My First Tourniquet

The first time I placed a tourniquet onto a patient, I was driving for the day. My partner and I responded to report of “bleeding.” The cops were on scene of a crash for 30 minutes or so, before they called for an emergency ambulance. Bleeding, huh? That is a call type that could mean anything. 

The scene began as a non-injury grinder. One of the damaged cars was being towed away and the tow truck driver had to sweep up broken glass from the street. He had a new, unassembled push broom where the bristle part was zip-tied to the handle part. The tow driver popped open his Spiderco and sliced the zip tie. The knife slipped and he stabbed his offhand wrist, opening his ulnar artery. The driver couldn’t get it to stop bleeding, so he mentioned it to the police officer on scene. The police officer couldn’t get it to stop bleeding, so he called for an ambulance. 

The patient was stabbed right about where the illustration labels the "Deep volar branch of ulnar."
Public domain image. Via Wikimedia Commons.

My partner and I were a little slow getting on top of it. I mean, it was a dinky little 2-centimeter lac in the ulnar side of the wrist – pinky side, not thumb side. If the guy’s hand was chopped off, we would have been all over it. As it was, we tried and tried to get this dumb little lac to stop spraying blood everywhere. I couldn’t get pressure onto it properly to get it to stop. We couldn’t really get the bleeding to even slow down. My partner and I shared a look: I can’t believe this! Do we actually need a tourniquet for this little thing?!?Yes. Yes, we did need a tourniquet. I pulled the TQ off my belt, placed it, and stopped the bleeding. All in all, it wasn’t a big deal to do it once the decision was made. That is like a lot of medical decisions: the hard part is deciding, not doing.

I learned two lessons. First, pull the strap as tight as you can before you velcro it down and start twisting the windlass. Take all the slack out of the system before cranking. I didn't pull it especially tight, so I had to twist way more than otherwise. If I would have put a grunt into the first placement, I wouldn’t have had to twist the windlass what felt like fifty times. Second, it hurts the patient a lot. Like, a lot. Make ready with the analgesia. 

After the bleeding was controlled, my partner started an IV and pushed some fentanyl into it. Then we had to debate whether we were going to transport emergent or nonemergent. On one hand it was a teeny little two-centimeter lac and the bleeding was now controlled. Emergent transport, for that? But on the other hand, a tourniquet was placed on the patient’s upper arm. Does it make sense to transport nonemergent with a tourniquet? I think we did a “paperwork 10”*.

We arrived to the trauma center and they assigned up a big room, with the whole trauma team, surgical residents, and such waiting. My partner gave the big room report and I could feel the surgical team’s skepticism as they examined the wound in the patient’s wrist. It was like they were saying: This?!? You placed a tourniquet for this little lac?!? One of them helpfully pointed out that a tourniquet should be placed only if other methods of bleeding control failed. (Thanks, buddy.) The team quickly came to the decision that the tourniquet should be taken down. One resident took it off. Spurting blood sprayed her surprised face and across her gown. That got everyone to believe the tourniquet was a good plan. Just like as happened with me, they could not get proper pressure onto the lac to stop the bleeding. They couldn’t even get the bleeding to slow enough to clamp or sew off the bleeding vessel. After a few minutes, they tried to put the tourniquet back on. Just like with me, they didn’t pull the strap tight before velcroing it down, so they had to spin and spin the windlass until the bleeding slowed.  

The final lesson is that even with the TQ placed, the guy didn’t lose his arm. With the bleeding controlled, they could get into the lac and tie off the bleeding vessels. Not a big deal, all in all. Better than needing to top the guy off with a transfusion or something. 

*Code 10 is the agency vernacular for lights-and-siren driving. So going somewhere ten means to drive there emergent. A “Paperwork 10” is going Code 10, but really more for the paperwork than for patient care needs, so take it easy. Don’t put yourself out there and endanger anyone. This is in contrast to Code 10s where I deeply want to be at the hospital as quickly as possible.

Fun With Toxidromes

Consider five patients...

Patient One: You respond to a house to visit a 23-year-old male with a history of paranoid schizophrenia. His mother called 911 because he is agitated, similar to previous episodes of medication noncompliance. After introducing yourself to the patient, you find that “agitated” is a good adjective for him. He is pacing, restless, and emotionally distressed, with rapid speech. He denies drug or alcohol use but is anxious about the presence of police. You get him to calm down a little and agree to a more complete exam. His head-to-toe exam is atraumatic, but he is sweating and twitchy. His pupils are equal and reactive from 8 to 7 millimeters. He has a blood pressure of 190/100, a heart rate of 120, and a respiratory rate of 22. When you question him why his blood pressure and heart rate are so high, he insists it is due to anxiety over the police. He and police officers have “some history.” What do you think is going on? Is he just nervous about the police, mixed with a dusting of undermedicated paranoia and psychosis? Or is there something else?

