state and national levels. EMS is much more fragmented. The one big difference we’ve especially noticed with nurses and doctors compared to EMS is that many states have license preservation programs in place for RNs and physicians, but not for first responders. That is, if they have a mental health or addiction issue, their state may have an official program in place to help them keep their license while getting help. Few (if any) states have a similar program for first responders. EMS doesn’t have that kind of well-organized advocacy yet.

Q: I expect many of our readers aren’t familiar with license preservation programs. What are they and what are the possible ramifications when we lack one?

A: My answer is based on the states I’ve lived in. From what I understand, most states have such a program set up for either doctors and/or nurses. Basically, the state has recognized that nurses and doctors spend considerable time and money to obtain their licenses, and that it is in everyone’s best interest to keep them on the job, rather than automatically revoking their license. Here is an example of how it would work: say a nurse starts diverting narcotics. She self-reports her behavior to her employer and to her state licensing agency. She will likely be suspended or fired from work, but if the state has a license preservation program her license will only be suspended. The licensing board will then review the case and outline what the nurse has to do to get her license reinstated. They may require her to complete a treatment program, attend weekly counseling sessions, and submit to monthly drug tests. As long as she meets those requirements, she can keep her license.

The issue with lacking a license preservation program is that it creates an atmosphere of fear. People will avoid seeking help for anything they think could possibly cause their license to be suspended, since they have no way of knowing the outcome of that. No license means no job, and unless you want to move to another state, you’d have to come up with a new career fast.

Q: In the absence of such programs, is there a real possibility that EMS providers can lose their jobs or even their certifications merely for reporting mental health issues? In other words, no diversion or actual violations, just the typical paramedic suffering from depression, anxiety, or PTSD?

A: This question is difficult to answer because it is based on the idea that people are routinely reporting their mental health issues to the employer or the state. Unless someone is seeking to use Worker’s Comp or other employment benefits for a mental health issue, there is no reason to be reporting routine treatment to anyone (unless it is required, like with some communicable diseases). Someone wouldn’t report that they’re being treated for asthma or hypertension to their employer or state licensing board, so why would they report depression or PTSD? Employment benefit issues aside, in absence of diversion or actual violation it really doesn’t make sense for anyone but the person and their treatment team to know anything.

Such programs are generally more reactive than proactive, although in the ones I’ve looked at it is strongly encouraged to self-report issues/violations before they are caught by an employer. In fact, at my employer you’re much more protected if you self-report to the EAP than you are if you get caught.

I think that no matter what the reality is, having programs like these make it so that people don’t feel like they are backed into a corner once they develop an issue. We don’t want people feeling like a situation is hopeless, we want them to be able to see there are options.

Q: I imagine that in most cases, “reporting” occurs in the circumstances of a worker’s compensation claim (i.e. asking the employer to pay for mental health services), or perhaps when an employee needs to take time off work.

In the real world, I expect some employers are inclined to be less than supportive about these types of requests. Are they sometimes refused? Are employees sometimes asked to “prove” that their condition is work-related? Is there a legal framework mandating employers to provide these services and accommodations?

A: We answered earlier that Worker’s Comp claims or using other employment benefits are the instances an employer is most likely to learn that someone is having issues. It is difficult to answer a straight “yes” or “no” to any part of this question. No one has sat down and studied how often requests like the above are made, how often they are granted, how often they are refused, and if the response to such a request is affected by the type of employer or the state the employee is located in. We don’t know how often time off requests for mental health conditions are granted or refused, or how often they are granted or refused compared to other time off requests at that same employer. We could come up with anecdotes of both positive and negative outcomes, but there is no data.

What is and what isn’t covered by Worker’s Comp will vary from state to state and employer to employer. We do know that there are states where psychological conditions are not covered for anyone, or are only covered for certain jobs, and the employer has no control over that. It’s not uncommon for Worker’s Comp claims to be investigated no matter what kind of claim it is, so we would not be surprised if people filing a claim related to a psychological issue would be subjected to some questioning. Just ask anyone who has filed Worker’s Comp for a back injury or knee injury. Worker’s Comp tends to be difficult no matter what.

Furthermore, people who have had to take time off for physical injuries will tell you that on top of their injury being investigated and questioned, they likely also had to jump through hoops in order to return to work. Fitness for duty evaluations, physical agility tests, etc. Because of the differences between state laws and agency policies it is very difficult to know if mental health conditions are being treated differently at a significant rate.

As for accommodations, that is even more complicated. Under the Americans With Disabilities Act (ADA) employers are mandated to provide reasonable accommodations for employees that have disabilities. Now, how many first responders do you know that are willing go through that process, and then admit to their employer that they have a disability that needs to be accommodated? Additionally, first responder agencies are in a tough spot when it comes to accommodations because this field is so unpredictable. Agencies can’t ensure that you’ll never run another pediatric cardiac arrest, or never have to respond to a certain address again. If someone has an anxiety attack while responding to a call, or on scene of a call, is taking them out of service going to be considered reasonable? Probably not. Accommodations get very complicated very quickly.

Q: Interesting. So despite these challenges, the problem is clearly an urgent one. What steps can field staff take to prevent and manage mental health issues, whether for themselves or for their colleagues?

A: Resiliency, and building resiliency factors, seems to be a key to helping prevent mental health issues from arising, so everyone should review what resiliency factors they have and work on building upon them. People also need to be able to recognize signs of decline in themselves, such as worsening sleep, increased drinking, and anger issues. For co-workers, the biggest thing is not to be afraid to say something to someone if you think there is a problem. Asking someone, “Are you thinking of suicide?” is not going to put the idea into their head — so if you’re concerned, ask.

Something else that is important is reducing the stigma around mental health in general. Don’t make jokes about “BS psych patients” or complain that psych calls are a waste of time. This contributes to the stigma and makes it harder for people to admit they have their own problem.

Q: What other points do you want do make on this important topic?

A: We need to keep talking about this and keep the conversation going. Changing how mental health is addressed is going to involve changing the culture, which is going to take time and effort.

For people who want to get involved there are several things you can do. Speak up if you hear someone speaking negatively about mental health, whether in the context of our peers or our patients. If you hear about a suicide, please report it to either Code Green or to the Firefighter Behavioral Health Alliance. All reports are confidential and we do not disclose information without permission.

If you know of a first responder–friendly mental health professional in your area, let us know so we can add them to our resource database. It may not seem like much, but this kind of stuff is incredibly helpful to us and to the cause.

Visit the website of the Code Green Campaign to learn more, read personal accounts, and see else what you can do to help.

The Long-term Care Ombudsman: Advocates on Call

Although we like to talk around here about exciting topics like shock and airway management, the reality is that for many EMS providers — particularly at the BLS level — a large part of this job isn’t stabilizing emergencies. It’s routine work like dialysis trips and stable transfers from nursing facilities. Some folks find this stuff dull, and it can be dull, but the best way to make it interesting is to approach it just like the exciting stuff and try to be excellent at both aspects of the job.

