Simplify - Part 3 - Take the easy road

Continuing in our discussion of simplifying our jobs, begun in Part 1 and Part 2, we move on to taking the easy road.  This is all based on the point that you have three finite resources when dealing with a patient – brain cells, air in your lungs, and two hands.  Those are the things that we need to free up so that they can be doing the most productive thing that they can.

This trick is to "take the easy road."  This is permission to be lazy, as long as it gets your patient to the desired outcome just as well as the harder road.

The easier road involves making the “lazier” choice if it does the job you need it to.  I am not advocating for a paramedic to care for patients at an EMT level or for an EMT to provide first responder-level care.  It is absolutely necessary to not slack on your ability to provide care.  What I am advocating is choosing the easiest, simplest path to your goal. 

The first step here is to think about what your deeper goal is.  For example, your goal isn’t really to start an IV; your goal should be to establish a way to deliver IV medications and/or fluids.  What is the easiest way within the constraints of your protocols to deliver fluids and medications?  Your goal isn’t to intubate a patient, it is to secure their airway.  Your goal is not to deliver IV fentanyl, rather your goal is to start to relieve a patient’s pain. Think about your actual goal and choose the easiest way to completely meet that goal. 

For example, I am a fan of simpler adjuncts like a King airway.  The goal of intubation is to control an airway and enable simpler ventilation, right?  Doesn’t a King airway do that?  An endotracheal tube involves a more complex process to place and requires a higher level of constant monitoring.  I can drop a King tube and mark “airway” off of my list, leaving me able to move on to another task. 

Consider the setting of a medical cardiac arrest.  In that setting, you will eventually have the goal of establishing venous access for medication administration.  Your goal is not to start an IV line, it is to be able to deliver IV medications and fluids.  If you can start an IV quickly on the first try, then do it.  If the IV will not be easy, however, it simplifies our job (when treating a cardiac arrest) to move straight to an intraosseous placement instead of screwing around missing improbable IV lines.  I understand that there are benefits to IV lines over IO lines (flow rate, for example) but if there is no obvious vein staring at me I will be more likely to just establish an IO line and cross “venous access” off of my to-do list.

Thinking on the subject of IV access, another trick that I like is to start two IV lines in the same arm, saving me the need to physically move to the other side of the ambulance, place a second tourniquet, and start the second line on the opposite arm.  My goal is to give myself (and the hospital) the ability to deliver fluid quickly, not to start an IV in each arm, right?

I can auscultate a blood pressure and grab a pulse off of that at the same time.  Why count a pulse and then take a blood pressure as two separate steps?  Do them both at the same time.  Shoot – even better is a NIBP automatic blood pressure cuff that collects a blood pressure for me, marks blood pressure off of my to-do list, and leaves me available to handle something else. 

Rolling a patient to their side before immobilizing them opens the back of their clothing to be cut from waist to collar.  You can then check their back before they are immobilized.  When they are rolled back supine, the shirt and jacket lift right off.  I hate arriving on scene to find someone immobilized and still wearing a shirt.  How good was the posterior chest exam, really?

There are tons of ways to make your job easier like this, if you know to find them. 

Working in the opposite direction, we can occasionally make our jobs tougher by performing tasks that don’t really need to be done.  A perfect example is illustrated by an ankle fracture.  The patient busted their ankle and thus needs analgesia, right?  So you start an IV…  Wait.  Fentanyl can be delivered intranasally or intramusculary.  The same thing goes for IM antiemetics.  So why start an IV?  Simplify! 

One of the best ways to not perform unnecessary tasks is to not completely interpret an ECG.  I know that this sounds weird coming from an ECG instructor, but think of a wide complex tachycardia.  The sicker the patient, the more important it is to simplify your job.  Thus, in the sickest WCT patients (i.e. pulseless), it doesn’t matter if the rhythm is ventricular tachycardia or a supraventricular tachycardia with aberrancy.  Electricity works for either rhythm.   Blast the patient and save the detailed ECG interpretation for when you aren’t in a hurry – like, say, after the call.  There is no need to waste your time looking at concordance, QRS morphology, and all the other findings when your patient is sick and needs your attention.

The take-home point that I want to make about the easy road is to not perform tasks that don’t need to be done.  Does the patient in the stabbing scenario in Part 1 need to be immobilized?  (No is the answer.)  Does he need to have his sugar checked?  ECG monitoring?  If you are convinced that a task needs to be done, then do it.  I’m not trying to talk you out of caring for your patient in a complete and competent way.  Treat your patient to your training level.  But when a patient doesn’t require immobilization, don’t immobilize them.  If hypoglycemia isn’t a likely problem, then don’t waste your time checking the patient’s blood sugar.  Adding steps and tasks is certainly something to be avoided. 

What else could you be doing with the time you can save by being “lazy?” 

Here is the take home message: The minimum that you should be doing with your new-found free time is to be thinking.  A paramedic’s (or EMT’s) most important piece of equipment lies between his/her ears.  Making your list of differential diagnoses more complete, thinking about your patient’s presentation, thinking of anything that you may have missed, and other cognitive tasks are important.  I would much rather be thinking, reexamining, reevaluating, and questioning than starting an unnecessary IV line any day.  Those more thoughtful processes can improve patient care and outcomes while lowering error rates, as well.