EMS Basics http://emsbasics.com Fundamentals of BLS care for the working EMT Tue, 30 Jun 2015 03:31:17 +0000 en-US hourly 1 The First EMS What-if-We’re-Wrong-a-Thon http://emsbasics.com/2015/06/01/the-first-ems-what-if-were-wrong-a-thon/ http://emsbasics.com/2015/06/01/the-first-ems-what-if-were-wrong-a-thon/#comments Mon, 01 Jun 2015 18:09:12 +0000 http://emsbasics.com/?p=2389 oops-my-bad

 

The EMS world is full of people with opinions.

This is a contentious business, and most days, it’s hard to kick a rock without hitting two paramedics having an argument. Usually, if you listen in, you’ll realize it’s one of the golden oldies, some debate older than Johnny and Roy — fire-based vs. private ambulances, ALS- vs. BLS-dominant systems, epinephrine in cardiac arrest, the role of spinal immobilization, and so on. These are topics with two opposing camps and very little room in the middle. (Nothing’s more odious than a fence-sitter.)

The thing is, if you step back and look at most of these debates, you have to admit that there are some massively intelligent, rational, well-educated people in both camps. It’s not The Smart People on one side and A Bunch of Loonies on the other. That wouldn’t really be a controversy, would it? We’d just ignore the loonies and move on. These issues only persist because there are legitimate arguments both Yea and Nay.

But you wouldn’t think that if you waded into the trenches and took your own stand. Although you might start out “seeing both sides,” by the time you’ve done your fifteenth blog post, your tenth column, your third published review, or your 100th lecture, all hammering the same bullet-points… well, after a while, you start wondering just how any nincompoop could possibly disagree with you. You’ve been dismissing the opposition’s arguments for so long that you can no longer give them any serious consideration.

Here’s an example: I am personally very skeptical about the value of emergency department thrombolysis for ischemic stroke. That doesn’t mean I’m convinced that it’s a bad idea, but I am fairly convinced that the evidence in its favor is poor, and I believe this with sufficient ardor that I start to get a throbbing headache whenever someone advocates too loudly for tPA. On a bad day, I’ll admit that I occasionally want to throw up my hands and say, “What are these morons thinking?”

Well, these morons are hundreds of exceptionally knowledgable researchers and physicians, and what they’re thinking is that they have a slightly different perspective on the data. They are actually not stupid or insane. And that’s the key here. Maybe I’m right, maybe they’re right. But we’re both wrong if we think the debate is over, and no rational person could disagree with us. Equipoise remains; reasonable people can go either way.

The debate rages on. We’ve just picked a side.

And so, while we may spend 99% of our time waving our preferred banners, it behooves us to occasionally take pause and remember that the other side is not composed of morons, and their points have some validity. It’s good to reflect upon why, even though we’re so smart, other smart people still disagree with us. And to truly weigh and consider those reasons as viable, not just as straw-men to be refuted.

That’s why today, we’re holding…

 

The First Great EMS What-if-We’re-Wrong-a-Thon

The what?

Today, six EMS writers, bloggers, and pundits have agreed to take one of their pet issues… one of the topics they argue, espouse, teach, and defend… and try to prove the other side.

If they believe that volunteer EMS is a tool of the devil, they’ve written an earnest screed arguing why volunteers are an essential feature of modern prehospital care. If they’ve based their career on railing against unnecessary use of helicopter transportation, they’ve done their best to defend air ambulances and prove their worth.

What’s the point of this exercise?

In part, it’s for the same reason that the Catholic Church appoints “devil’s advocates,” why debate teams are expected to be equally convincing from both “pro” or “con” positions, and why computer security outfits hire “penetration testers” to try to attack their own networks. Making a serious effort to destroy your own beliefs is the best way to strengthen them. You can’t do this from within your own fortress of opinions; inside there, it’s one big echo chamber without any perspective. You need to step outside your skin, pretend you haven’t spent ten years singing the same tune, and hold a Bizarro day in order to realize what you’ve been missing.

But that’s not the most important reason for this. The most important reason is humility.

We all think we’re right about what we believe. That’s why we believe it. And that’s fine.

