Either Lead, Learn, or Please Stop Talking



The Internet is a wonderful educational resource.

I hope this doesn’t come as a surprise to anybody, but it’s good to be reminded. As little as 20 years ago, it simply wasn’t possible to learn things in the same way or to the same extent as today, because you had to seek out the information like Indiana Jones hunting a lost jewel-encrusted kumquat. Now there are a thousand PhD’s worth of knowledge available for anyone with a modem (although it behooves us to remember that much of it is still more easily found offline, and some remains completely undigitized even now).

I have always relied heavily upon this resource, and the majority of the synapses currently rattling around my noggin wouldn’t be there if it weren’t for the ’net. I went to school, sure, but when it came to pursuing my interests and hobbies, that’s not where the money was. It even filled the bowl of my early work history — I worked in web design, various sectors of freelance writing, even as a certified locksmith, all of it made possible by self-education via an endless tap of bits and bytes.

When I first became involved in EMS, I expected that to remain true. But it wasn’t.


EMS 2.0: Good, bad, and ugly

Although somewhat inchoate in my early days, the EMS 2.0 movement was already getting legs, and was driven by an online community of paramedical luminaries hoping to remodel our damaged field into a modern, functioning system.

More recently, the larger arena of the medical community — with emergency medicine leading the way — has embraced FOAM, the general principle of free online medical knowledge-sharing. This is good stuff, and it’s just what we need.

But when I was a green EMT — and we all know how unprepared a freshly certified newbie can be — I turned to the web in the hopes it would help me learn, improve, and become better at my job. To some extent, it did. But I was also stymied.

Everywhere I turned I found veteran EMTs and paramedics advocating for increased education and training within our field. They seemed to passionately believe in making prehospital providers become better clinicians. Yet whenever I would ask medical questions to try and do exactly that — become better — I wouldn’t get answers. I would get further diatribes about the shortcomings of EMS education. Or suggestions to read a textbook (only rarely was one recommended). Or, if I pressed the point, the advice to go to paramedic or even medical school, because this sort of inquiry was likely to make me a fish out of water in my current profession.

Truth be told, I rarely got any answers where I didn’t dig them up myself. And I found this strange. Why would people purportedly so interested in advancing their profession seem to have so little motivation to actually do it?

Time has passed, and I have more perspective. In retrospect, the folks on the other end of the screen often didn’t know the answers to the questions I was asking, or only knew the answers in an incomplete or experiential way. Time has also brought along some actual progress, and there are more true FOAM resources out there.

Yet in the prehospital world, noisemaking still seems to predominate over knowledgemaking. For every blog post, website, forum thread, or social media group dedicated to transmitting information, there are ten whose primary occupation is posting long, repetitive screeds about the gaps in EMS education and the sorry state of our profession.

Now, everybody has a life outside of the internet (well, most everybody), and some of these people are indeed practicing what they preach. They’re teaching and precepting, writing and organizing, even lobbying to accomplish the changes we all dream of achieving.

Many others, though, seem to have endless time and energy for complaining about how dumb everyone else is, and very little for correcting that dumbness. More disturbingly, in recent times, the tone of these complaints has taken a strange turn toward arrogance. Novices foolish enough to poke out their heads are decried for not being up to the level of the complainer (interestingly, the level of the complainer is usually presumed to be the appropriate one — nothing more and nothing less). I imagine a great deal of this stems from frustration. But it certainly doesn’t contribute to a solution, nor does it speak very highly of the veterans behind the keyboards, who are missing the opportunity both to educate and to model professionalism. (Hint: there is no degree of expertise that ever makes arrogance appropriate.)

Yes, ideally we will move to a place where everybody staffing an ambulance has a strong initial education in anatomy, physiology, pathology, and medicine. Yes, this will probably entail degree-granting programs and a fundamental paradigm shift from our current model of training. But until then, there are thousands of EMTs and paramedics on the road or in the classroom with a grossly limited knowledge-base, and a significant number of them are motivated to do better than that. Are you going to blow them off until the day of rapture, or are you going to try and help?

