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 FRN.com (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.

 

 

 

 

Understanding Shock X (supplement): Fluid Choices

Although it may not be immediately relevant to most of us prehospital folks, the ongoing battle for supremacy in the world of IV fluids is a fascinating topic that’s worth following. We know that blood is the good stuff, but we remain interested in concocting an artificial fluid that can replace volume and mitigate the shock response — maybe even carry oxygen or support clotting — yet remain logistically feasible for everyday use. The current contenders are:

 

Normal Saline (aka NS)

Probably the most common fluid used today, this is nothing more than sterile water with .9% NaCL (table salt) dissolved in it. This amount of solute more or less approximates the concentration of our body’s water, which makes normal saline “isotonic”: its tonicity is approximately equal to our cells, making its osmotic pressure very low. In other words, it’s basically the same raw liquid we already have circulating, so its volume of distribution — the amount of saline that will leave the intravascular space, once we drip it in there — is relatively low.

That doesn’t mean we don’t lose a lot, though. Once it’s had a chance to settle out, quite a bit of infused saline will end up in the interstitial space. Typically this distribution will be in the ballpark of 1:3–1:4 — in other words, if we give a liter of saline, within an hour or so only about 250–300ml will remain in the intravascular space. Sicker people (who have problems like increased capillary permeability) have even higher volumes of distribution.

The benefits of normal saline: it’s very cheap. It’s very stable, lasting approximately forever on the shelf, and has minimal storage requirements. It’s compatible with every patient and every med. It’s easy to administer (any access will do, preferably large-bore).

The downsides: it carries no oxygen, impedes clotting, promotes inflammation, produces acidosis (called a hyperchloremic acidosis, since it’s secondary to the chloride content), and generally does absolutely nothing for you except increase the intravascular volume, and it does only an okay job at that.

 

Lactated Ringer’s (aka Ringer’s Lactate)

This stuff is basically normal saline with some extras. Like NS, it’s isotonic, so the volume of distribution is the same. But in order to mitigate the acidosis produced by NS, it’s got lactate added. Lactate converts to sodium bicarbonate in the blood, and bicarb is a strong base, so Ringer’s essentially comes “buffered” — it should have less impact on the pH. This is good, and large volumes of this stuff have a more benign effect than large volumes of saline. (Ringer’s also includes some other electrolytes, such as potassium and calcium, bringing it closer to the composition of blood serum.)

The downsides: for many prehospital services, the main “downside” is that they don’t want to stock multiple types of fluid, so once they’ve stacked NS on the shelves they’re done. Ringer’s is not as appropriate for general use, since it’s incompatible with some medications and contraindicated in some patients. There is also an old belief that it’s incompatible with blood products — that is, if you hang a bag of PRBCs on your Ringer’s line, the calcium in the Ringer’s will stimulate the coagulation cascade (PRBCs are usually stored by adding citrate, which prevents clotting by binding up calcium) and create emboli. This is now generally understood to be false.

 

Hypertonic solutions

Now we get into the more interesting stuff.

Remember we agreed that normal saline and Lactated Ringer’s are isotonic? What if we use a fluid that is hypertonic? This would mean that the fluid has a higher tonicity (more dissolved stuff) than our cells. Since the golden rule of osmosis is that water moves toward the space with the higher concentration of dissolved solids, adding hypertonic fluids to the blood — and hence making the blood hypertonic — will cause fluid to move from the intracellular into the intravascular space.

Why would this be good? Well, for one thing, it yields an awesome volume of distribution. Compared to the isotonics, distribution is actually reversed; we end up with more than we put in, not less. Infusing a liter of a typical hypertonic can yield an eventual volume increase of nearly 8 liters.

Isn’t it bad to suck fluid out of our cells? It would seem like it. However, for short-term use (such as emergency trauma care), the effects of this generally seem to be benign. In fact, there is some evidence that using hypertonic solutions may attenuate the inflammatory response associated with fluid administration — perhaps just because we don’t need to give as much of it.

So far, there’s insufficient evidence for the routine use of hypertonic fluids in the civilian world. So far, the research suggests that they’re “at least” as good as the isotonics. The military is another story, though; they love this stuff, because it’s light. Whether or not they should be doing that, in order for a combat medic to dump 4 liters of saline into someone, he’d have to carry 4 liters of liquid on his back — alongside absolutely everything else he’s going to need. Much better to bring some easily-portable 250ml bags of a hypertonic. It’s like an expand-o-fluid.