Yet if we cross the line into thinking we cannot possibly be wrong, we’re no longer engaging in rational debate. We’re just shouting, shouting, shouting our personal dogma. If the answer to the question, “What could convince you to change your mind?” is nothing!, that’s called religion, not reason.

Only an idiot is always right. So we asked some prominent figures from the EMS world to take a day and show us how they’re willing to be wrong.

Participating posts are linked below. Go flip through them, and applaud the authors for the courage it takes to hammer upon your own ramparts. Hopefully, you’ll be inspired to take a deep breath and acknowledge that you could be wrong too.

 

Authors

Michael Morse (Rescuing Providence) — Strong opponent of civilian Narcan (naloxone) distribution programs. He argues here why they actually might be a good idea.

Jeff Poland — Advocate of endotracheal intubation is the gold standard of airway management. He argues why we should be using supra-glottic airways as our first line intervention instead. (Guest hosted courtesy of Christopher Watford at My Variables Only Have 6 Letters.) He’s not to be confused with…

Ben Dowdy — … who argues why we should be abandoning prehospital endotracheal intubation altogether. (Guest hosted courtesy of Brooks Walsh at Mill Hill Ave Command.)

Greg Friese (EMS1) — Passionate proponent of non-traditional models of education. He argues why we should “unflip the classroom” and bring back standard lecture-based instruction for EMS training.

Vince DiGiulio (EMS 12-Lead) — Long-time believer in STEMI activation based on field ECG interpretation by well-trained paramedics. He argues why they should be transmitting their strips for physician interpretation instead.

Amy Eisenhauer (The EMS Siren) — Usually an advocate for professionalism among EMS providers; she makes a case here that sometimes, professionalism can have its downsides.

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Those who Save Lives: Kevin Briggs http://emsbasics.com/2015/03/18/those-who-save-lives-kevin-briggs/ http://emsbasics.com/2015/03/18/those-who-save-lives-kevin-briggs/#comments Wed, 18 Mar 2015 23:42:10 +0000 http://emsbasics.com/?p=2371

The Golden Gate Bridge in San Francisco has numerous claims to fame. Once the longest suspension bridge in the world, and still probably the most iconic, it’s a central feature of the SF Bay Area — my own home.

Less admirable is the fact that it remains among the most popular bridges in the nation for suicidal people to jump from. In fact, it’s one of the most “utilized” suicide spots in the entire world, with over 1,600 jumps made so far, most of them fatal. (Exact numbers are hard to come by for a good reason: bridge administrators and media outlets stopped keeping an official tally when they realized it was incentivizing people to ring in big milestones with their own attempts — lucky number 1,000 and so forth.) Someone still tries to jump about once every two weeks, which sounds insane, but is true.

Sergeant Kevin Briggs was a California Highway Patrol officer who spent a large part of his career patrolling that same bridge, which led to an interesting twist on his job description: suicide prevention. See, often times he was the one to notice a pedestrian who looked like they were considering jumping, or were even in the process of climbing over the rail. Sometimes he’d be called in by others who saw it first. Jumpers tended to stand on the “chord,” a ledge of piping just beyond the safety rail and the last solid ground before open air. Kevin would talk to them there, and try to convince them it was a bad idea.

It wasn’t something he had any training to do, at least not at first, or experience with, although he picked that up quickly. He had suicide in his family — as many of us do, since it’s incredibly common — but otherwise, he fell into the role the way many of us fall into our callings. Eventually, he made it his niche, leading a trained team of interveners.

Over the years, he spoke to hundreds of jumpers. At first, he’d approach benignly — “How are you feeling today?” and “What’s your plan for tomorrow?” For those without plans, he’d help them make some, because people with a plan tended to stick around to fulfill it.

Later, he became more direct, asking up front whether they’d come to hurt themselves. Or the simple question: “Others in similar circumstances have thought about ending their life. Have you had these thoughts?”

Either way, the encounters tended to unfold similarly. And as a rule, they went well. Of the countless desperate people he met, only two ended up jumping once he’d managed to make contact.