Patient Two: You respond to a sixteen-year-old girl who took an unknown amount of an unknown medication with suicidal intent. The patient is awake but doesn’t respond to questions. It looks like she may be hallucinating, because she holds eye focus on nothing at all. She is writhing around with occasional myoclonic jerks. Her secondary exam is atraumatic, her pupils are dilated at 8 mm, and her skin is flushed, hot (feverish feeling, subjectively), and dry. Speaking of dry, her mucus membranes are dry to the point of visible cotton mouth. Her blood pressure is 100/70, her heart rate is 120 beats per minute, and she has a slow respiratory rate at about six or eight per minute with a room air saturation of 92%. Any idea of what she took? Is there an antidote you can give her?

By Sam Metsfan (Apartment in New York) [Public domain], via Wikimedia Commons

Patient Three: You respond to a large home in the suburbs for an unconscious party. The patient is a 43-year-old female, in bed, gently snoring. She is dressed for bed in a nightgown and her family says she never woke up this morning to make them breakfast. When they went to check on her, she wouldn’t wake up even when they shook her. The patient has a history of low-grade depression and hypertension for which she takes an antidepressant and hydrochloro-something. The patient’s head-to-toe exam is atraumatic and there is nothing out of the ordinary in the room. There is no response to voice or painful stimuli. Her blood pressure is 100/70 with a heart rate of 60 and weak snoring respirations at 4 per minute. She has a room air saturation of 82% and there is some subtle purple cyanosis in her fingernails. Her pupils are small (2mm) and her blood glucose is 88 mg/dL. A firefighter has a BVM in his hand and raises his eyebrows as if to ask if he should get to work with it. Should he start bagging her? What do you think is going on? Why is she unresponsive?

Patient Four: This call is a nightmare. You respond to the report of chest pain in a 65-year-old male. His wife states he was cleaning out the shed in the back. He walked out of the shed holding his chest with both hands, sweating profusely, puked, and fell to the ground. He may have had a seizure but his wife is too upset to be a good witness. You find the patient supine, snoring, and profoundly diaphoretic. The firefighters on scene are suctioning some vomit and foamy secretions out of his airway. Judging by the overwhelming smell, he lost control of his bowels. There are some minor muscle fasiculations in his facial muscles. The twitching may be seizure activity so you check his eyes. His pupils are approximately 4mm and slowly reactive, but there is no nystagmus and his limbs are flaccid so it doesn’t seem as though this is likely to be an active seizure.  His blood pressure is 110/90, heart rate is 100 beats per minute, his respiratory rate is 28 gurgling breaths per minute, and his room air saturation is 88%. An ECG is attempted but unreadable because the electrodes won’t stick to his sweaty skin. What is happening here? What are you worried about on this scene?

Patient Five: You respond to a 35-year-old female pulled over for suspicion of driving while intoxicated. The police officer wants you to “clear the patient for jail” because she tells him she has medical conditions. She is obviously intoxicated, swaying in place with slurred speech. The patient doesn’t have any specific current complaints and gets too distracted to directly answer any questions about her medical conditions. She denies alcohol consumption and just wants to go home. Her secondary exam is atraumatic with midpoint pupils, no nystagmus, and no smell of alcohol. Her blood pressure is 100/70 with a heart rate of 62 and a respiratory rate of 12 per minute. Her blood glucose is 172 mg/dL. Her speech is slurred and her gait is slow and ataxic. She will fall asleep if you don’t interact with her, but points out that it is after midnight and she is tired. Is she drunk? Is she good to go to jail, or do you have a medical concern?

Each of those scenarios describes a patient who was poisoned by a specific toxin. Many substances cause consistent effects that can be grouped together and described as a toxidrome (toxic + syndrome = toxidrome). For example, the alcohol toxidrome would present with all the symptoms that come from alcohol consumption: the smell of alcohol on the patient’s breath, slurred speech, ataxia, nystagmus, nausea/vomiting, depressed or agitated behavior progressing to unconsciousness and even coma, and so on. There are probably dozens of toxidromes but five or six are well-known presentations that a good prehospital clinician should recognize.