There are various hypertonics out there, including high-concentration salines (such as 3.0% — call it abnormal saline if you want to be cute) and others. So far nothing’s really landed on top, although mannitol is often used to suck fluid from the brain and cause “shrinkage” during cerebral edema.

 

Colloids

Saline is a crystalloid fluid because it’s water with small ions dissolved in it. The sodium (Na) and the chloride (Cl) are not like particles of sand, swirling around in there but too small to see — they’re fully dissolved and dissociated.

Colloids are different. A colloid is a large molecule, something too big to easily cross cellular membranes. These don’t dissolve in the same way; they’re more like ice cubes rattling around in your glass. Blood itself is a colloid, since it contains big molecules like red blood cells.

“If blood is colloidal,” the wags say, “why not try giving colloidal fluids?” Well, all right then.

One big benefit of this would be the volume of distribution. Since the colloidal solids can’t easily escape across the membranes, they remain in the intravascular space and hence keep the oncotic pressure high.

But they’re usually expensive. And tend to be more complicated (in indications and contraindications) than crystalloids. And can be more finicky to store. And for the most part, have been shown to be no better than crystalloids. Oh well.

 

Artificial oxygen-carrying colloids

Well, here’s a neat idea. Maybe an arbitrary colloid isn’t much good, but can we make one that mimics blood — can we come up with a fluid that actually binds and carries oxygen in the same sort of way as our red blood cells? If we could create such a thing, and if it were broadly compatible and not too expensive and had a reasonable shelf-life, it would be the next best thing to using blood and a major breakthrough.

We have created such things, either wholly artificial or derived from purified (usually cadaverous) blood samples. You can store them for ages, although they’re not particularly cheap, being new, on-patent drugs. So far they all seem to have little to no benefit in outcome — and often an increased rate of complications like heart attacks. Hmm. The search continues. (The trick may be to come up with something that shares more of blood’s qualities, such as positive-feedback binding, and maybe even some clotting goodness. We’ll see.)

 

Hypotonic fluids 

Like half-normal saline! Good stuff, right? Wait, no. That would have a god-awful volume of distribution. Excellent, you’re paying attention.

 

Blood Products

You really were paying attention! Full circle we come. Although blood is not all things to everybody, and has its own negatives and caveats, at the present date if you lose blood the best replacement is blood. Of some kind.

Of what kind remains a bit of a mystery. Men in white coats continue to play with different mixtures of red cells, and plasma, and platelets, and even various concentrates and precipitates of specific clotting factors. One of the latest miracle additions is tranexamic acid, which antagonizes natural thrombolytics (remember plasmin?) and seems to reduce bleeding. There are also cool devices, used mainly during surgery, that “salvage” your own lost blood, rinse it off, and give it right back to you, which obviously simplifies some things.

Of note is an approach to transfusion developed by the anaesthesiologists at Shock Trauma in Baltimore. They like to give PRBCs and plasma until you reach a reasonably permissive pressure. Then they bolus some opiate goodness (fentanyl is nicely controllable). This puts a brake in the patient’s compensatory catecholamine response — their clamped-down veins and arteries relax a little. Which drops the pressure again. So they give some more fluid. Which raises the pressure again. Then they give more fentanyl. Repeat repeat repeat. The end result? A well-resuscitated patient — with a nice pressure — but with a relaxed, normal vasculature — and a normal volume. It’s not hard to fill up a severely compensating patient; their pipes are tiny. But it’s also not as good as filling them up to a normal perfusing volume. Neat idea. (Plus, pain management or sedation for surgery is no problem with that much fentanyl on board!)

Best of all, of course, is simply not to lose the blood to begin with. Tourniquets have really made a resurgence, and many feel that at this date, nobody with reasonably timely medical care should ever die from an extremity injury — not if you can slap a tourniquet somewhere proximal and cinch it down until the bleeding stops. The military has led the way with this, as with the use of hemostatic agents — powders you sprinkle on (or, nowadays, often come pre-embedded in a dressing) which help chemically promote clotting when combined with direct pressure.

 

Okay, so where does all of this leave us?

