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.

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The Slow Ride

March 26, 2012 by 2 Comments

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.

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Tiny Monsters

February 19, 2012 by 2 Comments

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.
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CPR for Dummies: How to Save a Life

November 23, 2011 by 6 Comments

One of the peculiarities of EMS education — and as a byproduct, of EMS practice and culture — is that we spend the majority of our time focusing on the minority of our calls. Think about it: your textbook has pages and pages devoted to ruptured aortic aneurysms, placentas previa, and mid-femur fractures — and when’s the last time you saw one of those? But scarcely a paragraph is given to the routine transfer, the drunk asleep on the sidewalk, or the MVC with minimal injuries. Call it an inverted pyramid: the most important stuff is low-volume, the most common stuff is pretty easy.

Whatever. The point is, at the very apex of this pyramid is the cardiac arrest. In its purest form, cardiac arrest is exactly why EMS exists. It couldn’t be higher stakes — as a disease, it’s absolutely certain to be life-threatening — and it’s terribly time sensitive, but the potential exists for a total cure if everything goes well.

Unfortunately, like many low-probability calls, we don’t get a great deal of experience with these — even less if your shift isn’t dedicated to emergencies. And when we don’t get much experience with something, that’s when training needs to fill in the gaps.

CPR and BLS resuscitation can seem like a confusing topic, especially given the frequent and seemingly arbitrary changes to the guidelines. The truth is, though, that it’s only gotten simpler and simpler — and you don’t need to follow the research (read: be a giant nerd like me) in order to know exactly what to do. Here’s the short, stripped-down, painless rules for how to save a life.

 

Push and Zap

Basically, after around sixty years of research on resuscitation, there are only two things that we know for sure help people survive cardiac arrest: chest compressions and defibrillation.

Literally, just those two things. Oh, there’s other stuff — ventilation, drugs, devices — that seem to help briefly, but so far nothing else has been proven to get someone’s heart beating again and let them walk out of the hospital with a working brain. Now, some of those other things do seem like pretty good ideas, and in many cases we started doing them before we knew if they’d really help or not, so we’re still doing them because people are used to it; it’s part of our training, and it’ll take some extra-compelling evidence to make us actually stop doing that stuff. But still, the story so far: chest compressions and defibrillation definitely help people survive, and that’s it.

What this means is that they should be your number one priority. If your patient is in cardiac arrest, that’s what they need. Other stuff? It may or may not be helpful; if you have the chance, or the personnel, and it doesn’t interfere with chest compressions and defibrillation, then you could go ahead and do it. It might help. But delaying or stopping the big two for that other stuff is like making a thirsty man wait for a drink of water while you comb his hair.

 

Early, Hard, Fast, Uninterrupted, and Full Recoil

Okay, so, chest compressions. Easy enough. Anyone can do ’em, all you need is your hands, just jump in there and push.

However, that’s not quite the whole story: the quality of compressions matters a great deal. We are literally pumping blood here; we are creating mechanical pressure to replace the squeezing of the heart. Just like you can wriggle a bicycle pump ineffectually without making much progress on inflating your tires, so too can you make goofy movements on someone’s chest without providing much perfusion. Even at its best, CPR only provides weak circulation compared to a real heartbeat; if you give poor CPR that’s even worse.

So here are the key components:

