Shot in the Calf. Bummer.

A few years ago, I had a paramedic student riding with me when we ran a dude in the southeast corner of the city who was shot through and through his calf.  I knew it was through and through, because I could see through it (science!).  I bet it hurt, but it wasn’t bleeding especially badly and didn’t seem life threatening.  I lifted his shirt to check his chest and back, but found no other wounds.  We were pretty close to a lower-level trauma center (Level III or IV), but since I wasn’t worried about the patient’s condition, I felt confident they could handle things.  More immediately, I was confident that the paramedic student could handle this call – there was nothing to screw up.

As we were about to leave, the patient told my student that his testicles hurt more than his calf.  My unvoiced thought was that it's a pretty bad day when you get shot, but it's a worse day when you get shot and have nut pain.  The paramedic student, though, got the patient’s pants off and took a look at the area of complaint.  He found nothing out of the ordinary.  Since that student was conveniently nearby, I told him that he was going to have to more thoroughly examine the patient: “Cup and lift, Junior.”

The patient was shot in the taint.  (On a side note, I still don’t understand how a person gets shot in the perineum.  One would assume that it is a pretty rare location to suffer a gunshot wound.)

I looked up 'perineum' on Creative Commons for photos that I could share.  It was… a mistake.  Don't do it.  Instead of a perineum, here is a picture of a calf. (Photo by Galia^)

All I can say is that I was really glad I had a paramedic student that day.  If I am being completely honest, it would be an especially rare situation to find me cupping and lifting.  But finding that wound was a game changer in a clinical sense.  The Level IV trauma center was out – the patient had a torso GSW.  Level I trauma center it is.  A torso wound is the difference between a macro for pain control and two large bore blood pumps.  The patient acuity completely changed.

Secondary exams are important.  I can’t stress this enough.  I can’t describe how many times in my career this lesson has been brutally taught to me by the EMS Fairy when I was being lazy, nor can I describe how uncomfortable each lesson was as I relearned it.  As paramedics and EMTs, we only have two ways to get information: ask questions and touch/view things.   History and physical.  The newer you are, the more important a detailed, thorough secondary exam is – from head to toe and everywhere in between, in order, all at once – because you have less experience to tell you what is important.  Secondary exams are critical skills for every provider on most every call, however.

Focused exams should be pretty rare.  Even a “simple” focused exam usually involves several body systems.  For example, picture a healthy adolescent who has twisted her ankle, breaking it, and fell down.  Do you just look at the ankle, or do you check if she hurt other body parts in the fall, as well?  How about the same ankle situation in a nursing home patient?  You would do a more complete exam then, right?

Going back to the guy shot in the taint, the really weird part of the story is that he had a third bullet wound.  It was dead center in his right butt cheek.  Equidistant between crack and hip, centered between his waist and thigh.

Dead.  Center.  Damn.

That wound track did not communicate with the taint wound, so I still don’t understand how dude was shot in the perineum.  I never knew about the butt wound because I hadn’t specifically looked.  EMS Rule #2 (Look cool) was unmet on this call.  Not that finding the wound would have made much difference – torso shot is torso shot.  But I hate not finding all the holes…

Doing a half-assed (yeah, pun intended) secondary is half-assing half your potential information.  Don’t skimp. 

My Easily-Broken Family Rider Rule

A few years ago, my partner and I were dealing with an elderly woman with chest pain.  I was driving that day, so I helped get my partner set up in back before we transported.  The patient’s adult daughter was in the front seat, because she was going to ride to the hospital with us.  After getting everything ready for the transport, I walked around to the driver’s seat and got in.  The patient’s daughter was drinking out of a Wendy’s cup.  Weird – where did she get Wendy’s?  I must have had a questioning look on my face because the rider said, “Oh, sorry.  I’m so nervous, I got cottonmouth.  What is this, lemonade?”

She was correcting her cottonmouth with my drink.  My drink.  Without asking.  Without shame or embarrassment.  She was surprised when I asked her to exit the ambulance immediately. 

