The previous “Simplify” article established that prehospital providers are freakin’ awesome and that two main ways to make our job easier and provide better patient care are to do things right the first time and to take the easy road. Here we will continue that topic by beginning to explaining what I mean by doing things right the first time.
Doing things right the first time is a huge trick, but it is so simple, so grounded in common sense that we don’t think of it as a trick. But I think it is a skill that is really important. It relates to efficiency. Perform something once and only once. That’s it.
There are three finite resources that you are personally responsible for on an EMS call: brain cells, lung air, and two hands. Each topic or task that you have to think about wastes synapses that could have been synapsing about something else. Each question you have to ask for a second (or third or fourth) time wastes air that could have been spent asking a different question. Each movement you have to repeat is energy wasted if it had been performed correctly the first time. Trust me - those wastes of synapses, movements, and air that feel individually insignificant can quickly add up.
There are examples on almost every call and they almost always drive me nuts. I am embarrassed to say that my personal most common failure to do it right the first time is when I don’t pay attention to a patient’s name and have to ask them for it again. It happens all the time. What it usually means is that I asked their name and began to think about my next question without listening to their answer. When I see it in trainees it makes me wonder what else they were told that they didn’t actually absorb and comprehend. So it kills me each time that I do it. It is wasted air that I could have used to ask a question that I haven’t already heard the answer to.
Paying attention to my findings so I don’t have to repeat them is critical. I hate it when I take a set of vital signs, get distracted, and forget the results. I despise having to waste time doing them again. Unfortunately, I struggled with this until I realized that I am just like the world’s worst waiter – no matter how sure I am that I will remember, I won’t and I need to write it down or I will mess up the order.
Every time I buckle any patient onto the pram I make sure to get the chest belt as high as possible into the patient’s armpits. The leg belt should run just superior to the patient’s knees. This is the position that a combative patient should be buckled into. But when I am confronted with a combative patient, I don’t want to take the time to think which path the seatbelts should take; I want to just get them strapped in. So doing it on every patient establishes the pattern as a habit that I don’t need to think about. More importantly, there are patients who surprise me by becoming combative suddenly and without warning. I don’t want to have to redo the belt paths after they are wound up. Why do it twice? If I begin the transport with the belts just above the knees and high in the axilla, if the patient gets squirrely all I have to do is tighten the belts. There is no need to be aggressive with belt tightness with a “normal” patient, but the location and path of the belts is an important habit. I don't have to use brain cells trying to decide if the patient needs more secure belting.
I have seen partners place four ECG electrodes, run the incomplete 12-lead (which is really a six lead strip with the diagnostic filters running), decide they need the full 12-lead, place the other six electrodes, then run the 12-lead again. Why wouldn’t you just do the 12-lead right the first time?!? This will probably be a complete post on its own eventually, but (and I hate to break this to you) it is 2013. An ECG includes 12 leads, not six. If it is important enough to need an ECG, it is important enough for all twelve.
One of my favorite partners from the past had the habit of listening to breath sounds after each blood pressure. He would lift the stethoscope off of the patient’s arm and place it onto their chest. If he took three blood pressures, he had three sets of breath sounds. The habit was established to the point that he never had to waste his attention span thinking about whether he wanted to take breath sounds or not – they were just taken. It also meant that he would hear something abnormal when it was unexpected (everyone expects adventitious breath sounds when treating an asthmatic, but you really look cool when you find abnormal breath sounds in a patient with an ankle injury).
This idea of doing a task right the first time reaches into everything that we do, and it is a huge timesaver. How many times have you had to send someone back to the bus to get a piece of equipment that you should have brought into the call in the first place? Have you ever had to make a second phone call to medical control because your first call was so incomplete? Have you ever had to return to an address to revisit the patient you should have just transported the first time you saw them earlier in the shift? How many times did you have to open the same cabinet on the same call?
Doing something once is twice as fast as doing it twice. How’s that for a wise quotation?
Next up: Taking the easier road
Doing things right the first time is a huge trick, but it is so simple, so grounded in common sense that we don’t think of it as a trick. But I think it is a skill that is really important. It relates to efficiency. Perform something once and only once. That’s it.
There are three finite resources that you are personally responsible for on an EMS call: brain cells, lung air, and two hands. Each topic or task that you have to think about wastes synapses that could have been synapsing about something else. Each question you have to ask for a second (or third or fourth) time wastes air that could have been spent asking a different question. Each movement you have to repeat is energy wasted if it had been performed correctly the first time. Trust me - those wastes of synapses, movements, and air that feel individually insignificant can quickly add up.
There are examples on almost every call and they almost always drive me nuts. I am embarrassed to say that my personal most common failure to do it right the first time is when I don’t pay attention to a patient’s name and have to ask them for it again. It happens all the time. What it usually means is that I asked their name and began to think about my next question without listening to their answer. When I see it in trainees it makes me wonder what else they were told that they didn’t actually absorb and comprehend. So it kills me each time that I do it. It is wasted air that I could have used to ask a question that I haven’t already heard the answer to.
Paying attention to my findings so I don’t have to repeat them is critical. I hate it when I take a set of vital signs, get distracted, and forget the results. I despise having to waste time doing them again. Unfortunately, I struggled with this until I realized that I am just like the world’s worst waiter – no matter how sure I am that I will remember, I won’t and I need to write it down or I will mess up the order.
Every time I buckle any patient onto the pram I make sure to get the chest belt as high as possible into the patient’s armpits. The leg belt should run just superior to the patient’s knees. This is the position that a combative patient should be buckled into. But when I am confronted with a combative patient, I don’t want to take the time to think which path the seatbelts should take; I want to just get them strapped in. So doing it on every patient establishes the pattern as a habit that I don’t need to think about. More importantly, there are patients who surprise me by becoming combative suddenly and without warning. I don’t want to have to redo the belt paths after they are wound up. Why do it twice? If I begin the transport with the belts just above the knees and high in the axilla, if the patient gets squirrely all I have to do is tighten the belts. There is no need to be aggressive with belt tightness with a “normal” patient, but the location and path of the belts is an important habit. I don't have to use brain cells trying to decide if the patient needs more secure belting.
I have seen partners place four ECG electrodes, run the incomplete 12-lead (which is really a six lead strip with the diagnostic filters running), decide they need the full 12-lead, place the other six electrodes, then run the 12-lead again. Why wouldn’t you just do the 12-lead right the first time?!? This will probably be a complete post on its own eventually, but (and I hate to break this to you) it is 2013. An ECG includes 12 leads, not six. If it is important enough to need an ECG, it is important enough for all twelve.
One of my favorite partners from the past had the habit of listening to breath sounds after each blood pressure. He would lift the stethoscope off of the patient’s arm and place it onto their chest. If he took three blood pressures, he had three sets of breath sounds. The habit was established to the point that he never had to waste his attention span thinking about whether he wanted to take breath sounds or not – they were just taken. It also meant that he would hear something abnormal when it was unexpected (everyone expects adventitious breath sounds when treating an asthmatic, but you really look cool when you find abnormal breath sounds in a patient with an ankle injury).
This idea of doing a task right the first time reaches into everything that we do, and it is a huge timesaver. How many times have you had to send someone back to the bus to get a piece of equipment that you should have brought into the call in the first place? Have you ever had to make a second phone call to medical control because your first call was so incomplete? Have you ever had to return to an address to revisit the patient you should have just transported the first time you saw them earlier in the shift? How many times did you have to open the same cabinet on the same call?
Doing something once is twice as fast as doing it twice. How’s that for a wise quotation?
Next up: Taking the easier road
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