  • Early: Compressions should be initiated as soon as possible after arrest. That means, if I go down now, ideally you’ll start pushing on my chest as soon as I hit the ground. Typically that’s not possible, but mere seconds really do matter here; the longer there’s no circulation, the more tissue is endangered (all tissue, but particularly the vulnerable heart and brain), and the less likely that defibrillation will be successful — or if it is, the more likely there will be permanent complications.
  • Hard: Good chest compressions are a violent, aggressive act. We now recommend a depth of at least 2 inches in adults, which if you examine a mannequin (or fellow human) is remarkably deep. (Yes, “at least” means that going deeper is fine; compressions that are “too deep” are rarely seen in real life.) This isn’t a gentle cardiac massage, it’s not the mellow bouncing you usually see in movies, it’s a deep, powerful, oscillating thrust. It should tire you out, which is why we recommend changing personnel frequently; even when you think you’re still doing well after a few minutes, you’re probably not.
  • Fast: The recommended rate is now “at least” 100 compressions per minute. Since nobody knows what this means without a metronome, I highly recommend “musical pacing,” or using the beat of a well-known song to learn the rate. Stayin’ Alive by the Bee Gees is the classic; I like Queen’s Another One Bites the Dust myself. Again, 100 is an “at least” rate, so faster is better than slower. Admittedly, if you go extremely fast the heart won’t have time to fill between squeezes, but most “ludicrous speed!” CPR tends to have poor depth, and self-regulates anyway once you get tired.
  • Uninterrupted: Just like it’s essential to begin compressions as soon as possible, it’s equally essential to stop them for nothing. It’s not just that every moment you spend off the chest is “dead time” in which no blood is circulating; it’s worse than that. Chest compressions need to generate some “momentum” in order to create enough pressure to perfuse the heart; several consecutive compressions are needed before you’re really moving much blood at all. If you keep stopping — and studies show that everyone stops far more than they realize, to fiddle with one thing or another — you’re wasting those gains as soon as you’ve achieved them. Maximizing this “compression fraction” should be a primary goal; once you get on that chest, don’t stop for anything else unless it’s literally more important than circulating blood.
  • Full recoil: Among otherwise skilled rescuers, one of the most common errors is failing to allow for full recoil of the chest. In other words, you press down deeply, but rather than releasing fully, you start the next compression before you’ve come all the way up. This shortens the stroke of the pump just as much as if you were giving shallow compressions, and for several complex reasons (in particular the loss of preload) can reduce circulation in other ways too. We do this one particularly when we start to get tired, and begin to leaaaan forward to rest on the chest.

Defibrillation

It’s really as simple as this: once the heart’s entered fibrillation (or to a lesser extent a pulseless V-tach), the only plausible way to fix it is with electricity. These people are not going to “come to”; they are not going to have a Baywatch moment where they cough out water and wake up, even if you give them great CPR. They have an intractable problem, and the cure for it is an electric shock. Defibrillation is life-saving.

For most of us, this means using an AED, the automated devices you see everywhere from airports to ambulances. The reason they’re everywhere is because their use is time-sensitive, and if you drop dead ten miles from the nearest one, it might as well be ten light-years. No matter where you are, compressions must be performed to buy you time, and a defibrillator must be found to shock you back. If both don’t happen quickly, you will probably stay dead forever.

There are argument about some of the technical aspects of defibrillation, such as pad placement and waveform, but so far none of these details have proven to be very important. What is important is that you shock early, and get ready to shock without interfering with those compressions. Whenever possible, while one person gives compressions, someone else should clear off the chest by cutting or pulling the shirt from under the compressor’s hands, place the pads around them, and start the AED’s cycle. For many models of AED, there will be a period of several seconds while it walks you through voice prompts (telling you to stay calm, call for help, etc; these devices are designed to be usable by laypersons with no training), which should be ignored while you continue your CPR.

Once the AED tells that it’s analyzing the rhythm, you will need to stop compressions; this is the computer’s opportunity to decide whether the patient can be shocked or not, and interfering with this will just delay the process. If it doesn’t advise a shock, get back on the chest; you may have better luck later. If it does advise a shock, get back on the chest anyway! It’ll need to charge first, which may take quite a few seconds, and remember — every second matters. (Just make sure the whole team’s on the same page here, so that nobody pushes “Shock” until you’re clear.)

As soon as the AED announces that it’s ready to shock, everyone should be ready: cleared from the patient and prepared to shock. In a coordinated fashion, the compressor should clear the chest, the shock should be delivered, and he should immediately resume compressions with a pause of only a second or two. Rinse, lather, repeat.

When do you stop this process? When someone much smarter than you says to stop; or when the patient demonstrates clear signs of life (such as movement, breathing, or improved skin signs — or for the medics, a spike in end-tidal CO2). Don’t keep stopping to palpate pulses and otherwise fiddle with the patient. Like a soufflé or a Schroedinger’s cat, you must have faith in the process here, because checking on the process will assuredly cause it to fail.

 

It Ain’t Rocket Science

People, there are other details to this process, which is why they make us take CPR classes and carry the little cards around. And in 2015, there might be some new ideas on how we can do it best. Research continues apace in the countless EMS systems around the world that are experimenting with different technologies, techniques, and methods to improve survival. That’s how we’ve come from 1–2% survival rates to the 50%+ that a few cities now enjoy. It’s slow going, but it’s going.

But the best methods won’t matter if you don’t use them, and a lot of effort has been given to make our current methods truly simple. You literally can’t go wrong if you give great compressions and defibrillate as soon as possible. You can certainly go wrong if you forget that those are the two most important, life-saving measures — but you’d never forget that, would you?

Push and zap, folks. It’s so easy, an EMT can do it.

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Spinning a Yarn: The Chronological Narrative

September 14, 2011 by Leave a Comment

I was never explicitly taught to write documentation in school. It fell into the “They’ll train you how they want it when you’re hired” category, and all we got was a rough idea that there were a few common formats for writing your narratives.

I’ve experimented with a few different models, including the typical SOAP, CHART, and chronological formats. I don’t want to rehash the basics of how these work, because you’ve probably either learned about them or you will. However, on a regular basis I get coworkers peering over my shoulder and commenting on my own somewhat unusual style, so I thought I’d share it for anyone looking for something new.

The biggest change in my own narratives came when I moved to a service that wrote their documentation on computers. I have poor handwriting, write slowly, and don’t enjoy it; however, I’m a fast and comfortable typist, so once we switched from pencil to keyboard my narratives improved substantially. One of the early changes I made was a conscious effort to remove 99% of the abbreviations and shorthand; when typing, it’s usually just as fast to write it out fully, and it makes everything much more readable. (If you ever think to yourself that “everyone knows what YEOIOCRIPIDRN means,” attend M&M rounds sometime and listen to a room full of fellow EMS professionals try to puzzle it out.)

The goal with my narratives is to produce an easily readable, standalone document that tells the story of the call in a similar order to how I experienced it. Because our electronic PCR software includes separate sections to record details of the physical exam, vital signs, and so forth, I’m able to omit many of the nuts and bolts. What I do mention explicitly is all unusual findings, pertinent negatives, and whatever mundane details are necessary to knit the story together. One of the risks with the free-form chronological narrative is forgetting to include this or that assessment finding, but fortunately the ePCR prompts me for these things in other screens. Typically for EMS, documentation is one-half a record of patient care and one-half covering our butts; so although I try to minimize it, I also include some amount of standard butt-covering. This should be customized to what issues your own employer happens to care about. (I had one that insisted every patient be covered with two wool blankets in the winter; so, guess what ended up in the paperwork.)

I modeled my template on the discharge notes you find in hospital charts. I always found these to be pleasantly readable and professional; particularly if you start with the ED and admission note, read the hospital course, and finally the discharge summary, you have a great top-to-bottom view of what’s going on with the patient. I write chronologically, because it keeps the story understandable and because it allows me to show the order that things occurred, which is a central part of many calls; for example, we did X treatment, but then the patient began complaining of Y, so we changed things up to Z treatment — very different from if we’d known about Y from the beginning. However, I don’t adhere zealously to the timeline if it’s not especially relevant, so I’ll often group together assessment or treatment items for efficiency; as a result it’s often not too different from a loose SOAP or CHART format.

I’ll give three examples of hypothetical calls here: one routine transfer, one typical medical emergency, and one critical trauma call. This will seem wordy, but for many unremarkable calls the majority of the narrative can be written prior to arrival, simply leaving blanks for the bits you don’t know, then filling them in and fixing anything unexpected afterwards. (It’s helpful to understand how the actual PCR will print out once it’s completed and [in our case] faxed; this lets you know how it reads, what inserts where, and so on.)

Dispatched non-emergent to Waldorf Memorial Hospital (6 West) for discharge to Mumford Rehab.

Arrived on floor and met by staff, who provide paperwork/signature/report. Patient is Mr. Jeeves, a 73 yo male with hx of COPD and CHF, who presented with chest pain and dyspnea. He was found negative on cardiac enzymes with nonspecific ECG changes, admitted for further monitoring, and eventually underwent cardiac catheterization with no acute occlusions found. He is now stable and is being discharged to short-term rehab for gait training.

He is found in bed, alert and semi-Fowler’s, fully oriented with some general confusion, and denying acute complaints. There is some peripheral pallor, and non-pitting edema of the lower extremities. Vitals unremarkable, as noted above [note: in our ePCR, the vitals screen prints out above the narrative]. A locked IV is present in his left forearm.