How can you excel at bringing Mr. Smith to his third doctor’s appointment this week? You can learn to be a really good patient advocate on his behalf, something that almost all residents of long-term care facilities need. We’re well-positioned to fill this role because we have a one-on-one relationship with our patients. Unfortunately, we often lack the know-how and leverage to resolve most of their problems.

Our feature in the August 2014 issue of EMS World talks about how to use the ubiquitous Long-Term Care Ombudsman program to help. It’s easy, it works, and even if you didn’t know about it, there’s one available in your area. Give it a read and think about bringing it to bear the next time the guy on your stretcher has something to say!

Toastmasters for Trauma Patients

Almost everybody in healthcare has to occasionally deliver verbal reports to their colleagues or counterparts, and almost everybody starts out bad at it. It’s a weird skill and one that takes practice, even though all you’re doing is describing what the deal is with a certain sick person.

Here’s a little walk-through discussing one important aspect of a good verbal report — a clear, coherent structure of tone, cadence, and body language that gives your words “shape.” You shouldn’t sound like a robot, because robots are hard to understand. Be Martin Luther King Jr; that’s a man who knew how to make himself heard.

We’ll be practicing with the hand-off report Sam gave to University Hospital on the Mystic St and Beverly Rd call.

Some Things to Say (part 3)

Becoming smarter is always a smart idea. But after they boot you out of EMT class, not only do you still need to learn a few textbooks-worth of medicine before you’re a semi-competent provider, you also need to acquire a more mundane body of knowledge: how to sound like you’re competent.

You’ll be talking to other prehospital personnel, to nurses, to doctors, and to CNAs and LPNs; you’ll be writing out copious documentation; and of course you’ll be asking questions of patients themselves. And it’s one thing to know what you’re talking about, but it’s quite another to express it without sounding like a knob. Unfortunately, some things are just hard to say concisely and cleverly. More importantly, for some things there’s simply one right way to say it, and anything else isn’t really accurate. The world of medicine has come up with conventional phrases to describe most of these, but you need to learn them before you can use ’em. It’s one of those subtle skills you develop as your experience grows.

Of course, providing shortcuts to experience is why we’re here. So here are a few terms that will make you sound a little more intelligent the next time you’re giving a report or writing a narrative.

Don’t say…

Pooping

Say…

Moving his bowels, having a bowel movement

“Have you been moving your bowels lately, Mr. McGillicuddy?”

Don’t say…

Peeing

Say…

Urinating, making urine

“She just started dialysis recently, but she does still make a small amount of urine.”

Don’t say…

Normal

Say…

Unremarkable

“Her vitals and physical exam are unremarkable.”

Don’t say…

It’s totally there, dude

Say…

Present, apparent, visible, palpable, appreciable

“A Foley catheter is present, and a 2cm hematoma is visible on the dorsum of the left hand. No other trauma is apparent. Breath sounds are appreciable bilaterally.”

Don’t say…

… and there’s tons of it.

Say…

Profound

“She reports profound vertigo elicited by any movement of the head.”

Don’t say…

CSM is totally good bro

Say…

Peripheral circulation and neuro function intact

“Does he have any neuro deficits?”

Don’t say…

Basically he seems okay

Say…

Stable, intact, atraumatic, without abnormality

“He appears grossly atraumatic, with no apparent injury to the head, and the neck and back are stable and non-tender.”

Don’t say…

You can hear it from Cincinatti

Say…

Audible from the bedside

“Coarse, biphasic crackles are audible from the bedside, and present in all fields upon auscultation.”

Don’t say…

We didn’t look too hard

Say…

Readily, grossly, obviously, generally, frankly

“He appears generally well, without obvious injury or gross neuro deficit. Radial pulses are not readily obtainable. No frank bleeding from the site.”

Don’t say…

Chow situation

Say…

Oral intake

“He has had minimal oral intake over the past three days”

Don’t say…

Pushes his feet

Say…

Plantarflex

“Equal strength bilaterally in grip and plantarflexion.”

Don’t say…

Shows

Say…

Demonstrates

“He demonstrates no speech slurring or pronator drift, but there is a mild left-sided facial droop at rest.”

Don’t say…

Eventually opened his eyes after we beat the shit out of him

Say…

Difficult to rouse

“He is found in bed, eyes closed and semi-Fowler’s. He rouses with difficulty to verbal stimulus, but repeatedly lapses back to sleep without ongoing stimulation.”

Don’t say…

AOx4

Say…

Describe it!

“He presents as alert, in no apparent distress, generally oriented with some confusion; he is conversational and aware of his circumstances, but is unsure of the date and demonstrates poor short-term recall.”

Don’t say…

Walks like a drunk

Say…

Ataxic

“He demonstrates slurred speech, generalized ataxia, and a sweet odor is detectable in his breath.”

Don’t say…

Pissed himself and shit everywhere

Say…

Voided, incontinent of bowel or bladder

“He’s incontinent of both bowel and bladder, and he did void his bladder en route.”

Don’t say…

“ehn rowt”

Say…

“on root”

“En route is from the French, and it’s pronounced ‘on root.’ Saying ‘ehn rowt’ is some weird faux-accented hyper-compensation that the public safety world has all started doing, but that doesn’t make it right.”

Don’t say…

Agrees only after we asked about it

Say…

Endorses

“He denies pain of any kind, but does endorse mild tightness and discomfort in the left shoulder.”

Don’t say…

Sniffles and other cold-like symptoms

Say…

Coryzal symptoms

“He notes a headache and coryzal symptoms for the past two days, and nausea beginning today.”

Don’t say…

General systemic symptoms preceeding a seizure, syncope, etc

Say…

Prodrome

“He denies prodromal symptoms preceeding the fall, and bystanders observed no apparent loss of consciousness.”

Don’t say…

Without torture

Say…

Easily, freely

“He ambulates easily, and freely rotates his head past 45 degrees without pain.”

Well, that’s what I’ve got. Toss ’em into your toolbox and use whatever works for you. Anybody else have some useful words to share?

More things to say in part 2

The 10 Easiest Ways to Violate HIPAA

Leave paperwork face-up on the dashboard or front seat.
Leave your computer unsecured wherever the hell you please.
Tweet a picture of the badass MVA you just did, with a victim obviously identifiable to anybody who reads the news (“A car struck a tree on Route 421 today, driver Jim Smith was rushed to the hospital…”).
Tell everybody about the celebrity you just transported.
Tell everybody about the coworker you just transported.
Crack jokes and make comments about the patient you just dropped off while in the elevator, or in the public ambulance bay outside — usually while the patient’s family is eavesdropping.
Post a Facebook status about the crazy shooting you ran, sharing intimate details about the patient who was probably the only person shot in your town that day.
Leave paperwork in the truck at end-of-shift.
Let a facesheet (demographics page) escape into the wind as you fruitlessly chase it down the street.
Answering curious questions about the patient’s status or destination from the random person on scene, I’m not sure who that is, probably just the nosy guy who lives downstairs.

