Archives for February 2012

Dialing it Down a Notch

Bringing order to chaos. It’s hard to suggest a more important skill for an EMT.

Emergencies are chaotic. Heck, even non-emergent “emergencies” are chaotic. The nature of working in the field is that most situations are uncontrolled. Part of our job is to bring some order to it all, sort the raw junk into categories, discard most of the detritus, and loosely mold the whole ball of wax into something the emergency department can recognize. Call us chaos translators. This is important stuff; it’s why the House of God declared, “At a cardiac arrest, the first procedure is to take your own pulse”; and it’s why we walk rather than run, and talk rather than shout.

The thing is, it’s not just those of us on the provider side that need this. Oftentimes patients need it too. Imagine: every other day of your life, you’re walking around without acute distress, in control of your situation and knowing what to expect. Today, something you didn’t anticipate and can’t understand has ambushed you — a broken leg, a stabbing chest pain — and you don’t know how to handle that. So you called 911 to make some sense of it all.

Most ailments are side effects of other problems: the fear of going mad, the anxiety of being so alone among so many, the shortness of breath that always occurs after glimpsing your own death. Calling 911 is a fast and free way to be shown an order in the world much stronger than your own disorder. Within minutes, someone will show up at your door and ask you if you need help, someone who has witnessed so many worse cases than your own and will gladly tell you this. When your angst pail is full, he’ll try and empty it. (Bringing Out the Dead)

With some patients, this is more true than with others. With some patients, there may be little to no underlying complaint; there is mainly just panic, a crashing wave of anxiety, a psychological anaphylactic reaction to a world that is suddenly too much for them. Particularly in those cases, but to a certain extent with everybody, bringing that patient to a place of calm may be exactly what they need. I have transported patients to the hospital who clearly and unequivocally were merely hoping to go somewhere that things made sense.

The burned-out medic likes to park himself behind the stretcher, zip his lip, and allow things to burn out on their own. This may sound merciless, but there is a certain wisdom to it.

We are very good in this business at escalating the level of alarm. Eight minutes after you hang up the phone, suddenly sirens are echoing down your street, heavy boots are echoing in your hall, and five burly men are crowding into your bathroom. We have wires, we have tubes, we have many, many questions. What a mess. So sometimes, once we’ve finished ratcheting everything up, it behooves us to pause, step back, and make a conscious effort to turn down the volume.

Take the stimuli of the environment, of the situation, and dial it way back. One of our best tools is to simply get the patient away from the scene — the heart of the chaos — and into the back of the ambulance, where we’re in control. It’s quiet, it’s comfortable, and there is less to look at. Move slowly, consider dimming the lights, and whenever possible avoid transporting with lights and sirens. Demonstrate calm, relaxed confidence, as if there’s truly nothing to be excited about. Some patients with drug reactions, or some developmental or psychological disorders (such as autism spectrum), may be absolutely unmanageable unless you can reduce their level of stimulation. Just put a proverbial pillow over their senses.

If you’re stuck on scene, try to filter out the environment a little. If bystanders or other responders (such as fire and police) are milling around, either clear out unnecessary personnel or at least ask them to leave the room for a bit. Make sure only one person is asking questions, and explain everything you do before you do it.

There’s a human connection here, and if you can master it, you can create an eye of calm even as sheet metal is being ripped apart around you. Look directly into your patient’s eyes, and speak to them calmly, quietly, and directly. Take their hand. Use their name, and make sure they know yours. Narrate what’s going on as it occurs, describe what they can expect next, and try to anticipate their emotional responses (surprise, fear, confusion). If they start to lose their anchor, bring them back; their world for now should consist only of themselves and you. To achieve this you need to be capable of creating a real connection; it is their focus on you that will help them to block out everything else. Done correctly, they may not want you to leave their side once you arrive at the hospital; you’re their lifeline, and it may feel like you’re abandoning them. Try to convince them that the worst is over, and they’ve arrived somewhere that’s safe, structured, and prepared to make things right. They’ve “made it.”