He is transferred to our stretcher, secured with straps x5 and rails x2, and loaded onto A56. Transport routinely with monitoring en route. No changes in status during transport.

Arrived without incident, offloaded, and brought Mr. Jeeves to his room. He is transferred into bed and left in a low position, rails up, with his call button and belongings. His care and paperwork are transferred to staff.

Dispatched emergent to apartment in Malden for abdominal pain.

Arrived on scene to find Malden FD and PD with an adult female seated, alert. She is Ms. Bergerac, a 66 yo female with hx of NIDDM, who awoke 2 hours prior with general nausea, weakness, and abdominal pain. She describes the pain as 5/10, dull and diffuse, with a gradual onset over the past several days; she states the nausea has been ongoing over the same period, with the weakness new since this morning. She states she has been taking her normal meds, but has not eaten since yesterday due to the nausea. She denies vomiting, chest pain, dyspnea, headache, or parasthesias, and states she has felt normal with no unusual events up until several days ago. She denies any falls or other trauma.

She presents as fully oriented but slightly obtunded and slow to respond, and somewhat ill in appearance. Her pupils are midsize and PERL, and her lungs are clear and equal bilaterally. Abdomen is supple and non-tender with no visible discoloration, distention or mass. She is negative for arm drift, facial droop, or speech slurring, and demonstrates equal and unremarkable CSM x4. She is tachypneic, with an irregularly irregular radial pulse; her BGL is 46.

She is given 15g of oral glucose, which she tolerates well, and is transferred to our stairchair. She is brought outside, then transferred to our stretcher, where she is secured with straps x5 and rails x2. She is loaded onto A80 and transported non-emergent to House of God Medical Center with continuing assessment en route.

Repeat vitals note a BGL of 60 and minor increase in pulse. No other changes during transport.

Arrived without incident, offloaded, and brought Ms. Bergerac into the ED. She is transferred to a bed and left with rails up. Care transferred to RN with report.

Dispatched emergent to Denmark St. and Mulvaney Rd. in Waltham for an MVA.

Arrived with Waltham FD to find two vehicles in the center of the road. A small sedan has a heavily damaged back end with 2ft of compression; a midsize SUV is behind it with a broken windshield and crushed front left wheelwell. An adult male is found ambulatory, who states he was the driver of the sedan, with no apparent injury and denying any complaints. He states that he needs no care but wants his son evaluated, a teenaged male still in the front passenger seat, who also appears well and denies complaints. The father states they were struck from behind at unknown speed while stopped at a light. Both occupants endorse restraints, and there is no gross intrusion or airbag deployment. They are left in care of FD and a second unit is requested for further care.

An adult male is found in the driver’s seat of the SUV, slumped to the right against his seatbelt. He groans to painful stimulus but does not rouse. His skin is pale and cool, respirations are slow and irregular at 8/min, and radial pulse is thready and regular at 124. Breath sounds are grossly clear and equal. Oxygen is provided at 15LPM by NRB. An open abrasion is present on his left forehead, with blood found on the left upright support. There is no other obvious external trauma. A frontal airbag is deployed. There is starring of the windshield, seemingly from the airbag, and no other interior damage. ALS is requested.

The patient is manually stabilized and a C-collar is applied; he is rapidly extricated, exposed, and fully immobilized to a long spine board. He is placed on our stretcher and secured with straps x5 and rails x2, then loaded onto A104. (A11 arrives and assumes care of the other patients; see their runsheet for further.) Transport emergently to Intergalactic Trauma Center with continuing assessment en route.

Bleeding from the head wound is minor. There is diagonal bruising of the chest consistent with seatbelt trauma, and no other major bleeding or deformity. The trachea is midline and there is no appreciable JVD. Chest rise is equal bilaterally, the ribs are stable, and the abdomen is supple and without distension. Vitals note a BP of 184/100, HR 80, and increasingly shallow respirations at 6/min. A grossly dilated right pupil is also noted to develop en route. An OPA is inserted and well-tolerated. Ventilations are assisted by BVM with mild hyperventilation at a rate of 20/min.

P4 intercepts at this time and assumes dual-medic care.

[Documentation note: See PCR 121512 for full patient demographics, billing, and ALS care en route.]

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