Podcast: EMS to ED Interface

Streamlining a patient’s entry to the healthcare continuum is one of our main roles in EMS, and the key step in most cases is when we transfer care at the emergency department. This isn’t rocket science, but you can do it well or less well, and frankly I think it’s tough to do right unless you can see the whole picture. We never really know in what ways we’re setting up people effectively for their ED care and in what ways we’re part of the problem, unless perhaps we work on both sides.

So I asked for a little help here. I sat down virtually with Dr. Brooks Walsh, ED attending extraordinaire — author of Mill Hill Ave Command and Doc Cottle’s Desk — and with Jeff, an ED nurse from my area. We discussed how to work and play together better, including topics like handoff reports, useful histories, and typical ED courses of care.

Click here to listen or download (1:15, MP3 format)

A few of the bullet-worthy points:

Jeff’s hospital saves time in all trauma, stroke, and STEMI activations by assigning patients an alias immediately upon notification by EMS. That way registration isn’t lurking around while the team is trying to treat the patient.
Cath lab activations from the field are still often about trust — whether staff knows the individual provider or the particular service calling. Rightly or wrongly, there’s also a stricter de facto standard for activation during off hours when nobody wants to get out of bed.
For stroke, neurology may be in the room when you arrive, but more often, especially in smaller hospitals, they’re available by page or teleconference.
When bringing in the stroke, try and ensure that family who can testify to time-of-onset/time-last-seen-normal, as well as consent to treatment on the patient’s behalf, are present — ideally transported with you — not unavailable in a taxi somewhere.
When you walk in the room, the typical team is a doctor, a nurse, a tech, then any extras — residents or other students, surgery, pediatrics, whomever. And registration is the dude with the clipboard or computer, of course.
When reporting to the doc, focus on: first, anything that needs to happen immediately; second, information he can’t get elsewhere (i.e. not patient medical history unless it’s not available in the records, laundry list of negatives, etc.), such as how you found the patient, general context, changes en route, etc.
Written PCRs are usually not read due to difficulty obtaining them and general unfriendliness (hard to find info, obscure writing), but sometimes there’s useful stuff in there, particularly in the narrative itself.
Baseline patient info from EMS is great if we know the patient well (frequent fliers); baseline info from bystanders, staff, family etc. is okay but less reliable.
Get patients to their usual facility if at all possible, especially those with complex histories, and especially anyone with recent surgical history — otherwise they’ll just get transferred later.
“Take me to x, my doctor is there” (meaning PCP or specialist) — less important, but can be nice if there are chronic issues and they’d like to maintain the existing treatment plan.
Disagreements over patient triage or treatment: find the attending or perhaps resource nurse and voice your concern. In the long-term: raise issues with the hospital’s EMS liaison (either directly or through your internal chain of command).

Live from Prospect St: The Big Crunch (conclusion)

Continued from part 1 and part 2

In the end, all three patients receive spinal immobilization. You transport both pediatric patients to Bullitt Medical Center; the P12 assumes care of the mother and transports her to the same destination. No significant injuries are found upon follow-up assessments; however, when the P12 checks Samantha’s blood glucose, they find it to be 32 mg/dL. They administer D50, normalizing her sugar, which improves her level of consciousness; however, she remains confused and becomes somewhat combative. She does endorse substantial alcohol ingestion, is somewhat unclear on drug use, and continues to deny a history of diabetes.

After transferring care, both crews fill out state-mandated documentation to report child abuse, with regard to the mother driving two young children while under the influence and without appropriate car seats or other restraints. You write your documentation with extra caution, aware that it may eventually be used in a court of law.

Discussion

This was a case where no patient was highly acute, but operational issues required some attention and medical confounders obscured the assessment.

General considerations for MVAs

With any significant MVA (or MVC for “motor vehicle collision,” since the DoT takes the position that nothing is truly accidental), there are several factors we should consider:

Scene safety. Wherever the scene may be, it’s generally at or near a roadway, and it’s a location that’s already proven itself accident-prone. In this case, we were situated in a truck yard somewhat off the main road. If it were a busier area, and we were first to arrive, we would want to park the ambulance to shield the scene from traffic, and request fire apparatus (for more blocking) and police (for traffic control). We should also consider the presence of chemicals or other hazardous material in an industrial area, which was not a problem here.
Extrication. The time to request additional resources is early. Heavy extrication, where vehicle frames need to be bent or cut, is usually performed by fire department ladder trucks or dedicated rescue apparatus; in this case, the driver’s door was dented and needed to be popped open (technically “confinement” rather than “entrapment”), and it was handled prior to our arrival.
Cause. Some accidents happen for obvious reasons, such as inattention. Sometimes they’re due to conditions, such as weather or visibility, which is a good clue that such conditions probably persist and might endanger you as well; protect the scene and be cautious during extrication and transport. Sometimes, accidents have a medical cause, which was the case here.
Damage. We are clinicians, not mechanics, but vehicle damage can provide clues to injury type and severity. Modern vehicles often develop horrific-looking body damage while yielding minor personal injury; automotive safety science has become quite advanced, and a large part of a car’s protection comes from intentionally crumpling to absorb impact. If occupants are restrained, the vehicle can easily eat up a large amount of shock without anyone suffering significant harm. In this case, we saw a front-left impact at seemingly moderate speed, so we anticipate a head-on type injury pattern with some lateral energy. Damage to the driver’s-side lower dashboard area, plus minor knee injury, suggested a “down and under” rather than “up and over” direction of movement, which is typical for a restrained driver; the windshield was also missing any apparent point-of-impact, which supports this. With the seatbelt and airbag, we were not too suspicious of frontal head injury, but we did look for evidence of lateral head impact against the window or side-wall; we found no obvious head trauma or internal vehicle damage. There was likewise no signs of internal impact from the children in the rear, although we remain suspicious of pelvic or abdominal trauma, since they were wearing lap belts without any torso restraints.
Number of patients. Life was made easier by the truck driver, who was obviously unharmed and decided to elope from the scene prior to our arrival. Samantha was making vague reference to her brother, but it seemed that he was coming to meet her and was not an occupant. It is somewhat bad form to forget about people, so it’s good to try and confirm these things, and the first-in responders (the fire department in this case) can help.

Assessment

Just like in most cases, the majority of essential information was communicated in the first few seconds on scene.

