Eight More Tips on Ambulance Wrangling

April 23, 2012 By 2 Comments

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?

Filed Under: Tools and Tricks Tagged With: ,

Psychological First Aid

April 4, 2012 By Leave a Comment

Eventually, we all reach EMS satori – I’m referring, of course, to the realization that most of our job doesn’t involve saving lives, or performing any high-level, acute medical interventions. Once we understand this, the question becomes: what does our job consist of?

One good answer among many is the management of psychological rather than physical injury. Can we help the person, even when there’s little need to help the body? We sure can, and it seems like after all the hours we spent studying airway management, we should spend at least a little time developing this other skill. If we’re going to surrender our identity as ET tube samurai, we’d better become experts at dropping mental balms.

It may not be rocket science, but there is certainly a right and a wrong way to help. One good source of ideas for doing it the right way is called psychological first aid.

Psychological first aid, or PFA, is a system developed jointly by the National Child Traumatic Stress Network and the National Center for PTSD. It’s meant to be a psychological counterpart to medical first aid — not a replacement for long-term professional therapy, but merely a method for addressing the immediate, acute mental stress response following crisis. It’s largely aimed at post-disaster scenarios, such as the victims of hurricanes and mass casualty incidents, and it’s become the preferred methodology for American Red Cross personnel. However, it also has valuable concepts that we can use every day on the ambulance, to help us care for both patients and any of their family or friends who are struggling.

This sort of thing may come naturally to some people, but PFA rolls it together into a standalone curriculum that can be transmitted to any professional, particularly those of us who don’t specialize in mental health. It’s also evidence-based: there is research behind most of its interventions, and the science tells us that it generally works. (Contrast this to CISM, which many feel is baseless at best and counterproductive at worst.)

Classes are available; check with your local Red Cross for more information. But here are some of the concepts:

 

General ideas

  • Take your cues from the patient. If they want to talk, listen. If they don’t, don’t force them.
  • You’re here as support and to listen, not as Dear Abby; limit your input and resist the urge to offer advice. Be sparing with relating personal anecdotes or “war stories,” even if they seem germane; it’s the patient’s crisis, not yours.
  • Cater your approach to the patient’s age and culture. Children in particular will need a different style than adolescents and adults. When approaching children, make contact with parents first, and understand that both parties will probably need to be attended to.
  • Reassure them that their emotions and reactions, no matter what they may be, are understandable and acceptable, not pathological.
  • Use language that’s clear, simple, and personal, avoiding medical terminology or jargon.
  • Understand your own role and limitations, and be ready to bring in better-trained specialists.

Avoid these types of remarks:

  • I know how you feel.
  • It was probably for the best.
  • She is better off now.
  • It was his time to go.
  • Let’s talk about something else.
  • You should work towards getting over this.
  • You are strong enough to deal with this.
  • You should be glad she passed quickly.
  • That which doesn’t kill us makes us stronger.
  • You’ll feel better soon.
  • You did everything you could.
  • You need to grieve.
  • You need to relax.
  • It’s good that you are alive.
  • It’s good that no one else died.

 

Major Goals

 

1. Contact and Engagement

As you go about the business of the call, make sure that you’re orienting yourself as somebody who’s willing and able to help. From the initial patient contact all the way until you shake hands and part ways, you should be presenting yourself as a compassionate professional; all it takes is one slip of the tongue or roll of the eyes to betray that you’d rather be back at quarters finishing your burrito.

 

2. Safety and Comfort

Obviously, you should ensure that you are both physically safe, and that immediate medical concerns are managed; this also includes the recognition of patients who could harm themselves or others (like you).

If you’re still at a scene or in the ED where upsetting things are happening (such as a resuscitation), try to move somewhere more quiet and controlled. Keep them physically comfortable, with blankets, a chair, food or water, etc. Remove them from anyone who is themselves panicked or emotionally distressed, but do help to put them in contact with social support, such as friends, family, or clergy.

Try to give people active, familiar things to do, rather than sitting there passively being overwhelmed. Anything, even minor tasks (“here, hold this”), that involve them with their own care or the care of their loved one is beneficial; perhaps they can make some phone calls or locate insurance information.

Share whatever information you have regarding what’s currently happening, including what’s happening to others affected, and what can be expected next (do use judgment on how much they want/need to hear at this stage, though). But don’t lie, guess, form unfounded predictions, or make promises beyond your control (“they’ll/you’ll be just fine”). Consider a broad interrogatory like “Is there anything else you’d like to know?”