I didn’t want to write this post, because I didn’t want to be part of the problem. This site aims to be zero percent complaining and 100% educating. But we’re just a drop in the bucket, because there are a lot of smart people out there who could do far more good than a hundred EMS Basics, and I wish they would remember it.

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

Child-rearing and You

Monkey Training School


Despite my forays into educational writing like this, I have never been an FTO.

Field Training Officers or preceptors are responsible for training and supervising new hires, who typically work for several weeks as an additional third crewmember (or “third rider”) while learning the ropes. For various reasons, I’m not sure I’d be good at this, and I’ve never pursued it. On the other hand, regardless of what I want to pursue, I’ve never been able to avoid working with new partners.

By “new,” I mean minty-green new — folks who have never worked on an ambulance, or in some cases, never worked a job at all. Since this kind of EMT is usually paired with a fairly senior partner early on — and since not many people stick with this job long enough to be “senior” — if you’ve been doing this for a few years, you’ll usually wind up with a new guy sitting next to you. It is what it is.

Standard operating procedure is to drink lots of coffee, grumble, boss them around, and let them gradually absorb whatever useful knowledge you inadvertently leak out. Unfortunately, this is both stressful for the new guy, and something less than fully enriching; they learn as many bad habits as good practices, and become jaded faster than they become competent.

I am not a gifted teacher when it comes to in-person training. But like most things in this job, by learning it the hard way, I’ve developed some useful insights. So here are a few pointers for bringing along your new guy and molding them into the very bestest EMT they can be.


Make your expectations clear

For you, it’s Wednesday, you’re tired, and for some reason your left knee keeps clicking. But for them, it’s their first day on an ambulance, and everything is new.

The best thing you can do is to clarify how this game is going to work. What’s going to happen when you walk into a call? How are you going to assign responsibility? What do they know, what do they need to know, and how will that process occur?

I once punched in to find a partner I hadn’t met before. Ten minutes into checking the truck, we got sent out to a seizure at the department store. I drove, she teched. But each time I tried to let her “do her thing,” she just froze like a deer in headlights. Turned out, this was the first shift she’d worked — ever — and her entire training period had been spent running routine transfers. She wasn’t just unpracticed, she hadn’t even seen most of what takes place on an emergency call, never mind attempted it.

Although you could call this a gross failure of the training process (I did), the underlying lesson is that you never know what you’re dealing with. Your partner may have years of experience at another service; he may have just finished high school and never worked a full-time job; he might be a new EMT, but just spent twenty years as a veteran CNA. Maybe he’s a few months in, comfortable with certain situations, but wholly new to others. You need to know where they’re coming from. Not only will they resent the stress and panic induced by stranding them when they don’t know what to do, but they’re just as likely to resent your butting-in (whether explaining something or actually taking over) when they do know what to do; the dividing line can be nearly invisible, but is very real.

Some points to consider:

  • Who drives? Many seniors tend to do most of the driving while their newbie techs in back. The theory here is that you should “learn the back before you learn the front” — that is, patient care before driving and navigation. I find this arbitrary, since driving is as important to this job (and sometimes as difficult to do well) as anything else. It’s reasonable to focus on one skillset before developing the other, but I think driving should start early, because eventually they’re going to be forced into it anyway (driving for an ALS unit, perhaps), and they need to be ready. Start almost immediately by letting them drive between calls on routine matters; this acclimates them to handling the ambulance and navigating your service area. Once they’ve figured that out, they can do some emergency driving on responses. When you’re comfortable they can safely get from Point A to Point B, let them drive while occupied with patients — if they know where they’re going, or at least have a reliable GPS. But don’t throw them into this without some instruction on how to drive smoothly and safely, or you’ll spend the trip getting angry while you slide around the bench, and they won’t know why.
  • Who does what on emergency scenes? Working with experienced partners, I cleave to the golden rule: the tech runs the call, while the driver shuts up and helps out. This makes it easy to avoid stepping on each other’s toes or going different ways. If you’re the tech and your new partner is driving, this still works, because you’ll make the calls and tell them what to do, and they can watch your amazing wizardry in action. But what if they’re the tech? I always try to let them take the reins, but if they pulled the tags off their first uniform yesterday, they’re probably just going to stand there. I give ’em a few beats and then take over (you can’t stand there forever staring at the patient). But between calls, go over what needs to happen, and try to gradually work them toward familiarity with their role.
  • How will feedback be given? Like in any relationship, communication is only ever bad when it’s not undertaken promptly and directly. From day one, make it clear that if they ever have a question, they should ask it (at the appropriate time); if they’re ever uncertain, they should request assistance (you’ll only be mad when they screw up because they didn’t ask); and if they want help, you want to provide it. Conversely, explain that after calls you’ll give suggestions and feedback, which should be taken constructively; they have a lot to learn and must embrace that. If you tend to adopt a direct or brusque manner, as many of us do, warn them that it’s not personal and you’re not rebuking them, you’re just too old and tired to sugarcoat everything. Reassure them that you’ll never talk shit to others when they mess up; when anybody asks, you’ll just make vague remarks like “oh yeah, he’s good.” Above all, remind them that although you’re here to support them, patient care comes first, so there will be times when “teachable moments” need to take a back seat.


Practice, Practice, Practice

The main problem for most new folks isn’t “knowledge,” it’s application. They may have memorized the EMT textbook (although that book, of course, is a little light), but there are a thousand tiny things that comprise the everyday functioning of this job, and they know none of it.

That’s one of the goals behind Scenarioville. To get good at this job, you need practice. And even in a busy system, in a given week you may only do one or two seizures, or drunks, or chest pains, or any other type of call, with a lot of other stuff in between. If they’re weak with something, it takes a long time to to practice enough to get any better.

You can fill that gap with drills, as realistic as possible. In your downtime, make ’em go through the paces. Trouble giving radio patches? Hand ’em the mic (turn it off first) and have ’em pretend they’re talking to the hospital, complete with pressing the right buttons and hearing static-filled replies from you. Do they need to practice driving? Find a parking lot and give them tasks to accomplish, such as backing in a straight line, turning corners, or navigating tight gaps. Bad at lifting? Give ’em workout homework (get thee to the gym and start deadlifting!). Watched them fumble with a skill? Make ’em do it: take a blood pressure off you (with various locations, sizes, and methods), assemble the nebulizer or apply a dressing, or execute a thorough neuro, abdominal, or trauma assessment. In some cases verbalizing a skill is all you can manage, but whenever possible, do it for real; a disposable neb is a small cost to pay for skill mastery, and the first time they open the package shouldn’t be on a sick person.

If they’re interested, you can certainly chat about deeper medical topics like V/Q mismatching and the citric acid cycle. But they can get that from a book. When it comes to practice, something more interactive is needed. Often, I’ll do verbal scenarios, describing a call and forcing them to make decisions as they go. Nothing is quite as frightening as a totally unscripted, unstructured situation, where you stop and stare and ask, “What do you do?” And don’t let them get away with vague invocations like “scene safety” or “manage the airway”; force them to describe exactly what they mean. Oh, you’ll check for a pulse? How? Where? What are you looking for? Okay, where’s that piece of equipment? How do you size it? Are you sure we’ve got one?

History-taking is the most difficult skill to acquire. Force them to talk directly to you as if you were the patient, because they need to be comfortable with that. With experience, you develop a patter, and you have go-to lines at each juncture — what you say in greeting, what to ask for certain complaints, how to unpack certain responses. They haven’t acquired those moves yet, but they need to develop them, so by presenting them with those situations in a practice setting, they have a low-stress way to hone their own tools.

Every new partner I’ve had has gone through a similar learning curve. At first, they don’t know anything. After a while, the first things they get comfortable with are the “skills,” simple, concrete tasks they know how to execute. As a result, when they walk into a scene and don’t know what to do, they immediately start doing whatever task they’ve mastered — taking a blood pressure, writing down meds, etc. The challenge is getting them to move beyond rote psychomotor skills to the nuanced business of actually approaching the patient, greeting them, assessing them medically with questions and focused physical examination, deciding what’s wrong, and making decisions accordingly. This is tough, and occasionally I’ve had to take things away from people (cuffs, glucometers, nasal cannulas, pens) so they couldn’t “hide” in them.