Our eyeball exam from twenty feet was enough for an initial assessment on the kids. The Pediatric Assessment Triangle is a model for identifying pediatric life threats that focuses on obvious, big-payoff findings rather than details (like specific vital signs) which can be tough to measure. The three components are:

General appearance. This is overall impression and rough neurological status. Are they conscious? If so, sluggish, alert, groggy, engaged with their surroundings, tracking with their eyes? Is there any muscle tone or are they limp? Are they crying? If so, are they consolable? Do they look sick or well?
Work of breathing. This is respiratory assessment. Is the child struggling to breathe? Are they tripoding or assuming a sniffing position to maintain an airway? Is there accessory muscle use, pursed-lip breathing, nasal flaring, chest retractions? Are grossly adventitious breath sounds audible (i.e. wheezing, stridor, grunting, snoring)?
Circulation. This is general circulatory status. Is skin pink and warm? Is there clear cyanosis, pallor, mottling? Obvious bleeding?

From the first moments on scene, we were able to observe that the pediatric patients were: conscious, crying loudly (therefore with a patent airway and adequate breathing), generally unhappy but not acutely distressed, without obvious bleeding or other trauma, and with normal skin signs. That’s plenty for the initial triage — a more full assessment will come later, but it’s unlikely that we’ll uncover any true life threats.

How about mom? We initially notice no obvious issues except for an altered mental status, which may be masking other problems (such as pain or neurological deficits). We also don’t know the cause of the AMS. Is there alcohol involved? Probably: she directly endorsed this. Drugs? Perhaps: vehemently denying drug use is not uncommon in drug users, and there were purpura consistent with needle “track marks” on her arm. But even if present, neither of those precludes a concomitant traumatic head injury; drunk and high people can bump their head too. And we were reminded of the first rule of EMS: everybody is diabetic. Although the circumstances didn’t necessarily suggest hypoglycemia as the most likely cause, it fit the presentation, and all drunk patients are somewhat at risk for this complication. If she’d stayed in our care, glucometry would have been wise during transport.

Is spinal immobilization needed? Local protocol comes into play. The children are probably low risk. The mechanism as a whole is potentially risky, due to the possibility of side-on energy transfer and head injury, but generally is not too alarming and the assessment findings are fairly reassuring. In the case of the mother, she is the classic example of a poor reporter who cannot reliably describe neck or back pain or participate in a neurological exam; most selective immobilization protocols (such as NEXUS or the Canadian C-spine rule) would advise immobilization in such cases. In this instance, due to equipment shortcomings, one child was immobilized via KED and the other two patients immobilized to long boards, with towel rolls used liberally. The children were liberated almost immediately after arrival at the ED, after a clinical exam by the pediatric emergency physician. The mother began fighting her board after she was roused with D50.

Transport and documentation

This case highlighted the need for intelligent patient assessment to guide transport destinations. Although low-acuity pediatric patients can sometimes be assessed in an adult ED, it depends on the receiving physician’s level of comfort, so in many cases they’ll prefer to transfer them to a specialty center (and any time a patient has to be transferred from where we brought them, we’ve failed them somewhat).

In a similar vein, acute patients needing surgical intervention should always be delivered to trauma centers. Does mom need a trauma center? Since we’re unable to rule out a traumatic cause for her mental status, it’s probably wise, although perhaps not essential. Do the kids need a pediatric trauma center? Probably not; they are, by all appearances, doing fine. Finally, although we could transport parent and kids to different hospitals, it would be distressing to everyone and create logistical headaches (involving consent, billing, and other concerns), so Bullitt Medical Center (an adult trauma center as well as a pediatric ED, although not a pediatric trauma center) is a sensible destination. (Since it’s a larger hospital, it’s also more capable of sustaining the “hit” of receiving three patients simultaneously than a small community ED.) Since the mother is a more challenging patient, it makes sense for the paramedics to take her while our BLS unit acts as a bus for the kids.

As for documentation, depending on state law we may be required to report all instances of child abuse to protective agencies. (In this particular region, reporting is mandated for any child or elder abuse.) If so, local procedures should be followed; although the hospital will most likely perform such reporting as well, in many states this does not absolve EMS of its own responsibilities.

When documenting the call, be aware that charges may be pursued against the mother for neglect, driving under the influence, or other offenses. These may hinge upon your documented findings, such as altered mental status, lack of appropriate child restraints, or statements about substance use. Depending on local laws for mandated reporters, you may be required to report these findings directly to police, or you may actually be prohibited from doing so by HIPAA laws; in either case, however, they should be noted in your report.

Thoughts from WMEMS

This past weekend, I was able to attend the Western Massachusetts EMS Conference alongside such luminaries as Scott Kier and Kyle David Bates (of the extraordinary Pedi-U podcast). We sat through two days of outstanding lectures on various EMS-related topics, and walked away with some ideas and information I haven’t found anywhere else. Here are just a few of the unique pearls from the conference. Thanks to everyone for the great time!

Kyle David Bates on Mechanism of Injury

In an MVC, ejected (that is, fully ejected) victims have a 1/3 chance of a cervical spine fracture.
They also have around 25 times higher chance of mortality than an equivalent non-ejected patient.
Is “another death in the same vehicle” a legitimate concern when considering mechanism? Yes, but make sure that death wasn’t from an localized cause—for instance, a girder in the face, or they had a heart attack before they crashed.
How about “intrusion”? Over twelve inches into the patient compartment where your patient is found (meaning, visible from inside—not from the outside, which includes the buffer space of the walls), not including areas like the hood, trunk, etc. Alternately, over 18 inches into the patient compartment in areas where your patient is not found—for instance, the rear seating area, when you’re treating the solo driver.
“Distracting injuries” can mean painful injuries that distract the patient, but also gross stuff that distracts the provider. Consider a head-to-toe on virtually everyone, even when the funky arm fracture is drawing your attention.
Many “trauma” patients are no longer being treated with surgery anyway, so sending everything to the trauma centers overloads them for no reason.
One more reason why the sternal rub is not a great diagnostic: if they do clutch at their chest in response, is that localizing—or an abnormal, decorticate flexion response? Different GCS scores, but you can’t tell.
Are extremity injuries significant mechanisms? Penetrating injury proximal to the elbows or knees should be considered threatening to the torso, so yes. Pelvic fractures? For sure. (“How much blood can you lose into your pelvis? All of it!”)
With the automobile safety technology available today, you can crash fast, turn your car into a paperweight, but walk away unharmed. We no longer care about “high-speed,” only “high-risk,” which has many factors (see the Rogue Medic’s recent post on this).
Auto vs. pedestrians: kids get upper body injuries; adults get lateral trauma as we turn and try to get out of the way. Both can get run over.
Motorcycles. Harley-type riders seem to have more head injuries: they get hit by cars, due to low profile and dark clothing, and they wear partial helmets. Sports bikes get more extremity injuries: they wear good protection, are higher visibility, but they ride fast and run into things, breaking any and every bone they have.
Rollovers: no longer trauma criteria. You can roll and do great if you’re restrained. Number of rolls, final position, even roof intrusion have no correlation to injury severity.
Extrication time >20 minutes: no longer trauma criteria. Sometimes it just takes a while due to weather, access, etc, and newer vehicles are supposed to crumple more anyway.
Are burns trauma criteria? No. If they need specialized care, it’s a burn center, but this is not that time-sensitive—more a long-term management thing—so someone with burns and trauma should go to the trauma center instead, can be transferred later for burn care.
Helicopter transport: costs can range from $2,000 to $20,000 depending on distance, and insurers are refusing to pay many of these bills due to lack of necessity. Also consider the possibility of everyone dying in a fiery crash. Weigh cost vs. benefit.

