Glass Houses: Suicide in Both Seats

Of all the skills we’re called upon to wield without adequate training, care for psychiatric complaints tops the list. In particular, it’s a rare shift when you don’t handle a person — whether on the initial emergency response or a subsequent interfacility transfer — who has thought about, or even attempted to commit suicide.

Probably because these patients aren’t very medically exciting and can be challenging to deal with (due to varying degrees of cooperativeness), many of us aren’t big fans. We also tend to have a cynically individualistic sort of streak, which says that deep down, patients are responsible for themselves. If someone wants to be healthy and they get unlucky, we’ll help out. But if they can’t be bothered to try, we can’t be bothered either, and if they’re actively trying to hurt themselves, surely we have better things to do than interfere with natural selection.

But before we throw stones, we should probably understand the disease we’re discussing. Just like you can’t treat CHF without grasping its pathophysiology, properly treating the suicidal patient — or even deciding not to care — demands knowledge before judgment.

Depression itself is hard to grasp from the outside. This easy walkthrough may shed some light, but if you haven’t been there, you probably shouldn’t pretend you understand it. Nevertheless, it’s one of those conditions that invites amateur opinions, because it seems like the sort of thing we all know something about.

Maybe depression is too loosey-goosey; maybe it’s better if we stick to concrete facts, yeah? And there’s nothing more concrete than suicide. Let’s talk about suicide.

Start by reading through this article at the Daily Beast. It’s long, but it’s real good, and you may start to change your mind about a few things by the end.

For instance, in 2010, in the developed world where we have good statistics, suicide killed more people in the prime of their life (ages 15–49) than anything else. Read that again. Of all the terrible insults we study and treat, from gunshots to heart attacks, car crashes to cancer, suicide was more deadly than every single one. Over a hundred thousand suicide deaths that year. Almost a million across all age ranges. Every murder, every war, every natural disaster you read about in 2010 — throw them all together, and they still don’t equal the number of suicides. There were probably even more that weren’t reported, and even that’s just the successful suicides, of course; those that were attempted but didn’t quite succeed make up a much larger group, perhaps twenty-five times larger. (Yes, 25 times.) And there are more and more every year.

When we talk about CPR, we often talk about quality of life. When a 98-year-old bed-bound dementia patient dies, we might ask whether we should jump through hoops to save them; even in the best possible case, they’re not going to return to a very long or very fruitful existence. But when the 20-year-old college student drops dead on the lacrosse court, we want very badly to bring him back, because if we can he might live another 70 wonderful years.

Well, the people committing suicide are the second kind. They’re often middle-aged, middle-class folks who could be happy and live long — if they can get past their illness. But dead people won’t get past anything.

Of course, we see a lot of depressed people, and most of them won’t kill themselves even if they’ve thought about it. Figuring out who’s most at risk of taking that step is a worthwhile goal, and the Daily Beast article describes three risk categories that you may find useful:

Those who feel alone, that they don’t belong anywhere
Those who feel like a burden to others
Those who have the willingness and capacity to go through with self-annihilation

Who feels alone? Everybody, at times. We need connection. Married people kill themselves less often than the unmarried, twins less often than only children, mothers raising small children almost never. Sometimes those who seem to have everything in life may have the weakest connections, which is why they say that money doesn’t equal happiness.

The life-saving power of belonging may help explain why, in America, blacks and Hispanics have long had much lower suicide rates than white people. They are more likely to be lashed together by poverty, and more enduringly tied by the bonds of faith and family. In the last decade, as suicide rates have surged among middle-aged whites, the risk for blacks and Hispanics of the same age has increased less than a point — although they suffer worse health by almost every other measure. There’s an old joke in the black community, a nod to the curious powers of poverty and oppression to keep suicide rates low. It’s simple, really: you can’t die by jumping from a basement window.

When nothing ties you down, when nobody cares what happens to you, what’s stopping you from shuffling off into the abyss? “I’m walking to the bridge,” one note said. “If one person smiles at me on the way, I will not jump.” Did you smile at your last psych patient?

Who’s a burden? Anyone who’s not achieving, contributing, responsible for something or someone. The unemployed, the chronically cared-for, those with debilitating diseases or intractable poverty. We do this job because we like taking care of people, but that means there’s always someone being taken care of, and nobody loves being on that side of the equation. Some people will go to their graves rather than add to the work or worry of those around them. A few will send themselves there.

Finally, who’s actually willing to end their own lives? It takes something special to close the deal, a particular resolve; no living creature’s natural instinct is to die. Even if you have the desire, it’s not easy to pull the trigger. It’s those with the gift or the learned ability to follow through with difficult deeds, the “athletes, doctors, prostitutes, and bulimics . . . All have a history of tamping down the instinct to scream.”