Patient One is a sympathomimetic patient. Sympathomimetic agents mimic the sympathetic nervous system. The sympathetic nervous system is the fight or flight side of the autonomic system, so everything gets ramped up. Some examples of sympathomimetic agents include cocaine, methamphetamine, ephedrine, theophylline, and even caffeine. Patients are hyperalert, agitated, and paranoid. Sympathomimetic overdoses dilate pupils (mydriasis) and cause hyperthermia, tachycardia, hypertension, and tachypnea. Patients are often diaphoretic, tremulous, hyperreflexive, and can even have seizures. Treatments for sympathomimetic overdoses are to counteract the accelerated body responses with medications that slow everything down. Sedative-hypnotics like benzodiazepines are a great choice. Don't be silly and treat the hypertension and tachycardia directly with nitrates or antiarrhythmics. Treat the overdose, and that means benzos.

So why would someone believe that anxiety, agitation, and paranoia aren’t explained by schizophrenia? The patient is upset, so that could explain the hypertension and tachycardia, as well. The big sign for me are the patient’s pupils. Psychiatric issues don’t often cause mydriasis. Diaphoresis would be unusual, as well. Sweating outside of the gym is always a big deal. This patient eventually admitted to methamphetamine use. 

Patient Two has symptoms that match up to a well-known mnemonic: “mad as a hatter, hot as hell, red as a beet, dry as a bone, full as a tick, and blind as a bat.” (I actually have a terrible time remembering this list. I think of this toxidrome as being like a dude in the desert.) Anticholinergic agents block the parasympathetic nervous system by blocking the action of acetylcholine. Think of the sympathetic-parasympathetic nervous systems like a teeter-totter. You can’t push both sides up at the same time. But you can get one side to elevate by pushing upwards, or you can have that side go up by pushing down on the opposite side. Anticholinergics lower the parasympathetic end of the teeter-totter, lessening the rest-and-digest actions and increasing the fight-or-flight side. 

People experiencing anticholinergic overdose often have altered mentation that can present as agitation, hallucinations, delirium (mad as a hatter), and even coma. Mydriasis is common again (blind as a bat). Vital signs show hyperthermia (hot as hell), tachycardia and hypertension. Skin and mucus membranes are dry (dry as a bone) and the skin is often flushed (red as a beet) due to hyperthermia and the inability to sweat. Urinary retention and constipation (full as a tick) comes along with the package but are more difficult to recognize in the prehospital setting. Common examples of anticholinergic agents include antihistamines such as Benadryl, tricyclic antidepressants, and anti-Parkinson agents. Atropine is an anticholinergic that we carry on ambulances. Belladonna alkaloids such as Jimson weed have anticholinergic effects. Treatment revolves around supportive management until the effects wear off. If the patient is agitated, benzodiazepines are again a good choice to manage that. This patient took more than 1,000 milligrams of diphenhydramine.

Patient Three is a common toxidrome, maybe the most common one that you will see in your career: opioid overdose. Opioids such as Vicodin, Percocet, Fentanyl, heroin, and morphine cause central nervous system depression that can present as an altered level of arousal and can easily progress to unresponsiveness and coma. The hallmark signs are pinpoint, constricted pupils (miosis) and ineffective respirations. The opioid intoxicated patient usually presents with bradypnea but apnea is common, as well. Pulmonary edema can be a consequence of ineffective breathing. Other vital signs can include bradycardia, hypotension, and hypothermia. Other clues of opioid overdose would be nearby equipment (syringes, spoons, and such), as well as needle marks on the body.

The treatment for opioid use is to provide supportive care. Make sure the patient’s airway is clear and support ventilations as needed. Naloxone isn’t the treatment for opioid overdose. Let me say that again: Narcan isn’t the treatment for opioid overdose. Narcan/naloxone is indicated to reverse ineffective breathing due to opioid overdose. There is a difference. As long as the patient is breathing well, I wouldn’t give Narcan even if I pulled a needle out of their unconscious arm. I have in the past, and got in fights for it. It isn’t so much that Narcan is likely to send the patient into unnecessary withdrawal, which is true, but rather that people sometimes take more than one drug. Sometimes the heroin is covering up the cocaine. When I removed the effects of heroin, all I was left with was full-on cocaine. And the fight started. So don’t ruin the high that people paid for. Give naloxone for respiratory depression, not opioid use. And remember that good BVM technique can solve ineffective respirations, even without Narcan.