In the end, the key to mastery is repetition. A single repetition is nothing. When the two of you run a call and you realize they need to practice something, debrief afterward by discussing the details, make them describe the considerations and goals, and spend the rest of the day verbalizing scenarios similar to the call you did. Once they’re absolutely sick of it, you’re starting to make progress, because boredom means they know what to do, and that’s the whole idea.


Managing your own blood pressure

One of the biggest challenges, of course, is not losing your mind.

Even smart students will sometimes drive you out of your gourd. Usually, this is because they don’t know something you figure they should. In fact, everybody should know that. In fact, how in god’s name can you be old enough to drive a car without being able to figure this out? It’s common sense!

The trouble is, it isn’t common sense. When you started out, you had to learn it. But that was so long ago, you’ve forgotten how much you originally had to learn; many of the routine aspects of the job are now second-nature to you. But they’re not second nature to your partner; he has to consciously learn them all, and think about them when he does them, and he can only internalize so many at a time. So while he’s trying to remember to do X, Y, and Z, he might forget A and B. Even if A is something that he does know. And maybe he never even learned C. See?

When they develop confidence, they improve exponentially, because once they relax they can actually think; most dumb stuff is the result of blind panic. (The secret of veteran providers is that they often don’t know what to do, but they use their noodle and do what makes sense. This isn’t a difficult skill, but you can’t do it while holding your breath.)

My own pet peeve is when I tell ’em something, and next week tell ’em again, and six months later I swear I’m telling ’em the same thing, and they’re staring at me like they’ve never heard it. Ain’t you listening to me, Jethro? Well, they are listening. But I’ve also been talking a whole lot, and between the V/Q mismatches and everything else, they’re not going to remember all of it; it’s going in one ear and most of it out the other. So either I can slow the flow a little, or expect to repeat myself. Either way, my problem, not theirs.

The point is that there’s a great deal to learn just to master the basics of this job, never mind acquiring true clinical acumen. Combined with the fact that many new hires are young, and haven’t developed the general problem-solving skills that only come with years and failures and overall life experience (being a good employee, talking to other humans, empathizing with suffering, avoiding dangerous situations, and so on), and you get a perfectly intelligent person who sometimes seems like they’ve had a lobotomy.

Take deep breaths, try to remember what it was like when you were in their shoes… and warn them early that you will occasionally get fed up, sometimes act short, and at the 15th hour of a shift, will not always be gentle Grandpa Patience. Advise them that you’re not perfect and will not always act out the principles you espouse. And request that, although you like to teach and you like your job, when you’ve been working for 60 hours straight you may need some quiet time.

Most of all, look around at all your competent coworkers who once upon a time made their partners pull out their hair and ask whether they were working with a trained monkey. Because it does get better, and years ago, that monkey was you.

Preparation vs. Improvisation

Everything in its place

I have a new partner who called me obsessive once.

“Eh?” I asked.

“Everything has to be just so. When you come in you make sure the collars are organized and facing the same direction, you fold over the ends of the tape and stack it in a certain order, you make sure the handles on the bags are easy to grab…”

“I’m not obsessive… have you seen my car?”

“Well, you are here.”

And it’s true. When I show up in the morning, I do my damnedest to ensure that all of our equipment is as stocked, ready, and prepared as possible. I’m the guy who checks the integrity of the air-filled gaskets on the BVM masks, and considers two spare O2 tanks one and one none. If my blood pressure cuffs aren’t labeled, I label them, and I ensure my map book is turned to the correct page.

