Archives for March 2011

Vital Signs: Respirations

In the eyes of many EMTs, taking vital signs is BLS bread and butter. I’m not sure if I agree, since there’s other butter I’d hate losing more, but unquestionably vitals are something we do an awful lot of and probably ought be good at. Mainly, it’s the big three: pulse, pressure, and respiratory rate (the fourth vital sign is temperature, which is not considered vital prehospitally, and the de facto fifth sign is O2 saturation, which is not always available).

But woe unto the poor freshly-anointed Basic who enters the field and discovers that taking a blood pressure off his classmate at a quiet desk has almost nothing in common with playing hunt-the-Korotkoff on an elderly PVD patient in the back of a vehicle that sounds, to the layman, almost indistinguishable from a steam locomotive. With experience, we figure it out and we get by, but I’m always interested in the tricks that people have come to rely on, and here are some of my own. Let’s start with…



The man who said that any blind monkey can count respirations has never tried it on sick people.

The first challenge here is getting away with staring at someone’s chest without giving them the skeevs. Women may be a little more wary about this, but if you’re unsubtle enough even men may ask if you “like what you see.” One method is a classic: while taking a pulse, count your beats and then start counting respirations without looking away or dropping their wrist. It gives you an excuse to stare blankly, and the patient is rarely the wiser. Good multitaskers can even count a pulse while simultaneously counting respirations over the same interval of time, although this is a bit much for my own second-tier brain.

Alternately, you can place yourself out of the patient’s field of vision, a technique that girl-oglers will recognize. In the back of the rig, you can usually pull this off by simply moving behind the stretcher — the captain’s chair is often too far, blocking your vision unless the stretcher is very reclined, but moving to the end of the bench seat is usually far enough and more convenient anyway.

How about the shallow respirations that virtually can’t be seen? You can put a hand on their chest to feel, but this is a little weird in the conscious patient and again betrays your intentions. You’re better off maximizing your visibility. Make sure there are no piles of blankets or folds of clothing in the way, and try watching both the abdomen and the thorax, as different people breathe in different fashions. If you’re still having no luck, auscultate! Place your stethoscope and count from the lung sounds. In fact, respiratory distress patients will sometimes produce wheezes or crackles that are audible from the bedside, allowing you to get a count with the naked ear.

Some texts recommend counting for at least 30 seconds; this is accurate, but feels like a geological epoch. Unless respirations are highly irregular, I count for 15. That does mean that your results will always be a multiple of 4, but here’s a way to improve it: count partial breaths as well. If you start with the chest “up” and 15 seconds later end on a “down,” call it a half stroke — so 4.5 x 4 would mean a respiratory rate of 18. You can get even fancier with quarter-strokes but that may be a little silly unless their rate is very slow.

A final note: “ehhh, looks normal” is not a valid method for counting respirations. There are times for estimation, but one hospital-based study showed that an overwhelming number of patients were documented at triage as breathing exactly 16 times a minute. A statistical miracle! In other words, you’re not as good at eyeballing as you think; take a few seconds and do your job.

For other Vital Signs posts, see: Pulse and Blood Pressure

Glove Monsters

There are services that carry teddy bears or other friendly objects with which to palliate their pediatric patients. I think this is a neat idea, but due to cost and infection-control issues, it’s not exactly a universal piece of equipment, so the rest of us have to make do with what we’ve got.

I started handing out glove balloon creatures a year or two back. They’re not for infants or the very young, but okay for anyone who can be trusted not to choke on a rubber glove, and I’ve always had a good response. You can make it in front of them while they watch curiously, then present it with a flourish. Click below for an ultra-high-production-value tutorial video featuring yours truly.

I always name my glove animals, and for some reason mine always end up with Hispanic names. Maybe I’m a glove racist.

One possibly surprising category of patients who may appreciate these is the older (stable, obviously) psych patient. I’ve made several of these for teenaged girls during transfers to inpatient psychiatric care for suicidal ideation, and although it didn’t cure what ailed them, it seemed to help. Thom Dick writes about telling suicidal patients, “Please don’t die.” In the same vein, a small gesture like a balloon — something they can carry with them, even if only for a while — seems to help show them that there are people in the world who do care about what happens to them. One girl, who was otherwise quiet and withdrawn, clutched hers (“Juarez,” as I recall) tightly to her chest and stridently refused to let it be taken it from her, even as she had to surrender her clothing, belt, and shoelaces. BLS care? I think so.

Good Partners

EMS today is almost invariably practiced in two-person teams.