Think about those categories. None of those are particularly insane thoughts to have. All it takes is their juxtaposition, and suddenly, something unthinkable becomes a very real possibility. Honest. It happens hundreds of thousands of times every year.

Suicide in EMS

“Well, what the heck,” you’re thinking. “That’s nice, but I’m not going to fix them, so why do I care? I’ll bring ’em where they’re going and say good luck; God and the doctor can take care of the rest.”

Fair enough. But I have a homework assignment for you.

Find that guy at work. You know the one. His nickname is “Doc” or “Papa.” He’s been doing this for twenty-plus years, since the days when ambulances were dinosaur-drawn wooden wagons. Ask about the other old-timers, the endless sea of faces he’s worked with over the years.

He’ll have good stories. Tons of them. Partners and coworkers and crazy SOBs. Hijinks were had, shenanigans performed, laughs all around.

But then ask what happened to those guys.

Because a lot of the time, they’re not running around on the ambulance anymore. Ol’ Doc is the exception. They’re not semi-retired, spending their afternoons fly-fishing and golfing. They didn’t jump careers to become bankers or meteorologists.

They’re dead. Or maybe in jail. Or shot robbing a 7-11 for $13. Or they were committed to a psych hospital so many times nobody knows what happened to him. Maybe they overdosed. Living on the street. Living who knows where.

And yes, some of them committed suicide.

Seems a little rich to judge your psych patients when, the way the odds go, you’re probably going to be the next one.

I suppose you could argue that EMS was different back then. Russ Reina talks about the time when most “ambulance drivers” were people who couldn’t find a job anywhere else, drifters and ex-cons. Not like now. Now we’re all as well-adjusted as Mr. Rogers. Right?

Yeah, sure.

Let’s be real. A lot of the people doing this job can’t stay employed even in our own dysfunctional field, and would never stand a chance anywhere else. Drug abuse and PTSD are common. And our social support networks often don’t extend past a partner or two.

Do we belong anywhere? Maybe you do in the police or fire service. But those of us who enter private EMS usually don’t last long before being sucked into a loop of working more and more overtime until we no longer have hobbies, no longer spend time with friends, no longer travel or expand our horizons. If we have spouses, significant others, or family, we neglect them. If we don’t have those relationships, we sure as hell don’t develop them from the driver’s seat of an ambulance. The last step — which doesn’t take more than a few years — is when we start to view every one of our patients as a nuisance. Burnout takes away the last string tying us to other people; if patients aren’t worth helping, aren’t hardly people at all, then the circle of humans in our life may become no larger than our uniform belt.

Are we a burden? In many cases, that shoe drops when we find ourselves off the clock. If our life has become the ambulance, what happens when we lose the ambulance? Your company goes belly-up. We piss off the wrong boss and get tossed out on our ass. Or, inevitably, we get injured. Suddenly, the only reason to get out of bed in the morning is gone. Sounds nice at first, but you realize quickly that having nothing to do actually means you’ve got no reason to be alive.

And are we afraid of dying? Who could be less afraid? We spend every day minimizing death, trivializing the human condition, ingraining a culture that teaches we should be able to order nachos after bandaging a burn victim. We drive fast; we laugh at seatbelts. Sometimes we snort cocaine and have sex in ambulances. (No, not you. But you know who.) There’s nothing beyond the pale for an EMT. Including pulling the trigger.

So is suicide a big deal? Yes. Should we try to understand it? Yes. Does it matter for us? Yes.

But more importantly: do we get to judge it? Do we get to pretend we’re above it? Are the kind of people who attempt it so bizarrely pathological that we’re nothing like them?

You can decide. But you only get to say that if you’re willing to say you don’t care about a disease that kills more healthy patients than anything else. Willing to write off hundreds of thousands of people every year.

And willing to say you don’t care that your partner could be next. Or your boss. Or yourself.

Check out The Code Green Campaign for mental health support for EMS. — ed. 1/17/15

A Saving People Thing

This isn’t a criticism, Harry! But you do… sort of… I mean — don’t you think you’ve got a bit of a — a — saving people thing?

Harry Potter and the Order of the Phoenix, JK Rowling

In a few weeks, I will be leaving the ambulance indefinitely.

I’m moving a couple states away to return to school, a Physician Assistant program that begins in June. And while I hope to try and work an occasional shift with a more local service, it remains to be seen whether that will be possible. So I’m now approaching a crossroads where, after approximately four years of wearing a patch on my shoulder (many different patches, to be sure), I might soon be giving it up forever.

It’s a strange sensation. It’s been pointed out that, unlike other professions — butcher and baker and candle-stick maker — EMS has a unique ability to dominate the lives of its men and women. How many doctors and nurses do you see with bumper stickers, tattoos, and T-shirts proudly advertising their trade? For many of us, you don’t work as an EMT or a paramedic, you are one; it’s part of our identity. (That’s why it can be so devastating when, through life or injury or the whimsy of employment, we suddenly find ourselves without a uniform to wear — many of us don’t know what to replace it with.) There are prominent physicians of many years who still include “NREMT-P” among their credentials. That’s like an attorney listing his high school oyster-shucking job on his CV.