And all of that may sound funny, because everybody knows that one of the hallmarks of EMS is improvisation, the ability to adapt to unusual situations and “make do.” If you’re juking around at a chaotic scene and discover that you haven’t got any splints, or your stretcher strap is broken, or your patient is dangling over the side of a balcony and needs to be boarded, you see what you have and use your noodle and make it work. Not long ago I saw somebody apply pressure to a laceration on top of a patient’s head by tying a bandage to both stretcher rails and rubber-banding it over their skull like a bow-and-arrow. Why not?

We find a way. So why am I so anal about being prepared while we’re still standing on solid ground?

The fact is, in this job, things are going to go wrong. They just are. And you’re going to handle them the best you can. But if too many things go wrong, the situation may reach a breaking point — your capacity to “adapt and overcome” is not infinite.

Have you ever read a book or watched a show about a major disaster? Plane crashes, reactor meltdowns, bridge collapses. What they have in common is that numerous intelligent people usually foresaw the possibility of such an event, and so they designed systems and safeguards to prevent it from happening. When disaster happens nonetheless, it isn’t because one thing went wrong. It’s because five, six, twelve things went wrong. The backups to the backups to the backups failed. More problems occurred simultaneously than anybody expected..

In this job, too, the only time when feces hit fans is when problems accumulate. It’s not that the patient was sicker than you expected. Or that the stairs were rickety and covered in snow. Those are a nuisance. It goes from whoopsie to trainwreck when you didn’t bring your stairchair and your suction. Then when you go back, the chair falls open while you’re walking, and as you try to fold it you trip over your untied laces, and when you finally get inside you realize the suction canister is missing a cap and won’t hold pressure. And then once you get the patient extricated they’re already unconscious, but you can’t find any Yankauer tips in the truck, and by the time you do they’ve stopped breathing…

See? With this job, even at the best of times, the line between well-in-hand and circling-the-drain can be pretty slim, and once you’re on that slope it’s hard to recover. The only way to stay safely in control is to create a buffer, and that means doing everything you can to prepare yourself when you have the chance, because you won’t always have a chance. If you don’t bother dotting your I’s and crossing your T’s before you enter the mix, then when things inevitably go wrong, the sum of those unhingings may be too much to handle.

Consider your emergency responses. It’s a safe bet that you’re going to drive past the address, or turn the wrong way, or get caught behind the world’s slowest schoolbus. Something is going to cause problems, whether it’s your dyslexic partner who confuses Gable Street with Bagel Street, or you forgetting the apartment number three times in a row. But that’s just a small delay. It won’t be a real problem unless you also stopped to pee before leaving the base, or forgot where your boots were, or had to spend five minutes backing out of where you parked. In that case, you already burned through your margin for error, and now when the unexpected (but inevitable) comes along, you’ve got no slack left.

In short, you can be the best in the world at rolling with the punches, and in this job, you ought to be. But that doesn’t mean you shouldn’t also try to be prepared to the point of obsessiveness. One lays a foundation for the other, and when you habitually have both to work with, you can handle whatever comes your way; if you’ve only got one, you’ll be lucky to get through your shift.

Staying in Place: Compensation and Endpoints

Red queen running


Man’s leaning against a wall. He doesn’t move for hours. Just stands there not moving. Finally, someone says, “You been here all day — don’t you have anything to do?”

“I’m doing it,” he answers.

“Doing what?”

“Holding up the wall.”


And who’s to say he’s not? Maybe he’s working as hard as he can to make sure that wall doesn’t fall down.

In this situation, the man is a compensating mechanism. He is struggling to prevent changes in the wall; keeping that wall upright is an endpoint he cares to maintain, to sustain, to keep intact.

How do we know that the wall isn’t holding up the man? Because we don’t care about the man. Whether he leans or falls doesn’t matter much to anybody. But it would be a terrible thing if the wall collapsed. So we’ll let the man lean or shift in order to prop up the wall when it starts to totter — we’ll use him, adjust him, to compensate for any wall-changes. That’s why he’s there.