Kids may appreciate something like a teddy bear, and you can use it as a proxy for their own care, for instance: “Remember that she needs to drink lots of water and eat three meals a day — and you can do that too.” Also, children especially are sensitive to alarming sights and sounds; try to shelter them from unnecessary stimuli.

 

3. Stabilization (if needed)

As we’ve talked about before, anyone experiencing an acute, uncontrolled emotional response needs to be stabilized and grounded before much else can be done. Be on the lookout for things like: glassy-eyed or vacant stares; aimless wandering or unresponsiveness; uncontrolled crying, hyperventilating, shaking, or rocking; or frantic, illogical, even potentially dangerous behavior such as perseverating on simple tasks (continuously searching for a pair of glasses) or walking thoughtlessly through traffic. Remember that reactions may ebb and flow in surges.

Rather than broad reassurances — “stay calm” — try to determine their specific concerns, even if not entirely rational, and help address them. If completely adrift, patients may be assisted in “grounding” by deep breathing and asking them to describe where they are or concrete aspects of their surroundings (I see a table, I see a clipboard).

Consider both giving them some brief privacy (do tell them when you’ll be back), and remaining present and available yet non-intrusive, such as sitting nearby while you finish paperwork.

 

4. Information Gathering: Current Needs and Concerns

Determine the specific problems and needs of the patient. Individual responses may be flavored by their own psychological backdrop (such as depression or anxiety), history of similar incidents (a prior MVA or death in the family), or other unpredictable elements (they can’t stand the waiting room music). In some cases, the need for referral to a specialist may become obvious here, such as uncontrolled schizophrenia or major stressors in the setting of known PTSD and a history of self-harm; don’t try to “wing it” in complex psychiatric cases.

Follow their lead, and don’t press for details — a CISD-type debriefing can come later, if appropriate. Listen actively and openly. Look for expressions of emotion in their remarks, then make clarifying comments such as: “It sounds like you’re being really hard on yourself about what happened” or “It seems like you feel that you could have done more.” No matter what, don’t judge.

 

5. Practical Assistance

Assist the patient with any practical issues, which may be dominating (or over-dominating) their attention. Offer to notify friends or family, arrange for needed support, or obtain information about their care. Larger needs (such as questions about the costs of treatment) may be beyond your immediate power to address, but you can often take the first step, such as notifying hospital staff of their concerns. At the very least, provide whatever information you can and discuss a plan for resolving the problem. Even small measures like a warm blanket can have both practical and psychological benefit.

Remember that, although you may not be the most knowledgable or appropriate resource for many concerns, as an EMS provider you may be the only person who has the time and ability to address them. If you don’t make that phone call or find them a glass of water, it may be a long time until anybody else does; and it may not seem like a priority to find someone to move their car, but imagine how much better they’ll feel after it gets ticketed and towed.

 

6. Connection with Social Supports

Make an effort to enlist the patient’s support structure. In some cases, the first step may be to actually ask some version of, “Do you have a support network?” Some patients, such as the elderly or homeless, may not, and may need to rely particularly on institutional support, such as social workers.

When multiple individuals are in a group, such as family members at a scene or in the waiting room, ask if they have any questions or requests; this can provide a jumping-off point for further communication.

Make particular effort to bring children together with their parents or caregivers, and try not to separate them unnecessarily. Consider engaging children with simple activities, such as tic-tac-toe, “air hockey” (wad up paper and try to blow it across a table into the opposing person’s “goal”; this also promotes deep breathing), or the scribble game (one person scribbles on a paper, and the other tries to make it into something coherent).

 

7. Information on Coping

This step focuses on describing common stress reactions so that individuals will be more equipped to manage them. It is probably best left to more specialized professionals, since our own training is usually limited here.

 

8. Linkage with Collaborative Services

Help pass the patient along to existing resources, either by providing contact information or through direct referral. Most hospitals will have phone numbers or extensions for mental health, social work, counseling, and other services, and there are hotlines available for individuals not in care at a facility. (It’s worth having this sort of thing in your phone or on a cheat sheet, so that it’s available when you need it.)