Patient Four is a cholinergic overdose. Where anticholinergic overdoses (see above) are dry, everything that can secrete secretes in a cholinergic overdose. DUMBBBELS is a good mnemonic for cholinergic overdose signs and symptoms, if you’re into that kind of memory aid thing. Diarrhea, Urination, Miosis (pupil contraction), Bradycardia, Bronchorrhea (mucus), Bronchoconstriction, Emesis, Lacrimation, and Salivation. Patients can also present with confusion or even unconsciousness, muscular fasiculations, and seizures. The most common cholinergic agents are organophosphate pesticides that are common in a lot of garden chemicals. Carbamate insecticides, some nerve agents, nicotine, and physostigmine are also cholinergics. The good news from a treatment perspective is that cholinergic overdoses are treated with anticholinergic agents, and we have a good one – atropine. The bad news is that we don’t carry enough atropine to do much more than scratch the surface. Patients will need A LOT of atropine before they are better. Just keep giving all you have until the secretions dry up. 

One of the bigger concerns with this scenario is scene safety. The organophosphate agent can attach to the patient’s clothing and pass to rescuers. In addition, continued poison absorption can still occur. Decontamination is necessary and provider safety should become paramount as soon as a cholinergic overdose is suspected. At least get dude’s clothes off and get any obvious contaminants off of him.

Finally, consider Patient Five. Is she intoxicated? She certainly acts like it on the surface. She is ataxic with slurred speech at a DUI stop. On the other hand, however, are the absence of the smell of alcohol on her breath and the absence of nystagmus. Honestly, I don’t look for nystagmus all that often. And my olfactory nerve is burnt out on alcohol. I can’t smell it anymore. I can certainly smell other odors, especially armpits, feet, ass, and despair. But not alcohol.

Sedative-hypnotic medications are central nervous system depressants that have similar presentations to alcohol intoxication. There can be CNS depression, confusion, and even unconsciousness. Pupillary signs are unhelpful here and vitals can often be normal. If vitals are altered, one would usually find signs of CNS depression again such as bradycardia, hypotension, and bradypnea. Common sedative-hypnotics include benzodiazepines, barbiturates, and alcohols like methanol. In this case, I think I would be uncomfortable in “clearing the patient for jail” unless I was absolutely comfortable with that outcome. I don’t feel like I should be comfortable here, in the absence of alcohol on the breath. What could be too many wine coolers could easily be too many Xanax. This lady took her evening Valium and then wound up behind the wheel for whatever reason. She wasn’t drunk.

Take the time to learn toxidromes. Medicine is funny. I mean, different patients can have the same problem and present differently. Two demographically similar patients can both be having an MI and be complaining about two completely different sets of symptoms. One can be hypertensive and the other hypotensive. That is what makes medicine interesting. But with toxic exposures and overdoses, many times the signs and symptoms are similar between patients. That is the power of the toxidrome.

SickNotSick

This is probably part one of who knows how many because it is an important topic. But nobody wants to read a multi-hour dissertation all at once.  So enjoy the smaller bolus.

A few shifts ago, I had a good friend and long time medic as my partner. He has been a medic long enough that I don’t mind watching him work, so I happened to be driving that day. One of the first calls on the shift was to a dyspneic patient. We arrived to a small bungalow on the south side of town to find a 20-something woman lying on the couch moaning. She was supine, with her feet elevated on the arm of the sofa and her right arm thrown across her face. I relaxed and settled in to doing my job as the driver on the call – finding demographic information, seeking medications, and getting bystander stories; generally doing the necessary tasks that would make it easier for my partner to focus on the patient. I knew I wasn’t in a rush. After several minutes of questions and examinations, my partner assisted the patient to her feet and out the front door to the ambulance. I followed, leaned against the side door of the ambulance, and waited for my partner to buckle the patient onto the pram and set himself up for the transport. Eventually I let him know the information I had found out, handed him a piece of paper with the patient’s demographics on it, and walked around to the driver’s seat to head to the hospital.

The next call was also a patient experiencing shortness of breath. We arrived to an apartment building to find the patient on the front porch. She was sitting on a rickety aluminum chair, leaned forward with her hands on her knees. Her head was pushed forward and she gasped out a few syllables to explain that her asthma was bad that morning. I didn’t hear that, though. As soon as I caught sight of her on my way up the front walk, I turned around to get the bed. I pushed it toward a waiting firefighter, asked him to hustle it to my partner, and remounted the ambulance to spike an IV bag and set up a nebulizer treatment. I even planned to get the drug kit out to set out some epinephrine for my partner, but he arrived back to the ambulance before I could do that. We both got to work once the pram clicked into the bracket. My partner got to work getting a blood pressure while I put the neb into the patient’s mouth and explained how I wanted her to breathe through it. I put a pulse ox probe onto her finger and my partner grabbed the drug box to find some epi. I quickly wrapped a rubber tourniquet around the patient’s arm and stabbed a 16 gauge catheter into her large antecubital vein. Rather than finish the line, however, I attached the vacutainer hub to the catheter and taped it down lightly. My partner saw that and nodded: “I will finish that. Saint Elsewhere, please.” I hopped out of the ambulance and hurried around to the driver’s seat.