Applying these ideas isn’t always simple, and learning to recognize how much each patient needs the volume turned down requires experience. But just remember that no matter who they are, no matter what their complaint, most people didn’t call 911 because they wanted things more chaotic. Try to be a carrier of calm.

Happy New Year

On this most auspicious of Sundays, EMS Basics is one year old!

A year ago exactly, I threw this site into the EMS 2.0 blender <head>-first, giving me something to engage my brain between dialysis runs and hopefully teaching a few new and new-at-heart EMTs which way is up. Since then, we’ve made 81 posts on a variety of vaguely educational topics, and over 30,000 people have landed on our digital shores.

Our five most popular pages:


The top five search results leading here, not surprisingly:

  • agonal breathing (or agonal respirations)
  • coagulation cascade
  • orthostatics
  • jugular vein distention (or jvd)
  • cheat sheet


The most commented-upon post:


All in all, it’s been a great year from my side of things, and I hope you’ve have gleaned something of value as well. It’s a truism that the best way to learn is to teach, but I can personally attest that even if nobody in the world had clicked in this site, it would still have taught one person a great deal — me. The research that goes into every post, and the actual act of developing and writing it, has made me a far better provider, never mind educator.

As we round this milestone, I want to call attention to a few shadowy figures behind the curtains. This site would not exist without the work of Dave Konig (The Social Medic), who runs the entire EMS Blogs network. Dave is a hard-working, incredibly selfless enabler and supporter who is now directly or indirectly responsible for the voices of over 20 EMS bloggers reaching the public eye, including some of the very best. He does this for no real pay (ad revenue comes back to us authors), minimal recognition (he’s out there plugging our sites, not his), and presumably no reward except the desire to help further the community. But today, for once, we should drag his butt out into the spotlight. Because although he didn’t invent the EMS blog, he’s done more to promote it than anybody else.

I also want to mention Tom Bouthillet. Tom has been a driving force in bringing the art and science of ECG interpretation back into the forefront of modern emergency care, and his website is one of the best resources available for anybody who makes clinical decisions using the electrocardiogram. It’s true that he’s been well-recognized for many of these efforts, including most recently a web series at (go check it out!). However, he’s more than just an ECG wizard. (He also makes a wicked cherries jubilee…) As I hope this site demonstrates, I’m a real believer in the power of the web to educate and elevate those of us working in medicine. The key attributes that make such distributed training possible are: it’s free; it brings world-class experts directly to your screen; and it allows interaction and discussion that pools our collective resources. EMS 12 Lead and Tom’s other projects are an absolutely shining example of how this can work, and although he would not admit it even with thumbscrews applied, he has been a true role model to me. If I can reach half as many people in half as profound a way, I would consider this site an overwhelming success, but even my meager achievements wouldn’t be possible without his example.

Finally, I’d like to point a finger at David Hiltz of the AHA and HEARTSafe. David is an example for everyone who claims to serve the public with his utterly tireless, shameless, unflagging devotion to improving survival from sudden cardiac arrest. In any cause célèbre, there are those who dip their toes in, look for the easy gains, and jump ship when things get rough; but the people who watch them come and eventually see them go are the ones who get the real work done. If there’s one thing that’s true about cardiac arrest, it’s that most of the aces have already been played, the silver bullets deployed, and everything from here forward is going to be a slog. There’s little glamour or reward in that grind, and we should acknowledge the efforts of those pushing the millstones, because twenty years from now, it’s the fruits of their labor that we’ll be enjoying. Most of all, though, David is a generous and earnest supporter of small fry like myself, and I owe him a great deal for his help and guidance.

I hope to see you all in another year. Remember that if you have any questions, requests, or suggestions, my door is always open via blog comments or email. In particular, I love to hear what type of material you like to see — although I can get a certain sense from site traffic and links, it’s not always obvious, and what seems valuable to me may not be interesting to you. So stay in touch (the Facebook page is an easy way, and we share other interesting tidbits there too), and don’t go far — more good stuff is just around the corner.

Tiny Monsters

Hand hygiene.

Wait, come back!

It’s not very exciting, which is one reason we don’t seem very impressed by it in EMS. Also, I have a theory that most prehospital providers (probably most people in general, with the possible exception of those who have taken a microbiology course and seen gross things) don’t really, on a visceral level, believe in germs.

Whatever the reason, we really drop the ball on this one. Walk into your nearest Mega-Lifegiving Medical Center, where the best and brightest are using the latest and greatest methods to save lives every day, and look at the hand sanitizer mounted to every wall. Look at the giant signs reminding everyone to clean their hands, cover their nose with their elbow, and lock themselves into an airtight bubble if they think they’ve got the flu. Watch nurses exit patient rooms wearing full-body gowns, eyeshields, respirators, and gloves. Then watch the ambulance crew wander in wearing week-old uniforms, touch everything, scoop up the patient like a sack of potatoes, heave him onto a suspiciously gray and drippy stretcher, and do just about everything but lick the doorknobs.

Admittedly, one difference between us is that the hospital makes its money in part based on metrics that include the number of nosocomial (healthcare-acquired) infections it sees. But maybe that’s a good thing. If our billing started depending on how many patients we infected, suddenly we might start believing in germs. Just a prediction.

Why should we care about universal precautions? For one thing, to stay alive. Not long ago I transferred a nurse between facilities. She was being admitted to a medical floor for a massive MRSA-colonized abscess on her cheek; it had been surgically incised and drained, and she was now beginning a course of antibiotics and further care. The cause? She’d idly scratched her face one day at work.

For some reason, I find this argument unconvincing to many of us EMTs and medics. I suspect that, as usual, we consider ourselves immortal. Whatever the case, if you find it compelling, go with it, but otherwise, try its mirror image: precautions keep your patients alive.

You may be a romping, stomping, deathless badass. You’re 18, you take your vitamins, and you’ve never been sick in your life. Staph tells stories about you to scare its children. But your patient is elderly, takes immuno-suppressant drugs, and has leukemia coming out of his ears. How’s his immune system? Do you want to find out?

He’s the reason that the hospitals have become so paranoid about cross-contamination — because this guy is right across the hall from a guy infected with Ultra-Virulent Pan-Resistant Skin Melting Brain Bleeding Disease, and it’s very, very easy for staff to touch one of them, then touch the other. Or touch the doorknob, which someone else touches, who then touches… etc. This is why hospitals are such dangerous places for sick people.

That’s why I’m not particularly paranoid about germs in my everyday life, but I try to bring a little paranoia to work with me. Because our patients may pass through many medical hands, but most of those hands are now climbing aboard the sanitation train. Yet the system is only as good as the weakest link, and especially when it comes to interfacility transfers, EMS may very well be that link. We wear the same uniform from patient to patient (if not from day to day), we don’t always replace linen or clean the stretcher, and equipment — never mind the ambulance itself — gets decontaminated far less often than after every call.

And perhaps, due to the nature of our work, some of this is necessary. We work in a more difficult and less controlled environment than the ICU, and maybe we can’t maintain exactly the same standards. (This argument is less convincing when it comes to non-emergent, routine transfer work, though — particularly when a patient’s infectious status is already known.) However, there are some things we can do that are easy, routine, and when introduced into our habits, create essentially no added work.

Number one is hand hygiene.

Whenever possible, I wash my hands after every call. It’s no burden. If I’ve delivered a patient to a hospital or other facility, I simply find the restroom (which I probably want anyway, because my bladder is the size of a grape) and wash. Many times a sink may even be available in the patient’s room.

The proliferation of waterless hand sanitizers, usually alcohol-based foams or gels, has given us an alternative to this. When there aren’t any sinks, it’s the only way. But I don’t like ’em. They leave a residue that’s palpable, and which smells — and if you’re planning on eating anything, tastes — foul. They are also, in many cases, literally less effective. Although alcohol and similar agents kill most microorganisms, they don’t kill all of them (Clostridium difficile and the norovirus being notable exceptions), and like all contact sanitizers, they disinfect but do not clean. Any gross dirt, grease, or other contaminants on your hands (and this includes particles that are “macro”-sized but still too small to see) can cover or encase microbes, preventing antiseptics from reaching them. Unlike contact sanitizers, washing with soap and water is an essentially mechanical process: you are physically rinsing contaminants away from your skin and down the drain. (All that the soap does is “lubricate” hydrophobic particles to make them easier to rinse off.) Some soaps now are “antibacterial,” meaning they contain a germ-killing substance as well, but it’s not clear that these do any better of a job for routine purposes, and they may contribute to drug resistant strains. (They do, however, leave a microstatic coating on your hands afterwards, which helps to keep things clean a little longer.) Either way, most soap in healthcare facilities does contain an antimicrobial agent. In any case, I use the waterless sanitizers only when soap and water aren’t available.