Kyle David Bates on Shortness of Breath

Anxiety is caused by hypoxia; the cure for this is supplemental oxygen.
Sleepiness is caused by hypercapnia; the cure for this is bagging.
OPA or NPA? Testing the gag reflex may create a bigger airway problem (vomit). Better yet, check the mouth for pooled saliva; if present, there is no gag, use an OPA. If absent, they have a gag and are managing their own secretions, use an NPA.
Respiratory distress means there’s a problem, but they’re compensating (compensatory signs like tachypnea).
Respiratory failure means they’re decompensating (hypoxic/hypercarbic signs like altered mental status, cyanosis, falling sats)
Respiratory arrest means they’re not breathing.
Normal inspiration:expiration cycle about 1:2. Obstructive pulmonary problems impede expiration first, because that’s the passive process—it’s easier to inhale past obstructions because it’s an active process. So asthmatics have ratios like 1:4 or 1:5, they’re using active exhalation, and using auto-PEEP maneuvers. (Pursed lips in adults, grunting in kids.)
In adults, look for retractions intercostal (between the ribs) and sternal notch (between the clavicles); in kids, look substernal (below the ribs).
40% of patients hospitalized with asthma have a pneumothorax! (Not necessarily clinically significant, though.)
Pulsus paradoxus/paradoxical pulses are a useful early sign of significant pulmonary dysfunction.
90% of asthma attacks linked with an allergic reaction; however, rhinovirus (the common cold) may now be a contender. Others include: exercise (not sure why; maybe the temperature differential), active menstruation (asthma very common in young post-pubescent women—maybe the hormones), psychological (stress, panic), aspirin use.
Kids compensate great, so cyanosis (a decompensation sign) in kids is very late and very bad.
Risk-stratify these patients, because high risk patients can decompensate fast even if they look okay now. Previous hospitalizations? ICU admits? Intubations?
Cough asthma: no dyspnea, just dry coughing. It happens.
Smokers: measured in pack-years. 1 pack a day for 20 years is 20 pack-years, 2 packs a day for 5 years is 10 pack-years; 30–35 pack-years is where we start to see bad dysfunction.
Best place to check skin? Under the lower eyelid—lift it and check the mucus membranes. Dry for dehydration, pale for shock, blue for cyanosis, the whole gamut.
Ascites is a sign of fluid overload; try the fluid wave test. (Scroll down to “Examining for a fluid wave” here.)
Nebulized ipratropium/Atrovent: its role is mainly to reduce mucus and secretions (cf. atropine). Tachycardia etc. is not a contraindication, because it’s not absorbed systemically; it remains in the lungs.
Give nebs by hand-held mask or T-piece instead of strapping it to their face; that way you have a warning of deterioration when they can no longer hold it to their face.
Bronchodilators may not work great in beta-blocked patients.
Steroids take hours to have an effect, but the earlier they’re given the better the outcomes; give ’em if you have ’em.
If they need RSI, ketamine is nice because it also bronchodilates.
“Facilitated intubation” (i.e. snow ’em with a ton of benzos/narcs)? Be careful, because if you don’t get that tube, it’ll take forever to wear off; these aren’t short-duration drugs.

Kyle David Bates on Pediatrics

Use the Pediatric Assessment Triangle! Appearance, Work of Breathing, Circulation.
Appearance: General activity level and impression. Muscle tone, interactivity and engagement, look/gaze, crying. Appropriate appearance depends on age. Indicates a CNS/metabolic problem. (Make sure to check their sugar.)
Work of Breathing: Flaring, retractions, audible sounds, positioning. Remember they’re belly breathers.
Circulation: mostly skin. Cyanosis (bad), pallor, mottling (pallor + patchy cyanosis), marbling (in newborns—bright red skin with visible blood vessels, maybe some white areas—this is normal). Check cap refill on bottom of foot in little kids.
Shock in kids is most often from dehydration.
Airway: crying is a great sign. Remember to pad under the shoulders when lying flat, their huge heads can tip them forward and block the airway. Avoid NPAs in infants. In very small kids, breath sounds can transmit, so you may hear upper sounds in the chest or chest sounds in the trachea.
Under 2 months: peripheral cyanosis is normal, central cyanosis is bad. Limited behavior, often won’t visually track. Ask parents if their behavior is normal. Ask about obstetric history, it’s still relevant. They have no immune system really, so any infection (temp over 100.4) is a serious emergency.
2–6 months: social smile, will track visually, recognize mom, strong cry and can roll/sit with support. May still be okay with strangers, but try to keep them with parents; if parents like you, they’ll like you
6–12 months: stranger anxiety (unless they’re raised very communally). Very mobile and explore with their mouth, so always think about foreign body airway obstructions, especially up the nose, especially for dyspnea with sudden onset. Separation anxiety, so keep with parent. Offer distractions (toys, etc.). Do exam from toe to head so they get used to you before you reach their face.
1–3 yrs (toddlers, “terrible 2s”): mobile, curious, opinionated, ego-centric, can’t abstractly connect cause-and-effect but learn from experience. Keep with the parents, distract them, assess painful part last (or everything you touch afterwards will hurt). May talk a lot or not much, it’s all normal, but they always understand more than they let on, so be careful what you say.
3–5 yrs (preschool): magical thinkers, misconceptions (“silly” ideas like if they leak too much they’ll run out of blood), many fears (death/darkness/mutilation/aloneness), short attention span. Explain things in simple terms, relate to them (any cartoons or toys in the house you recognize?), use toys, involve them (here hold this, which arm should I use, etc). Don’t ever negotiate, just tell them what to do; praise them often; never ridicule.
6–12 yrs (school aged): talkative, mobile, may not get cause and effect, want reassurance, involvement, praise. Live in present, may not think about danger or risk. Peer involvement. Speak directly to them, anticipate questions (will this hurt? am I going to die?), give simple explanations, don’t ever lie, respect privacy. If you need to do something painful (IVs, etc.) don’t tell them until just before, or they’ll dwell on it. Head-to-toe okay.
13–18 (adolescents): regress when hurt or sick—act like big toddlers. Can understand and theoretically have common sense, but still take risks. Peer support. Speak directly, give concrete explanations, respect privacy, have patience.
Under 21 usually considered “pediatric.”
Degree of fever temp not associated with severity. No actual danger to brain until 106–107 degrees F or so.