There are probably many reasons for this. Buckman has observed that becoming an EMT is one of the fastest and easiest routes to “feeling important” — one quick class, and you can break traffic laws and tell everyone you’re a lifesaver. We like that, I’m sure. There’s a lot of ego in this business.

But I suspect that it also attracts people who embrace its fundamental nature. At the bottom, this job is about going to people in distress and helping them. And there is something in us — I think in everyone, although stronger in some — that wants to do that. It resonates with us as humans. (Of course, many other things resonate with humans, including sex and bacon and a great parking spot. But that’s all right. We’re complex creatures.)

The point is, this business allows us to play that role in a unique way. I believe that someday I may enjoy sitting in an office and treating patients who walk in the door, or waiting in an emergency department, or roaming a hospital floor. But that’s different; you are the all-knowing Man on the Mountain, and your patients come and form a line to beg for your wisdom. On the ambulance, people call for help, and we go to them. We take the trouble; we’re the humble servant. Yes, they have to ask, but once they do, we bring the noise, we say: “There, there. We’re here now. Everything’s going to be all right.” In the simplest, most fundamental template of this job, people have problems and they call us; we hear the call and we drive toward them; we walk into their home or business or any of the places that people go; we see a human being in distress; and we kneel beside them and ask, “How can I help?”

By coming to people in their time of need, we get closer to the heart of it all. By our willingness to kneel, we open ourselves for the dying eight-year-old to ask: “Mrs. Nurse, will you hold my hand? I’ve never died before and I’m scared.” And that’s special, and it’s not such a bad thing to elevate it, even though — as Thom Dick reminds us — no matter how much we love it, it won’t love us back.

No matter where I go from here, for me, EMS will always be about that feeling of kneeling beside someone. Or the experience of sitting on the ambulance bench, alone, just my own thoughts and a trusting and vulnerable patient.

That moment when I walk into the room, and all eyes turn to me.

The mental perk-up as the radio crackles, and the extra acuity that dials in as I recognize my call sign and my gears start turning.

Opening my mouth to give a report to a trauma bay filled with nameless people wearing scrubs.

Holding an old lady’s hand as we bounce down the road.

Touching a shoulder as I say good-bye.

Iced coffee from Dunkin’ Donuts, titrated to my tiredness.

The smell, sound, and non-stop rumbling of a diesel engine.

Black shoe polish.

Sitting beside a partner and feeling like it’s the two of us against the world.

There’s a lot that’s wrong with this job. But there’s something that’s right about it, too, and it’s something important. And that’s why we keep coming back.

I’ll be busy soon, and this site will have to take a back burner. Updates will come less frequently, and I can’t guarantee new scenarios or new posts or new Library material on any reliable schedule. But wherever I end up, I don’t plan to turn my back on it. Because even if you leave the ambulance, I’m not sure if you ever stop being an EMT.

Surly Librarians and their Rants

The Digital Research Library has really grown legs over the scant weeks since its creation, and we couldn’t be happier about it. But as useful as it is to present the bare facts and data, it’s also valuable to read deeper, discovering context and patterns. Try as we might, we couldn’t find an elegant way to include this in the library as it stands, and it would clutter up the front page here obnoxiously.

So we made another blog. Introducing: Lit Whisperers. Check it out, know it, love it — updates will be posted to our Facebook page or via EMS Blogs.

Child-rearing and You

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

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

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

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

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

Make your expectations clear

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

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

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

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

Some points to consider:

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

Practice, Practice, Practice

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

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

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

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

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

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

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

Managing your own blood pressure

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

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

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

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

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

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

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

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

Cutting the Ribbon: The EMSB Digital Research Library

Around here, we’re big believers in evidence-based medicine. Yes, it has flaws, and yes, it can be challenging to properly interpret and apply, but like they say about life, it’s the only game in town.

And sure, you can let other people read the research and tell you how to treat patients. And since by and large, we work under protocols written by physicians, that is inevitably what we do. Yet everybody understands that within that framework, there’s still a great deal of leeway — there are decisions that need to be made every day, and you cannot make them intelligently without understanding what you’re doing and why. If you’re not basing your decisions on science, you’re basing them on personal prejudice, anecdotal experience from your career (which is inevitably weaker than you think), and the similar poor compasses of colleagues and coworkers.

No good. We should all strive to have reasons for the things we do, because that lets us modify our actions, omit them, prioritize them, and otherwise tailor our care to the unique situation and unique patient in front of us.