The jumpers met the pattern recognized by psychiatry as comprising the depressed and suicidal. They exhibited hopelessness — the outlook that things are terrible and will never get better. Most of us can ride out terrible storms, but if there’s no prospect of the storm ever ending, why bother? (“What do you do,” asked one, “when hope isn’t there?”) Then helplessness — the belief that there’s no remedy, solution, decision, medicine, or lifeline that can make a difference. People withdraw socially and lose interest in things they once enjoyed. They retreat from the world. They show up at the bridge because there’s no reason to be anywhere different.

Inexplicably, we in EMS seem to have developed the belief that most suicidal patients are “crazy” — as in psychotic — or dangerous — as in homicidal. As a rule, neither is true. These people aren’t out to hurt anybody. (One of the “ones who got away” politely shook Briggs’s hand and apologized before jumping.) They just want to escape the pain. With alcohol, with drugs, with sleep, with death.

How did Kevin Briggs have so much success? It’s a question that gets more perplexing the more you consider it. By definition, these are people who have lost all hope, exhausted all options, discarded alternatives until they’re ready to embrace the most permanent solution possible. And yet, a total stranger was able to approach them at their final moments and convince them to see things differently. How?

Through no secret system. He didn’t argue, cajole, or debate them. Nor did he tell anybody he knew how they felt or blame them for their actions. Mostly he listened to understand. Used their name to keep them anchored to reality. Occasionally, he’d share personal stories, things nobody else knew, as if bestowing them upon someone made them responsible for his secrets. In the end, merely being there seemed to make the difference.

Many interventions were successful within 10 minutes. Some lasted many hours. The longer the conversation went on, the better his odds, Briggs would say. The human connection grew stronger and stronger. People ready to jump away from nothing would reconsider, because now they were leaving something behind. It’s impolite to leave a conversation. It’s wrong to fail when someone cares about your success. Kevin had made it clear that he cared if they died, and they didn’t want to let Kevin down.

The most important secret of all is that this medicine wasn’t temporary. Another common truism in EMS is that preventing suicide is a Sisyphean task, because if someone wants to take their life, eventually they’ll succeed no matter how many times we slap the gun from their hand. Surely if they don’t jump here, they’ll just jump from the next bridge instead. But that’s not what the facts show. 94% of the ones who reconsidered jumping never tried again, instead living out long and fruitful lives. And the ones who jumped and survived nearly all described the same thought: the moment they stepped from the bridge, they regretted what they’d done. Despite what they’d thought, they didn’t really want to die. “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable — except for having just jumped,” reported one.

Much like reperfusing the STEMI, stabilizing the CHF exacerbation, or patching up the gunshot wound, this business was one of pulling people back from a preventable brink — people with the real potential to eventually leave it behind them.

As one mother wrote Briggs: “Thanks so much for standing up for those who may be only temporarily too weak to stand for themselves.” That sounds like our job, doesn’t it?

Sgt. Kevin Briggs recently retired from the CHP to continue pursuing suicide activism. And last year, work was finally approved on an anti-jumping safety net to be built beneath the Golden Gate Bridge. Maybe soon his brand of heroism won’t be necessary there. But it’ll be needed somewhere. Others are doing their part. Shouldn’t we do ours?

(By the way, the Code Green Campaign, which is trying to make a dent in the number of suicides among EMS providers, has so far been forced to announce a new one every 3.5 days this year. Fire safety isn’t doing any better. But heck, suicide’s not our problem, right?)

Sources and more reading:

Read about more lifesavers at Those who Save Lives: The Royal Humane Society and Those who Save Lives: Harry Watts

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Either Lead, Learn, or Please Stop Talking http://emsbasics.com/2015/02/28/either-lead-learn-or-please-stop-talking/ http://emsbasics.com/2015/02/28/either-lead-learn-or-please-stop-talking/#comments Sat, 28 Feb 2015 17:30:39 +0000 http://emsbasics.com/?p=2360 computer-punch

 

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.

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What the Heck is a General Impression? http://emsbasics.com/2014/08/16/what-the-heck-is-a-general-impression/ http://emsbasics.com/2014/08/16/what-the-heck-is-a-general-impression/#comments Sat, 16 Aug 2014 20:24:41 +0000 http://emsbasics.com/?p=2339 I’m tired of all the mumbo-jumbo.