I’ve had family riders steal objects from my partner’s and my bags.  I’ve had riders start fights with the patient in back.  I’ve had riders that turned out to be the bad guy that actually caused the patient’s injuries.  I’ve had riders who told me they were uninjured complain of neck pain upon arrival to the hospital.  I’ve had riders suddenly flip out and interfere with driving.  I’ve had riders listen to medics working in back say things like, “This dude dead.  What’s that coca cola shit coming out of his eyes?” (The medics didn’t know the rider was up front).  I’ve had riders ping the metal detector upon arrival to the hospital with their concealed pistol.

Thus, I hate to take riders.

I work in a good place that has no demanding policy about family riders.  Our policy is that riders are at the crew’s discretion.  My personal policy is: “No riders, sorry.  We’re not allowed.”  I’ve had too many riders not work out for me. 

But, like everything in EMS, there are certainly exceptions to my no-rider policy.  I despise if-then situations.  I hate not making a decision – it makes me feel like I am not in charge.  I am willing to accept the responsibility, so let me choose.  I will decide on the merits of each situation.

I always try to weigh a cost-benefit analysis with every decision.  I hate working around paramedics that live in a black and white world.  I’d hate to work in an agency that sets firm rules on this topic.  I start on the ‘no riders’ side of the fence, but there are always exceptions.  So let me work through the cost-benefit list in advance.

The costs include the fact that riders can become distractions to driving and patient care, they are another body that I am responsible for, they may be “secret patients,” they can be emotionally scarred from watching aggressive medical care, they may witness a call falling apart, they can steal, and they can be the perpetrator. 

One final big cost – patient confidentiality is ruined by having a rider in the bus.  This is the main reason for my no-rider policy.  Essentially every medical problem is of a personal nature.  I don’t need to be discussing how my bowel movements have been over the last few days with people listening – even my wife.  We ask about medications, drug and alcohol use, sexual activity, bodily functions, and other embarrassing topics.  It doesn’t embarrass us because we are professionals.  You will get more truthful answers if your exam, history, and care are performed in a private setting.

I try to avoid riders when:

• The patient may become combative, like intoxicated, confused, or post-ictal patients.
• The rider is intoxicated.
• Emergency transports – by definition, these settings require a lot of focused attention and work.  I don’t like to add a potential distraction.
• The rider was in the crash as well.  Too many get to the hospital as an uninjured rider and become a patient: “Yeah, my neck is killing me.”  Then I am the jerk who ignored the hurt guy.
• Non-family, like acquaintances or co-workers.  I get the impression that most co-workers who offer to hang out at the hospital for a few hours are just busybodies who feel nosy.
• Any patient problem is of a private nature, which is most of them.

On the allow-the-rider side of the ledger, riders can be legally required (as in the case of minor patients), they can provide information about the patient’s medical history and recent events, and they can be kept safer by riding to the hospital than remaining on scene. 

So, I will make exceptions to the no-rider rule for:

• Parents of young children.  I try to not take riders of teenagers when I think the parents will get in the way.  I need truthful answers and parents can sometimes get in the way of that.  I also try not to take riders when I am dealing with critically ill children.  But as a father, I understand that there is no way I am stepping away from my kid to let a stranger deal with it.  Not happening.  So that is why I say ‘I try not to take riders…’
• People in dangerous situations.  I won’t leave the patient’s girlfriend in a seedy neighborhood, at night, with no easy way out.  I won’t leave kids alone.  There are usually other options, like police or fire department help, but sometimes I’m in a hurry and it is faster to take the rider.
• Helpless people.  I’m not leaving the patient’s wife of 50 years at home, when he is having a stroke and she is blind. 
• The rider benefits me.  If a rider hits any of the list of benefits above (like they know a detailed history of events), then there is a benefit to me for taking a rider.

If I make the wrong choice, I will pull over, kick them out, and call the cops if need be.

