Tag: transport

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!

Murder by Checklist

Reader Steve Carroll passed along this recent case report from the Annals of Emergency Medicine.

It’s behind a paywall, so let’s summarize.

 

What happened

A young adult male was shot three times — right lower quadrant, left flank, and proximal right thigh. Both internal and external bleeding were severe. A physician bystander* tried to control it with direct pressure, to no avail.

With two hands and a lot of force, however (he weighed over 200 pounds), he was able to hold continuous, direct pressure to the upper abdomen, tamponading the aorta proximal to all three wounds.

 

Manual aortic pressure

 

Bleeding was arrested and the patient regained consciousness as long as compression was held. The bystander tried to pass the job off to another, smaller person, who was unable to provide adequate pressure.

When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

The result?

Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED.

The patient did not survive.

 

When the cookbook goes bad

The idea of aortic compression is fascinating, but I don’t think it’s the most important lesson to this story.

Much has been said about the drawbacks of rigidly prescriptive protocol-based practice in EMS. But one could argue that our standard teachings allow for you to defer interventions like IV access if you’re caught up preventing hemorrhage. Like they say, sometimes you never get past the ABCs.

The problem here is not necessarily the protocols or the training. It’s the culture. And it’s not just us, because you see similar behavior in the hospital and in other domains.

It’s the idea that certain things just need to be done, regardless of their appropriateness for the patient. It’s the idea that certain patients come with a checklist of actions that need to be dealt with before you arrive at the ED. Doesn’t matter when. Doesn’t matter if they matter.

It’s this reasoning: “If I deliver a trauma patient without a collar, vital signs, and two large-bore IVs, the ER is going to tear me a new one.”

In other words, if you don’t get through the checklist, that’s your fault. But if the patient dies, that’s nobody’s fault.

From the outside, this doesn’t make much sense, because it has nothing to do with the patient’s pathology and what might help them. It has everything to do with the relationship between the paramedic and the ER, or the paramedic and the CQI staff, or the paramedic and the regional medical direction.

Because we work alone out there, without anybody directly overseeing our practice, the only time our actions are judged is when we drop off the patient. Which has led many of us to prioritize the appearance of “the package.” Not the care we deliver on scene or en route. Just the way things look when we arrive.

That’s why crews have idled in ED ambulance bays trying over and over to “get the tube” before unloading. That’s why we’ve had patients walk to the ambulance, climb inside, and sit down, only to be strapped down to a board.

And that’s why we’ve let people bleed to death while we record their blood pressure and needle a vein.

It’s okay to do our ritual checklist-driven dance for the routine patients, because that’s what checklists are for; all the little things that seem like a good idea when there’s time and resources to achieve them. But there’s something deeply wrong when you turn away from something critical — something lifesaving — something that actually helps — in order to achieve some bullshit that doesn’t matter one bit.

If you stop tamponading a wound to place a cervical collar, that cervical collar killed the patient. If you stop chest compressions to intubate, that tube killed the patient. If you delay transport in penetrating trauma to find an IV, that IV killed the patient.

No, let’s be honest. If you do those things, you killed the patient.

Do what actually matters for the patient in front of you. Nobody will ever criticize you for it, and if they do, they are not someone whose criticism should bother you. The only thing that should bother you is killing people while you finish your checklist.

 

* Correction: the bystander who intervened was not a physician, but “MD” (Matthew Douma), the lead author, who is an RN. — Editor, 7/22/14

Advanced CPR Techniques for Basic Providers

Handstand CPR

 

So you’re an EMT operating at the BLS level, and you understand that when it comes to cardiac arrest, you’re the man. Sure, you’ll call for the medics if you get there first, but the stuff that’s really important — compressions and defibrillation — well, that’s right in your wheelhouse.

But it may seem a little simple. Simple is beautiful, but maybe you’re wondering what else you can do to really master the art of resuscitation, especially when you’re out there on your own. Take it up a notch, if you will. And a lot of the cool stuff that’s being tried in the big world, such as pit-crew choreography and various supportive devices, are only available if your service makes a large-scale decision to adopt them. What can you do as an individual provider to absolutely ensure your peri-dead patients have the best chance of survival?

Here are some ideas.