If the wall gets weak enough or tilts too far, though, he won’t be able to keep it up. He’ll try, but he’s not infinitely strong, and then maybe the wall begins to tilt or collapses completely. Since we know that under normal circumstances, he’s doing his best to prevent this, if we walk in and see that the wall is tilting, that is not a good sign. It may mean that despite his best efforts, the man has exhausted his strength and is no longer able to resist further wall-changes; or it may mean that, for some reason, the man isn’t doing his job properly. Either way, any further tilting will be unopposed, and will probably happen rapidly and uncontrollably.


Compensators and endpoints

This same dynamic plays out within the human body. As we know, living organisms seek to maintain a certain homeostatic equilibrium. We put our vital metabolic processes in motion and we don’t want them to halt or change, despite any insults or fluctuations imposed upon us by our surrounding environment. So our bodies struggle to keep all of our complex systems at an even keel, using a diverse and powerful array of knobs, dials, and other regulatory tools. Not too hot or too cool, not too acid or too basic, not too fast or too slow. Just right.

The kicker is this, however. Some of our physical parameters are more important than others. In other words, while some parameters have room to adjust, others aren’t negotiable, can’t change much, without derailing our basic ability to function and survive. Things like blood pressure (or at least tissue perfusion, for which blood pressure is a pretty good surrogate measure) are essential to life; your pressure can fluctuate a little, but if it drops too low, you are unquestionably going to suffer organ damage and then die. And yet there are many insults that could potentially lower our blood pressure if we let them: if we bleed a little, or pee a little, or don’t drink enough water, or sweat, or even just stand up instead of sitting down. How do we preserve this vital parameter despite such influences?

By compensating, of course. Our body gladly modulates certain processes in order to preserve other, more important parameters. So in order to maintain blood pressure, perhaps we accelerate our heartrate. In an ideal world, it might be nice if the heart were thumping along at — let’s say — a mellow 80 beats per minute. It’ll use little less energy and less oxygen than if it were beating faster. But it’s really important to keep our blood pressure up, and speeding up the heart can increase the pressure, so we gladly make that trade and induce tachycardia. (Many of these compensatory systems are linked to the sympathetic nervous system, our body’s standard “all hands on deck” response to stress and crisis.)

So imagine we find a patient who’s bleeding and notice that he’s tachycardic, with a normal blood pressure. This suggests a compensated shock; the body is using tachycardia to maintain that normal pressure we see; although his volume is lower than usual, the critical endpoint of adequate blood pressure is still intact.

But what if instead, we found him tachycardic and hypotensive? Well, that’s not good. We see that the body is trying to compensate, but we also see that the important endpoint — blood pressure — is falling nonetheless. The body would never intentionally allow that; BP is too important. So we recognize this as decompensated shock. The hypovolemia has progressed so far, and volume is now so low, that he can’t make up the difference anymore — the compensatory slack has run out — and any further decreases in volume will probably lead to an immediate and unopposed drop in pressure. There’s nothing more the body can do on its own; it’s out of rope.

The skilled clinician — or “homeostatic technician” as Jeff Guy says — uses this predictable progression to understand what’s happening in almost any crisis. Because primary insults are initially covered up by compensatory mechanisms, they may not be immediately apparent, and the earliest and most detectable signs of physical insult are usually nothing more than the footprints of the answering compensation. Thus, when when we encounter those, we know to suspect the underlying problem even if it’s not obvious yet. It’s like seeing brakelights flash from cars on the road ahead; even if you can’t see an obstacle yet, you know people are slowing down for something.

Obvious signs of decompensation usually show up late. Once the primary, underlying problem is revealed by failure of the corrective mechanisms, it’s often progressed so far that it’s too late to address. If you wait to brake until you can see the wreck itself, you might not be able to stop in time.


Two signposts for decompensation

There are two great ways to recognize which signs and symptoms connote decompensation.

The first is to understand which physical parameters are endpoints — which functions the body tries to preserve at all costs. These processes are only compromised as a last resort, so if you see them deteriorate, things are in the end-game; the body doesn’t intentionally sacrifice these for the benefit of anything else.