Proper handwashing isn’t hard, but since it requires mechanically washing each portion of skin, it helps to have a system or you can easily miss spots. If you’re scrubbing in for surgery or a similar sterile procedure, you’ll need a much more stringent method than I use — but you’re not going to practice that ten times a day. So I use an approach that hits essentially the whole hand with as few steps as possible. Once you have the basic pieces in place, you can then do it fast for a routine wash, or spend much longer on each surface if you know that your hands are funky.

Here’s how I like to wash. It may seem elaborate or awkward at first, but with a little practice it’ll become second nature.

The same method can be used with waterless sanitizer. In the past, frequent washing tended to dry out your skin and lead to cracks (great windows for infection), but nowadays most soap in the hospitals contains moisturizer to prevent this.

A few points to remember:

  1. Washing is a mechanical process! Mere contact with soap doesn’t clean anything. If you didn’t rub an area of skin at least briefly, you didn’t clean it.
  2. Use warm water. Cold is a less effective solvent, and hot abuses your hands.
  3. If you’re also using the bathroom, consider washing before and after to avoid contaminating your… important areas.
  4. Drying with a towel is part of washing: it helps physically clean the hands, and wet hands are microbe-magnets.
  5. Although I don’t religiously practice the turn-off-the-water-with-the-towel technique, if you know that your hands were grossly contaminated, it’s a good idea; remember that whatever was on your hands before you washed is probably now on the knob.
  6. In an ideal world, we probably wouldn’t wear watches. In the real world, just try to be aware that it’s a great shelter for contaminants, and find a way to clean it (watch and band) regularly.

The Way You Do the Things You Do

Cops are gruff and authoritative. Librarians are helpful and a bit bookish. When a plumber bends over you can see his crack.

We’re all sophisticated and modernized folks here, so we understand that stereotypes aren’t true. Moreover, their broad, unthinking application can lead to many errors and evils.

Still, there’s often a certain amount of truth to them, or at least a systematic error behind them, and it can be worthwhile to ponder on this kernel. Why, for instance, do we associate certain personalities and affects — certain demeanors — with certain professions?

There are doctors of every shade out there, but what do you typically expect when you meet one? Probably his shoes are tied (and even polished) and he looks well-groomed. He shakes your hand and looks you in the eye. He listens carefully, expresses himself clearly, and generally presents the image of a serious and dedicated professional.

Nurses? Again, there are more varieties here than at any Baskin-Robbins, but we find that some traits are common. A bit hurried and no-nonsense, you might say, and a little feisty. Yet deep down, they’re caregivers at heart. And they wear comfortable shoes, and they dig free coffee.

My point is, we have these stereotypes because to a certain extent, the jobs dictate, demand, and develop certain types of behavior. The physician spent twelve years working towards this job title, a large portion of which was spent either trying to get himself accepted somewhere important or being instructed on how he should look, talk, and think. The nurses, they spend eight hours a day walking quickly from bed to bed, playing middleman between the vagaries of difficult patients, difficult doctors, and difficult bureaucracies. Imagine how you’d behave.

So, once we’ve put in enough time that we’re walking the walk and talking the talk, how do we behave in EMS?

Mostly, we behave with a kind of breezy insouciance. One part humor, one part world-weariness, one part quiet competence (if not outright cocky arrogance), and a large dash of sarcasm and cynicism (which we hopefully remember to switch off when we meet patients). We strive to be the kind of people whose panic-o-meter has no readings higher than Hmm…

We are unflappable; we’ve seen it all, done it all, and the only thing crazier than the stories we hear in the crew room are the ones we try to top them with. We are generally unimpressed. We haven’t run toward or away from anything since high school gym class. We happily eat our lunch after cleaning brain matter from our boots.