The main exception to this is in the fire service, which — even when called in an EMS role — is often built up from crews of three or more. And on 911 calls in many areas, ambulances are routinely dispatched alongside the fire department and sometimes police or other resources, so it’s not unusual to see a half-dozen responders or more on a scene.

Nevertheless, this job is fundamentally one that you perform alongside one other person, and that environment defines how we live and work. In fact, the dynamic between you and your partner can come to resemble the relationship of a married couple, an observation made by many a poor spouse after realizing their significant other spends more time with a mustachioed paramedic than with them.

You spend upwards of 10 hours a day sitting in a small box with this individual, talking to them, listening to them, and sharing all their favorite habits, odors, and bodily noises. You experience the best of their personality, but also their worst, and you learn what they listen to, who they hate, and how they address and solve their problems. To do your respective jobs, you’ll have to find ways to compromise where you don’t agree, adhering to what you think is right but ultimately doing what’s necessary in order to get the task done.

We all hope to work with a good partner when we check the schedule, but what is it that makes for a good partner — how can we be that person to someone else? There are many qualities, and some (such as personality) are heavily subjective, but one I think is universal.

Good partners are reliable. This is a word that doesn’t get much respect nowadays — reliable is boring, 8-track tape and grayscale television, reliable is what your grandparents and Dick Van Dyke were. Certainly, although intellectually we acknowledge that it’s a good thing, “reliable” may not exactly be the byword we’d want on our EMS tombstones.

But reliability is a funny thing. Like good life insurance, it’s something nobody wants, but that we all want in the people around us.

Not everyone works this way, but I have a simple system when working on a dual-EMT crew. On any given call, one person drives, one person techs. If I’m the tech, I’m in charge of the call: I do all the history-taking and communicating with the patient; I give and receive the reports; I make the decisions about next steps and the course of care; I stay by the patient’s side from start to finish, and in the end I’ll write up the documentation. As for the driver, he obviously is responsible for driving, getting us from Point A to B and later to C, and related tasks like the radio; but most of all, his job is to help me out. Record vitals, retrieve equipment, start interventions, take heat — whatever is necessary to free me to do what I need to do.

It’s the job of the tech to keep the entire situation in perspective and paint the path that will, when viewed in retrospect, be clearly visible as the ideal course of care given the patient’s complaint. But many obstacles may interfere with that path, and the more that my partner can help clear those away without a hiccup or hesitation, the more smoothly things will go. This means doing what I ask without question, or better yet, anticipating it even before I ask; it means seeing and foreseeing problems and knowing how to pave them over without diverting us from our primary goals. I can be somewhat anal about this division of responsibility, not because I’m a control freak — I’m happy to play the other part when my turn comes — but because the best way to drop the ball and fumble through a run is by having two chiefs and no indians. Although there are times for collaborative discussion, and times to throw up your hands and refuse to do something foolish, the majority of actions and decisions on any given call are simply things that need to be performed by someone, rather than tabled for debate by committee.

Here’s where the issue of reliability comes in. As a crew, we have the potential to do some wonderful things, including pushing boundaries and getting creative in ways that are anything but boring. But in order for me to go out on a limb, I need to know that you are going to be able to back me up — cover your end of the show, pick up the slack and fend off any looming hazards. If I can’t rely on that, then I can’t extend myself, because I’ll need to hold something in reserve to pick up whatever you drop. If you don’t know how to get us to the hospital, then I may not be able to accomplish very much in the back, because I’ll need to divide myself between the patient and helping you navigate. If I need to ask questions, read meds, take vitals, and package the patient all at once, don’t be surprised if only half as much gets done, because I’ll be doing the work of two. I may be able to handle a rough call with the most useless partner in the world, but it’ll be done in the most bare-bones fashion, merely trying to get through it without any disasters and struggling to hold our heads above the standard of care. However, if you manage your end of things seamlessly and effectively, that frees me to step everything up; the more you can do, the more I can do. Reliability is boring if it’s all there is, but when it’s the immutable backdrop of your care, it’s actually the foundation for all creativity and excellence.

(Now, there are crews out there who don’t work this way. Instead, they handle things cooperatively, each member doing what needs to be done and nobody in charge. This works best when they’re very experienced and familiar with each other, in agreement on most decisions and practiced at staying mutually out from underfoot and functioning synergistically. This is not common. However, the important thing is that even on a crew like this, reliability is all the more important, because it has to run both ways — if we each have equal opportunity to drop the ball, then we each have to be absolutely reliable.)