We’re not sure. Despite decades of research into this topic, best practices remain uncertain. But the following are probably true:

  1. Extremes are probably to be avoided. Too much or too little of anything is rarely good.
  2. If there is any benefit for non-oxygen-bearing, non-clotting fluids in hemorrhagic resuscitation, it is likely limited to a supplemental or temporizing role.
  3. Further evidence may or may not demonstrate a benefit from hypertonic solutions.
  4. A really usable “instead of blood” fluid remains the holy grail, and is not yet available.

and most of all…

  1. There are significant negatives associated with any fluid administration, so in order to produce real improvements in survival, any benefit must be substantial enough to outweigh this basic harm.

Thanks to everyone who stayed with us through this lengthy chat about shock! I want to give particular thanks to Dr. Jeffrey Guy, whose teachings were instrumental in forming the core of my own material.

 

Back to Part IX

Understanding Shock IX: Assessment and Recognition

To wrap up our story on shock, let’s discuss how to recognize it.

We all have some idea what shock looks like. Like many pathologies, its loudest early markers are actually indirect — we’ll often recognize the body’s reactions to shock rather than the shock itself.

Although there are a few ways to classify the stages of shock, let’s just use three categories here.

 

Early or Insignificant

Shock that is very early or minimal in effect may have no particular manifestations. One situation where significant or late shock may also be “hidden” is in the elderly patient, or anyone with significant comorbidities; if their body’s ability to mobilize its compensatory mechanisms is poor, then the red flags won’t be as obvious. This doesn’t mean the shock isn’t as bad; in fact, it means that it’s worse, because their body can’t do as much to mitigate it.

The way to recognize shock at this stage is from the history. If we see an obvious bullet hole in the patient’s chest, and three liters of blood pooling on the ground beside him, then it doesn’t matter how the patient presents otherwise; we’re going to assume that shock is a concern. Blood volume is proportional to bodyweight, but for a typical adult, a fair rule of thumb is to assume about 5-7 liters of total volume. (Not sure what a liter looks like? The bags of saline the medics usually carry are a liter; so are those Nalgene water bottles many people drink from. “Party size” soda bottles are two liters.) Losing more than a liter or two rapidly is difficult to compensate for.

Remember, of course, that blood can also be lost internally, and aside from the occasional pelvic fracture or hemothorax, the best environment for this is the abdomen. Always examine and palpate the abdomen of the trauma patient, looking for rigidity, tenderness, or distention. Remember also that the GI tract is a great place to lose blood; be sure to ask your medical patients about blood or “coffee grounds” (old blood) in the vomit or stool.

Fluid enters and leaves the body continuously, and any disruption in this should be recognized. If a patient complains “I haven’t been able to eat or drink anything in two days,” they’re telling you that they haven’t taken in any fluid for 48 hours. If they tell you they’ve been vomiting or experiencing profuse diarrhea, that’s fluid leaving their body in significant volumes. What about the man who just ran a marathon and sweated out a gallon? Did he drink a gallon to replace it?

 

Compensated Shock

Significant shock will result in the body attempting to compensate for the low blood volume. Much of this work is done by the sympathetic system, and there are two primary effects: vasoconstriction and cardiac stimulation.

By constricting the blood vessels, we can maintain a reasonable blood pressure and adequate flow even with a smaller circulating volume. We normally vasoconstrict in the periphery — particularly the outer extremities and skin — “stealing” blood from those less-important tissues and retaining it in the vital core. This causes pallor (paleness) and coolness of the external skin. The sympathetic stimulation may also cause diaphoresis (sweating), which is not compensatory, but simply a side effect of the adrenergic release.

The heart also kicks into overdrive, trying to keep the remaining volume moving faster to make up for the loss. It beats faster (chronotropy) and harder (inotropy), resulting in tachycardia. Note that patients who use beta blockers (such as metoprolol) may not be able to muster much, if any, compensatory tachycardia.

A narrowing pulse pressure (the difference between the systolic and diastolic numbers) may be noted; since the diastolic reflects baseline pressure and the systolic reflects the added pressure created by the pumping of the heart, a narrow pulse pressure suggests that cardiac output is diminishing (due to loss of preload), and that more and more of the pressure we’re seeing is simply produced by shrinking the vasculature.