Here’s my beef. Every medical provider, particularly those who work in the acute setting (such as prehospital medicine, critical care, or the emergency department), talks about a concept familiar to us all: the overall, gut sense of how ill a patient appears. In EMS training this is often described as the “general impression,” the “view from the door,” “big sick vs. little sick,” or other euphemisms. It’s your basic opinion of whether a patient is doing okay or not, and it’s formed within the first moments of contact.

Whatever you call it, it’s important. In fact, this one factor is often what really drives your management decisions. If a patient looks truly sick, it may not matter what the vital signs show or how the history sounds; they’re getting zipped over to the hospital with bells on. Conversely, if they look really well, it’s hard to get excited even if they complain of “12 out of 10 pain” and their pulse is 100.

Here’s the rub: everybody acts like this quality is completely impossible to describe. If you tell me the patient “looked sick” and I ask what you mean, you’ll probably wave your hands and reply that it’s ineffable; that you “had to be there”; that you know it when you see it, but that it can’t be quantified and can’t be analyzed.

If true, that would mean it can’t be taught, either. New providers would have to learn to recognize this mystical patient presentation by dint of long, hard-earned experience.

And perhaps this is true. Certainly there are other aspects of patient evaluation and management that actually are too complex to reduce to simplicities. Indeed, one of the central skills of medicine, and one that humans are uniquely equipped to perform (hence the last one that computers will take from us), is our ability to extract a diagnosis from a large number of variables by recognizing subtle patterns.

But I doubt that’s true here. Why? Because you form your general impression within the first moments you meet a patient. There just aren’t very many factors that can come into play, because you haven’t obtained much information yet. The view from the door isn’t going to include ECG findings or subtleties of the OPQRST.

So I have a theory, and here it is. The entire mythical gestalt of your general impression actually involves only three things: the patient’s behavior, their breathing, and the appearance of their skin.

Behavior

The first thing you notice when you meet a person is their behavior. This mostly means two things: their mental status and their level of distress.

A sick patient may be unconscious, or visibly lethargic; healthy people are awake and alert, because the brain is one of the last things the body allows to shut down. They’re also not obviously loopy, such as profoundly confused or combative, unless they have a chronic condition such as dementia.

And if sick people aren’t so sick they can’t complain at all, then their complaints reflect their acuity. They scream, they moan, they are visibly distressed by pain or fear. They say things like they’re dying or can’t breathe or can’t see or can’t move.

Some interpretation is needed here, because appropriate behavior can depend on the circumstances. Malingerers may say they can’t breathe when they clearly can. Panic attacks may present with greater distress than the physiology warrants. A child is most reassuring when grabbing at your stethoscope and stealing your gauze. And an infant may be normal when he cries vigorously and sick when he sits in silence. But it all comes down to how the patient is behaving.

Breathing

The patient’s breathing can be evaluated from across a parking lot. You can’t auscultate or measure their oxygen saturation, but you can get a general idea.

Are they breathing at all? Are they laboring, wheezing, gasping agonally, gurgling through pulmonary edema? Are they chatting easily with the firefighters, or is sucking down air the sole focus of their attention?

Skin

Skin appearance is an idiot-proof and instantly recognizable finding.

The most common sick skins involve pallor and diaphoresis. Shocky or otherwise sympathetically-charged patients are starkly white and sweating like they’re in a sauna. It’s one of the most characteristic appearances of acute illness.

Cyanosis is next up. “Shortness of breath” in a patient who’s pink, warm, and dry is one thing, but it’s quite another when they’re turning blue.

Less common findings include the red-hot skin of fever, the yellow skin of severe jaundice, the dry skin of dehydration, and the dependent lividity of the very dead.

That’s all, folks

When you talk about a patient who looks sick, or “doesn’t feel right,” or has some other nebulous problem like being “toxic,” you’re not tapping into some vast, indescribable vault of clinical judgment. All you’re doing is using shorthand that refers to the patient’s behavior, breathing, and skin. (Notice how these factors are emphasized in our initial assessment.)

A gut belief that a patient has a big problem after a full work-up (including an H&P and diagnostics) is a different phenomenon, and suggests that your intuitive side is recognizing a larger pattern that your conscious self hasn’t yet been able to label. But that’s a distinct process from the instantaneous triage you perform when you first walk into a room.