Dr. Lisa Patterson on Trauma and Field Triage

RR <20 in infants is trauma center criteria since this is the one easily-measurable vital sign for them.
Crushed/degloved/mangled extremities: although not life-threatening, still worth the divert, because usually needs multi-specialty care (plastic surgery, orthopedics, hand specialists, etc.) to maximize function.
Calling in “altered mental status” or “unresponsive” is not super helpful—give a GCS or otherwise specify what you mean, there’s a big range here.
Trauma activations here are typically three tiers: category 1 (life threat), category 2 (no immediate emergency, but some concern or suspicion due to mechanism or presentation), consult (no concern on initial presentation, but later decision to admit, trauma paged down to consult).
Activation may alert/standby numerous parties including radiology, OR, pharm, blood bank, lab, ICU, respiratory, anesthesiology, social workers, etc. Not a small thing.

Sean Dorr on OEMS investigations

[This is Massachusetts-specific information; local providers can contact me directly if they want to hear about some of this material.— ed.]

Ginnie Teed on Organ and Tissue Donation

Donation is hugely hugely valuable and lifesaving, but there’s not nearly enough. About 60-70% of Americans are registered donors, around 100 million people, but only 1% end up as usable donors and we need far more. Low rates aren’t from consent, they’re from the logistics of getting viable candidates.
Uniform Anatomical Gift Act (UAGA) is federal regulation providing basic requirements for process; states use this standard to form their own systems. Registered donors must be recognized and organ procurement agencies are required to advocate for them even against wishes of family, etc. Driver’s license “opt-in” now considered legal consent in some but not all states.
National Organ Transplant Act establishes the rules of the registry, blinds the entire process, prevents manipulation or line-jumping; the database is centralized and controlled; you can’t legally buy or otherwise get around the system. Manipulation is taken very very seriously and massively investigated, because it’s not only unethical, the pall it casts over the process makes others decide not to donate—the result is many lives lost.
Referrals (i.e. calling procurement organization to say, “we have a potential donor”) come from hospitals, nursing homes, clinics, whomever. This process is exempt from HIPAA.
Tissues tested more heavily than organs, because if an infection is carried through transplanted (i.e. nonliving) tissue, it’s almost impossible to eradicate.
Organs used: vital organs. Heart, lungs, kidneys and livers (most common), pancreas, sometimes small bowel. Max 9 organs per donor.
Tissues used: not living, usually good for about 24 hours after death. Bones (not marrow, which is living), although we try to not obviously mutilate people (for their family’s sake), skin (hugely beneficial), corneas, vessels, heart valves, pericardium, connective tissue (for orthopedic repairs).
Three ways to declare death: neurological (no brain activity; body only alive due to our mechanical support; recovery team responds to site and performs planned recovery); cardiac death (heart stops; not planned); planned extubation/cardiac death (patient is mechanically supported, determination made that there is no possibility to survive on their own; vent is pulled, if heart stops within 59 minutes they can take some organs; usually just the durable liver and kidneys unless bypass is available).
Live organs can only be taken from perfused patients. Someone “dead” (i.e. no pulses) can be a tissue donor but not an organ donor unless you get ROSC. No point in continuing CPR to “maintain the organs” if there’s no possibility of getting return of circulation.
EMS documentation absolutely critical for determining donor eligibility. Need to know downtime in arrests, how much CPR, any ROSC no matter how brief, events/mechanism leading to arrest. There are hard limits on fluid/blood/colloids received, so they must know how much fluid you gave (reasonable estimate is fine). Must document all needlesticks, number and location; if they find any holes that aren’t accounted for they’ll have to assume they’re a drug user or that additional lines were started and extra liters given. If you don’t want to document something at least tell the receiving staff.
If blood is drawn, label must be placed so that expiration date of tube is still readable (FDA requirement).
Every donor can save up to 200 people; failure to document can kill just as many.

UMass Memorial LifeFlight on Air Ambulance Transport

Consider: how do you want the helicopter used? Need their higher level of care? Rapid transport to trauma center? Transport multiple patients in an MCI to more distant hospitals to reduce burden on closest facilities? Can even split the crew to provide higher level of care for multiple ground ambulances.
Many services simply will not fly into a hazmat situation.
Best makeshift landing zones are schools—big open areas, everyone knows where it is.
Wires are a major hazard, make sure to warn pilot—you can see them but he can’t.
Need about 100 x 100 ft for an LZ, or 35–40 big-ish strides per side. Secure the area against bystanders.
Hazards to clear, alert the pilot to, or just pick another spot: poles, antennas, trees, bushes, livestock, stumps, holes, rocks, logs, mile markers, debris. Tall grass can hide hazards. Close all vehicle doors, put your chinstraps on, secure loose items. Don’t stare at the bird landing, turn your back and watch for hazards.
Bad surfaces are dust, dirt, snow, ice, hay. Snow should ideally be very fluffy or very packed. If they land and get iced they may not be able to take off again. Don’t wash down a dusty LZ unless pilot requests it. Paved areas are simplest and best. Large clear roadways can land multiple choppers in a row.
Lighting options: orange traffic cone at each corner, with a handlight placed in each at nighttime. Or, flashing ministrobe at each corner. Or, vehicle headlights crossing the LZ. Don’t shine anything up at the helo, don’t mark with loose material, don’t use flares.
Designate one person as LZ Command (not the IC). Nobody else communicates with the helicopter. Your portable radio probably won’t reach them; use the mobile in the truck. If there’s any hazard on final approach, say one word—”STOP”—and pilot will abort.
Most crashes are pilot error, and most pilot error is due to fatigue. There should be hour limits for a pilot, and this is a valid reason to refuse to fly.