Tachypnea (rapid respirations) are also typically seen. In some cases, this may be due to emotional excitement, and there is also a longstanding belief that it reflects the body’s attempts to “blow off” carbon dioxide and reduce the acidosis created by anaerobic metabolism. (Interestingly, lactate — a byproduct of anaerobic metabolism — can be measured by lab tests, and is also a sign of shock, particularly useful in sepsis.) Additionally, it ensures that all remaining blood has the greatest possible oxygenation. However, it is also plausible that this tachypnea serves to assist the circulatory system: by creating negative pressure in the thorax (the “suction” you make in your chest whenever you inhale) and positive pressure in the abdomen (due to the diaphragm dropping down), you “milk” the vena cava upward during inspiration, improving venous return to the heart and allowing greater cardiac output. This “bellows” effect helps the heart fill more and expel more with each beat.

The more functional the patient’s body is — such as the young, strong, healthy victim — the more effective these compensatory systems will be. Hence the old truism that pediatric patients “fall off a cliff” — they may look great even up through quite profound levels of shock, due to their excellent ability to compensate, then when they finally run out of room they’re already so far in the hole that they become rapidly unhinged. It’s great that these people can compensate well, but it does mean we need to have a high index of suspicion, looking closely for signs of compensation (such as tachycardia) rather than outright signs of shock — because by the time the latter appears, it may be very late indeed.

Patients in compensated shock may become orthostatic; their bodies are capable of perfusing well in more horizontal postures, but when gravity pulls their remaining blood away from the core, this added challenge makes the hypovolemia noticeable. Less acute shock due to causes like dehydration may result in dry skin (particularly the mucus membranes; try examining the inside of the lower eyelid) with poor turgor (pinch a “tent” out of their skin and release it; does it snap back quickly or sluggishly?), and potentially with complaints of thirst. Urine output will usually be minimal. Generally, the more gradually the hypovolemia sets in, the more gradually it can be safely corrected; it’s the sudden, acute losses from causes like bleeding that we’re most worried about.

 

Decompensated Shock

As shock continues, compensatory systems will struggle harder and harder to maintain perfusion and pressure. Eventually they will fail; further vasoconstriction will reduce rather than improve organ perfusion, beating the heart faster will expel less rather than more blood, and the blood pressure will start to drop.

The hallmark of this stage of shock is the normal functioning of the body beginning to fail. The measured blood pressure will decrease and eventually become unobtainable. Pulses will weaken until they cannot be palpated. As perfusion to the brain decreases, the patient’s mental status will deteriorate. Heart rate and respirations, previously rapid, will begin to slow as the body loses the ability to drive them; like a government office that can’t pay its workers, the regulatory systems that should be fighting the problem begin to shutter their own operations. As the heart continues to “brady down,” eventually it may lose coherence (ventricular fibrillation), or keep stoically trying to contract until the last, but lose all effective output due to the lack of available blood (PEA). Cardiac arrest ensues, with dismal chances for resuscitation.

 

Alternative Forms of Shock

Although we have focused so far on hypovolemic shock, particularly of traumatic etiology, there are other possibilities. A wide range of shock types exist, but speaking broadly, there are only two other categories important to us: distributive, and cardiogenic/obstructive.

Distributive shocks include anaphylactic, septic, and neurogenic. The essential difference here is that rather than any loss of fluid, the vasculature has simply expanded. Rather than squeezing down on the blood volume to maintain an appropriate pressure, the veins and arteries have gone “slack,” and control of the circulating volume has been lost; it’s simply puddled, like standing water in a sewer pipe. (Depending on the type of shock there may also be some true fluid losses due to edema and third-spacing.) Imagine tying your shoes: in order to stay securely on your feet, the laces need to be pulled snugly (not too tight, not too loose). If the knot comes undone and the laces lose their tension, the shoe will likely slip right off. Your foot hasn’t gotten smaller, but the shoe needs to be hugging it properly to stay in place, and it’s no longer doing its job.

The hallmark of distributive shock is hyperemic (flush or highly perfused) rather than constricted peripheral circulation. The visible skin is warm (or hot) and pink (or red), and the patient may be profoundly orthostatic. Septic shock is associated with infection; anaphylactic with an allergic trigger; and neurogenic with an injury to the spinal cord.

Cardiogenic and obstructive shocks are a different story. In this case, there’s nothing wrong with the circulating volume, or with the vasculature it flows within; instead, there’s a problem with the pump. Cardiogenic shock typically refers to situations like a post-MI heart that’s no longer pumping effectively. Obstructive shock refers to the special cases of pericardial tamponade, massive pulmonary embolism, or tension pneumothorax: physical forces are preventing the heart from expanding or blood from entering it, and hence (despite an otherwise functional myocardium) it’s unable to pump anything out. In either case, we can expect a clinical picture generally similar to hypovolemic shock, but likely with cardiac irregularities — such as ischemic changes or loss of QRS amplitude on the ECG, irregularity or slowing of the pulse, or changes in heart tone (such as muffling) upon auscultation. Pulsus paradoxus (a drop in blood pressure — usually detected by the strength of the palpable pulses — during the inspiratory phase of breathing), electrical alternans (alternating QRS amplitudes on the ECG), and jugular vein distention also may be present in the case of tamponade or severe tension pneumothorax.

 

In sum, remember these general points:

  1. The history and clinical context should be enough to make you suspect shock even without other signs or symptoms.
  2. The faster the onset, the more urgent the situation; acute shock needs acute care.
  3. Look both for signs of compensation (such as tachycardia) and for signs of decompensation (such as falling blood pressure). However, remember that due to confounding factors (such as particularly effective or ineffective compensatory ability, or pharmacological beta blockade), any or all of these may be absent.
  4. Distributive shocks are mainly characterized by well-perfused peripheral skin; cardiogenic/obstructive shocks are characterized by cardiac irregularities.

Interested parties can stay tuned for a brief appendix discussing fluid choices for resuscitation — otherwise, this journey through shock is finally finished!

 

Go to Part X (appendix) or back to Part VIII

Now with Organization!

Although somewhat late out of the gate, we’ve finally put together an organized, all-inclusive site index for archived posts. Browse by topic and brief description to find what you’re looking for; we’ll make an effort to update the index regularly with new material, and it’ll be periodically reorganized as needed. Have at it!

Understanding Shock VIII: Prehospital Course of Care

Now that we have a pretty good idea of how shock works, what does it all mean for our treatment in the field?

Much like cardiac arrest and some of the other “big sick” emergencies, there are really a couple essential interventions we need to execute, maybe a couple others that aren’t a bad idea, and beyond that, our main job is to ensure that we don’t kill our patient by wasting time doing anything else.

 

Step 1: Control the bleeding

As we emphasized ad nauseam, the number one goal with the bleeding patient is to stop the bleeding. No need to beat this to death, but just remember: if you can control the bleeding, yet don’t get much of anything else done, you’re doing absolutely fine.

 

Step 2: Transport to surgery

In most significant cases of hemorrhage, definitively controlling the bleeding will require surgical intervention. We don’t do surgery, but we do set the stage, which is why it’s essential for us to know what we’re doing. Get thee to a trauma center, and quickly!

Can other hospitals perform surgical intervention? Sometimes. Maybe. A world-class trauma surgeon might happen to be in the building for a conference. Maybe the operating room is between scheduled procedures and happens to be clean and available. But the point to a trauma center is that it’s guaranteed to have certain resources available, and that’s the kind of place we want to bring these patients. 9 times out of 10, if we transport them elsewhere, they’ll simply end up being transferred back out to the trauma center anyway, making the whole exercise essentially one very long transport. Can a small community hospital help stabilize the patient before surgery? Sure — but as we know, everything else is a distant second priority to bleeding control. Even transfusing blood may need to be done sparingly until the leak has been corked.

What about ALS? Do these patients need paramedics? Now, if they acutely decompensate and need airway management or other interventions you can’t provide (or have other issues like pneumothorax), then ALS-level care would be valuable. But outside of that, and even granting that to a certain extent, a medic unit is not going to stitch up the bleeding, and meeting them will certainly delay transport to surgery at least by a few minutes. True, they’ll be able to initiate IV access that can be used for blood later, but in most cases this takes mere seconds at the ED (where there’s plenty of room, good lighting, and ample personnel) — and prehospital IVs will sometimes be replaced anyway.

 

Step 3: Promote oxygen delivery

Okay, you shock technician, now what?

Can we talk about coagulopathy of trauma — aka the “deadly triad”?

Bleeding control is the priority, right? And bleeding control requires clotting. But there’s a set of conditions guaranteed to obstruct clotting, and three of them are almost always present during hemorrhagic shock.

One is hemodilution. When we top off our bleeding patients with non-blood fluids, as we’re so fond of doing, it dilutes both oxygen-carrying capacity (since we’re not adding red blood cells) and clotting speed (since we’re not adding platelets or clotting factors). So this one’s our fault, and can be readily avoided by simply resisting the urge to replace blood with salty water.