Unfortunately, directly engaging with peer-reviewed medical research is challenging. Searching through it is an acquired skill, reading it takes practice, and in many cases, we simply don’t have access to published full-text articles unless we’re affiliated with a university. The result is that many prehospital clinicians who want to practice intelligent, evidence-based medicine aren’t able to do so, at least not easily.

In response to this, we’ve launched a new project. Drum roll please…

The EMSB Digital Research Library!

This is an index of medical papers on topics relevant to EMS, ranging from spineboards to sepsis; it’s easily searchable, and can be organized or filtered by the user according to whatever characteristics are desired. Rather than a raw data-dump from all the world’s journals, it’s hand-curated by our volunteer editors, who read each piece from cover to cover, summarize the contents, file them and rank them by quality and relevance. The result? If you want to discover what we know so far on a specific topic, instead of facing a blank, unending sea of medical research, you’ll have a structured library of material organized for your convenience.

When you find the research you’re looking for, what then? If you lack academic or institutional journal access, we’re here for you. Simply email us a request for the papers you need, and we’ll provide them to you privately. We wish it were possible to simply post them online for the world to access, but that would violate copyright law in an egregious way. (When specific papers have been made freely availably by their publisher, we do link them directly in the index.)

How effective is aspirin for chest pain? What’s the chance a patient with head injury has a C-spine fracture? Does it matter if your stroke patient walks to the stretcher? Is supplemental oxygen important during sepsis? What’s the number-needed-to-treat for endotracheal intubation? These are the kinds of questions that are hard to answer now, but will be easy to answer using our library — at least, once it’s grown enough to address those topics. There are tens of thousands of papers out there, and one day we’d like to list them all, but we’re starting with a seed of about a hundred — a very well-developed body of spinal immobilization literature (probably over 90% of the quality research on the subject), plus a scattering of interesting material in other topics. Everything starts somewhere, and it’ll continue to expand.

The Library is managed at this time by my colleague Vince DiGiulio, Head Librarian and Master of Evidence-Based Codices. I help him out, along with a team of associate librarians. In any case, general library-related queries, research questions, or paper requests can all be submitted to librarian[at]emsbasics.com. Please remember that we’re all volunteers over here, so give us a little while to reply. And if you’re willing to contribute some time to help curate the database, let us know — we need help!

Folks, this will be a constantly-growing project. We’ll be striving to continually add more material, both new and old, and updates will be announced on the library page (as well as the Facebook group). The entire system is still in the early stages, so bear with us through any changes or hiccoughs. And remember: if you’re not thinking about how you know what you know, you’re not a clinician, you’re a monkey. And if the way you know what you know isn’t through science and reason, you’re just a witch doctor.

Use this stuff. Don’t be a witch doctor.

Year Two

Two years!

The inaugural post on this website was published two years ago to the day, and starting tomorrow, we’ll be moving forward into year three.

Time flies like a banana, doesn’t it? Over the past year, the site has grown and evolved. Due to personal obligations (I’ll be heading up in a few short months to matriculate at a PA program), I confess that the output of general content has dropped off. In comparison to the 81 posts made in the first year, this past year I cranked out only 34. Despite that, annual traffic has swelled from 30k unique visitors to over 72,000.

Some things stay the same. The most popular pages are still the What it Looks Like series (which we continued with a popular edition on Cardiac Arrest and CPR), the Drug Families: Anticoagulants and Antiplatelets tutorial, and our guide to orthostatics. We keep talking about how to be a good EMT, and ran some posts about the basic challenges of patient care and how to manage them. In keeping with the basic mission of the site, we discussed things like performing great BLS-level resuscitation.

But some things change. We ran a new multi-part guide on glucometry that was well-received, and a series of posts examining BLS airway and ventilation that have become some of the most popular on the site. We tried our first collaborative community podcast and experimented with video lecturing.

Perhaps most excitingly, we launched our most ambitious project yet: Scenarioville, an alternate reality allowing us to present frequent everyday patient scenarios in a consistent environment. Although we’re still tinkering with the format, after the first 16 scenarios I’m very happy with how it’s working out, and I think it allows for learning in a unique way. The only downside is that it’s also a time sink — by making a commitment to post a new scenario every week, with chapters added Monday-Wednesday-Friday, I’ve had less time for producing new front-page posts with real meat behind them.

What’s next? It remains to be seen how the site will continue to unfold, particularly as my spare time becomes increasingly thin. But I’ll keep punching out as much good stuff as I can — and there’s a new project unveiling soon that’ll bring things in a whole different direction. I think you’ll like it.

The good folks I acknowledged last year still deserve a nod. And I want to extend my thanks to everybody in the audience who’s been reading, commenting, and sharing across social media; this content wouldn’t have reached nearly as many eyes otherwise, and perhaps I wouldn’t still be creating it.