Detective John LeClair, EMT-P, on Opiates and Prescription Pills

Heroin is still big, but pills are a huge player now too. You get an easy prescription from a walk-in clinic or ED, pay maybe a couple bucks with Medicare/Medicaid, and can not only sell them for easy cash but can crush and snort/shoot it for the same effect as heroin. Then if money or access runs low, you end up on heroin anyway to chase that high.
Oxycontin/oxycodone best selling narcotic in the nation ten years ago, but now on the wane. You scrape off the time-release coating, crush it and snort or chew it. “Hillybilly heroin,” “blue,” “oxycotton,” “kicker,” etc. Street price about $1/mg (40mg, 80mg, 160mg common), so many turned to crime. In Aug 2010, manufacturer (Purdue) added a “geling” agent which turns it to gel when it contacts water, making it difficult to snort. Try to snort this Oxycontin OP and it turns into a ball in your nose. Some people are sticking straws/tubes up in there to try and get it deeper and deeper, so airway obstructions are happening.
Percocet: oxy plus acetaminophen. For years the most common analgesic for sports injuries, so common among youth. Kids shared ’em, put out bowls of them at parties, girls prostituted themselves for pills. Taken with alcohol the APAP/Tylenol kills your liver. “Littles,” “little babies,” “little dogs.”
Opana/oxymorphone: getting popular after Oxy OP started ruining everyone’s fun. Same idea but you can still snort it. Twice as strong, and costs twice as much ($2/mg)
How to grind? Take a hose clamp, cut it, straighten it, tape it down, run the pill across the holes to grind it. Or use a Pedi-Egg, which collects the powder for you. The finer, the better high.
Heroin: snort, “skin pop” (subcutaneous), mainline. Must be pretty pure to snort, which it now tends to be, so popularity grew (people were afraid of needles due to HIV). However now some HIV/Hep is spreading through bloody noses and sharing straws anyway.
Smack, horse, china white, chiva, junk, H, tar, black, fix, dope, brown, dog, food, negra, nod, white horse, stuff. Dealers have their own “brand names.”
Heroin addicts are creatures of habit; get high same place, same way. Any change in their routine (e.g. different location) can get them amped up, changing their sensitivity and leading to OD even with their usual dose. Consider this if you find an OD somewhere like a car or alley.
“Cotton fever”: they pluck out wads of cotton from cigarette filters and drop it in the heroin to help filter it. Sometimes when they draw out the liquid they get a bit of cotton, and when they shoot it they get a sort of phlebitis/infection/sepsis.

Ensuring Appropriate Triage

It’s no secret that I’m a strong believer in patient advocacy, and that I feel one of the most important roles for EMS is to ensure that patients get directed to the right destination with the right priority and resources. Bob Sullivan at EMS Patient Perspective recently gave a post that hits on all of these points, discussing how to ensure that “undertriaged” patients don’t fall through the cracks at the ED. These details on how to work the system are some of the most valuable things we learn with experience, and to a large degree they’re what allow the ten-year veteran to help patients in ways the novice can’t. Give it a read!

Live from Prospect St: The Reluctant Tumble (conclusion)

Previously part 1 and part 2

Being reluctant to force Joe into an undesired ambulance ride, the crew contacted their supervisor. He arrived, evaluated the patient, agreed with their conclusions, and called Dr. Scrubs to discuss the matter. He was unable to dissuade the doctor from his decision.

The crew and supervisor approached Joe together and informed him of the circumstances; although all parties agreed that he should rightly be able to refuse transport, they felt they had been overruled by a higher authority, and if he would not come voluntarily they would be forced to compel him. Under this duress, Joe finally agreed to be transported, loudly and vocally protesting.

He was taken to his preferred hospital and care was handed off to staff with a full description of the situation. Less than 30 minutes later, another crew was sent back to the hospital to return Joe home; the attending ED physician had deemed his involuntary hold to be invalid and inappropriate, and refused to hold him against his will. No further evaluation was performed.

The encounter was documented extensively and quality improvement measures involving EMS and the base physician are expected.

Discussion

This case was not medically complicated, but it involved some difficult issues of consent and risk. Let’s look at the medicine and then at the wrinkles.

Medical Considerations

We were dispatched for a chief complaint of a fall — a very common mechanism of injury. When evaluating the fall, what should our main concerns be?

First, we should examine the mechanism itself. How far was the fall? In this case, as it often is, the fall was from a standing height, and from a standstill (i.e. not propelled while running, stumbling while breakdancing, etc.). This is often seen as the dividing line for significant versus non-significant falls; in many areas, falls from standing height or greater are considered an indication for spinal immobilization. (Other areas say greater than standing height; 3x standing height or more; or other numbers.) The elderly in particular are considered at higher risk for spinal injury, due to weakened bones and tighter ligamentous connections between vertebrae.

Typically, a blow to the head with loss of consciousness is also considered high risk for spinal injury. This is under the assumption that a blow with enough force to cause LOC may also have enough force to damage the spine. These considerations are all valid, but should only be seen as some of the many factors involved in stratifying risk; they must be considered alongside other elements like the physical assessment. In some systems, you may be forced to immobilize based on mechanism without other considerations. In others, you may be allowed to rule out immobilization based on certain findings, most of which Joe has; for instance, he denies neck or back pain or tenderness, denies peripheral parasthesias (numbness or tingling) or weakness, ambulated well, turns his head, and has no confounding factors like a distracting injury or altered mental status. In any case, the post-fall presentation was so benign that risk seemed low, and given the patient’s overall reluctance it is highly unlikely that he would have consented to a collar and board.

The use of warfarin (trade name Coumadin), on the other hand, does significantly increase the risk of intracranial hemorrhage (ICH), especially after blunt trauma to the head. Although again, Joe’s assessment was very reassuring — normal vitals, no complaints, and a baseline neurological status — it is very possible for ICH to have a delayed onset of presentation. The best example of this is the subdural hematoma, where cases of moderate severity sometimes take hours or days to develop, due to the venous rather than arterial source of bleeding. This delay is particularly common in the elderly, where (possibly due to shrinking of the gray matter, which leaves additional room for blood to collect before pressure begins compressing the brain) a classic scenario is the fall with a blow to the head, no complaints for hours afterward, and then sudden deterioration. Some sources state that 60% of geriatric fall patients who experience LOC from a blow to the head will eventually die as a result. Since in this case, we were delayed on scene for quite some time, there would be value in ongoing and repeated assessments of symptoms, neurological status, and vital signs while we waited around.

The patient’s pupils were unusual in appearance, which can be an indicator of brain herniation; however, this syndrome typically presents with one very large and round pupil. An irregularly shaped pupil as we saw here is more indicative of a structural defect, the most common of which is probably cataract surgery, which can leave the pupil off-round.

An incomplete medical history is common in scene calls involving the elderly. However, many do carry med lists, and in most cases you can reconstruct the majority of the patient’s diagnoses based on their medications. In this case, we found digoxin (or digitalis), which is almost always used to control atrial fibrillation; this is consistent with the patient’s irregular pulse, and with the warfarin, which helps prevent A-fib induced clots. Metformin (Glucophage) is an antidiabetic that helps control glucose levels. Citalopram (Celexa) is a common antidepressant of the SSRI type. Advair (fluticasone and salmeterol) is a preventative asthma/COPD inhaler combining a steroid with a long-acting beta agonist; it is used regularly to minimize flare-ups and is not a rescue inhaler. Omeprazole (Prilosec) is used for gastroesophageal reflux disease (GERD), aka heartburn. Ibuprofen is a non-steroidal anti-inflammatory (NSAID) used for pain relief and reduction of inflammation.