 

Don’t Stop Compressions, at All, Ever — Seriously, Just Don’t

Hopefully at this point you don’t need to be convinced that stopping compressions is a bad thing. It truly is. The mountain of evidence is unequivocal: any time spent not-compressing kills people; each interruption in compressions kills people; pausing after compressions before defibrillating kills people; pausing after defibrillating and before resuming compressions also probably kills people; and so forth.

The trouble is that, despite this knowledge, we still stop all the goddamned time. There’s a lot going on during a code, and a lot of things you might want to pause for. But let’s go through a few and see if we really have to stop:

 

Stop for Pad Application?

As soon as you found the patient, you began compressions, right? As long as they weren’t wearing a honking seal-skin anorak, you can do that just fine over a shirt, blouse, or other light garment. (Hint: anoraks and similar loose outerwear can often just be pulled off the arms overhead, like removing a T-shirt.) Bam, in you went.

Now your partner needs to apply AED pads, though. Should you stop what you’re doing? Heavens, no. Let him work around you if he needs. He can unzip, rip, cut around your hands, tug the fabric out from under them as pressure lifts between compressions, and clear as much of the chest as he needs. Then he can simply apply the pads. No interruptions, no problem.

In some cases, a CPR-feedback device will be present, either combined with the pads as a one-piece unit, or as a separate “puck.” Either way this usually needs to go between hands and chest, but you should be able to slip it under there with (at most) a brief hiccup in the rhythm

 

Stop for Rhythm Analysis?

Unfortunately, if you’re using an AED (rather than a manual monitor like the medics are toting), you will need to stop compressing and come off the chest in order for the device to analyze the rhythm. Otherwise, the electrical motion artifact produced will confuse the computer. So as soon as the device tells you to stop compressions for analysis, clear the body — but don’t go far (in fact, I would simply hover), and as soon as it’s finished, get back on there.

You may need to stop for manual rhythm analysis as well, but some monitors have a filter that can allow the medics to “read through” compression artifact.

 

Stop while Charging?

So the AED finished analyzing and advised a shock; now it’s charging. Can you compress during this period? Yes. Both common sense (it won’t shock unless someone pushes the button, so… don’t push the button) and at least one study (albeit for manual, not automated defibrillators) have shown this to be safe. There are some AEDs that will get confused if you compress during this time, so know your gear. [Edit: per our “para-engineer” friend Christopher Watford, the Philips FR2+, FRx, and FR3 AED models, plus the Zoll AEDPlus and AED Pro, may complain and possibly halt if you try to compress while charging or shocking. Lifepak AEDs should be mostly okay. Chris and David Baumrind — two of the conspirators behind EMS 12-Lead — wrote a feature for JEMS discussing the behavior of various AEDs if you attempt these maneuvers. Required reading!]

Once the device has charged and is ready to shock, clear everybody except the compressor, ensure that they’re clear, and coordinate between the compressor and button-pressor. Something like, “I’m going to count to three, and when I say three, I’m going to come off and you’re going to press shock, okay? One — two — [come obviously clear] and shock — aaand back on.” The actual defibrillatory shock takes a fraction of a second, and the device will verbally announce once it’s delivered, so you can get back on the chest almost immediately after pressing “shock.” There is no residual “charge,” it doesn’t “take a while” to deliver, it’s a quick blip, so you’ll only need to clear the chest for a moment — no more.

 

Stop while Shocking?

As a matter of fact, do we need to clear the chest to shock at all, or can we keep our hands down, compressing continuously while the electrons flow?

Instinctively, most of us say “No thanks!” However, a little logic suggests the risk may be low. Electricity follows the path of least resistance, and if pads are properly placed and well-adhered to the chest, this path should always be through the patient’s chest. The alternate path up into your hands is much longer, and will only exist at all if you have a connection to the ground, which (if present at all) will probably run through fabric and other insulators. Since almost all AEDs now are biphasic — these use less current than the old monophasic devices — and since pretty much everybody wears rubber gloves while they compress, risk is probably quite small.

The evidence supports this somewhat. Consider these studies: Lloyd, Neumann, Sullivan (supports multiple-gloving in my view), Yu, and Kerber.

This idea has been gradually gaining traction, and some folks have already started doing it routinely, mostly of their own volition. Salt Lake City Fire has even been experimenting with making it a standard option during all resuscitations. For the most part, the worst adverse effect reported seems to be a tingling sensation, particularly if there’s a tear in your gloves. It’s reasonable to ensure that you’re wearing intact gloves, especially over prolonged efforts (multiple shocks may break down the material), and probably wise to double- (or triple-) glove. If there’s a feedback device between your hands and the chest the risk is even lower (or you could lay something like a rubberized blanket over the chest to totally insulate yourself, as in the Yu study).

Now, everybody has a story about a guy who knows a guy whose ex-partner’s bartender was touching a patient during defibrillation, got blown across the room and set on fire, and now can’t pronounce vowels. For the most part, this seems to be purely legend. The trouble is that there isn’t sufficient evidence yet proving it’s safe to make this an official practice on a top-down level; but that doesn’t mean you can’t make the decision for yourself.

If you have an arrhythmia (especially with an ICD or pacemaker), or another legitimate reason to be concerned about your own heart, it’s probably reasonable to pass. For everybody else, to paraphrase Dr. Youngquist of SLC Fire, this practice is probably safe for providers — if not yet for administrators. So you might not see this in your protocols for a little while, but I’ll bet it doesn’t say not to do it, either. The decision is yours.

(There is a possibility that some AEDs, particularly those with feedback technology, may detect the ongoing compressions and refuse to deliver a shock. Again, see above for more info.)

 

 

Stop for Ventilations?

Until you get some kind of tube into the patient’s airway, you’re going to have a hard time bagging any air in unless you pause compressions first. One option would be to simply skip it and perform continuous compressions, which is very reasonable, especially early in the code, or really whenever in doubt. But if you do pause to ventilate, take as little time as possible — pause, breathe goes in, exhale, second breath, and then immediately back into compressions (no need to wait for the second exhalation).

 

Go Faster — and Probably Harder

The currently recommended rate for chest compressions is “at least 100 per minute.” In other words, that’s not a target, that’s a minimum. Can you go too fast? Probably, but it’s hard, and it’s much easier to go too slow.

There’s an accumulating body of evidence, however, that points toward a more exact rate — right around 120/minute. Up to that number, more people survive if you push faster; above that number, fewer survive. It’s not for-sure yet, but in this business, not much is totally sure.

Since it fits the official “over 100” recommendation anyway, I now use 120 as my target rate, and I think you should too. It does mean that your old go-to songs for musical pacing, such as Stayin’ Alive (or perhaps Another One Bites the Dust) won’t work anymore, since those are matched to 100/minute beats. But 120/minute is simply twice per second, and most people can approximate that pretty well, or you can find a faster song (try this app for suggestions).

With that done, are you pushing hard enough? The recommendations are at least two inches deep in adults, so you should at least be hitting that. (It’s deeper than you think.) But as much as some people are willing to go wild on the rate, few people ever seem to challenge the depth. Unless you are an 800-lb gorilla and the patient a 70-lb granny, you are unlikely to cause meaningful damage, and there is a direct link between depth of compressions and cardiac output. Try to really aim for the mattress, and whatever depth you’re hitting, even if you think it’s pretty good, go a little deeper.

 

The Knuckle Hinge

Does it matter how you hold your hands against the chest? Maybe.

What really matters is that you provide good compressions, but hand position can affect that. What you should do is find a CPR mannequin and experiment until you figure out what works best for you. But while you’re experimenting, here’s something to try.

Most people lay one palm over the back of their other hand, and either interlace their fingers (as the AHA videos usually depict) or don’t (I don’t, since I find it somewhat awkward, but since it forces your arms to externally rotate, it can help encourage providers to lock their elbows). Either way, as you meet the chest, you’ll be making contact with the heel of a palm and one set of knuckles.

“Glue” these knuckles to the chest; they don’t move, so once you’ve found your position, you’re locked-in. But each time you compress, do allow your palm to lift off the chest, “hinging” at the knuckles as they remain in contact. Don’t come up very far — just enough that you could slip a sheet of paper between palm and chest — but get a little daylight in there.

What’s the point? One of the more common errors when otherwise high-quality compressions are performed is a failure to allow the chest to fully recoil. You can go deep, but if you don’t come all the way up at the top, you’re still not producing the largest possible stroke. What’s more, unlike poor depth, this isn’t always obvious by looking at the chest (either to you or to others), so the safest method to ensure full recoil is to actually lift off the chest. If you remove your hands completely, though, you tend to lose your place, and your hands can “wander” until you’re pushing on the patient’s feet or your partner’s face. The knuckle hinge allows the best of both worlds.