The final important point is to not be an asshole about it.  I put on a friendly smile and explain, “Sorry, we're not allowed to take riders.  He is in good hands, and nothing bad is going to happen today.  We’re not using lights and sirens to get there, so you shouldn’t either.  As a matter of fact, he will probably be there for a few hours, so take your time before you leave.  We’re going to X Hospital, over at Main and First.  Do you know where that is?  Do you need a map or directions?”

Hopefully you work in a progressive agency like mine.  Make your own choice about riders, and do what you’d be proud to defend.

The Power of 'What the F**k?"

‘What the F**k’ is a powerful tool in the EMS arsenal.  You can think of it as ‘Whiskey Tango Foxtrot’ or ‘Huh?!?’ or whatever you like, based on your comfort level with profanity.  I cuss all the time (entirely too much, I will freely admit), so the rule to me is ‘What the f**k?’  But the point remains the same. 

Here’s the trick: You need to be deeply cognizant of the times that your subconscious brain asks, ‘What the F**k?’  Your subconscious brain may not even ask a question, but it may bring your eyebrows together and raise one of them in a questioning expression.  Whatever.  Those times are markers for needing more information.  It should lead you to asking questions, touching patients, talking to bystanders, or other methods of gathering intelligence.  Figure it out.  Get the whole picture.

Me: Do you have health problems?  Asthma, high blood pressure, stuff like that?

Patient: I have diabetes.

Me: Do you take insulin or pills?

Patient: Neither.

What the f**k?

You arrive to the scene of a dirt-transfer mechanism minor accident to find a cardiac arrest in the driver’s seat of one of the cars.

What the f**k?

Me: Has this ever happened to you before?

Patient: Yep.

Me: [Waiting patiently for more information.  Waiting.  Waiting…]

What the f**k?

You arrive to find an adult male lying prone on the ground, sweaty and roaring nonverbally, being held down by three civilians.

What the f**k?

You arrive to the scene of an adult male wearing a clown costume running in a small circle screaming at the top of his lungs about “…the man in the grey suit…”

What the f**k?

Me, opening the first aid room door: Um, hi.

Male: My employee, here, fell down and I want you to make sure she is okay.

Female: I’m okay.

What the f**k?

Patient: Don’t worry – I faint all the time.

What the f**k?

Dispatch: You’re going emergent to an intersection on a down party.  Look for the man next to the shopping cart with the cardboard sign.

What the f**k?

You pull up to find tire tracks in the snow on the left side of the road, and a vehicle stuck in a ditch on the right side of the road. 

What the f**k?

You arrive on scene of a reported incident of chest pain to find an adult male sitting with the precordial salute. 

What the f**k?

You are sent to a clinic to transfer a patient with a cough to the emergency department. 

What the f**k?

You, asking about a confused elderly patient: What is his baseline mentation? 

Family member: Pretty good.

What the f**k?

You: What does that mean?  Does he normally know what day of the week it is?

Family: Sometimes.

What the f**k?

You find a patient in controlled atrial fibrillation, with a verbalized history of “irregular heartbeat,” but also denying that he is prescribed medications.

What the f**k?

Patient: I had a heart attack last month.  I had to spend all afternoon in the hospital.

What the f**k?

You are walking through the mall and find a large puddle of blood at the base of the escalator.

What the f**k?

A car has a head star in the windshield over the steering wheel.  The reported driver is uninjured.  The reported passenger has a forehead hematoma and laceration.

What the f**k?

What the f**k? Why is there a family of stuffed raccoons in this article?
I guess you need to ask more questions to figure it out, huh?
(Photo courtesy Jeremy Johnson, Meddling with Nature)

You begin every call like this.  The process comes into play when you first arrive on scene.  You begin your call with wondering what is going on here, right?  (What the f**k?)  At that initial point of patient contact, can we agree that questions need to be asked and exams (of vehicles, bystanders, patients, etc.) need to be performed, right?   Why wouldn’t that need for information when feeling a nonspecific feeling of confusion continue throughout the call whenever anything doesn’t make sense?

If something doesn’t make sense, you need to figure it out so that it does make sense.

