If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

21 November 2013

Scenario of the day...part II

The "Scenario of the Day" was presented here. If you did not check it out, go on over.
OK…in looking at what you were presented, it is apparent that the driver struck the deer and veered off of the roadway then overturned. The signs and symptoms presented, along with the vital signs, suggest that the patient is hypothermic, highly probably given the patient’s age and the ambient surroundings. The inside of the vehicle being ‘covered with newspapers’ was an indication that maybe this guy is a newspaper delivery person and this occurred a little while ago and was only recently discovered. Nobody specifically asked, but that was the deal.
Couple of points about the vital signs-

As the body’s core temperature cools the blood pressure drops, the heart rate slows, peripheral pulses fade out, and the respiratory rate slows. If you cannot get a good blood sample, you may get to get the ‘error’ message on the glucometer and you are probably not going to be able to get a good sample. The temperature is a deal clincher, but then the ECG provided the next big clue- Osborn waves, which are prominent as the core temperature goes below 90°F. Blankets are in order- surely more than one. And be wary of exposing the patient- we have to, but remember that the body loses heat by way of convection and radiation. If it is cold outside, put a blanket on the backboard to act as a little bit of a barrier between the patient and the cold backboard. And don’t forget to warm up the ambulance. If you’re comfortable, it ain’t warm enough- turn up the heat.

Even though the SPO2 is only 62%, remember, that peripheral circulation is slowed due to vasoconstriction during hypothermia, which reduces the ability to get a good reading with a pulse oximeter. The lack of cyanosis could be a good clue that the patient is still oxygenating. Given that we lose body heat through respiration, judicious use of oxygen, especially arbitrarily via NRB, should be considered.
Given the patient’s depressed mental status, it is reasonable to go with spinal motion restriction precautions (be alert to potential airway compromise if the patient vomits). There are no apparent extremity injuries, and even though many would consider the blood pressure as ‘low’, it is still above 90 mmHg systolic, so be judicious with the fluids. Also, ‘warmed’ fluids would be appropriate, but be careful not to rewarm the patient too fast. Don't have an IV fluid warmer? There are some ways to accomplish that, but...you're not trying to rewarm them, just stave off the continued drop.

With the fast extrication he obviously was not pinned. There were no obvious injuries, however, just due to the GCS and his age in the setting of a potential traumatic event, he meets Trauma Notification Criteria per CDC guidelines. However, that does not necessarily indicate flying him out. With the short drive time, it will be doubtful if there is any true time savings going by air. If you're not going to save any clinically significant time, why bother. I know, helicopters are sexy.
Cancel the bird.
But what if the helicopter lands? Well, if the patient needs it, and the helicopter is going to save a significant amount of time, the put them on it. But, when you figure in the turnover time, the loading time, the take-off and flight time, along with the off-loading time and going into the hospital, you are not saving anything over a 20 minute ground transport time. This guy is fine to go by ground.


20 November 2013

How well do YOU take care of people?

Not long ago a friend of mine relayed his experience with EMS in another county during a family emergency. That chat reminded me of an experience my parents had with EMS several years ago.
A while back over on The Happy Medic, San Francisco Fire Department Paramedic Justin Schorr wrote about his family’s experience with a child’s medical emergency. And of course, Justin zeroes in on some EMS related issues. Be sure and go over to read his blog. Good stuff, it is.

But anyways, once again, it kind of got me to thinking. How well do we really take care of people?

It depends upon what you think it involves. Of course, we have protocols to follow, skills to do, and on and on and on. But there are other things that we need to do that are just as important. And they have nothing to do with starting an IV, reading a 12-lead, or any of that other stuff you learned (hopefully) in paramedic (or EMT) school. It’s all about how you take care of people.

Justin mentioned something in his blog about warming a stethoscope. So just how many times do you take the time to warm up a stethoscope before you place it on a patient? Especially in the winter time when it has been hanging in the back of an ambulance, probably on that catch-all-netting at the head of the bench. Even when it is wrapped around your neck it gets cold. Little kids and elderly patients are kind of sensitive to that cold stethoscope. And guess who makes up a large number of our patients? Yep, you got it. So take a few seconds, tuck the bell under your arm. Probably would be a good thing to do when you are introducing yourself to your patient. You do introduce yourself to your patient, don’t you?

Another thing I have noticed is that the entrance to Walmart is smoother than the entrance to most of this area’s Emergency Departments. So, do you take it easy over those entrances, or just bump on across? Based upon what I have seen, most of us just bump on across. Probably feels really good with that broken hip, bone cancer, or any one of many maladies that hurt when you move. 

And when entering the ambulance entrance to several of the area EDs, it seems that the worse part of the trip is when you are turning into the ED. And we know doubt know it since we do it enough. So how many of you just turn on in, bumping and swaying? And how many of you think about your patient (and partner) in the back of the specialty vehicle you are driving that is NOT known for its smooth ride? If you are the one that just drives on in without consideration for your passengers, I bet you are the one that does not slow down and ease across railroad tracks as well.