 

Assign a Monitor

Isn’t this tiring? Now you’re pumping away crazy deep, twice a second, full recoil, and not stopping for almost anything.

Even if you’re an Olympic decathlete, this will start to wear you out fairly quickly. You’re full of adrenaline, and you’re a rockstar lifesaver, so you won’t say anything, and perhaps you won’t even notice; you’ll keep plugging away. But before long, you won’t be pushing quite as hard or deep, or quite as fast, or maybe you’ll start leaning on the chest instead of recoiling all the way. I promise you will; many studies have shown this; and what’s more, you’ll probably still think you’re doing good work.

No problem. As long as we have adequate manpower (and in most places, there are plenty of people on scene at a code), simply assign one person to monitor the quality of compressions. If it’s you, your sole job is to sit somewhere with your head close to the action, staring at the up-and-down, and ensuring it follows all the criteria we’ve discussed. If it needs to be faster, you tell them to speed up until they’re on pace. If it needs to be deeper, tell them. If they ever pause for any unnecessary reason, yell at them like an Italian grandmother until they start back up. And once it’s clear that they’re fatiguing, you make them swap out, and ensure that the swap happens with minimal delay. The AHA recommends switching every two minutes, but use a smart approach; some compressors will last less, some more, and if you reach a mandatory pause (for rhythm analysis, say), you might as well change even if the current person has some juice left.

Depending on resources, they may be swapping with you, or there may be enough people sitting around that you can have a rotating pool of dedicated compressors. You can maintain the same person as monitor (the easiest method, if you can spare them), or just have each on-deck compressor act as monitor.

Useful tools for the monitor include a watch with chronograph, but even better would be a metronome. That way you can set up an audible pace (120/minute, remember) that any monkey can follow. A few services do carry actual digital metronomes, but if not, most smartphones have metronome apps available. (Find and download it now, not in the patient’s living room.) You can also throw an MP3 from an appropriately-paced song onto your phone, if nobody minds running a code to a soundtrack (probably not ideal when there’s an audience). The monitor person can keep track of other times as well, such as the ventilatory rate once an advanced airway is placed, total duration of the code, times of medication administration, and so forth. A pad of paper or strip of tape down the leg are helpful.

An electronic feedback device is a helpful adjunct to this role, and if resources are limited can replace it, but it’s not quite the same. If it is available, tracking the automatic feedback (and ensuring the compressor obeys) is the monitor’s job.

Whether or not a monitor is assigned, everybody performing compressions (really everybody at the scene) should understand that it’s still their responsibility to ensure quality. This is particularly important when it comes to eliminating interruptions, because even if there’s somebody to yell at the compressor when he stops, if he’s stopping all the time that’s still a lot of pauses. An effort should be made when assigning a compressor (who isn’t you), such as a first responder or bystander, to make them understand that they “own” their compressions, and it’s their responsibility to do ’em right and stop for nothing. The monitor’s job? Just to keep them honest.

 

Ask Why

Cardiac arrest happens for a reason, and even though it’s the most time-sensitive, treat-the-ABCs syndrome that exists, there are still times when you’ll never fix the problem without understanding the cause.

In a perfect world, you’d show up, compress, apply AED, shock, get a pulse, the patient sits up and hugs you, you transport and all’s well. In a realistic world (depending on your area), usually ALS shows up at some point and things take a more technical direction. But if you’re working the arrest for more than a couple minutes, have adequate manpower, but are still BLS-only, then your extra providers shouldn’t be sitting around twiddling their thumbs; they should be gathering information, planning the next step, and preparing for transport.

Ideally, one person is running the code. Either that person or somebody competent he delegates to should communicate with family or bystanders, examine available records, dig through the meds, whatever — try to determine both the history of the present event, and a reasonably-complete past medical history and medication list. Partly, this is for later management; the medics or the ED may need it. But it’s for you, too, because it may suggest your course of care.

Without an ECG, you haven’t got much to tell you what’s happening, except that the patient’s got no pulse. (Auscultating the chest may indicate whether a regular heart rhythm is present which is simply not perfusing — PEA, or if you’re a magician you may be able to “hear” V-tach — but you have to stop compressions to appreciate much.) You’re unlikely to be able to magically predict whether you’re dealing with V-fib versus torsades versus asystole. But you may be able to guess that certain correctable causes are present.

