October 4, 2013

Simplify - Part 1

This is a rant that begins to touch on what I think separates prehospital care from other realms of medicine and nursing. 

Our job is insanely difficult.  I don’t actually think that enough paramedics (and even EMTs) understand that fact.  That is not to say that a nurse’s job isn’t difficult, or that a physician’s job is easy, but bear with me for a second.

Think about this fairly simple scenario: You and your partner respond to the report of a stabbing.  You arrive to find a twenty-something year old male patient with a single stab wound to the epigastric abdomen, just inferior to the xiphoid process.  It looks like a 2-centimeter full-thickness laceration with a small amount of venous bleeding, but the wound is consistent with his story of being stabbed.  He is tachycardic, a little grey, sweating a bit, and is a bit tachypneic, but he did just run a block or two away from the fight where he was wounded.  He doesn’t appear dyspneic, per se, and his mental faculties seem to be completely intact.  The scene is as safe as it can be, with plenty of cops around. 

First off, it is freaking awesome that a skilled prehospital provider can tell all of the information in that paragraph in 10 seconds by lifting a shirt, asking how he is doing, and feeling the patient’s radial pulse.  In any case, though, what is the list of tasks that you need to accomplish with this patient from this point?

At a minimum (in no specific order), the list includes cutting away all of his clothing, performing a search of the patient to ensure your own safety, positioning him on the bed with seat belts in place, taking a complete set of vital signs including a diastolic blood pressure (no palping a pressure here – the diastolic pressure and mean arterial pressure are important), performing a complete exam that includes breath sounds, making sure he isn’t stabbed elsewhere that you haven’t found yet, obtaining more information about the symptoms and circumstances of the call from the patient, contacting the trauma center, transporting to said trauma center, applying the correct oxygenation adjunct, establishing at least one (but preferably two) large bore IV lines, directing other caregivers in the care that they are performing, considering other information such as pulse oximetry, and constantly performing reassessments so that there are no surprises that you don’t see coming.  Oh, don’t forget to get enough demographic information to complete a patient care report.

From there, consider the sub-steps that each task requires.  Starting an IV isn’t like in some half-assed classroom scenario where you can just “call it” and we can all consider it to have been done.  You have to spike the bag, hang it, get your supplies, rope off the arm, find a vein, clean the chosen site, stab, maybe fiddle around searching for the blood flash, advance the catheter, tamponade it, attach the IV line, clean up any leaked blood, and tape the line down.  All of that is the minimum, if all goes well.

Going back to the stabbing scenario, additional style points rapidly accrue for a scene time that is measured in seconds rather than minutes, a repeat set of vital signs, drawing bloods off of one of the IV lines, sounding mellow and unpanicked on the phone call, helping the patient to relax and understand that he is in good hands, and not getting blood on your uniform.  Style points rapidly increase if the entire to-do list, from attaching seat belts onward, is done with the ambulance wheels turning.

That is all if the call remains easy and straightforward.  Beyond all of this, the most skilled medics must think and plan two steps ahead to not be caught out flat-footed.  Keep in mind that this patient could easily arrest, could turn into a jerk or become combative, could require needle thoracostomy, could require blind nasotracheal intubation or rapid sequence intubation, or just plum worsen (hypotension, mentation decline, etc.).  What could the wound track have hit if it was downward versus upward?  Is this an abdominal wound or a thoracic wound?

Complications exist and may work against you smoothly running this call.  Other caregivers that may be in the back of the ambulance with you could accidentally pull IV lines.  Instructions may be misunderstood or resisted.  A police officer riding along wants to get a statement while you want to ask medical questions.  It is pretty easy to see how things can go pear shaped pretty quickly.

And we, for the most part, get it done.  Think about that.  All of the post above is generally accomplished. 

You will do all of this pretty much alone, at least in my EMS system.  Only two hands and one brain will accomplish all of this.  Sure, we can bring along extra hands for skills like ventilating the patient or performing CPR, but the solitariness of prehospital care remains the same.  The care that you are providing to that patient by yourself will be taken over by at least one physician, two nurses, and a handful of ED techs and ancillary personnel like phlebotomists and respiratory therapists.  Backing all of them up with a quick phone call are anesthesiologists, surgeons, radiologists, and all of the other features of a modern hospital.  There are a ton of whatever–ists available, usually with a quick phone call.  But you as the prehospital provider of this patient's care are handling this alone, at least for a (hopefully very) short time.  In addition, you are doing it in a moving vehicle, speeding along poorly paved roads, and in a 12’x5’x6’ closet that is either too hot or too cold.  Oh, and the speeding closet may be involved in a fiery crash without warning.  Feel lonely yet?

So my rant is that paramedics need to simplify.  Simplify your job.  What you are doing alone in a moving vehicle is about to be replaced by a whole pack of skilled providers, each of whom probably have longer initial trainings, greater education levels, and more required experience than you have!  I’m not saying to not do your job to your utmost ability.  If you’re a paramedic, you need to care for people at the paramedic level.  Even though treating people like you’re a first responder when you’re an EMT qualifies as simpler and can probably be done faster, it is not the best answer for patient care.  The two biggest tricks to simplification while maintaining full skill and competence are to do things only once and to take the easier road if it gets you to the same place.  Upcoming posts will cover both of these points soon.  In the meantime, think about what tricks you have learned to help you simplify a complex call and take a minute to mentally congratulate yourself on being a badass who has to be replaced by an entire group of people.

1 comment:

Bettina S said...

Hi Bill,

Love your blog, happy to see you are doing well! Good perspective and it's good to have the healthcare facility based folks understand more about the field. I started in pre-hospital, but always did some work in a hospital, eventually winding up as an ED nurse at DG/DHMC. There is a physicality about both jobs...to me EMS was brute force labor, usually in bad weather, dead-lifting patients in a reeves down winding staircases, or hoping that the cone of protection in a dangerous scene surrounded us working on patients, like a bubble. The ED was like running a marathon..on your feet for 12+ hours juggling many simultaneous patients...and maybe elsewhere they had phlebotomists/pharmacy support etc, we at least a 1:10+ patient ratio, 6 of which could be vented/critical fresh trauma patients that you had to schlep to CT and get nuked with them to keep them alive, don't remember much help. In my years in the field, wow I made some dumb mistakes out there, like standing motionless in a doorway, highlighted from behind by the light, in front of a dark staircase leading down to a place where shots were fired...you get the idea. I got savvier, and mostly stayed safe by being uber-calm at all times...and learned the gift of disarming conversation, which calmed down many volatile scenes, and which I transferred to good use in the ED. I would love your opinion on, well, how cynical we can all get, which seems to afford some sort of protection against the graphic realities of life that we are exposed to on a daily basis. That, and any lessons learned that transcend the excellence in technical skills and diagnostic perception that is the hallmark of a skilled paramedic and healthcare provider. Any soft skills that are your favorite to relay to those new to the field? Especially working inner city, how do you maintain empathy, diffuse difficult situations, train newbies and maintain clinical excellence? :-)