What is the difference between these two calls? 

The difference is in the answer to one of the first questions providers ask themselves: Is this patient sick or not sick? SickNotSick?

When you walk into a scene and catch sight of the patient, ask yourself, “Sick or not sick?” Start with your general gestalt, the same way a layperson would. There is no need to work through a bunch of questions; just think about whether the patient makes you worried (or a little frightened) from across the room. It involves skin color and moisture, but also the patient’s position, the work of breathing, and how frightened the patient appears. Next, if it is a trauma call, the mechanism comes into play. Is the car crash a terrible one, or was paint exchanged between bumpers?  Someone shot in the groin is probably sick and someone shot in the foot is less likely to be sick. And so on. When you are incredulous and ask for clarification, it often makes you lean toward the patient being sick: “Wait, this dude fell from where?” 

As you get closer to the patient and ask a few simple questions, you can tell a lot about the patient’s mental status. More than mental status, you can tell where they fall on the alertness AVPU scale. Finally, vital signs are an important part of deciding whether a patient is sick or not. Hypotension is bad. Extremes of tachycardia and bradycardia are too. Respiratory patterns matter more than we credit them. How many syllables can the patient say before gasping? Does the inhalation match the exhalation, or is the patient working harder to accomplish one or the other? What do the pulse oximetry, capnography, and ECG tell me?

Twisted all through the decision regarding sicknotsick is the provider’s experience level and personal history. If a respiratory patient has ever crumped on you and died without warning, you have a higher level of respect for respiratory signs like tachypnea. After a patient died shortly after a firefighter told me, “She is getting hard to bag,” the way to get my full and undivided attention is to say that to me. After overreacting to hyperventilating dramatic patients a few times, you recognize what carpopedal spasms look like. Some of the best lessons I have ever received were from making the wrong sicknotsick choice and paying for it.* 

The foundational test of sick-or-not-sick, however, is the janitor test. The janitor test holds that if a janitor walks past your patient and thinks, “Wow, that dude looks like he is dying!” then he usually is. I try to remind myself to balance the medical knowledge I have been given with good, solid common sense. I don’t want to miss the forest for the trees. I don’t want my own prejudices to steer me wrong. As an EMT or medic improves in his or her skills, they start to pick up on sick patients who have more subtle presentations. That is the mark of a Jedi medic. 

Start asking yourself whether you think the patient is sick or not sick after being on scene with the patient for about a minute. You can always change your mind later. Work more quickly on the sick patients. Reevaluate. Make sure you are on the correct path. Reevaluate again. Don’t be afraid to back down from sick to not sick if it is clearly warranted. Then reevaluate. Be ready to upgrade to sick from not sick and reevaluate again. Even more fun: Ask trainees and paramedic students whether they think the patient is sick or not after a minute or two on a call. Then help the learner to align their impression with yours.

*Hopefully I pay for my own mistake with a little embarrassment, rather than the patient paying for my overreaction or underreaction with their health and wellbeing.

Expensive Technological Mirrors

A few weeks ago I responded to the result of a brawl at a seedy bar. The story I was given was that two patrons had a disagreement about something – I am sure it was something very important and academic, warranting violence to settle the discrete differences of intellectual opinion. But the reason for the fight doesn’t really involve me. The patient I was called to see was a fifty-five year old male patient who had suffered the indignity of having a glass beer bottle broken over his head. It was unopened, which makes the impact heavier if nothing else. I asked what kind of beer. Corona. Full bottles of anything hurt, so that sucked for my patient.

Corona Extra, the thinking man's makeshift club. By N-Lange.de via Wikimedia Commons Source

I examined the fellow and chatted with him while I checked him out. He had no complaints, denied medical history, and said he just wanted to go home. Bystanders reported that the man had been knocked to the ground by the blow, but did not appear to lose consciousness. He had consumed several beers, but appeared generally sober to me. The whole bar smelled of stale beer, so I couldn’t assess dude’s breath, but his speech was clear and he did not exhibit ataxia. My opinion was that he possessed decision-making capacity at that time. The man appeared to be uninjured, except for a large, complex, full-thickness laceration to the apex of his scalp. Bleeding had been controlled prior to my arrival, and his skull and facial bony structures were stable to palpation.