There may be exceptional cases where something different sets off your alarm bells. But I bet most of the time, it can still be linked back to one of these three categories. (An example might be the frequent flier, well-known to you, who is usually stoic but today seems worried and wants transport. That’s a discrepancy in their behavior, ain’t it?)

Don’t believe me? Just think of how you tell the stories of your sick patients. I’ll bet you say things like, “I walk in, and he’s bent over gasping; his skin is completely soaked and looks whiter than copier paper.” Those are the factors that we recognize as important, and that’s why they’re so vividly evocative. They’re the colors we use to paint the picture of badness.

I may raise some ire by dismissing the voodoo surrounding the clinical gestalt, but here’s my challenge: if you believe there’s more behind your general impression of “sick or not sick,” then reply in the comments and tell me what it is. Maybe I’m missing or forgetting something. Maybe I’m doing it wrong and you’re doing it right. But if you can’t point to what’s missing, then I’m betting there’s nothing more to it after all.

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The Long-term Care Ombudsman: Advocates on Call http://emsbasics.com/2014/08/07/the-long-term-care-ombudsman-advocates-on-call/ http://emsbasics.com/2014/08/07/the-long-term-care-ombudsman-advocates-on-call/#respond Thu, 07 Aug 2014 19:26:47 +0000 http://emsbasics.com/?p=2335 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!

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Murder by Checklist http://emsbasics.com/2014/07/19/murder-by-checklist/ http://emsbasics.com/2014/07/19/murder-by-checklist/#comments Sat, 19 Jul 2014 18:46:23 +0000 http://emsbasics.com/?p=2319 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

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Worthy Words http://emsbasics.com/2014/06/29/worthy-words/ http://emsbasics.com/2014/06/29/worthy-words/#respond Sun, 29 Jun 2014 14:57:28 +0000 http://emsbasics.com/?p=2299 Quotation Marks

I admit that I’m a sucker for a good quote. Truth be told, medicine is exactly the type of enterprise that needs quotes. It’s a basically noble endeavor that’s nevertheless rife with the sort of frustrations, obstacles, and everyday nonsense that tends to make us forget why we’re doing it.

Quotes help us remember. A few concise, perfect words from people smarter than us — they needn’t be real people, either, because sometimes fiction is more true than fact — can paint a picture that reminds us in a flash how to do this job, why we’re doing it, and to whom it matters.

To that end, we’ve set up a page to collect the best medicine-related quotes we can find (you can find it in the menu above as well). Some are about EMS, some aren’t, but if you’re on the job, I bet many of them will ring true. Take a look and check back when you can; we’ll try to keep adding the good stuff as we come across it.

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Toastmasters for Trauma Patients http://emsbasics.com/2014/03/22/toastmasters-for-trauma-patients/ http://emsbasics.com/2014/03/22/toastmasters-for-trauma-patients/#respond Sat, 22 Mar 2014 21:41:57 +0000 http://emsbasics.com/?p=2264 Almost everybody in healthcare has to occasionally deliver verbal reports to their colleagues or counterparts, and almost everybody starts out bad at it. It’s a weird skill and one that takes practice, even though all you’re doing is describing what the deal is with a certain sick person.

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

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

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Those who Save Lives: Harry Watts http://emsbasics.com/2014/03/19/those-who-save-lives-harry-watts/ http://emsbasics.com/2014/03/19/those-who-save-lives-harry-watts/#comments Wed, 19 Mar 2014 16:14:37 +0000 http://emsbasics.com/?p=2236 Harry Watts

Who was Harry Watts?

You probably haven’t heard of him, unless you’re English — like he was — and you lived in the 19th century — like he did.

That’s because he was nobody special. He wasn’t a prince or a pope, he never invented a robot or discovered a mountain. Probably never even kicked a ball on television.

What did he do, then? He was born in Sunderland and lived poor. Poor as hell; no shoes poor, family-all-in-one-room poor. His father was a sailor. He had two sisters, and two brothers, one of whom drowned during a storm while Harry watched.

Starting work when he was young, Harry made his living first as a sailor, then as a rigger in the docks, and finally as a deep-water diver (the guys who wear big brass suits and suck air from a hose to the surface). He married and had two kids.