For instance, was the patient complaining of classic MI symptoms (crushing chest pain, nausea and vomiting, dyspnea) for twenty minutes before he finally became unresponsive? And he’s had two heart attacks before, with several stents placed? It’s a fair bet that he’s had another, which caused this arrest, and you may not have much luck getting him back until that artery can be opened back up. You can and should still work him initially on scene, but your mental goal should be delivering him to a PCI-capable hospital, so while you do your thing, stay on that track. If you get a few “no shock advised” messages with no pulse, or perhaps shock once or twice but he remains severely unstable, try to get him packaged as you continue your awesome compressions, notify the hospital of the situation and your suspicions, and get him over there. Try for ALS, who can perform a 12-lead ECG, which will facilitate this process (and your protocol may not permit you to divert to a more-distant PCI hospital otherwise).

Do you have reason to suspect hypovolemia as the cause of arrest? Is there obvious external bleeding… or is there a rigid and distended abdomen, perhaps with a story of abdominal pain or blunt trauma? In that case, you can push or shock all you want; you’re not going to refill an empty pump. Maybe chest trauma with a potential tension pneumothorax or cardiac tamponade? Transport ASAP to a trauma center (and perhaps ALS, since they can decompress a pneumo and give some volume if appropriate).

Is this a hemodialysis patient who missed two sessions, has been lethargic and sick-appearing, poorly-tolerating exercise, and finally fell asleep and didn’t wake up? Suspect hyperkalemia, a true “ALS-curable” condition, so if medics are available, work it until they arrive. If they’re on the dark side of the moon, transport with the best compressions you can manage.

Is the patient a known diabetic, taking insulin, and a story consistent with hypoglycemia? Check that sugar if you can, and if it’s something perverse like 7 mg/dl, get them to either ALS or an ER — both can administer intravenous sugar.

Could it be a hypoxic arrest? All arrests are hypoxic after a few minutes — dead people don’t breathe — which is why it’s usually reasonable to breathe for them (although far from a top priority). But if you walk in to find a post-drowning victim, or a hysterical mother saying her child choked and now has no pulse, you may have a cardiac arrest whose underlying cause is nothing more than hypoxia: their heart didn’t get enough oxygen, so eventually it gave up too. They still need compressions, and may need to be shocked, but most of all they need oxygen, so opening the airway and bagging in high-concentration O2 is a top priority. (Compare this against the post-MI patient above, who doesn’t need any oxygen at all until you have enough hands to provide it without delaying compressions and AED use, and even then doesn’t need much.)

Possible pulmonary embolism? Poisoning? Commotio cordis? The list goes on. The point is, if you have the resources to take a moment, gather some information, step back, and think, you can often do a pretty good job of guessing what brought you here, even without the benefits of the ECG. In some areas, your policies and protocols will dictate pretty clearly what decisions you can make, and it may not matter much. But flip through that rulebook now, because often times people assume it says more than it does (for instance, “closest appropriate facility” is more common than “closest facility”). When in doubt, you can always call medical control and make your case.

(As a general point of safety: continuing CPR while packaging and transporting emergently is difficult at best, and both unsafe and low-quality at worst. This should factor into your decision-making, as should the specific obstacles presented by extrication, and the potential availability of a mechanical compression device, which can make the process substantially easier.)

Just don’t ever try to argue that only ALS is allowed to think.

BLS is all yours, and cardiac arrest remains a fundamentally BLS problem. Own it.

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 (part 2)

Continued from Part 1

Since the two children appear generally intact, you ask your partner to evaluate them more fully while you head for the sedan to find the driver. Anticipating three transports, two stable and one potentially critical, you ask your dispatch to continue the P12, and also to ensure that police are en route (they are).

Arriving at the sedan, you find a middle-aged woman in the driver’s seat, alert. She is pink and warm, perhaps more diaphoretic than you’d expect for the ambient temperature, and does not initially notice as you kneel beside her. A firefighter is holding C-spine immobilization from the back seat.