As VinceD noted in the comments, one essential question in any fall — and indeed in almost any traumatic event — is what caused it. Here we have a somewhat vague account which suggests a mechanical fall, i.e. tripping or loss of balance; this is not necessarily benign, as a history of repeated mechanical falls suggests deteriorating coordination or strength, but it is usually not indicative of an acute medical problem. However, many elderly patients (and some of the younger ones, too) will attribute any fall to tripping, so this claim should be taken with a grain of salt. It helps to have a witness to the event, as we do here, although witnesses are not always reliable either. In any case, what we want to know is: what happened just before the fall? Was the patient simply walking and tripped on a rug? Did he have seizure-like activity? Was he standing normally when he suddenly lost muscle tone and collapsed? Did he complain of feeling faint or dizzy? Was he exerting himself or straining on the toilet? Things happen for a reason.

Ethical and Legal Considerations

The bigger question is whether it’s okay for Joe to refuse transportation.

This is an odd question, because ordinarily we assume that people are free to go where they want, and calling 911 (or having it called for them) does not surrender this right. However, there is an attitude among those with a duty to act, such as healthcare providers and public safety officers, that individuals who are not cognitively able to understand their situation and make decisions in their best interest need to be protected from their own impaired judgment. This is equivalent to taking your friend’s keys so he won’t drive drunk, under the assumption that he wouldn’t want to drive drunk were he making sensible decisions. The legal term is implied consent, the same principle by which we transport children, drunks, and unconscious people.

How do we know if somebody is unable to make their own decisions? There is not an obvious line. For many providers, their rule of thumb is the old “A&Ox4”: if someone knows who they are, where they are, when it is, and what’s going on, then they are alert and oriented and capable of making decisions. Of course, this is only one piece of the mental puzzle. Social workers, psychiatrists, and other specialists have a full battery of tests that can help further reveal cognitive capacity. Can you perform these in the field? It’s probably more than you’re likely to do, although you might perform something simple like the MMSE. But some basic questions that highlight the patient’s judgment can help supplement your routine assessment — questions like, “Suppose you were at the mall when you started to smell smoke and heard the fire alarm. What would you do?” where any rational response is acceptable.

It’s important for the patient to be able to demonstrate that they understand what’s going on. Even someone with ordinary mental competence — unless they’re a fellow knowledgable healthcare professional — needs to be informed (to the best ability of the provider) of the possible risks and consequences of refusing care. In this case, it would involve giving them some description of the above possibilities (spinal fracture, head bleed, etc.), and ideally having the patient then relate them back to you, demonstrating good comprehension of those facts. The base physician’s view that Joe hadn’t fully demonstrated this understanding was a key part of his decision that he needed to be transported against his will.

Other important points are to ensure that the patient knows that refusal doesn’t preclude future care (“if you change your mind, you can always call back”); and that the ability of the providers to evaluate the patient on scene is at best limited. Any implication that you know what’s really happening to the patient or can definitively rule in or rule out any medical problem is unwise and legally risky. In fact, even suggesting possibilities or probabilities can be problematic if you’re wrong; on the other hand, failing to do so can leave them uninformed, so this can be a Catch 22. Your best bet is to outline some basic possibilities, carefully inform them of the limits of your training and resources, and be smart enough that you generally know what you’re talking about in the first place.

One complication in this case is the presence of someone who claims to be Joe’s health care proxy. A proxy (closely linked to the idea of a durable power of attorney) is a person whom, while of sound mind, you designate to make decisions for you if at a later time you are not of sound mind. Crucially, if you are still capable of decision-making, a proxy does not have the ability to override you; their role is to act on your behalf when you cannot. In other words, the decision of Joe’s proxy is only relevant if we do find (or in some areas, if an authority such as a judge has decided) that he’s incompetent to refuse or consent to treatment; thus, her presence does not necessarily alter the basic dilemma.

In this case, the physician’s attitude was that the problem was primarily medical: does the patient need emergency department evaluation to rule out dangerous processes? Medically, he does. However, the first question actually needs to be: Is the patient capable of evaluating risk and making decisions in his own best interest? If he is, then he is technically “allowed” to decide whatever he wants. Even a clearly dying man can refuse medical care based on religious views, personal preference, or any reason whatsoever (although barring a proxy or advanced directive, once he’s unconscious he can usually be treated under implied consent). This is different from the person who actively tries to take his own life; for philosophical reasons we view this as different from passively allowing oneself to die for lack of medical treatment. We prevent people from committing suicide but allow them to refuse medical care.

Realistically, although this fundamental right does not change, it’s fair to consider the surrounding medical circumstances to help decide how pressing and high-risk the matter is. In this case the doctor clearly felt that the risk was so high that it required going to extraordinary lengths, including overruling the patient’s own decisions and potentially even harming him, to ensure that a dangerous situation wasn’t “missed” — in short, that the ends justified the means. Dr. House is famous for this approach.

Legally, in most areas EMS providers are seen as operating under the bailiwick and legal authority of their medical director, and online medical control is an extension of this authority. In other words, within reason we are bound by the orders of medical control. The details of this relationship vary, and are not always fully explored. For an example, consider this true story from 1997 in New Jersey:

A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Downtime is unknown, and they work the code for a number of minutes without response. Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. After a “joint decision” the base physician verbally talks them through performing an emergency C-section on scene. They deliver and successfully resuscitate the fetus, and both patients are transported. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. The physician is forced to undergo remediation training to maintain his medical control privileges.

Is the moral that acting in the patient’s best interest is not always a defense against liability? Maybe. Is the moral that medical control cannot authorize you to perform otherwise illegal acts? Maybe. Is the moral that we should protect ourselves before the patient? I don’t know about that, but it’s something to think about. In this case, the course for Joe that seems most ethical to me — allowing the patient to make his own decisions — also lets us avoid potential liability for battering and kidnapping. However, it does force us to refuse a direct order from medical control. Invoking our supervisor gives us a bigger boat either way, and would be a big help to protect us from trouble coming from our employer, one of the most likely sources. It’s also true that, while we may have believed that Joe was competent, he is at least somewhat diminished, so we’re less than completely confident. Nobody wants to put themselves on the line by taking a stand, only to be proven wrong.

Fortunately in this case we were able to avoid getting violent at all, but it was a near thing. If it did prove necessary, it should have been done with ample manpower and many hands; in some areas chemical sedation by paramedics may also be authorized. And I would certainly not recommend acting without the doctor’s signature on a legal document.

With everything viewed in retrospect, the situation would have been much more easily resolved had the doctor not been involved in the process. At the same time, however, if a simple refusal had been accepted, and CQI later went over the call — especially if Joe experienced a bad outcome — the crew would have been in a difficult place.

No matter what, such a situation is highly unusual, flush with liability, and should be thoroughly documented in all respects.