Oh, right. Also, all on his own, he saved the lives of 36 different people.

 

What, what?

While apprenticing on his first ship, he watched his fellow apprentice take a fall overboard. Harry’s automatic response was to dive in after him, pluck him up, and pull him to safety upon some floating timber. That was number one.

On his second voyage, he was waiting to receive the captain who was paddling back to the ship in a small canoe. He suddenly capsized, however, and was floundering in the waves. Harry grabbed a rope, swam out to the captain, and towed him back to the ship’s ladder. That was number two.

Number three was on the same voyage, when a boy was thrown into the water during a major storm, and the waters were too rough to lower a boat after him. Harry went in, and somehow, they both came out.

He rescued four and five on his next cruise — at the same time. So at the age of 19, he’d saved the lives of five human beings.

“Did you get any reward for these doings, Harry?” he was asked.

“Rewaard! Wey, sartinlees nut; nivver thowt o’ sich a thing. But we helped the two men wi’ dry claes an’ things.”

Indeed.

He got six more all together when an anchor line broke and dropped the anchor directly into a passing boat. There were six men aboard, and Harry went straight overboard while calling for help, landing directly on the wrecked boat in time to save them all.

Then one day at the dock, he saw a crowd gathering to watch a boy drowning in a rough sea. He leapt in, swam out to him, and brought the boy successfully back to shore on the verge of exhaustion.

At age 36, he made a career change from sailor to diver. At this point, he’d saved 17 people (plus one dog), most through risk to himself — sometimes grave. On one occasion he swallowed so much contaminated water from the Thames river (this during the cholera epidemic which had essentially turned it into a flowing sewer) that he was bed-bound for months and nearly died.

Many of those saved were sailors; many others were young children. And if you’ve never plunged twenty feet into rough water, wearing boots and heavy sailor’s clothing, and pulled out a panicked child (clinging like an octopus and trying hard to drown you)… well, you’re missing out. At this point, by the way, he had never received reward or recognition of any kind. As they say,

… There is a hackneyed platitude to the effect that virtue is its own reward, but it is safe to say that the average man does not find such a result sufficient. It might be so in an ideal world inhabited by ideal people, but in this work-a-day world, in addition to the approval of our conscience, we love to have the approval of our fellows and to know that our  acts are appreciated, and especially is this the case when we are actuated by altruistic motives. This is, of course, a form of vanity, but then vanity is almost a universal failing. [source]

But if Harry wanted applause, he certainly wasn’t clamoring for it. Just chugging along and saving lives as they presented themselves.

 

People take notice

Not long after that, he swam out to save two boys from drowning — while wearing one of his lead diving boots. (Yep.)

About a year later, he saved a couple more, and finally, there came the very first mention anyone had made of his efforts, a brief story in the newspaper:

Yesterday afternoon, about half-past three o’clock, a lad named Smith, about 16 years of age, son of an engineer employed on one of the Commissioners’ dredgers, narrowly escaped drowning. He was on board a dredger in the new Graving Dock, which was full of water, when he accidentally fell overboard. Mr. Harry Watts, in the employ of the Commissioners, gallantly jumped into the water and rescued him. The lad was very much exhausted, but restoratives were promptly used, and he was soon brought round. This is the twenty-second time that Watts has so nobly exerted himself in saving persons who have been in imminent danger of being drowned.

For a while, eyes turned away again. Then he hit number 25, and another story ran in the news, mentioning the man with “a perfect penchant for rescuing lives.” After that, people finally began to notice, and most of his saves received at least a little local attention.

He had countless saves while diving, such as the man who became tangled in a chain and was whipped overboard by a sinking weight — Harry dove in after and managed to free him underwater before they both drowned. Between rescues, he had plenty of interesting adventures, diving at the time being a trade full of explosives, accidents, and rockslides (he even had one memorable fight with a giant angler, or “devil fish,” which he ended up dispatching with a boat hook).

If that was his job, however, his hobby was volunteering with the Sunderland Lifeboat service; there was hardly a wreck nearby that Harry didn’t attend, they would say, and he was involved in rescuing over 120 sailors in extremis during storms. (Those don’t count on his score, of course, since they were team efforts. Just icing on the cake.)