When you greet her and pat her on the shoulder, she gives no response, but with more vigorous stimulation she looks over and acknowledges you distractedly. With multiple attempts and some yelling, you’re able to get answers to a few questions, but she is slow, tangential, and often ignores you outright. She gives her name as Samantha, but cannot or will not provide her last name; she is unable to describe the events that led to the collision; and she gives no medical history or current medications. She does state several times that she’s fine and would like to leave. When asked about her passengers, she mumbles “my kids” and mentions her brother several times. She endorses pain when asked explicitly, but does not specify where. She agrees that she drank “a little” alcohol; when asked about any drug use, she denies it vehemently.

Physically, she appears generally unremarkable. She is breathing somewhat shallowly but effectively, and her radial pulse is around 100 and slightly weak. Her seatbelt is not in place, but it’s unclear whether it was removed at some point. No gross trauma is apparent upon her head, face, or neck, and she does not complain or grimace upon palpation. She is uncooperative with a neurological exam, but demonstrates spontaneous movement of all four extremities. Her pupils are equal and seem appropriately small on this moderately bright day. Chest rise is generally equal and her abdomen is supple; no bruising consistent with seatbelt injury is visible. Her left knee is abraded and somewhat swollen. A sprinkling of dark blotches and streaks are noted on her left ventral arm in the antecubital region. Both frontal airbags are deployed; the windshield is cracked, but lacks a “starred” point of impact; and the plastic dashboard in the driver’s knee area is damaged and cracked. No blood or other damage is visible in the interior compartment. There are no child seats.

Your partner comes over. “The kids seem fine, just upset. One’s complaining of some abdominal pain, but it looks okay. They’re little troopers. Fire says they were wearing regular lap belts with the shoulder strap tucked behind them.”

When you wonder aloud whether there are more patients, he says, “There was nobody else in the car when fire arrived. The truck driver gave a statement to the police about how she was swerving across the road and plowed into him, but then he eloped.” He looks over your shoulder. “Oh, and the P12 is pulling up now.”

 

What is your treatment plan for these three patients? What are their respective priorities, any points of concern, and how could you shed additional light on their status?

Who will transport which patient, and to which destinations?

What special considerations should be made during documentation?

 

The conclusion is here

Eight More Tips on Ambulance Wrangling

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.

  1. 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.
  2. 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.)
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
Anyone else have some good ones to share?

The Slow Ride

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:

  1. Move to the rightmost lane.
  2. Throw on your 4-way hazards.
  3. Drive about 5 MPH.
  4. 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.

Finally, we offer a recommended soundtrack.

Dialing it Down a Notch

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.

Understanding Shock VIII: Prehospital Course of Care

Now that we have a pretty good idea of how shock works, what does it all mean for our treatment in the field?

Much like cardiac arrest and some of the other “big sick” emergencies, there are really a couple essential interventions we need to execute, maybe a couple others that aren’t a bad idea, and beyond that, our main job is to ensure that we don’t kill our patient by wasting time doing anything else.

 

Step 1: Control the bleeding

As we emphasized ad nauseam, the number one goal with the bleeding patient is to stop the bleeding. No need to beat this to death, but just remember: if you can control the bleeding, yet don’t get much of anything else done, you’re doing absolutely fine.

 

Step 2: Transport to surgery

In most significant cases of hemorrhage, definitively controlling the bleeding will require surgical intervention. We don’t do surgery, but we do set the stage, which is why it’s essential for us to know what we’re doing. Get thee to a trauma center, and quickly!

Can other hospitals perform surgical intervention? Sometimes. Maybe. A world-class trauma surgeon might happen to be in the building for a conference. Maybe the operating room is between scheduled procedures and happens to be clean and available. But the point to a trauma center is that it’s guaranteed to have certain resources available, and that’s the kind of place we want to bring these patients. 9 times out of 10, if we transport them elsewhere, they’ll simply end up being transferred back out to the trauma center anyway, making the whole exercise essentially one very long transport. Can a small community hospital help stabilize the patient before surgery? Sure — but as we know, everything else is a distant second priority to bleeding control. Even transfusing blood may need to be done sparingly until the leak has been corked.

What about ALS? Do these patients need paramedics? Now, if they acutely decompensate and need airway management or other interventions you can’t provide (or have other issues like pneumothorax), then ALS-level care would be valuable. But outside of that, and even granting that to a certain extent, a medic unit is not going to stitch up the bleeding, and meeting them will certainly delay transport to surgery at least by a few minutes. True, they’ll be able to initiate IV access that can be used for blood later, but in most cases this takes mere seconds at the ED (where there’s plenty of room, good lighting, and ample personnel) — and prehospital IVs will sometimes be replaced anyway.