When bringing in other aid, and even when making routine hand-offs to ED staff and the like, try to smooth the transition of care. Patients often feel as if they are passing through the hands of an endless series of personnel, with each one demanding to hear their story (and probably take their vital signs). Make an effort to give full, complete reports, and to establish your credibility through word and deed so that receiving staff feel less of a need to do it all over again; in particular, try to communicate whatever concerns or emotional state the patient is currently experiencing, so that the job of managing it can be seamlessly turned over. Introduce the new “helper” (for instance, the RN) directly to the patient, and let them know that they’ll be taking care of them; don’t just disappear, or they may feel abandoned.

 

Further information can be downloaded here from the National Center for PTSD.


Filed Under: Skills Tagged With: , , ,

The Slow Ride

March 26, 2012 By 2 Comments

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.


Filed Under: Skills Tagged With: , ,

What it Looks Like: Cardiac Arrest and CPR

March 15, 2012 By 4 Comments

Although we’ve talked about the fundamentals of good CPR before, the fact remains that the first step of any resuscitation is recognizing the presence of cardiac arrest. In fact, failure to do this in a timely fashion is a common problem at all levels of healthcare: because these situations don’t happen often, we are reluctant to accept when they’re happening now. (Real emergencies don’t come heralded by a change in soundtrack.) The result is delays, often for many minutes, before anybody initiates CPR and attempts defibrillation. We can’t just point fingers at the bystanders and lay providers — it’s also the EMTs, the nurses, even the doctors doing this. “Is that a pulse?” we muse. “I think there’s a pulse. Here, come feel.”

It’s true that cardiac arrest, at least in the early stages, is often not easily distinguished from other maladies (such as unconsciousness due to seizure or drugs). A few clues may be immediately obvious, such as pallor of the skin if some time has passed, or if a bystander actually witnesses the patient suddenly collapse. However, in the end, the way to make this call quickly and reliably is to simply follow the algorithm. You’re not the first person to deal with this, and the American Heart Association has spent years simplifying the decision process — because the goal isn’t to eventually “figure it out,” the idea is to immediately recognize it and start lifesaving measures within seconds.

Is the patient responsive? (No; they appear unconscious, and make no response whatsoever to painful stimuli.) Are they breathing normally? (No; they’re not breathing, or merely performing agonal, “gasping” breaths.) Is there a carotid pulse? (No, no pulse is palpable within a few seconds.) That’s good enough for us. Start pushing on their chest and don’t stop unless it’s absolutely essential — and the only things that are absolutely essential are checking their cardiac rhythm (just a few seconds) and delivering a shock (less than a second).

We’re going to look at a number of examples of real-life cardiac arrest (or “codes” in the usual lingo). As a rule, the actual CPR that you’ll see here is of relatively poor quality. This is due to a number of factors, but primarily it’s because 1) Many of these clips are five, ten, or fifteen years old, from a time when CPR was taught and practiced differently; and 2) Even today, many people do not perform good CPR.

So: focus on the patients. Watch how they present, their breathing, their skin, their responses to the interventions. Watch the challenges that the providers face as far as managing the patient and the environment. Watch how their approaches differ by region, circumstance, or personal preference. But for the most part, do not do what they are doing. We’ll watch a couple examples of really good CPR at the end so you know what to strive for.

 

We’ve linked this before, and for good reason; it’s one of the best videos I know of a real code. This is older CPR, with less emphasis on compressions and more on ventilation, but otherwise fairly true to the textbook. Notice the early “activation” of EMS, and the brief pulse check. Notice how rather than trying to “one-man” the BVM, they take advantage of the many available hands, allowing one person to hold the mask and one to squeeze the bag. Notice how they quickly dry the chest for the AED without being obsessive about it. As for the compressions, nowadays we would like to see them faster and deeper, with fewer and briefer pauses.

In the patient, watch the spastic, gulping movements of the mouth and tongue; this is agonal breathing. Notice also the decorticate posturing of the upper body, suggesting neurological dysfunction. Finally, notice how (after the third round of CPR + defibrillation), he begins to breathe spontaneously, with obvious chest rise, and this is clearly different from the prior agonal respirations.

 

(watch through 8:45) Despite the numerous pauses for commentary, this is also good. The initial compressions are rapid — a little too rapid, which is okay, but not deep enough, and if they were deeper they would likely be at a more reasonable rate. The second compressor goes deeper, but does not recoil fully at the top. The third (male) rescuer gives perhaps the best compressions, but notice his elbows — although pushing hard and deep, he allows his elbows to bend slightly each time. This is a very common error in otherwise skilled compressors, and is a good way to fatigue yourself quickly. Make a conscious effort to lock the elbows out completely, allowing you throw your full weight behind each compression rather than “pressing” with the arms. Notice also how frequently the rescuers stop compressions for one reason or another. Chest compressions need to build upon each other for several compressions before you’re producing anything like the coronary perfusion pressures you want to see; repeatedly stopping and starting sacrifices all your hard work.