But what about other things along the lines of ‘taking care of people’?

Do you explain what you are going to do and why you are going to do it? As I get older I am exposed to the healthcare system just a little bit more. At my colonoscopy I saw a wide variety of ‘explaining’ and the lack thereof. The nurse that started my IV had a good technique (well, her tourniquet technique sucked) but she barked out orders like a drill sergeant- “Put your arm down”, “Make a fist”, “Hold still”. And when she was done she just walked away. Oh yeah, and there was that introduction- “I’m gonna start your IV”.

Well, she did tell me what she was going to do. And what do to. In no uncertain terms. But ‘why’ would have been nice. So would a personality.

I always tell my patient (even if they are unconscious) what I am going to do, why I am doing it, if it’s going to hurt, etc. And you should too. It is part of the reassuring process. For a lot of people (I like to think most of them) the whole process of getting hurt or sick and calling 9-1-1 is a pretty stressful and frightening event. A big part of our job is reassuring them and alleviating their fears. And to do that you must tell them what you are doing, why you are doing it, and quite frankly, if something is going to hurt. Before we do it.

And how well do you ‘relate’ to your patient? You know, that rapport that you have to establish early on to gain their confidence. I have seen some people that are really good at it, while others…well, some people are really good at it. It’s all of the stuff above, and a little more. In my old system we used Panasonic TOUGHBOOK laptops to complete our call reports. And there was a natural tendency to type as you rode. And that is OK if you can pull it off. By 'pull it off' I mean that you have to maintain that rapport, that relationship, with the patient. And that means you have to talk to them. Pay attention to them. And, egads, reassess them.

Reassess means more than let the Zoll's blood pressure monitor recycle every few minutes and take a look at the pulse oximeter reading every few minutes or so. It means talking to them. It means asking them if they feel better, if the oxygen is helping them or if the pain medication is working. Or if they’re feeling worse. And you CAN’T sit in the ‘captain seat’ and do that. And sitting in that captain seat, typing away, and asking your patient, from behind them, without making eye contact, if they are OK, to me, is worse. I know someone who did that and arrived at the ED with a deceased patient...who was not deceased when they put them in the back of the ambulance.

Taking care of people is a total package. Sure, starting that IV and reading that 12-lead is important. But being nice (because nice matters) is just as important. Maybe more so. In the end, it is the total package that matters. It is the total ‘A’ game.

And you have to bring that total ‘A’ game to every call, every time.

Anything less is not doing your patients (or their families) any favors.

19 November 2013

Scenario of the day...(UPDATED)

You are dispatched for an MVC at 06:33. The location is on a rural road approximately six miles from your station. A fire officer arrives, establishes command, and tells you that you have an elderly male, unresponsive, and entrapped in the vehicle. Command notifies the dispatch center to “put a bird in the air”.
You arrive to find an approximate 65 year old male in the driver seat.  Damage is as noted in the picture. There is no passenger compartment intrusion and the patient appears to have his seat belt on. The inside of the vehicle is covered with newspapers (dozens and dozens of them) and many more are on the ground around the vehicle.
First look at the patient- GCS 1-1-1, RR 12 shallow and snoring, pale looking skin.

There is a large, dead deer lying along the roadway near the crash.

It is early morning, the sun is rising, it is cloudy, 34° F, 54% humidity, and the wind is at 15 mph out of the SW. Traffic is light. You have an EMT for a partner. You have a QRV-based supervisor within 15 minutes; your next nearest ambulance is 20+ minutes away.
What are you going to do?


The first vital signs after you get in the vehicle-

BP 94/58
HR 40 weak and irregular
RR 10 shallow and snoring
Pupils equal and reactive
Finger stick gets an ‘error’ reading
Tympanic temperature 84°F
SPO2 is 62%
Skin is pale and dry without cyanosis

The first ECG-
courtesy of Dr. Smith's ECG Blog
 Ground travel time to Level I trauma center is 15-18 minutes. Travel time to community hospital is 15-20 minutes.
The fire department has the patient free within 10 minutes. The helicopter is “five minutes out”.
Patient is exposed- no obvious deformities to any extremities. Chest expansion is equal bilaterally and lung sounds, while faint, seem to be clear. Carotids are faint- radials and pedals are absent. Upon extrication patient GCS is rated at 3-4-5.
You find three pill bottles in the vehicle (you DO take a quick look for such things, don't you?)- levothyroxine sodium, morphine sulfate, and paroxetine hydrochloride.
I have one response so far (Thanks, Cathy!). C'mon folks...
What do you think? What special things (if any) are you going to do? Is there anything different that you might do? Let's hear it.
Note: If you need a bigger copy of the ECG, email me at the address to the right.