 

Step 3: Promote oxygen delivery

Okay, you shock technician, now what?

Can we talk about coagulopathy of trauma — aka the “deadly triad”?

Bleeding control is the priority, right? And bleeding control requires clotting. But there’s a set of conditions guaranteed to obstruct clotting, and three of them are almost always present during hemorrhagic shock.

One is hemodilution. When we top off our bleeding patients with non-blood fluids, as we’re so fond of doing, it dilutes both oxygen-carrying capacity (since we’re not adding red blood cells) and clotting speed (since we’re not adding platelets or clotting factors). So this one’s our fault, and can be readily avoided by simply resisting the urge to replace blood with salty water.

One is acidosis. If you’ve been paying attention, you know that acidosis tends to develop in shock due to anaerobic cellular activity, and can be further encouraged by overzealous fluid administration. Is this the end of the world? (After all, a little acidosis might even improve oxygen delivery by shifting the oxyhemoglobin dissociation curve.) Well, the trouble is that acidosis also leads to coagulopathy. According to some in vitro studies, in fact, even mild acidosis can precipitously decrease platelet aggregation, and in significant acidosis platelets won’t activate at all. Zero.

The last is hypothermia. Not only do cold patients have poor oxygen delivery and other problems, they clot poorly; low temperatures cause coagulopathy too.

Now, we can’t do much about the initial trauma. We can discourage acidosis by limiting fluid use, and ensuring that ventilations remain adequate. What about hypothermia? Do our trauma patients get cold? What would you expect when you take someone who’s bleeding, strip them naked on a cold sidewalk, pump cold saline into their veins, and chuck them into an ambulance carefully heated to your comfort?

Keep your trauma patients warm. This is not about human kindness or TLC, this is a serious and important intervention for shock. Hypothermia is great for cardiac arrest, it may be beneficial in some other scenarios, but it is not good for bleeding people.

How about supplemental oxygen? Well, I suppose so. In the patient with adequate respirations, it is doubtful that “topping off” their PaO2 will affect them appreciably; but as they begin to decompensate, they’ll need all the help they can get.

Positioning? Remember how big a deal they made about the Trendelenburg position in school — how it pulls blood from the lower extremities into the core? And ever noticed how it’s not exactly our number one emphasis in the field? Trendelenburg has little real evidence supporting it, and the bulk of what does exist suggests its effect is fairly minimal — it moves only a little blood, the effect is transient, and the body’s compensation can actually cause a paradoxical reduction in core perfusion. Mostly these studies were done in healthy people, so it’s possible that our shocky patients do get a little benefit — and one supposes that if things are dire enough to need every last cc of blood, you can give it a shot. But typically it won’t do you too many favors. (I certainly wouldn’t advise propping the patient bolt upright, though!)

 

Step 4: Supportive care

Supportive care means battling secondary problems as they arise.  It doesn’t mean waffling over nonsense while your patient bleeds out.

If the patient’s airway is compromised, or you have legitimate reason to think that it may become compromised, then it should be managed. If they’re breathing inadequately, they’ll need assistance. Beyond that, any other care should only occur after you’ve stuck a cork in the bleeding and started rolling toward the guys with knives. Cardiac fiddling, pain management, splinting or minor bandaging — these should take place en route or simultaneous to other care, if at all. Shock kills people; is a nice sling-and-swath going to save them?

Spinal immobilization? It’s been pretty definitively shown to hurt rather than help in penetrating trauma. What about combined blunt and penetrating? There’s no evidence that it helps and some evidence that it’s harmful. We have no reason to think that tying people to boards does anything good, but we do know that wasting time here does everything bad. So if your local protocols demand immobilizing these patients, I won’t tell you otherwise — but please, at least, try and hurry.

That’s it, folks. Let’s wrap it all up next time by talking about recognizing the beast.

Key points:

  1. Stop the bleeding to the greatest extent possible in the field.
  2. Immediately and without delay transport to a facility capable of emergency surgery.
  3. Provide other supportive care as necessary, without delaying #1 and #2.
  4. Maximize oxygen delivery with supplemental O2, keeping the patient warm, and consider the Trendelenburg position.
  5. Minimize delays created by any and all non-essential care.

 

Go to Part IX or back to Part VII