In the patient, notice the pallor (paleness) of his skin, and the total lack of tone (limp flaccidity) of his body. Notice how he convulses with the shock, and how his chest rises and expands with ventilations. Finally, notice how his abdomen recoils outward in a seesaw manner with each downward compression of the chest.

 

(watch through 7:10) This is a chest pain patient that codes on camera. Despite the low image quality, notice how poorly he immediately presents; he is obviously fatigued, wan, and struggling with some sort of pain or other internal distress. Upon attempting to stand, he loses consciousness and demonstrates agonal respirations (listen to the heavy snoring). They ask if he has a history of seizures; a substantial number of cardiac arrests are initially mistaken for seizures, and may present with seizure-like activity (such as foaming of the mouth). There is obvious difficulty with compressions due to the high position of the stretcher. Bubba was very fortunate to arrest in the immediate presence of paramedics.

 

(watch through 3:43) Notice again the initial hesitation due to bystanders believing a seizure is occurring. These compressions have the kind of violent depth we want, although at about half the rate. Notice again the slight arm bend.

 

(watch through 2:25) This is a volunteer crew from AMR’s disaster response team in Haiti. There seems to be initial confusion about whether the patient is pulseless or merely apneic, hence the initial focus is on the airway; nowadays we would frown upon interrupting compressions for intubation, and the bagging after the tube has been placed is far too fast (every 6-8 seconds only, please). The teamwork is good, and return of spontaneous circulation (ROSC) is achieved after a few minutes. Notice the decision to defer a blood pressure measurement, since the patient has a strong radial pulse — an indicator of a decent pressure, if not an exact number. The patient does have fixed and dilated pupils, indicating a probable poor neurological status.

Keep watching only if desired; the patient is transported to the field hospital, where she rearrests, and the doctor there halts resuscitation efforts.

 

(watch through 23:50) This is a neonatal resuscitation immediately following a field delivery of twins; one infant is apneic following birth. BVM ventilations and compressions are performed, as well as an aborted attempt at intubation; however, in the end the neonatal fundamentals of warming, suctioning, stimulation, and supplemental oxygen end up effectively reviving the child.

 

Keep your eye on the left side of the screen at :19. This is a soccer player who arrests during a match. Not much of the actual resuscitation is visible, but watch as much as you’d like. Remember: although syncope has many causes, sudden and complete syncope of this type is almost always cardiac in origin. He literally passes out on his feet, and is totally unconscious before he hits the ground.

 

Another collapse at a sporting event. There is no backstory available on this, so it may not be a true arrest, but if so it would be consistent with commotio cordis, when a blow to the chest (such as a punch) causes an arrhythmia (due to an R-on-T induced by the physical blow; this is the evil brother of a precordial thump, with the opposite effect). This type of arrest has extremely good prognosis for recovery if immediate CPR and defibrillation is performed, since there may be little to no underlying disease; it’s a healthy young patient who simply got whacked wrong.

 

(watch through :38) Some brief miscellaneous footage of an arrest post-drowning, with a few pretty good compressions.

 

(watch through :57) Another near-drowning. Nice compressions. Notice the pallor and lack of tone.

 

Finally, let’s look at a couple examples of really spot-on, perfect resuscitation. Since perfection is rare in life, and having a camera in the room is even rarer, these will be simulations.

Click here for a teaching video from the Austin/Travis County medical director’s office. It demonstrates their “pit crew” model, where each member has a designated role, and each action is carefully crafted to match the latest evidence for best practices to promote survival. Notice how compressions begin almost immediately, once the rescuers have noted a lack of responsiveness, breathing, and pulse — and compressions stop for almost nothing, no matter what else is happening. (I would call these compressions very good, but a bit fast and shallow.) Secondary tasks like bagging can happen in the background. This crew does stop compressions while the AED charges, while I personally prefer to compress during this interval (between analysis and shock); the longer you delay between last compression and delivery of the shock, the less chance of getting a pulse back.