The second clue is more subtle. In this case, you observe a compensatory mechanism (not an endpoint), but find that it’s no longer successfully compensating — it’s failing, and starting to unwind and scale back, rather than doing its job. The changes in the compensatory system are inappropriate, resulting in less of what we need, not more. This happens when our systems are so damaged that they can’t even fix problems and pursue homeostasis anymore; our infrastructure, maintenance, and repair systems are breaking down. Consider this: we saw how tachycardia could be compensatory, but could bradycardia ever be beneficial in shock? Probably not. So if we found a shocked patient with bradycardia (and likely hypotension, the failing endpoint), we should be very alarmed indeed. There’s nothing helpful, compensatory, or beneficial about bradycardia in the setting of shock, so we recognize that the body would never go there on purpose. It’ll only happen when the machinery itself is falling apart.

Consider, for instance, Cushing’s Triad, the collection of signs often encountered after severe traumatic brain injury, when intracranial pressure has increased enough to squeeze the brain out from the skull like toothpaste. The triad includes hypertension, bradycardia, and irregular or slow respirations. What’s interesting is that, while all are a result of increased ICP, one of these is compensatory, while the others are merely the result of damage. Hypertension is the body’s compensatory attempt to force blood into the brain despite the elevated pressure in the skull. But bradycardia and bradypnea simply result from pressure upon the regulatory centers of the brain tasked with maintaining breathing and heart-rate. That’s why hypertension may be seen earlier, while the other two signs won’t usually manifest until the brain is actively herniating. One signals compensation, the other two decompensation.

Of course, there can be other reasons why compensatory mechanisms might fail, or at least exhibit lackluster performance. Some medications or other aspects of a medical history (potentially unrelated to the current complaint) might throw a wrench in the system. For instance, beta blockers (such as metoprolol and other -olol drugs) limit heart-rate as part of their basic mechanism, so patients with beta blockade often have trouble mustering compensatory tachycardia during shock states. That doesn’t mean they’re any less shocked; in fact, it means they’re more susceptible to hypotension, and that you must be especially on the lookout, because you won’t see one of the red flags (a rapid heart-rate) you might usually expect. Elderly patients with many comorbidities are generally not able to muster up effective compensation for anything, so they can deteriorate quickly, and without much fanfare. Ironically, healthy pediatric patients are the opposite: since they’re so “springy” and smoothly functioning, they compensate very well, with few changes in observable endpoints, until suddenly running out of slack and crashing hard because they’re already so far from shore.

Here are a few important compensatory signs, breakdowns of compensatory systems, and vital physical endpoints:


Appropriate signs of compensation

  • Tachycardia — increases cardiac output
  • Vasoconstriction (cool, pale skin) — raises blood pressure
  • Diaphoresis (sweatiness) — decreases temperature when necessary, but is often just a side effect of sympathetic stimulation
  • Tachypnea — increases oxygenation, CO2 blowoff, and cardiac preload
  • Fever — part of the immune system’s response to infection
  • Shivering — warms a hypothermic body

Inappropriate changes in compensatory mechanisms

  • Bradycardia — reduces cardiac output, rarely useful in illness; as a chronic finding may be the result of high levels of cardiovascular fitness (in healthy young patients) or medications (in sick old patients); but acutely, it is an ominous finding
  • Bradypnea — reduces oxygenation, CO2 blowoff, and cardiac preload
  • Hypothermia (or normothermia when a fever is expected) — suggests a failure of temperature regulation

Inviolable endpoints

  • Blood pressure — can elevate in stress states, but should not drop below resting levels
  • Mental status — except in the presence of a drug or similar agent directly affecting cognition, maintaining appropriate alertness and mentation are always a top priority for the body
  • Blood glucose — kept at normal levels in almost all situations, except when the regulatory systems fail, as in diabetes mellitus
  • pH — most of the cellular machinery fall apart if significant acidosis or alkalosis occurs
  • Low O2 saturation or cyanosis — although oxygen saturation can dip briefly without harm, and in some patients (particularly those with COPD, or long-time smokers) it may run low at baseline, a significant acute drop — or the clinical equivalent, which is frank cyanosis — is always inappropriate.