He was 27, and up to 23 lives, when he received his first parchment award from the Royal Humane Society. A little while later when he ticked off number 25, they gave him their bronze medal as well, and when the local “Diamond Swimming Club and Humane Society” heard about that, they thought it just wasn’t cutting it, so they awarded him a gold medal of their own. The RHS gave him another parchment at number 26, and he continued to accumulate medals for his diving and rescue work — even one from the local temperance society for his good-natured efforts against the evil drink.

In fact, when he reached number 32, the local sailors (“gentlemen,” noted the newspaper, “because what constituted a gentleman was the performance of gentlemanly acts”) personally chipped in to cast him a silver medal in recognition of everything he’d done for them, despite the many years since Harry had personally sailed. Later, by widespread acclaim, his mayor wrote to the Queen to recommend Harry for the Albert Medal. Due to bureaucracy or who knows why, nothing came of the request.

An unfortunate turn came when Harry loaned his medals to the local church for an exhibition, and as night rolled around, the entire set was stolen by an unknown burglar. Harry was crushed, and the town of Sunderland felt it a slur on their name; the burglar was caught before long, but the medals were melted and gone. A popular movement arose, and within weeks they had struck replacements for the lot, and they returned them with dignity at a town ceremony. There, the thief himself expressed remorse, saying he wished he were drowned; Harry replied, “Mister, if ye were droonin’ aw’d pull ye oot bi th’ neck!”, and refused to press charges against the man.

He was 51 when he was approached to dive 150 deep to effect a mechanical repair. He was a little past such stunts for pay, he said, although of course he’d do so to save a fellow man, and he recommended some others who were younger and more willing. Their diver went down, and contact was soon lost; they returned to Harry and asked him to live up to his words, as nobody else was willing to go down to attempt a rescue.

He suited up and dived. The working depth was perhaps 120 feet, but it was upon a tiny platform across a bored-out shaft which continued another 300 feet past that; anybody who slipped was going a long way down until they looked like a recycled soda can. Feeling around, he located the other diver, who was dead (fainted, probably, then asphyxiated). He resurfaced, reported the news, then dived again to retrieve the body.

At the ripe age of 52, Harry was one of the divers who volunteered to recover bodies after the Tay Bridge disaster. He offered his services for no charge; when the diving commission attempted to pay him afterwards anyway (maybe because he was a million years old and a living legend), he politely refused and asked it be passed to a charity of their choice. (The man got around; somehow he was on hand at the Victoria Hall disaster as well, and widely applauded for his assistance in the aftermath.)

But never mind all that. His last life was saved at age 66. He and his wife were walking along the docks toward their home when he heard the cries of a drowning boy. His wife begged him not to, but he went; relenting, she cried, “Be quick, Harry!” and in he dove. Grab hold, haul over to a rope, out they came.

Thirty six lives. Not bad for a poor old seaman.

 

Harry finally rests

When he was 70, Harry retired at last. And although many people didn’t realize it, his wallet was thin; the diving commission didn’t offer a pension, and he’d quietly turned down others from grateful benefactors. That’s how things were when Andrew Carnegie passed through Sunderland to open a library.

Visiting the local museum, Carnegie saw an exhibit of Harry’s medals and asked after the man, now 84 and still full of vim. Surely he must be a war hero of some kind?

Nope. Just a life saver. When he learned who he was dealing with, and had the pleasure of shaking his hand, Carnegie inducted him into his Hero Fund on the spot.

At long last, Harry Watts no longer had to worry.

In Carnegie’s words,

I have to-day been introduced to a man who has, I think, the most ideal character of any man living on the face of the earth. I have shaken hands with a man who has saved thirty-six lives. Among the distinguished men whose names the Mayor has recited, you should never let the memory of this Sunderland man die. Compared with his acts, military glory sinks into nothing. The hero who kills men is the hero of barbarism; the hero of civilisation saves the lives of his fellows.

At the age of 85, Harry’s town of Sunderland was worried that after his death, such a remarkable, yet humble man might be forgotten in the distance and darkness of history. In response, the mayor and several of the town’s luminaries commissioned a biography to be written about his life. You can read it here, and much of this story came from it.