I also want to give a wave and a tip of the hat to a smaller gang of friends. There’s a circle of some very smart and passionate folks who I’m proud to know, namely Christopher Watford, Vince DiGiulio, David Baumrind, Tom Bouthillet, and others. Through collegial discussion, sharing circulating noteworthy cases, bouncing ideas hither and yon, and overall collaboration in the best spirit of EMS 2.0 and the internet age, they’ve had a tremendous influence upon my way of thinking, my bank of knowledge, and my belief in the education of prehospital providers. Keep an eye on them, because people with this much dedication and brainpower can’t help but change the world.

I hope everybody has learned something from these pages and enjoyed the process a little bit too. And I hope to see everyone again, and new faces too, as we move forward into another year.

Stay safe and sane, and check back soon.

Super Soakers: Building a BLS Irrigation Device

Preparation vs. Improvisation

I have a new partner who called me obsessive once.

“Eh?” I asked.

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

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

“Well, you are here.”

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

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

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

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

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

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

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

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

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

The 10 Easiest Ways to Violate HIPAA

Leave paperwork face-up on the dashboard or front seat.
Leave your computer unsecured wherever the hell you please.
Tweet a picture of the badass MVA you just did, with a victim obviously identifiable to anybody who reads the news (“A car struck a tree on Route 421 today, driver Jim Smith was rushed to the hospital…”).
Tell everybody about the celebrity you just transported.
Tell everybody about the coworker you just transported.
Crack jokes and make comments about the patient you just dropped off while in the elevator, or in the public ambulance bay outside — usually while the patient’s family is eavesdropping.
Post a Facebook status about the crazy shooting you ran, sharing intimate details about the patient who was probably the only person shot in your town that day.
Leave paperwork in the truck at end-of-shift.
Let a facesheet (demographics page) escape into the wind as you fruitlessly chase it down the street.
Answering curious questions about the patient’s status or destination from the random person on scene, I’m not sure who that is, probably just the nosy guy who lives downstairs.

Advanced CPR Techniques for Basic Providers

So you’re an EMT operating at the BLS level, and you understand that when it comes to cardiac arrest, you’re the man. Sure, you’ll call for the medics if you get there first, but the stuff that’s really important — compressions and defibrillation — well, that’s right in your wheelhouse.

But it may seem a little simple. Simple is beautiful, but maybe you’re wondering what else you can do to really master the art of resuscitation, especially when you’re out there on your own. Take it up a notch, if you will. And a lot of the cool stuff that’s being tried in the big world, such as pit-crew choreography and various supportive devices, are only available if your service makes a large-scale decision to adopt them. What can you do as an individual provider to absolutely ensure your peri-dead patients have the best chance of survival?

Here are some ideas.

Don’t Stop Compressions, at All, Ever — Seriously, Just Don’t

Hopefully at this point you don’t need to be convinced that stopping compressions is a bad thing. It truly is. The mountain of evidence is unequivocal: any time spent not-compressing kills people; each interruption in compressions kills people; pausing after compressions before defibrillating kills people; pausing after defibrillating and before resuming compressions also probably kills people; and so forth.

The trouble is that, despite this knowledge, we still stop all the goddamned time. There’s a lot going on during a code, and a lot of things you might want to pause for. But let’s go through a few and see if we really have to stop:

Stop for Pad Application?

As soon as you found the patient, you began compressions, right? As long as they weren’t wearing a honking seal-skin anorak, you can do that just fine over a shirt, blouse, or other light garment. (Hint: anoraks and similar loose outerwear can often just be pulled off the arms overhead, like removing a T-shirt.) Bam, in you went.

Now your partner needs to apply AED pads, though. Should you stop what you’re doing? Heavens, no. Let him work around you if he needs. He can unzip, rip, cut around your hands, tug the fabric out from under them as pressure lifts between compressions, and clear as much of the chest as he needs. Then he can simply apply the pads. No interruptions, no problem.

In some cases, a CPR-feedback device will be present, either combined with the pads as a one-piece unit, or as a separate “puck.” Either way this usually needs to go between hands and chest, but you should be able to slip it under there with (at most) a brief hiccup in the rhythm

Stop for Rhythm Analysis?

Unfortunately, if you’re using an AED (rather than a manual monitor like the medics are toting), you will need to stop compressing and come off the chest in order for the device to analyze the rhythm. Otherwise, the electrical motion artifact produced will confuse the computer. So as soon as the device tells you to stop compressions for analysis, clear the body — but don’t go far (in fact, I would simply hover), and as soon as it’s finished, get back on there.

You may need to stop for manual rhythm analysis as well, but some monitors have a filter that can allow the medics to “read through” compression artifact.

Stop while Charging?

