Live from Prospect St: The Big Crunch (part 2)

Continued from Part 1

Since the two children appear generally intact, you ask your partner to evaluate them more fully while you head for the sedan to find the driver. Anticipating three transports, two stable and one potentially critical, you ask your dispatch to continue the P12, and also to ensure that police are en route (they are).

Arriving at the sedan, you find a middle-aged woman in the driver’s seat, alert. She is pink and warm, perhaps more diaphoretic than you’d expect for the ambient temperature, and does not initially notice as you kneel beside her. A firefighter is holding C-spine immobilization from the back seat.

When you greet her and pat her on the shoulder, she gives no response, but with more vigorous stimulation she looks over and acknowledges you distractedly. With multiple attempts and some yelling, you’re able to get answers to a few questions, but she is slow, tangential, and often ignores you outright. She gives her name as Samantha, but cannot or will not provide her last name; she is unable to describe the events that led to the collision; and she gives no medical history or current medications. She does state several times that she’s fine and would like to leave. When asked about her passengers, she mumbles “my kids” and mentions her brother several times. She endorses pain when asked explicitly, but does not specify where. She agrees that she drank “a little” alcohol; when asked about any drug use, she denies it vehemently.

Physically, she appears generally unremarkable. She is breathing somewhat shallowly but effectively, and her radial pulse is around 100 and slightly weak. Her seatbelt is not in place, but it’s unclear whether it was removed at some point. No gross trauma is apparent upon her head, face, or neck, and she does not complain or grimace upon palpation. She is uncooperative with a neurological exam, but demonstrates spontaneous movement of all four extremities. Her pupils are equal and seem appropriately small on this moderately bright day. Chest rise is generally equal and her abdomen is supple; no bruising consistent with seatbelt injury is visible. Her left knee is abraded and somewhat swollen. A sprinkling of dark blotches and streaks are noted on her left ventral arm in the antecubital region. Both frontal airbags are deployed; the windshield is cracked, but lacks a “starred” point of impact; and the plastic dashboard in the driver’s knee area is damaged and cracked. No blood or other damage is visible in the interior compartment. There are no child seats.

Your partner comes over. “The kids seem fine, just upset. One’s complaining of some abdominal pain, but it looks okay. They’re little troopers. Fire says they were wearing regular lap belts with the shoulder strap tucked behind them.”

When you wonder aloud whether there are more patients, he says, “There was nobody else in the car when fire arrived. The truck driver gave a statement to the police about how she was swerving across the road and plowed into him, but then he eloped.” He looks over your shoulder. “Oh, and the P12 is pulling up now.”


What is your treatment plan for these three patients? What are their respective priorities, any points of concern, and how could you shed additional light on their status?

Who will transport which patient, and to which destinations?

What special considerations should be made during documentation?


The conclusion is here

Eight More Tips on Ambulance Wrangling

Our apologies for the lack of updates while we battle technical difficulties here at EMSB HQ. Here’s a few quick tips to tide you over until the next meaty helping of knowledge.

Still learning your way around that temperamental home-away-from-home we call the ambulance? Try these ideas for making life easier. As always, they apply foremost to the Ford diesel chassis, but may work elsewhere as well.

  1. If your stretcher mount is misadjusted, you may have trouble getting the side-rail to “release” and lock home when you insert the stretcher. Whether it’s too tight or too loose, try the following maneuvers, in this order: pull back (toward you); stand on the step and lift it directly up; sit on the leftmost side of the bench seat, place your feet on the lower deck of the stretcher base (this is the rail upon which the wheels are mounted, not the upper rail that holds the mattress), and use your legs to firmly press it into the side bracket. Do not, except in utter extremis, solve this problem by “slamming” the stretcher against the wall.
  2. If your backboards don’t fit their slot snugly, they tend to bang around at every turn. Try folding a large towel or two into a thin strip (6″–12″), rolling it tightly so that it forms the thickest possible pad, then stuffing it into the void so that everything’s held snug. (You can stuff anything in there, but you need something pretty substantial and the rolled towel seems to work best.)
  3. If you have a module power switch in the cab, but no remote switch for the patient compartment heat/AC, get in the habit of leaving the thermostat switched on in the back, blasting whatever air is appropriate for the weather. Then to save the battery, kill the module power whenever you shut off the engine. That way, you can pre-heat or cool the passenger compartment while on your way to a call by just throwing the switch up front.
  4. If you’re not feeling up to shutting your door to the cab, you can usually get it to close by shoving it outward hard and letting it “bounce” off the hinge and recoil shut. In fact, you may be able to bounce the passenger-side door closed (if you’re at the wheel and an absent-minded partner leaves it open) by tapping the gas and then hitting the brake. A caveat: I have yet to hear the opinion of fleet maintenance on this practice.
  5. If it’s a truly scorching day, park in the deepest shade you can find, set the high idle (usually by locking the parking break), and prop open the hood to help ventilate. (The hood will often stay open without use of the support rod if you lift it all the way up and rest it against the windshield.) Remember that “Max A/C” recirculates the interior air, making it increasingly cold, while “Norm A/C” will continuously introduce fresh air.
  6. From the “off” position, turn the ignition key backward (towards you) rather than forward to activate the “accessories” mode. This activates the FM radio, windows, etc. but will automatically shut off power before your battery runs dangerously low; that way you can sit there with power without running the engine. However, test this to see if your two-way radios will remain on in this mode; I’ve seen it work both ways.
  7. Look around the passenger compartment, particularly on the rear doors. Are there any speakers visible? If so, you can probably pipe music back here from the FM radio in the cab, a great way to keep patients entertained if they’re game. Just like in your car, the radio should have settings to adjust the balance, which controls how much volume comes through the left vs. the right speakers, and the fade, which controls how much volume comes through the front vs. the rear speakers. Normally, it will be faded all the way forward; just adjust it into the middle to pump your jam through the speakers in both compartments. Try asking what genre they prefer, and for bonus points, plug in your iPod for a fully DJ-able experience. Just remember to fade everything forward again at the end of the call, or you’ll inadvertently subject all your future patients to your Taylor Swift Experience.
  8. Run your seatbelt adjuster (there should be a slider where it attaches to the wall) all the way up to the top, keep it buckled, and the belt will make a pretty decent pillow for your cheek.
Anyone else have some good ones to share?

The Slow Ride

As I was discharging the patient to rehab, she described the municipal EMS crew that had initially brought her from home with a fractured hip. “It took 20 minutes to get here,” she said, “and my house is only a mile down the road.”

Annoyed? Hardly. She couldn’t have been happier.

It’s well and good to be a really great driver. (In fact, if you ask me, it’s just about an essential skill.) Good drivers can push the efficiency of the “smooth vs. fast” curve, and this is important, because we want it both ways. But every now and then, you get a patient who simply needs to be transported at the distant, snowy left side of that balance. A patient who almost can’t be moved at all.

These are the patients with unfixated hip fractures. Or grim decubitus ulcers. Perhaps terrible, chronic back pain. Anybody who’s doing okay at rest, but experiences agony upon uncontrolled movement. Some of these are emergency patients, some are routine transfers, and a few of the latter may even be repeat customers while their problems gradually heal (or never do). Whoever they are, they’re patients you wish you could transport by either teleporter or hovercraft.

You touch them, and they scream. You move them, and they scream. You look at them vigorously, and they open their mouth to get ready to scream.

I can’t help you with extrication or getting them onto the stretcher; that’s your problem (or at least another post). But once you hit the road, there’s a solution. All it takes is patience. Here’s the formula:

  1. Move to the rightmost lane.
  2. Throw on your 4-way hazards.
  3. Drive about 5 MPH.
  4. Avoid every single bump.

Please understand what I’m saying here. I already know that you drive pretty well; you try to give your partner a great ride, and that usually means driving a little slower than you would in your personal vehicle. But for these patients, that’s still too rough. So you slow it down more, so you can pick a better path between cracks and potholes, and when you do hit a bump its effects are less dramatic. And that’s still too rough. So you slow, slow, slow it down. As slow as you need in order to completely negate the bumps, bounces, and turns. Your actual speed will depend on the quality of the road; on beautifully smooth, brand new city roads, you may be able to eke out 10, even 20 MPH. On particularly bad roads, with irregularities that look like speedbumps — or come to think of it, when you’re traversing actual speedbumps — you may literally be crawling along at about 1 MPH.

In most cases, you will probably find yourself driving with the brake pedal rather than the gas pedal. In other words, you’ll be lucky if your foot ever touches the accelerator; most of the time, you’ll “accelerate” by easing off the brake a bit more, and decelerate by pushing it harder. (Remember to ease in and out; in smooth driving, everything happens slowly!)

Obviously, this is only appropriate when you’re in no particular hurry. Critical patients need to move a little faster. Furthermore, your ability to execute this maneuver is somewhat dependent on how far you’re actually driving; the shorter the trip, the better, because a long trip taken at 1 MPH will end up lasting all week. The prototypical transport begging for the slow ride is the stable hip fracture from the nursing home, heading to the ED across town — not too far, but with nasty urban roads the whole way.

Other tips:

  • Other drivers will probably not be thrilled at this behavior. As long as there are multiple lanes, stay to the right, and they can go around. If you’re stuck on a one-lane road for a while, periodically try to pull aside and let vehicles pass.
  • Although it may seem smart to throw on your emergency lights, most drivers expect an ambulance running hot to be moving faster than traffic, not slower, so it generally causes more confusion than it’s worth.
  • At this speed, you have some real options for maneuvering. Mentally trace the double track that your wheels will describe on the ground ahead (remembering that your rear wheels may be slightly fatter, if you have “dualies” back there), and choose a route that places that path between the worst bumps. You can go left, you can go right, or you can straddle them.
  • When crossing a wide, straight barrier, such as a speed bump, railroad track, or the threshold of a ramp, try to “square up” first, striking it perpendicularly so you’ll make contact with left and right tires simultaneously. The back-and-forth rocking created by hitting it diagonally, resulting in asymmetrically bouncing across 1-2-3-4 wheels, is miserable no matter how small the actual bump.
  • Remember that the pain level of many unstable musculoskeletal injuries can be improved by smart, snug splinting. If you have time to drive like this, you probably have time to splint well — which may allow you to drive a little faster!
  • Although this may be obvious: paramedics, remember that you carry analgesics for a reason; Basics, remember that paramedics are available.

Pulling this off takes a little confidence, and a healthy dose of not giving a damn. And there will occasionally be roads or driving conditions that make it actually unsafe. But short of that, no matter how many stares you get, it’s a perfectly sensible maneuver, and one of the very best things you can do for these patients.

Finally, we offer a recommended soundtrack.

Dialing it Down a Notch

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

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

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

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

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

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

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

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

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

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

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

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