The prototypical paramedic rocks out to Journey en route to the call; he jokes with the patient and reassures them with casual self-assuredness; he easily improvises an IV using a cocktail straw and large safety pin; he’s businesslike and to-the-point with bystanders; and he flirts with the receiving nurse at the hospital. A hundred years ago he could have gotten away with wearing a cape and a sword; a hundred years from now he’ll probably own a jetpack. He is not quite a god, but he does understand if you got them confused.

As always, there are variations. But this is the basic mold of our kind.

Why are we this way? And is it a good thing?

In EMS, we do our work fast, and cut shallow. Most of our patient interactions last under an hour in total, which doesn’t leave much time for either nonsense or space-filling. Yet we also work with high-acuity, high-risk pathologies — heart attacks, major trauma, and so forth — that need to be quickly found, explicated, and managed. In the chaotic prehospital environment, our patient, our scene, and our course of care is often muddled with obstacles and red herrings; in order to function, we have to cultivate powerful and aggressive pattern filters that allow us to isolate the essential elements of a situation and pursue the key decision-points like an unshakable bloodhound.

The attitude also protects us, and perhaps it protects our patients. By skimming over the surface of every call and every patient, we never get dragged too deeply into the mud. As they say, it’s not our emergency, and if we acted like each emergency was a freak-out, we wouldn’t last very long. If we treat it like a laundry run, we can remain ready and in service for the next one. And the patients? They get the reassuring sensation of being cared for by someone who projects the message: “I’ve treated six people sicker than you already, and I haven’t even had my coffee yet.”

So is this a good thing? It clearly has benefits. But it has its negatives as well.

When we try to imagine behaving in the field like that well-tempered physician behaves at the bedside, the very idea seems bizarre to us. A swashbuckling air seems central to who we are; could we still bang through a full patient interview and physical exam in 120 seconds otherwise? Could we still concoct the same weird and wonderful solutions for our problems? C’mon, we couldn’t do this stuff by speaking slowly and wearing a cardigan.

And maybe there’s truth to that. But it’s also true that we lose something when we go this route. We lose a degree of professionalism, which affects our perception in the eyes of colleagues, patients, and the public. We lose the ability to form a certain type of bond with the patient, based upon a certain type of trust and respect; we gain a different sort of bond, but the loss is still real. And maybe, by standing too far back from the action and poking it with our toe, we also lose some of the compassion and humanity that make this job worth doing at all.

So I don’t have any prescriptions, and I’m not suggesting that we make an industry-wide effort to change our culture. But these are things worth thinking about, because automatic or implicit behaviors are the hardest to recognize, and the fact that we all do something doesn’t mean it’s the best thing.

What’s it got in its Pockets?

As a reward for bearing with me on the very, very, very, very, very long journey through shock, let’s turn to a somewhat lighter topic. This is a perennial favorite on the online EMS haunts: what do ya carry in your pockets during your shift?

Personally, I’m of the belief that everyone on the ambulance should have at least a few essential items:

Gloves — a more or less essential tool, even if you don’t always wear them you should always be prepared to, and there’s nothing worse than needing to hunt down a pair when things are moving quickly. Sometimes I’m surprised at how many you can go through on a single call. I keep a handful in one pocket and a single lonely pair in another, so I have a “ready” set that can be easily grabbed without having to peel them off from the wad. Remember to restock your supply when the call is done.

Paper — something to write on. Although I find that I write down less the more experienced I become, this is still a non-negotiable tool. I’ve carried a variety of small pads, but nowadays prefer a stack of 3×5 index cards held together with a binder clip — they work better when you’re writing something to hand to someone else, which I often am (noting vitals to give to my partner, for instance). Cards are also useful for holding open the latch on self-locking doors, leaving notes, and various other miscellaneous tasks.

Pen — ’nuff said. Even if your service has gone mostly digital, an EMT without a pen is like a knight without a sword. Also useful for poking blood samples from catheters for glucometry, testing sharp peripheral sensation, and stabbing zombies in the eyeball.