So the AED finished analyzing and advised a shock; now it’s charging. Can you compress during this period? Yes. Both common sense (it won’t shock unless someone pushes the button, so… don’t push the button) and at least one study (albeit for manual, not automated defibrillators) have shown this to be safe. There are some AEDs that will get confused if you compress during this time, so know your gear. [Edit: per our “para-engineer” friend Christopher Watford, the Philips FR2+, FRx, and FR3 AED models, plus the Zoll AEDPlus and AED Pro, may complain and possibly halt if you try to compress while charging or shocking. Lifepak AEDs should be mostly okay. Chris and David Baumrind — two of the conspirators behind EMS 12-Lead — wrote a feature for JEMS discussing the behavior of various AEDs if you attempt these maneuvers. Required reading!]

Once the device has charged and is ready to shock, clear everybody except the compressor, ensure that they’re clear, and coordinate between the compressor and button-pressor. Something like, “I’m going to count to three, and when I say three, I’m going to come off and you’re going to press shock, okay? One — two — [come obviously clear] and shock — aaand back on.” The actual defibrillatory shock takes a fraction of a second, and the device will verbally announce once it’s delivered, so you can get back on the chest almost immediately after pressing “shock.” There is no residual “charge,” it doesn’t “take a while” to deliver, it’s a quick blip, so you’ll only need to clear the chest for a moment — no more.

Stop while Shocking?

As a matter of fact, do we need to clear the chest to shock at all, or can we keep our hands down, compressing continuously while the electrons flow?

Instinctively, most of us say “No thanks!” However, a little logic suggests the risk may be low. Electricity follows the path of least resistance, and if pads are properly placed and well-adhered to the chest, this path should always be through the patient’s chest. The alternate path up into your hands is much longer, and will only exist at all if you have a connection to the ground, which (if present at all) will probably run through fabric and other insulators. Since almost all AEDs now are biphasic — these use less current than the old monophasic devices — and since pretty much everybody wears rubber gloves while they compress, risk is probably quite small.

The evidence supports this somewhat. Consider these studies: Lloyd, Neumann, Sullivan (supports multiple-gloving in my view), Yu, and Kerber.

This idea has been gradually gaining traction, and some folks have already started doing it routinely, mostly of their own volition. Salt Lake City Fire has even been experimenting with making it a standard option during all resuscitations. For the most part, the worst adverse effect reported seems to be a tingling sensation, particularly if there’s a tear in your gloves. It’s reasonable to ensure that you’re wearing intact gloves, especially over prolonged efforts (multiple shocks may break down the material), and probably wise to double- (or triple-) glove. If there’s a feedback device between your hands and the chest the risk is even lower (or you could lay something like a rubberized blanket over the chest to totally insulate yourself, as in the Yu study).

Now, everybody has a story about a guy who knows a guy whose ex-partner’s bartender was touching a patient during defibrillation, got blown across the room and set on fire, and now can’t pronounce vowels. For the most part, this seems to be purely legend. The trouble is that there isn’t sufficient evidence yet proving it’s safe to make this an official practice on a top-down level; but that doesn’t mean you can’t make the decision for yourself.

If you have an arrhythmia (especially with an ICD or pacemaker), or another legitimate reason to be concerned about your own heart, it’s probably reasonable to pass. For everybody else, to paraphrase Dr. Youngquist of SLC Fire, this practice is probably safe for providers — if not yet for administrators. So you might not see this in your protocols for a little while, but I’ll bet it doesn’t say not to do it, either. The decision is yours.

(There is a possibility that some AEDs, particularly those with feedback technology, may detect the ongoing compressions and refuse to deliver a shock. Again, see above for more info.)

Stop for Ventilations?

Until you get some kind of tube into the patient’s airway, you’re going to have a hard time bagging any air in unless you pause compressions first. One option would be to simply skip it and perform continuous compressions, which is very reasonable, especially early in the code, or really whenever in doubt. But if you do pause to ventilate, take as little time as possible — pause, breathe goes in, exhale, second breath, and then immediately back into compressions (no need to wait for the second exhalation).

Go Faster — and Probably Harder

The currently recommended rate for chest compressions is “at least 100 per minute.” In other words, that’s not a target, that’s a minimum. Can you go too fast? Probably, but it’s hard, and it’s much easier to go too slow.

There’s an accumulating body of evidence, however, that points toward a more exact rate — right around 120/minute. Up to that number, more people survive if you push faster; above that number, fewer survive. It’s not for-sure yet, but in this business, not much is totally sure.

Since it fits the official “over 100” recommendation anyway, I now use 120 as my target rate, and I think you should too. It does mean that your old go-to songs for musical pacing, such as Stayin’ Alive (or perhaps Another One Bites the Dust) won’t work anymore, since those are matched to 100/minute beats. But 120/minute is simply twice per second, and most people can approximate that pretty well, or you can find a faster song (try this app for suggestions).