 

This is the pit crew model from the Resuscitation Academy in Seattle, mecca for CPR nerds; if you’re going to collapse somewhere, do it in the Space Needle. Their method is similar to Austin’s. Note the careful attention to mutual monitoring, such as keeping time or watching each other’s compressions to ensure depth and rate. (These compressions are pitch-perfect.) Watch how they count down to prepare for the pauses in compressions: the moment hands come off the chest, rhythm analysis begins; the moment rhythm analysis finishes, compressions resume; then they coordinate the hands coming off for less than a second while the shock is delivered. The total time-off-chest is kept to a bare minimum, without interfering with the two critical steps (analysis and shock).

 

There you have it, folks: what dead people look like, and what it looks like when we try to bring them back. Typically the process is chaotic, and we do our best, but often drop the ball on what’s important. Nobody’s perfect, but we can direct our focus toward the pieces that matter the most, and this lets us “streamline” our efforts away from the distractions and toward the critical elements. Recognize the problem early, compress hard, deep, and fast, and don’t stop for anything unless it’s defibrillation. Ain’t so hard, is it?

 

Sincere thanks to James Oz (Melclin) for assistance with compiling these video clips.

 

Check out also what Jugular Venous Distention, Seizures, and Agonal Respirations look like


Filed Under: Knowledge Tagged With: ,

Confidence vs. Competence

March 5, 2012 By 1 Comment

 

Do you know what you’re doing?

Do you look like you know what you’re doing?

Although these things are connected, they aren’t the same.

Some of the most common advice a new EMT might hear is to be more confident. And it’s justified: the typical new guy looks and behaves like a scared bunny, and it’s perceivable by everyone around him. You can’t be an effective field provider that way. Other responders won’t take you seriously, patients will decide they’re better off taking the bus, and other medical personnel will mentally delete your input. You won’t make the right decisions, because you won’t have the confidence to commit to them. Plus, your shifts will be nerve-wracking, and your hair may fall out. No good.

Oddly enough, though, this isn’t the worst-case scenario. Worse still is this: you’re supremely confident… even though you’re clueless.

Confidence is a statement. It says to the world, “Don’t worry, I know what I’m doing.” In response, they grant you further responsibility. “If this guy knows what he’s doing, then let him handle it,” they think.

If you project that message, yet are making things up as you go along, you’re telling a lie. You will be given responsibility, only to err terribly. You were trusted according to your level of confidence, but didn’t deserve it; your confidence exceeded your actual competence.

So, you need both. We want EMTs on the ambulance with the ability to assess, treat, and transport sick people. And we want them to demonstrate that they have that ability, by their words, body language, and appearance.

The good news is that confidence tends to grow from competence, which how it should be. As you learn the ropes, you become more comfortable, smoother in your actions, and more certain of your conclusions. Rest assured, you’ll broadcast this difference to everyone around you.

So where’s the problem? The problem arises when there’s an imbalance between the two qualities. Some people are just naturally “nervous-looking” or withdrawn; they may be entirely competent, but you wouldn’t know it by looking at them. These are the folks who need a slap on the ass, and to be told to throw their chest out, strut a little, and say it like they mean it. Even generally mousy people can usually learn to develop a “patient face,” a professional, commanding persona they wear during calls. (Think of your favorite medic… now think of his “medic voice.” Talk about heavy artillery.)

Conversely, some people are either overly confident in their abilities, or have simply been taught to fake it until they make it. (“A commander can be wrong,” as Arthur C. Clarke once wrote, “but never uncertain.”) In fact, some of the most difficult partners to work with fall into this category — the “newish” guy who can perform the everyday basics of the job, but whose cockiness swelled far beyond his actual knowledge, to the extent that he can no longer be educated or corrected. He knows it all, so he’s done learning. These folks need to be taken down a peg, because while ignorance is temporary, wrongness can last forever. If they’re simply afraid to admit when they’re unsure, it helps to reassure them that nobody has it all figured out yet, this is a team sport, and asking for help is much better than dropping the ball.

In the end, the goal should be supreme confidence, clearly palpable to those around you, yet directly built upon a foundation of clinical competence. If you’re good enough, you don’t have to put on a show; you can even hide your moves a little, because they’re going to come out anyway, and a certain amount of humility is professionally appropriate. (Plus, you won’t have to act like a douche all the time.) If you know your stuff but come up short in confidence, that’s your cue to start strutting a little more. And if you lack both, then start by developing quiet competence — not ignorant cockiness.


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