There’s a major interpersonal element to all this, which is trust. Trust is the coin you pay back for reliability. I need to be able to trust my driver to do his job, and likewise he needs to be able to trust that I’m making smart decisions. If I’m sitting in back and tell him to hit the lights and divert to a nearer hospital, I need to be able to trust him to get us there safely and quickly, otherwise I’ll be forced to take time from the patient to monitor and direct him. But he also needs to trust that I’m making an intelligent decision based on a sound assessment, because he doesn’t know what’s going on back here either, and I may not have time to explain. How bizarre of a request can I make without him balking or refusing? That depends; how much does he trust me?

Just like in a personal relationship, the fear of lending this trust comes from a legitimate aversion to risk. Although trust in an intimate relationships puts us at risk of emotional harm, trust on this job places our career and the lives of our patients and ourselves on the line.

If I was wrong to trust my driver, he might get lost, panic, plow through an active intersection and kill us all. Of course, if he was wrong to trust me, our patient might receive the wrong care, die in a trauma room somewhere, and we’ll both be fired and stripped of our certifications. Extreme, but possible. In many jurisdictions including my own, both members of a crew are held equally responsible for all aspects of patient care; this fact alone makes trust tremendously important if we’re ever to divide up responsibilities at all.

For this reason, I feel that trust has to extend to before and after the call as well. Everyone has heard these rules, and everyone has broken them. “What happens on the truck, stays on the truck” is a popular one, mainly because we’ve all confided something to a partner only to hear them later repeat it to the wrong person — either innocently or seditiously. This sort of thing is fertile grounds for drama, which is no fun, but what’s key is that trust isn’t compartmentalized, and if you can’t trust your partner in a personal capacity, you won’t trust him professionally either.

I recommend these basic rules:

  1. Never relate any personal information told to you by your partner, unless you either request permission first, or “HIPAAfy” it so it can’t be linked to him (“one of my partners was telling me…”).
  2. Never tell any stories that could paint a past partner in a bad light, unless you either request permission or HIPAAfy it.
  3. Never involve supervisors or management staff in personal or operational problems, unless critical and intractable patient care issues are concerned.

These are pretty simple rules to understand, although harder to consistently apply, because we’re all blabbermouths at heart and don’t realize when something innocuous to us is private and personal to someone else. The gist is simply that there is a bond of trust between your partner and yourself, regardless of whether they’re a close friend, a hated enemy, or a total stranger; and that bond should not be violated except in extreme circumstances, generally involving the safety of yourself or others. Even in cases like that, every effort should be made to resolve the situation without violating their trust, which isn’t always the easiest method, but it is the best for everyone involved.

Again, this serves to reduce drama and maintain personal relationships, but we’re talking about it because it directly impacts your work. You must be able to trust your partner, or you will be a dysfunctional crew. (If I know you can’t be relied on, I can’t trust this blood pressure you took, can I?) Moreover, you will never be able to help your patients in any but the tightest, most minimal and conservative way, because you don’t know if anything else won’t come back to bite you. You’ll move through your day tense and fearful of being under the eye of someone you don’t trust. Bad news all around.

I’m not suggesting that these ideas are easy, because they aren’t, and dealing with their results and fallout is what makes up a lot of our daily troubles. But this is a team sport, and it can’t be done right any other way.

Cheat Sheets

Now and then you see someone with one of those little spiral-bound EMS “pocket guides.” They make sense for paramedics, who have drug dosages and other information-dense (and in some cases, rarely used) protocols that need remembering; but they always seemed a little silly for the EMT-B, who mostly needs to remember not to drop anyone.

There are a handful of things that would be useful to me in a reference, however, and therein lies the rub: preprinted field guides invariably consist 75% of what you already know and are missing 50% of what you actually need. For instance, when I moved two years ago, one of my main concerns was learning the different points-of-entry in the Boston metro area (trauma, STEMI, etc.), a service area which runneth over with so much healthcare that even your hairdresser might be an RN. But I’m not going to find that information in any book I can find on a shelf.

The answer? Homemade references! I made my own cheatsheet by laying out what I needed on the computer (I used Adobe InDesign, but a word processor would work), printing it in foldable handbook size, and gluing and stapling it together into a booklet. This fits unnoticeably in my back pocket and goes everywhere with me during my shift, and it works great — it’s full of exactly what I need and nothing else. My original one has been falling to pieces, so I just recently revised it and made up a new one. I’ve considered laminating it, but I don’t want to make it any thicker, and that would make it difficult to write on for any revisions.

I recommend making your own cheat sheet if you get a chance. You can check out mine here; here’s a couple sample pages as an example.

And the final product: