The Laws of EMS

May 11, 2012 by 3 Comments

One more post about glucometry is pending, but for now, something lighter.

Decades of medical interns have been raised on the Laws of the House of God. The House of God was a cynical and dark look into the world of modern medicine, and its “Laws” were about as uplifting as condensed soup, but they rang true enough that you’ll still hear them quoted in the halls of medicine today (including those of the real-life “House of God,” where I find myself more shifts than not).

In any case, laws come in handy. Although I’m a believer in the nuanced and detailed analysis, as I age and my neurons gradually turn to cotton candy, I increasingly see the value in basic rules of thumb to guide us through the tangled web of life, and especially of this job.

A good law is simple. It’s always true, or almost always, and the exceptions prove the rule. It’s not specific to a certain region or company, but is something you can keep under your hat and carry with you throughout your career. It’s clear and it say something fundamental about the kind of provider you want to be. But most of all, a good law is not just an empty platitude, but rather an actionable guide-post that can answer real questions in real situations. When times are hard or temptations loom, it’ll tell you what to do.

With no further ado, then, here are mine. I believe in them, I follow them, and like good unguent, I wholeheartedly prescribe them for universal application. I am not wise, but whenever I do a good job of faking it, it’s by following these principles.

 

THE LAWS OF EMS

  1. Help your patient in any way you can.
  2. Be nice to everybody. It’s your job.
  3. If you can’t save their life, make their day a little better.
  4. Protect your partner.
  5. Have a reason for everything you do.
  6. Leave the patient better off than when they met you.
  7. It should get calmer when you show up.
  8. Good habits make doing the right thing easy.
  9. Tomorrow, nothing will remain but your documentation.
  10. Everything’s a bigger deal to the person on the stretcher.

 

But that’s just me. What laws do you believe in?

Editor’s note: this post was expanded into a feature piece for EMS World Magazine in the March 2014 issue.

Filed Under: Principles Tagged With: , , ,

Psychological First Aid

April 4, 2012 by Leave a Comment

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

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

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

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

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

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

 

General ideas

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

Avoid these types of remarks:

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

 

Major Goals

 

1. Contact and Engagement

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

 

2. Safety and Comfort

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

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

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

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

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

 

3. Stabilization (if needed)

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

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

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

 

4. Information Gathering: Current Needs and Concerns

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

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

 

5. Practical Assistance

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

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

 

6. Connection with Social Supports

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

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

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

 

7. Information on Coping

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

 

8. Linkage with Collaborative Services

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

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

 

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

Filed Under: Skills Tagged With: , , ,

Dialing it Down a Notch

February 28, 2012 by 5 Comments

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

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

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

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

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

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

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

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

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

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

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

Filed Under: Principles Tagged With: , , , , ,

The Way You Do the Things You Do

February 6, 2012 by 5 Comments

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.

Filed Under: Musings Tagged With: ,

Because it’s Cold Out There

January 7, 2012 by 1 Comment

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.

Filed Under: Principles Tagged With: , ,
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