The patient and I had different opinions of the best thing for him to do. To me, it was an obviously suturable laceration; he needed to come with me to the hospital. If he had a ride easily available, we could discuss it but him going with me would make everything easier. That was my opinion. His opinion was that he had been hit much harder at previous times in his life and it probably wasn’t as bad as I was saying. He just wanted to go home (which probably meant to a different bar). I was having a hard time convincing him about the gory nature of his laceration. “Buddy, your skull is visible. You need to get that cleaned out and stitched closed…”

In the end, it was his decision to make. I didn’t feel like I should chicken-wing the man and drag him off to an ED, kicking and screaming. He was sober and had decision-making capacity. But I didn’t feel like he was making an informed decision. The conversation I was having with the patient felt like he wasn’t absorbing the information I was giving him. I felt like he didn’t understand the severity of his wound.

I asked the patient for his cell phone, which he gave to me. I used it to take a picture of his scalp lac, which he couldn’t see (it being on the top of his head). I actually took a short video, so I could pull the lac apart a little and make it look like it was chewing food. I made a growling “blah blah blah” noise when I pulled the lac apart. I showed the nasty video to him.

“Oh, hell,” he said. “I had no idea it was that bad! I thought you were overreacting!”

“That’s what I’ve been saying!” He went to the hospital with me and got some stitches. By transporting him, I didn't need to worry about whether his sobriety fell on which side of which line, or anything else. He went to the hospital and got stitched up. Simple. (I actually think he may have gotten stapled, though. Whatever. Same thing...)

Camera phones make for good mirrors. They are even better than mirrors, in a lot of ways. You don’t have to align two mirrors to see the back of your head. You don't have to look like you are preening. You can see the same thing a patient does. Also, a mirror can't post a funny story to Facebook. I prefer cell phones to actual mirrors in most cases, as a matter of fact, because the view is better than a patient gets in a side-view mirror at the side of a highway.

When you do this, try to use the patient’s phone for the pictures. It is easier to explain, you don’t have privacy concerns, and there isn’t a need to clear your deleted pictures. I don’t want my phone involved in calls, unless absolutely necessary.

But cell phones can definitely be handy as mirrors.

Dog In The Road

In my first EMT class, I learned about a code phrase: Dog In The Road. The idea is that the provider in the back of the ambulance can shout “Dog in the road!” when confronted with a very dangerous situation, such as when a violent patient escapes their restraints. What do you do when you're behind the wheel and a dog is in the road? Brake, I hope. Rather than the attendant quietly taking a whuppin’, the phrase causes the driver to immediately slam the brakes as hard as s/he can – both feet on the brake pedal and strain until the ambulance is stopped. The driver comes as close to simulating a wall impact with the brakes. Sixty-to-zero as fast as possible. The idea is that the provider in the back of the ambulance is prepared for the sudden stop, but the dangerous patient isn’t ready.

You know what I can’t remember ever saying in 20 years of EMSing? "Dog in the road!"

When I learned about the phrase, I figured it would be something that everyone knew about and that was used fairly often. Not daily, or anything, but at least once or twice per year. The first time I had the opportunity to use the Dog In The Road phrase, I didn’t remember to use it. The code phrase I used to ask for help: “Hey! Don’t undo those! Leave your seatbelt on! No! Sit down! Sit down! Sit down! Greg!” Greg pulled over and we put the patient back in the bed.

The most recent time I needed my partner to help me in the back with a dangerous patient began with a deep, exasperated sigh: “Dude, give me a hand back here, will ya?” It is similar to climbing commands - when the climber is falling, s/he is supposed to call "Falling!" to the belayer. What is usually called out is either a scream or profane cursing. I think I've heard "Falling!" called out as much as I've heard "Dog in the road!" shouted.

I have a problem with code phrases. Not everyone is on the same page and people under stress forget the phrase. If I asked to take my lunch break over the radio, what action do you think should occur? How about if I hit my panic button and then told dispatch: “We’re all good here. Everything is Code 5. No problems…”?

What I have learned over time is to avoid even approaching a situation where a dangerous patient can harm me. I try hard to not let things escalate to Dog In The Road levels. Patients are restrained, and are not allowed to touch the seatbelts. Seatbelts are inverted, by the way, making it harder for them to quickly click the belt off. Patients are not allowed to remove safety restraints in a moving ambulance, ever. A patient might get one command to leave the belt alone, followed by immediate wrist restraint. A patient might be able to slip out of wrist restraints, but they get immediately re-restrained (I don’t ask them to sit down and call for my partner nowadays). A patient struggling against physical restraints needs the addition of chemical restraints. As a matter of fact, chemical restraint is used early and often in my ambulance. Some Haldol or Versed is a lot safer and more dignified than being thrown forward during aggressive braking, or a wrestling match, or a full-on donnybrook.

Listen, if I am transporting Officer Jim Pembry and he sits up and removes his face skin
to reveal a cannibal serial killer, "Dog In The Road" is warranted.
But rather than calling out "Dog in the road," what would probably come out
would be a significant amount of urine and a high-pitched shriek of terror...

(Via YouTube; Silence of the Lambs, 1991)

It is safer for everyone to be properly restrained. Sudden braking to throw escaped patients around is usually a failure on the part of EMS. 

The Third Time I Was Fired

I have crashed ambulances more than once. For the most part, most crashes weren’t my fault. In the case of some grinders, I may have had a small piece of culpability, mostly due to slightly suboptimal decisions on my part, at least in hindsight.

One of my first crashes occurred on a snowy night. There was an inch or two of fresh snow sticking to roads when my partner and I had to respond to an emergency call. I have to admit, I was having a good time. Non-medics may not know this, but turning the lights and sirens on during a snowstorm with big, fluffy flakes in the air makes the view out the windshield look like you’re accelerating the Millennium Falcon into hyperspace. I was roaring southbound on a three-lane road that was congested by traffic. But the far-right lane opened up and I got into it. Having no other traffic in the lane allowed me to increase my speed. Punch it, Chewie!

I was approaching 40 miles per hour or so when I realized why there was no traffic in the far-right lane. It was a turn lane. As a matter of fact, it was a right-turn only lane that ended at a triangular curb island. The island had a lightpole sticking out of it. You know what I mean, right? One point of the triangle curb separates the turn lane from the continuous traffic lane.

Like this. But not so obvious without the red line around it. And covered by snow.
(Via GoogleMaps)

I realized it was a turn lane when I hit that curb at 40 miles per hour. In my defense, the snow on the road had hidden the island. It was as deep as the height as the curb - it made the curb invisible! We may have gotten a little air, with snow and slush flying around us. I have no idea how I missed the foot-wide lightpole in the middle of the island – I guess when we got air, we rotated a little. When we landed, we skidded sideways right toward a flabbergasted driver in a crappy sedan. I was skidding sideways and had no ability to stop at all. I started flailing my arm at him as a signal for him to get out of the way. He stared at me with his mouth open. Finally, he pulled forward and the ambulance skidded and sparked to a stop right where he had been parked. I took a deep breath and tried to calm my nerves. My partner unleashed a string of profanities that were mostly aimed at me and my utterly inadequate driving skills.

I was hoping that the ambulance wasn’t damaged and we could go on our way without letting anyone else know what had happened. Chances were probably low, being that the ambulance was sitting at a tilt, there was a not insignificant amount of steam spewing from the grill, and the steering wheel was able to spin freely. When I got out and looked, I found that each wheel on the ambulance was pointing in a different direction. We notified dispatch that our response would not be completed by us and that we had been in a non-injury crash.

My partner and I sat in the ambulance waiting on a tow truck. I tried to interrupt his string of angry curses and get him to focus on our story. I was leaning toward the crash being caused by me trying to avoid a school bus full of nuns and handicapped children – the maneuvers that caused the accident were heroic, see? In the end, there were too many holes in that story, so I decided that the truth would set me free. The truth, as I recalled it, was that I was crawling along very slowly in accordance with the weather conditions when I slightly clipped a curb.

A sport utility vehicle pulled up behind us. What kind of jerk stops at a busted ambulance at the side of the road? I thought. What, does he think he can help? We don’t have a radio? Seriously, who does that?!?

The owner of the ambulance company does, that’s who.

Crap. The owner got out of his Suburban and my partner got out of the ambulance and hustled over to him. Crap. I hoped my partner would be gentle. I didn’t think he was completely clear on the “...gingerly driving very slowly due to the weather…” tale. I approached cautiously and heard part of the explanation he was giving to the boss: “…I’ve never been so frightened! It was terrifying! I’m shocked we weren’t killed…” Crap. You’ve got to be kidding me! He can’t deliver the story any more gently than that? I mean, help a brother out!

Thump thump. That was the imaginary  sound of the metaphorical bus running me over.

So that was the third time I was fired from that job. I’m pretty lucky that each time I got canned, they let me keep working and continued to pay me. I’m also lucky that my driving mistakes and errors of judgment didn’t result in worse outcomes.