With that done, are you pushing hard enough? The recommendations are at least two inches deep in adults, so you should at least be hitting that. (It’s deeper than you think.) But as much as some people are willing to go wild on the rate, few people ever seem to challenge the depth. Unless you are an 800-lb gorilla and the patient a 70-lb granny, you are unlikely to cause meaningful damage, and there is a direct link between depth of compressions and cardiac output. Try to really aim for the mattress, and whatever depth you’re hitting, even if you think it’s pretty good, go a little deeper.

The Knuckle Hinge

Does it matter how you hold your hands against the chest? Maybe.

What really matters is that you provide good compressions, but hand position can affect that. What you should do is find a CPR mannequin and experiment until you figure out what works best for you. But while you’re experimenting, here’s something to try.

Most people lay one palm over the back of their other hand, and either interlace their fingers (as the AHA videos usually depict) or don’t (I don’t, since I find it somewhat awkward, but since it forces your arms to externally rotate, it can help encourage providers to lock their elbows). Either way, as you meet the chest, you’ll be making contact with the heel of a palm and one set of knuckles.

“Glue” these knuckles to the chest; they don’t move, so once you’ve found your position, you’re locked-in. But each time you compress, do allow your palm to lift off the chest, “hinging” at the knuckles as they remain in contact. Don’t come up very far — just enough that you could slip a sheet of paper between palm and chest — but get a little daylight in there.

What’s the point? One of the more common errors when otherwise high-quality compressions are performed is a failure to allow the chest to fully recoil. You can go deep, but if you don’t come all the way up at the top, you’re still not producing the largest possible stroke. What’s more, unlike poor depth, this isn’t always obvious by looking at the chest (either to you or to others), so the safest method to ensure full recoil is to actually lift off the chest. If you remove your hands completely, though, you tend to lose your place, and your hands can “wander” until you’re pushing on the patient’s feet or your partner’s face. The knuckle hinge allows the best of both worlds.

Assign a Monitor

Isn’t this tiring? Now you’re pumping away crazy deep, twice a second, full recoil, and not stopping for almost anything.

Even if you’re an Olympic decathlete, this will start to wear you out fairly quickly. You’re full of adrenaline, and you’re a rockstar lifesaver, so you won’t say anything, and perhaps you won’t even notice; you’ll keep plugging away. But before long, you won’t be pushing quite as hard or deep, or quite as fast, or maybe you’ll start leaning on the chest instead of recoiling all the way. I promise you will; many studies have shown this; and what’s more, you’ll probably still think you’re doing good work.

No problem. As long as we have adequate manpower (and in most places, there are plenty of people on scene at a code), simply assign one person to monitor the quality of compressions. If it’s you, your sole job is to sit somewhere with your head close to the action, staring at the up-and-down, and ensuring it follows all the criteria we’ve discussed. If it needs to be faster, you tell them to speed up until they’re on pace. If it needs to be deeper, tell them. If they ever pause for any unnecessary reason, yell at them like an Italian grandmother until they start back up. And once it’s clear that they’re fatiguing, you make them swap out, and ensure that the swap happens with minimal delay. The AHA recommends switching every two minutes, but use a smart approach; some compressors will last less, some more, and if you reach a mandatory pause (for rhythm analysis, say), you might as well change even if the current person has some juice left.

Depending on resources, they may be swapping with you, or there may be enough people sitting around that you can have a rotating pool of dedicated compressors. You can maintain the same person as monitor (the easiest method, if you can spare them), or just have each on-deck compressor act as monitor.

Useful tools for the monitor include a watch with chronograph, but even better would be a metronome. That way you can set up an audible pace (120/minute, remember) that any monkey can follow. A few services do carry actual digital metronomes, but if not, most smartphones have metronome apps available. (Find and download it now, not in the patient’s living room.) You can also throw an MP3 from an appropriately-paced song onto your phone, if nobody minds running a code to a soundtrack (probably not ideal when there’s an audience). The monitor person can keep track of other times as well, such as the ventilatory rate once an advanced airway is placed, total duration of the code, times of medication administration, and so forth. A pad of paper or strip of tape down the leg are helpful.

An electronic feedback device is a helpful adjunct to this role, and if resources are limited can replace it, but it’s not quite the same. If it is available, tracking the automatic feedback (and ensuring the compressor obeys) is the monitor’s job.

Whether or not a monitor is assigned, everybody performing compressions (really everybody at the scene) should understand that it’s still their responsibility to ensure quality. This is particularly important when it comes to eliminating interruptions, because even if there’s somebody to yell at the compressor when he stops, if he’s stopping all the time that’s still a lot of pauses. An effort should be made when assigning a compressor (who isn’t you), such as a first responder or bystander, to make them understand that they “own” their compressions, and it’s their responsibility to do ’em right and stop for nothing. The monitor’s job? Just to keep them honest.