That is the main lesson.  The power of ‘What the f**k’ should not be underestimated.  Whenever your subconscious, or conscious, brain asks ‘What the f**k,’ more information needs to be gathered.  Repeat the process until your brain shuts the f**k up.

The Tree of Knowledge

In Christian theology, the tree of knowledge bore the fruit eaten by Adam and Eve in the Garden of Eden – eating the fruit was the original sin.  In EMS, the tree of knowledge is different, but still involves original sin (but not theologically).

Think of an EMS call as a tree.  At the beginning, when I am assigned the call, I’m not even sure if there is a tree there, let alone if it is an oak or pine tree.  Is it old, or a sapling?  Has it been hit by lightning in its life?  Is the bark smooth or craggy?  Are there leaves on the tree, or is it winter? 

(Courtesy CopyrightFreePhotos: http://www.copyrightfreephotos.hq101.com/main.php)

Patient contact usually begins with a question: “What’s the matter?”  Think of this piece of information as the EMS tree’s trunk.  The actual wording of the question is not important.  “What can I do for you?”  “What seems to be the problem?”  “Are you hurt?”  All of these beginning questions start the call and give us an idea of what we are doing on that scene.  If there is no problem, there is no tree.

Every call begins with dispatch information; what the caller thinks is going on, third party caller statements, a guess as to the nature of the problem, and that kind of information.  Dispatch information comprises the roots of our tree – we may not be able to see the roots, but there is information there if we were inclined to dig it up.  How much digging will be required depends on how well that knowledge is passed on to responders.

Separating off from the “trunk” are the main branches of our tree.  In general, I use the OPQRSTA mnemonic: onset, provoking, quality, radiation, severity, timing, and associated symptoms.  The mnemonic you use, or even if you use one, is not important.  But most calls require some information about each of those points.

Each “OPQRSTA-branch” has sub-branches of questions.  So for onset, the main branch question is “Really.  I’m sorry to hear that.  How long has that been going on?”  Forking off of that question are the sub-branches: “What were you doing then?”  “Oh, yeah?  How long had you been doing that?”  “Has this ever happened before when you were doing that?”  “How was that time similar?”  The main “onset branch” thus separates out into smaller and smaller branches all the way out to little twig questions.  That pattern of questioning is repeated for each of the main OPQRSTA branches.

In most cases (where time isn’t a factor), it is not important whether you skip from branch to branch, or to pick one branch and follow it to its end before switching to another.  Start with onset or start with associated symptoms (“What else is wrong with how you feel?”).  Ask all of the main branch questions before asking detailed twig questions or skip from branch to branch as the conversation leads you.  It doesn’t matter.  What matters is that, no matter the order, each branch is thoroughly examined out to its end.

Physical exams are important too.  I think of this as fleshing out my tree – the equivalent of looking at the bark, leaves, and animals that live in the tree.  The more information I have, the more accurate the picture of my tree.  Find out if the texture of the bark.  Is there a bird’s nest in the tree?  Are the leaves green and healthy, changing colors, or fallen off?  How thick are the branches?  There is a difference between a centuries-old craggy-assed oak tree and a sapling that was just planted.  They’re both oak trees, but it is the specifics that make each tree unique.  Think of the physical exam as showing you those differences.

Is that a spruce or a pine? Better ask more questions.
(Photo courtesy Anthantor, CC3.0 license)

Original sin comes into our model because, in many cases, most bad decisions on an EMS call come from not having an accurate picture of your tree.  You think you have a pine tree, so you talk the patient into staying home.  But it isn’t a pine tree – it is a cedar tree you’re dealing with.  Cedar trees should go to the hospital.  Whoops. 

That is kind of written in jest, but it is a serious point that decisions made without accurate information are only good decisions by accident.  Most incorrect decisions come from inaccurate or incomplete information.  We all know how to treat an MI, for example, but missing the fact that we’re dealing with a subtle presentation of an MI makes it almost impossible to make purposefully correct MI treatment decisions.  Tracing back poor decisions usually leads to incomplete exams and inaccurate histories. 

So mistreating the patient is a sin, but doing it because of an incomplete history and physical is the original sin.