Not a bad goal. Live your life so that when you’re old, someone will insist on writing a book in your honor.

In their words,

The modest merits of this good citizen may, so far as the public are concerned, be summed up in the simple statement that he has saved upwards of 30 lives from drowning. When we consider what are the awards usually apportioned by mankind to the destroyers of their species, the presentation of a gold watch and chain, accompanied by a framed parchment from the Royal Humane Society, in the precincts of a disused School Room, must appear an inadequate acknowledgment of services so signal. But we are new at the business and shall improve as we go forward.

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Somebody Should be Upset http://emsbasics.com/2014/03/12/somebody-should-be-upset/ http://emsbasics.com/2014/03/12/somebody-should-be-upset/#respond Thu, 13 Mar 2014 01:25:51 +0000 http://emsbasics.com/?p=2228 Dog at grave

Anybody who’s spent time in medicine (and it doesn’t take long, because nowadays this is often covered in initial training) has heard two contradictory lessons:

  1. Good caregivers must demonstrate empathy and compassion for the suffering of their patients.
  2. Good caregiver must not become too close or attached to their patients.

The reasoning behind both truisms is simple enough. If you don’t care about your patients, you can’t practice good medicine, because that requires caring about what’s ailing them and wanting to do something to help. On the other hand, if you become entangled in the suffering of everybody who sits down on your stretcher, you will die a thousand times in the course of your career. That’s too much tragedy for anyone to bear.

So, you should care, but not too much. We’ve all known providers who don’t care. They’re bad. Bad at medicine, bad people, they don’t like their jobs and patients don’t like them. We’ve all known providers who cared too much, too. They’re good at their jobs, for about six months, then they flame out and quit. See how long you last when you have an extended family of hundreds, it grows each shift, and they’re all dying.

You can find your own strategy to walking this tightrope. Experienced, durable providers seem to become skilled at connecting with their patients, but compartmentalizing it appropriately, so that when things go badly, it doesn’t hit them too hard. You do your best, they survive or they don’t, and you move on to the next patient. It’s not your emergency.

This is probably the right approach. However, I’ve always found it a little bit distasteful. Click here to watch a clip from House that helps demonstrate why.

“When a good person dies, there should be an impact on the world. Somebody should notice. Somebody should be upset.”

Doesn’t that seem right?

A human being, with a lifetime of living behind them, has disappeared forever. There’s no life that isn’t complex enough and full enough and astonishing enough that we couldn’t put it up on a pedestal and watch it for days and discuss it and applaud it and munch popcorn while savoring all the decisions and revisions that we didn’t make, but which are awfully familiar. Even the mistakes aren’t usually so alien that we don’t recognize a little bit of ourselves in them.

When a person like that — and they’re all like that — drops off the face of the world, it should raise an alarm. People should put down their newspapers and look up. It should be a big goddamned deal. There are billions of human on the planet, and they’re all going to die eventually, many in the hands of medical providers, some of them in yours. But the numbers don’t change the fact that for the person who died, their life was their whole life. There should be grief.

Maybe it’s better when there’s family and friends and others to care. If a passing leaves a room full of loved ones in tears, maybe that makes it easier to walk away, knowing the job of mourning is well in hand. No silent snuffing of a candle here; the loss was recognized. That’s not very rational, but it’s how it feels to me. When somebody dies and nobody seems to know, or care, it seems like your duty to give a crap.

Isn’t it an insult to blow it off? When you were chatting with that patient and building your rapport and connecting as fellow people, would you have told them, “Listen, there’s something you should know. We’re getting along now, and we’re friends, and I want the best for you, and I’d fight for it too. We can laugh together or shake hands or hug. If you walk out of here, maybe we’ll even maintain a relationship. But if you die, I’m going to document it, wash my hands, and walk away like you’re just another number. Hope that’s okay.”

Isn’t that a little two-faced and deceptive — like acting friendly to someone, then badmouthing them as soon as they leave? How can you behave both ways and see both as compatible?

I don’t know, and maybe it’s not our job to be professional mourners. Maybe it’s not our job to mark each person’s passing. But in some sense, if we truly care about our patients, it seems like it is, and that’s quite a burden to add to our responsibilities.

What do you think?

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