Watch — admittedly not usually stored in the pockets unless you’re Mr. Monopoly. Other than mundane needs like determining when you get to go home, without a working timepiece you can’t properly take vital signs. (Pulling out your cell phone here is only one step better than recording your signs via x-ray “vital vision.”) Something durable, light, and cheap is recommended, but anything that counts seconds will work.


That covers the absolute essentials. But there are a few other items that I’d place just barely behind essential, including:

Flashlight — some sort of small but bright penlight usually works well. This isn’t a clinical penlight for examining pupils — you’d probably burn their jelly right out — but something bright enough for searching a night-time scene, finding things you’ve dropped, and otherwise navigating the darker areas of life. Quite essential on certain shifts and valuable at all times; I recommend something water resistant, with a clip. I like the Streamlight Stylus Pro.

Shears — for all those things in the world that need cutting, a pair of standard trauma shears can’t be beat. Aside from stripping clothes off your patients, with a firm grip these can cut anything including the horizon — seatbelts, wayward tubing, tape, whatever. They also come in handy for wedging into doors, holding open fuel handles, reflex testing, and chucking at angry geese.

Knife — most people seem to carry one, and there’s always one guy who asks “why? shears work better.” Shears do work better for most cutting, but a knife works better for prying, poking, scraping, or levering, and that’s typically how it gets called into use. In almost no case will a knife be useful (or appropriate) in a clinical role, but it seems to be continually called into use for the daily minutiae of EMS — opening packages, fixing equipment, and so on. An affordable but quality folding knife with a clip and a lock is a good choice, and I’m a believer in half-serrated blades — that way you have a smooth edge for prying or slicing, but also an aggressive edge to start cuts in tough materials. I use a Spyderco Delica, an old classic.

Phone — perhaps it shouldn’t be, but nowadays a good cellphone seems almost irreplaceable. I use mine to speak with dispatch or supervisors when the radio isn’t appropriate, to call medical control, occasionally to give ED entry notifications… to note door codes and other tidbits… it has a GPS when needed, and useful reference apps like Epocrates (which includes cool tools like a pill identifier)… you can Google to check drugs names or disorders you’re unfamiliar with… real-time language translators are available… the list goes on. See the DroidMedic for ideas on using these little multitaskers.

Stethoscope — most folks seem to own one, but they don’t always have it on them. If there’s one truism to this job, it’s that the times when the poop hits the fan are never the times you’d expect it to, so try and be prepared. Your service probably provides cheap scopes, which tend to be loud but poor at filtering out background noise, making them less than useful in a busy scene or ambulance. For better or for worse, a stethoscope is also something of an identifier for the medical professional, and can do much to convince the public that you Know Things. Littmann is the most famous and popular brand, but you can probably spend less on others if you know what you’re getting. If it’s not in your pocket you’ll probably forget it when you need it, so I like a model that’s fairly light and can lay flat; I use a Littmann Master Classic II, which has no bell (which tends to be difficult to use in the chaotic prehospital environment anyway) and as a result has a very low-profile head. Mine’s in the most obnoxious baby blue I could find and my name’s all over it, in an attempt to discourage light-fingered coworkers.


Finally, there are the things that aren’t particularly vital, but come in handy if you’re willing to stick them in a pocket somewhere.

Penlight — a standard assessment tool. Probably available in your bags or cabinets but it’s convenient to have one immediately available.

Pocket reference — I recommend making your own.

Extra pen — because pens disappear. I also like to carry a permanent marker for things like labeling unmarked BP cuff bags (put on a bit of tape and write on that — is it an infant cuff? adult cuff? a bunch of OPAs?), marking pulse points, and the like.


There have been other things I carried in the past, but nowadays this about makes up my pocket milieu, and seems to strike a good balance of utility vs. clanking like the Tin Man. (Some people like to store stuff on their belt, but I tend to find that a little silly.) I have a work bag with other junk in it, but that’s a topic for another day.

Anyone have other items they find terribly useful? The variety on this issue seems nearly limitless.