One is acidosis. If you’ve been paying attention, you know that acidosis tends to develop in shock due to anaerobic cellular activity, and can be further encouraged by overzealous fluid administration. Is this the end of the world? (After all, a little acidosis might even improve oxygen delivery by shifting the oxyhemoglobin dissociation curve.) Well, the trouble is that acidosis also leads to coagulopathy. According to some in vitro studies, in fact, even mild acidosis can precipitously decrease platelet aggregation, and in significant acidosis platelets won’t activate at all. Zero.

The last is hypothermia. Not only do cold patients have poor oxygen delivery and other problems, they clot poorly; low temperatures cause coagulopathy too.

Now, we can’t do much about the initial trauma. We can discourage acidosis by limiting fluid use, and ensuring that ventilations remain adequate. What about hypothermia? Do our trauma patients get cold? What would you expect when you take someone who’s bleeding, strip them naked on a cold sidewalk, pump cold saline into their veins, and chuck them into an ambulance carefully heated to your comfort?

Keep your trauma patients warm. This is not about human kindness or TLC, this is a serious and important intervention for shock. Hypothermia is great for cardiac arrest, it may be beneficial in some other scenarios, but it is not good for bleeding people.

How about supplemental oxygen? Well, I suppose so. In the patient with adequate respirations, it is doubtful that “topping off” their PaO2 will affect them appreciably; but as they begin to decompensate, they’ll need all the help they can get.

Positioning? Remember how big a deal they made about the Trendelenburg position in school — how it pulls blood from the lower extremities into the core? And ever noticed how it’s not exactly our number one emphasis in the field? Trendelenburg has little real evidence supporting it, and the bulk of what does exist suggests its effect is fairly minimal — it moves only a little blood, the effect is transient, and the body’s compensation can actually cause a paradoxical reduction in core perfusion. Mostly these studies were done in healthy people, so it’s possible that our shocky patients do get a little benefit — and one supposes that if things are dire enough to need every last cc of blood, you can give it a shot. But typically it won’t do you too many favors. (I certainly wouldn’t advise propping the patient bolt upright, though!)

 

Step 4: Supportive care

Supportive care means battling secondary problems as they arise.  It doesn’t mean waffling over nonsense while your patient bleeds out.

If the patient’s airway is compromised, or you have legitimate reason to think that it may become compromised, then it should be managed. If they’re breathing inadequately, they’ll need assistance. Beyond that, any other care should only occur after you’ve stuck a cork in the bleeding and started rolling toward the guys with knives. Cardiac fiddling, pain management, splinting or minor bandaging — these should take place en route or simultaneous to other care, if at all. Shock kills people; is a nice sling-and-swath going to save them?

Spinal immobilization? It’s been pretty definitively shown to hurt rather than help in penetrating trauma. What about combined blunt and penetrating? There’s no evidence that it helps and some evidence that it’s harmful. We have no reason to think that tying people to boards does anything good, but we do know that wasting time here does everything bad. So if your local protocols demand immobilizing these patients, I won’t tell you otherwise — but please, at least, try and hurry.

That’s it, folks. Let’s wrap it all up next time by talking about recognizing the beast.

Key points:

  1. Stop the bleeding to the greatest extent possible in the field.
  2. Immediately and without delay transport to a facility capable of emergency surgery.
  3. Provide other supportive care as necessary, without delaying #1 and #2.
  4. Maximize oxygen delivery with supplemental O2, keeping the patient warm, and consider the Trendelenburg position.
  5. Minimize delays created by any and all non-essential care.

 

Go to Part IX or back to Part VII

Understanding Shock VII: Negatives of Fluid Resuscitation

The last time we talked, we learned about the arguments in favor of non-blood fluid resuscitation. What are the arguments against it?

 

The “blow out the clots” argument

The vascular system is a pressurized circuit. Bleeding means poking an opening in this circuit, and we know that repairing this hole is our number one priority.

The body is pretty good at fixing leaks in its vasculature. But it’s not magic. It’s going to try to form a stable clot that covers and seals the hole, just like wrapping tape around a leaky pipe fitting.

What’s a good way to make this task harder? Increase the pressure inside the pipe. The faster that blood wants to rush out of the hole, the tougher it’s going to be to get a clot to stick there.

Imagine your inflatable raft has a pinhole in it, so you cover it with a piece of tape. It seals well. Then you drop a cooler of beer onto the raft, increasing the internal pressure. The tape blows off. Simple.