Status Epistaxicus

You and your partner respond to a downtown office for an epistaxis call. You find a 35 year old male patient who has had an atraumatic nosebleed from his left nare for 10 minutes. He seems to be holding pressure on the anterior part of his nose correctly. He has a pulse of 90 beats per minute, a respiratory rate of 16, and a blood pressure of 180/100.  He is warm and dry without blood on his shirt, but he explains how severe the bleeding is, with alarming and horrifying descriptions of “gushing” blood (but no evidence of severe bleeding on him or in the area). He does not feel like he is swallowing blood. How do you proceed?

Only about 60% of the population will experience an epistaxis in their lifetime, and 6% will need medical care to stop the nosebleed. Most cases occur for children between two and ten years of age and older adults between 50 and 80. (Those stats surprised me. I’m 42 and get nosebleeds weekly. Who are these 40% of people who don’t get nosebleeds?!?) Causes of epistaxis include epistaxis digitorm*, dry air, chronic sinusitis, foreign bodies, intranasal neoplasms, irritant vapors, rhinitis, trauma, hemophilia, hypertension (maybe; see below), leukemia, liver disease, anticoagulant use, and thrombocytopenia. The list of causes is even longer than that. Like with most things, the more benign causes such as epistaxis digitorum (awesome term!) and dry air are more common. Unfortunately, that doesn’t help us stratify each specific patient’s relative risk. About 90% of nosebleeds come from the anterior nasal septum – an area called Kiesselbach’s plexus. The other 10% are posterior bleeds that require emergency department treatment to stop.

The location of Kiesselbach's plexus in in the anterior septum. This is your target when you're pinching. It involves the soft part of the nose, rather than the nasal bones. Photo source.

I deal with epistaxis by starting with the concept of status. Status epilepticus is defined as a seizure lasting for more than five minutes, or multiple seizures without fully regaining consciousness in between. But a seizure can be also regarded as “status” if the patient is still seizing when I arrive on scene. A similar concept occurs with status asthmaticus – a severe asthma attack that doesn’t respond to standard treatment. I look at epistaxis the same way. If I arrive on scene and the patient has been making a reasonable attempt at stopping the bleeding,  I feel like I can regard the nosebleed as having achieved “status” level: status epistaxicus. I mean, the nosebleed was bad enough that 911 had to be called, right? It didn’t respond to normal treatment and it is still going on when I arrive. Status.

I begin with any needed adjustments to the nose-squeezing procedure, followed by some quick information collection. I want to know duration, frequency, estimated blood loss, inciting factors, past medical history, and so on. To treat the nosebleed, I first get the patient to blow their nose. Often, ineffective treatment prior to my arrival has created clots that are difficult to compress and aren’t aiding in hemostasis. So those clots have to be blown out. Be ready for the bleeding to increase, and have somewhere for some occasionally giant clots to go.  Next, I spray topical phenylephrine into the nares. A lot of medics reserve this step for severe, intractable bleeding but I feel like it is appropriate for any “status epistaxicus” that I come in contact with. Next I pinch the patient’s nose with my fingers to find the best pressure spot to stop the bleeding, and then I replace my fingers with a plastic nasal clamp. The timer starts at that point – fifteen minutes without peeking or loosening the pressure.

The concept of status epistaxicus is reserved for treatment decisions, not for transport decisions. Status seizures and status asthma will generally result in transport. That isn’t true with nosebleeds, of course. If I can get it stopped and there aren’t other concerns, I usually hope to leave the patient on scene. Transport is initiated for posterior bleeding (minimal anterior bleeding, but blood going down the throat, choking on blood, and so on), large objective blood loss, when the patient is on blood thinners, hypertension that isn’t decreasing, and if the treatment above fails to stop the nosebleed.

High blood pressure usually isn’t the cause of epistaxis. Chronic hypertension without effective treatment may cause blood vessels in the nose to become more fragile, but most experts believe that any hypertension is the result of the nosebleed rather than the other way around. See, people get anxious at the sight of blood, especially blood that was recently inside of them. That anxiety can increase the patient’s blood pressure. Studies rarely find a cause-effect relationship from hypertension to epistaxis. For example, this study found that there was “no definite association between epistaxis and hypertension.” But studies do find a correlation, like here. In the end, hypertension probably doesn’t cause nosebleed but may prolong it.

Here and here are short videos about Kiesselbach’s plexus and nasal anatomy, including internal views. Enjoy.

* Epistaxis digitorum is a phenomenal way to describe a very common cause of nosebleed – nose picking. Awesome terminology!