Ask Why

Cardiac arrest happens for a reason, and even though it’s the most time-sensitive, treat-the-ABCs syndrome that exists, there are still times when you’ll never fix the problem without understanding the cause.

In a perfect world, you’d show up, compress, apply AED, shock, get a pulse, the patient sits up and hugs you, you transport and all’s well. In a realistic world (depending on your area), usually ALS shows up at some point and things take a more technical direction. But if you’re working the arrest for more than a couple minutes, have adequate manpower, but are still BLS-only, then your extra providers shouldn’t be sitting around twiddling their thumbs; they should be gathering information, planning the next step, and preparing for transport.

Ideally, one person is running the code. Either that person or somebody competent he delegates to should communicate with family or bystanders, examine available records, dig through the meds, whatever — try to determine both the history of the present event, and a reasonably-complete past medical history and medication list. Partly, this is for later management; the medics or the ED may need it. But it’s for you, too, because it may suggest your course of care.

Without an ECG, you haven’t got much to tell you what’s happening, except that the patient’s got no pulse. (Auscultating the chest may indicate whether a regular heart rhythm is present which is simply not perfusing — PEA, or if you’re a magician you may be able to “hear” V-tach — but you have to stop compressions to appreciate much.) You’re unlikely to be able to magically predict whether you’re dealing with V-fib versus torsades versus asystole. But you may be able to guess that certain correctable causes are present.

For instance, was the patient complaining of classic MI symptoms (crushing chest pain, nausea and vomiting, dyspnea) for twenty minutes before he finally became unresponsive? And he’s had two heart attacks before, with several stents placed? It’s a fair bet that he’s had another, which caused this arrest, and you may not have much luck getting him back until that artery can be opened back up. You can and should still work him initially on scene, but your mental goal should be delivering him to a PCI-capable hospital, so while you do your thing, stay on that track. If you get a few “no shock advised” messages with no pulse, or perhaps shock once or twice but he remains severely unstable, try to get him packaged as you continue your awesome compressions, notify the hospital of the situation and your suspicions, and get him over there. Try for ALS, who can perform a 12-lead ECG, which will facilitate this process (and your protocol may not permit you to divert to a more-distant PCI hospital otherwise).

Do you have reason to suspect hypovolemia as the cause of arrest? Is there obvious external bleeding… or is there a rigid and distended abdomen, perhaps with a story of abdominal pain or blunt trauma? In that case, you can push or shock all you want; you’re not going to refill an empty pump. Maybe chest trauma with a potential tension pneumothorax or cardiac tamponade? Transport ASAP to a trauma center (and perhaps ALS, since they can decompress a pneumo and give some volume if appropriate).

Is this a hemodialysis patient who missed two sessions, has been lethargic and sick-appearing, poorly-tolerating exercise, and finally fell asleep and didn’t wake up? Suspect hyperkalemia, a true “ALS-curable” condition, so if medics are available, work it until they arrive. If they’re on the dark side of the moon, transport with the best compressions you can manage.

Is the patient a known diabetic, taking insulin, and a story consistent with hypoglycemia? Check that sugar if you can, and if it’s something perverse like 7 mg/dl, get them to either ALS or an ER — both can administer intravenous sugar.

Could it be a hypoxic arrest? All arrests are hypoxic after a few minutes — dead people don’t breathe — which is why it’s usually reasonable to breathe for them (although far from a top priority). But if you walk in to find a post-drowning victim, or a hysterical mother saying her child choked and now has no pulse, you may have a cardiac arrest whose underlying cause is nothing more than hypoxia: their heart didn’t get enough oxygen, so eventually it gave up too. They still need compressions, and may need to be shocked, but most of all they need oxygen, so opening the airway and bagging in high-concentration O2 is a top priority. (Compare this against the post-MI patient above, who doesn’t need any oxygen at all until you have enough hands to provide it without delaying compressions and AED use, and even then doesn’t need much.)

Possible pulmonary embolism? Poisoning? Commotio cordis? The list goes on. The point is, if you have the resources to take a moment, gather some information, step back, and think, you can often do a pretty good job of guessing what brought you here, even without the benefits of the ECG. In some areas, your policies and protocols will dictate pretty clearly what decisions you can make, and it may not matter much. But flip through that rulebook now, because often times people assume it says more than it does (for instance, “closest appropriate facility” is more common than “closest facility”). When in doubt, you can always call medical control and make your case.

(As a general point of safety: continuing CPR while packaging and transporting emergently is difficult at best, and both unsafe and low-quality at worst. This should factor into your decision-making, as should the specific obstacles presented by extrication, and the potential availability of a mechanical compression device, which can make the process substantially easier.)

Just don’t ever try to argue that only ALS is allowed to think.

BLS is all yours, and cardiac arrest remains a fundamentally BLS problem. Own it.