Many providers have therefore moved towards the practice of permissive hypotension — resuscitating only to a lower than normal blood pressure — and/or delayed resuscitation — waiting for substantial fluid replacement until bleeding has been controlled. Permissive may mean a pressure of 80, 90, or 100; it may mean giving crystalloids sparingly and only until blood becomes available; or it may mean giving nothing at all except the good stuff. Or you can take a page from the military, which says to resuscitate until a radial pulse is palpable, and the patient’s mental status is restored — then stop.

 

The dilution argument

There’s another reason why filling the patient with salt water might make it harder to control their bleeding.

Their body is trying to build clots at the location of injury. We want to encourage this process. In order to occur, it requires the activity of circulating platelets and clotting factors.

Mixing the patient’s blood with saline increases its volume but doesn’t increase the number of these clotting precursors. In other words, we’re diluting their blood, just like a bartender watering down your drink. There’s more volume in your cup, but there’s no more of the stuff we care about. And since the ability to form clots is closely related to the concentration of the clotting components, diluting the blood means slower clotting.

Together, these two arguments form a compelling case against the “volume for the sake of volume” theory. The patient’s ability to form clots and stop the bleeding isn’t a small thing; in a way, it’s the only thing. In fact, INR (a measure of clotting speed) has been shown to be a key predictor of whether a trauma patient will survive their injuries.

 

The proinflammatory argument

One of the key forces in the shock cascade is inflammation. So it seems like promoting more inflammation is the last thing we’d want.

But surprise: infusing fluids can do exactly this. It’s not entirely clear why this happens, but it’s unquestionably true; fluids encourage the inappropriate immune response and increase inflammation and tissue dysfunction. Suffice to say that this is bad.

Back in Vietnam, when aggressive fluid resuscitation really became trendy, doctors were perplexed to find many of their volume-resuscitated patients with a severe condition called “Da Nang lung” (nowadays Acute Respiratory Distress Syndrome) — wet, failing, edematous lungs with no cardiac cause. The combination of increased fluid volume plus increased inflammation means failing lungs. Or check your nearest ICU to see some abdominal compartment syndrome, where fluid fills the abdomen until the organs fail. What were you were saying about fluids being harmless?

 

The acidosis argument

The pH of our bodies is a hair over 7. Pick up the nearest bag of normal saline and read the label. What’s its pH?

Is it 7? No? More like between 5.0 and 6.0? Interesting. Remember that pH is a logarithmic scale, so we’re talking a difference of 10–100 here. So that nice “normal” fluid can promote significant acidosis.

Is this bad? Only if you like clotting. Acidosis is detrimental to coagulation (among other things), for reasons we’ll get into later. Clotting is good!

 

The what’s-the-point? argument

In the end, the most compelling argument against pouring what amounts to water into trauma patients is this: fundamentally it is not what they need. Their problem is not a lack of normal saline. “When I find a patient who’s bleeding crystalloid,” some providers are fond of saying, “I’ll give them crystalloid. But usually, the puddle on the ground is blood.”

Now, in some patients, crystalloid may indeed be what’s missing; we’ll touch upon situations like sepsis and dehydration later. But if they’re bleeding, it seems like — at best — playing with any fluid except those that can restore oxygen-carrying capacity or promote clotting is a waste of time that could be spent patching the hole and rushing toward surgery. And at worst, it may be exacerbating the problem.

For a long time, paramedics were taught to fill the hypotensive patient with fluid until their blood pressure was normal. The jury is still out on the best practices for fluid resuscitation, but there is fairly widespread agreement now that this is a bad idea. Many progressive systems have gone the route of giving no crystalloid whatsoever for hemorrhagic shock, or at least giving it very sparingly. Seeing the numbers 120/80 on the monitor seems like a good thing, but shock is not a blood pressure, raising the blood pressure is not necessarily beneficial, and we’re supposed to be making the patient feel better, not ourselves.

So, stop the bleeding, and restore the stuff that matters. Since we rarely give blood in the field, the first one is the main business of EMS. And oddly enough, it’s very much a BLS skill.

Summary:

  1. Increasing the blood pressure interferes with bleeding control.
  2. Diluting the blood discourages clotting while doing nothing for oxygen transport.
  3. Aggressive fluid resuscitation promotes inflammation, edema, and organ dysfunction.
  4. Current best practices are unclear, but likely involve a minor role for crystalloid resuscitation, in favor of bleeding control, blood products, and early surgical intervention.

Next time: mastering the field treatment of hemorrhagic shock.

 

Go to Part VIII or back to Part VI

Because it’s Cold Out There

http://www.youtube.com/watch?v=3pO2mdVpN20

We rarely think about it. If we did, we’d probably lose our marbles.

But it’s true.

The universe doesn’t care.

We are born, we live for a little while, and eventually, we die. In the duration, we will have hopes and fears, passions, desires, successes and defeats, joy and pain. The whole gamut is out there. And as a rule, the inexorable pull of the world is downward — into darkness, into chaos. Scientists call it entropy. We just call it life.

But it means that at any given moment, if we want to be happy — comfortable, fulfilled, free from suffering — we have to be waging a constant battle. If we ever stop paddling, we start to sink.

There’s a certain point in your youth (maybe this is the moment that you become an adult) when you realize this battle is nobody’s but your own. When you’re a child, your parents agree to fight in your ranks until you can walk and talk and drive a car. But once you step out onto the world stage, the only one wearing your colors is you. As self-centered people, we find this hard to believe; we feel like we’re important players in the grand scheme. But the truth is that although everybody else feels the same way about themselves, they certainly don’t feel the same way about you.

Nobody cares about your problems like you do. Not even remotely close. They’re busy with their own battles, which are just as burdensome to them as yours to you. So we learn that if we want to solve our problems, change our circumstances, or just keep from backsliding in the constant undertow of life, we’re on our own. The tools we bring to the table are the only ones available, and our to-do list has only our name at the top. There is no oversight, unless we have strong religious views; no referee ensures that the dice land fair; and if the game proves too difficult, we don’t get to quit and try another.

Isn’t this horrible?

Of course it’s horrible. What could be more horrible than to be utterly alone in an uncaring universe?

So we try to build ties. From the little twirling piece of driftwood we’re clinging to, we throw out ropes to the other flotsam and jetsam. We bring them close and tie knots in the hope of building a raft that can stay afloat during the next storm. Maybe this way, we think, if I capsize, someone will pull me back in.

This is hard work, though. Because our own problems are bad enough, and to tie ourself to someone else means we’re taking on some of theirs, too. It means when they get hit, it’s our job to try and keep them afloat. That’s a lot of responsibility, and our plate was already full to begin with. (Everybody’s plate is full, no matter how big it may look from the outside.) So at the best, we only make a few really strong ties.

Oh, we might have a lot of weak ones. Folks we know, and who will occasionally drift by to exchange favors or chat. Maybe a group that we’ll cruise with for a while. But make no mistake: they might be floating alongside us, but they haven’t tied any knots in that rope. If you start to founder, the best you can hope for is a little sympathy as they sail on ahead, and maybe toss you a spare life preserver. It’s not their problem.

The ones who really throw in their lot with you — who say that in thick or thin, in sickness or health, they’ll be at your side, fighting to keep you afloat — they’re few and far between. Maybe a little family, one or two close friends. A significant other. That’s all.

 

What do you think happens when you get older?

If you have the good fortune to live to a very old age, then a lot of things will change. Life is not going to suddenly become easy; if anything, it will become harder. And where are those ties you’ve built?

Dead. Moved away. No longer capable of anything more than clinging to life.

The luckiest among us will make it to the very last pages of life with our partners-in-crime still at our side. The spouse of fifty years, the close and loving family, the lifelong friend. But for most of us, these lifelines are lost over the years, one by one. And eventually, we may have nobody. Nobody to fight for us, to love us, or even to note our passing.

 

The next time you transport the 80-year-old man with dementia, who never seems happy and complains about everything —

The next time you’re called to the home of the little old lady with toe pain, whose husband died recently after a lifetime spent together —

The next time you pick up the same homeless man from under the bridge, drunk once again —

Try to imagine what it would be like to be truly alone.

Nobody to lean on. Nobody to throw you a rope when you start to founder. Most of all, nobody who gives a damn you exist. Imagine what it would be like to know that you could walk into the sea tomorrow and nobody would even know you’d died — let alone that you’d lived.

We can’t be everything for these people. But one day, hopefully not soon, you might just find that you’ve become one of them. So do what you can, knowing that nobody else is likely to. Knowing that, even when it has little effect, the difference between having somebody to fire a few shots for you, and having nobody — can be all the difference in the world.