October 25, 2014

Narratives

I’m a maniac!  A maniac, I tell you!  I fear no angry comments!  Let’s get some fights on this blog! 

Let’s talk about narratives!

Medics love their narrative patterns, and think that everyone else’s are stupid.  So I can take a minute to explain my narratives and you can then tell me why they are lame and ineffective.  It's a fun EMS game!

The best way to hand-off patient information to other caregivers, in my opinion, is in a conversational-style handoff report with time for questions to be asked and answered.  But we’re busy and have to leave the patient’s side eventually, so we leave PCRs for the hospital.  In a PCR, the narrative holds the best information, especially for follow on providers like physicians and specialists who contact the patient after you have left the ED. 

It seems like every EMS agency has a different PCR, with different layouts and different information in different locations.  Most providers look for the narrative – it is pretty easy to find, and it will (hopefully) tell the whole story.  I also prefer narratives to electronic, check box-style documentation because I can type out a much better description almost as quickly as I can check a box.  Which would you prefer:  Head > Laceration; or “Head: 3cm full thickness laceration superior to left eyebrow”? 

Narratives are the best place to show off the good work that you do.  If you do good work, make sure to show it off.  If a medication or procedure requires that certain conditions be met, make sure to point out those conditions in your narrative.  The reverse is also true – I make sure to explain why I didn’t immobilize a patient, or didn’t initiate care for a cardiac arrest. 

I personally prefer the SOAP narrative format, which I usually shorten further into SOP.  But I don’t think most people care if you write in CHART format or chronological narratives.  However you write a narrative, it is critical to ensure that communication occurs.  Make yourself clear.  Make sure that your narrative is an appropriate length.  Excessively long PCR narratives make finding important information more difficult.  Excessively short narratives don’t contain all of the pertinent information. 

SOAP stands for subjective, objective, assessment, plan.  Subjective information is information that you are told by someone else.  You can’t be held responsible for the veracity of subjective information.  In contrast, objective information is data that you gained by your own actions.  You saw it with your own eyes.  People can tell me that their arm hurts (subjective information), but I can see the flinching tenderness response when I touch their arm (objective information).  The assessment section is the place for me to take a shot at what is going on with the patient.  I state what I was working up the patient for, be it MI, abdominal pain, kidney stones, whatever.  Finally the plan section is a list of the treatments that I performed in chronological order.

Personally, I don’t include information that is elsewhere in the PCR unless it enhances the readability of the narrative.  A lot of medics start their PCR narratives with something like: “Medic 440 responded Code 3 for report of chest pain…”  The unit, response mode, and dispatch nature are already provided elsewhere in the PCR.  Why waste time with that?  With that in mind, my plan section is usually just a brief list of treatments: “Exam, VS, IV, O2, transport without change or incident.”  If someone wants the details of my IV, they can look in the procedure section. 

I use the SOP layout for medical, trauma, and cardiac arrest calls, whether the patient was transported or not.  The only difference is that some settings (like cardiac arrests) shorten the subjective section.  So my arrest narratives end up having really short subjective (found down, no further information) and objective (grossly atraumatic) sections with much longer plan sections.  But I still follow the same pattern.

So here is my base narrative.  (The information between the < > signs is to be filled in.)
Upon arrival, found patient complaining of <complaint>.  <Explain the complaint – how long, PQRST stuff, etc.>  Patient denies <include pertinent denials such as chest pain, shortness of breath, nausea/vomiting, dizziness, etc.> <Bystander statements, if they are pertinent>

Upon exam, patient awake, alert, calm and cooperative in no apparent distress. Decision making capacity: Intact; Skin warm/pink/dry.  Head: Atraumatic, PERL, Speech clear, No alcohol on breath; Neck: Supple and nontender without JVD; Anterior/posterior chest: Atraumatic with equal expansion, breath sounds clear to auscultation bilaterally; Abdomen: Soft and nontender to palpation; Pelvis: Stable: Extremities x4: Atraumatic and unremarkable. Sensation and movement intact and equal; SaO2: Whatever; ECG: Whatever; EtCO2: Whatever; BG: Whatever
Upon exam <vehicle description>

<Briefly list treatments and other interventions>, Transport without change or incident.
If I don’t examine a pelvis, I delete the pelvis part.  If I don’t look at the patient’s eyes, I delete the PERL part.  If there is no vehicle involved, I delete the vehicle exam. 

The finished subjective portion will read something like: “Upon arrival, found patient complaining of 10/10 chest pain radiating to left shoulder and jaw for 30 minutes.  Onset occurred while walking and patient describes pain as severe pressure associated with mild shortness of breath and anxious feeling.  Patient denies nausea/vomiting, abdominal pain, attempted treatments prior to EMS arrival, recent trauma or illness, alcohol or drug use, and previous similar episodes.”  Make sense how that fits together?

Notice a few things.  First, I don’t use abbreviations very often nowadays.  I have an electronic PCR system with my base template saved on it.  Some providers save their base narrative on a flash drive – same thing.  If it is saved, the abbreviations don’t save me much time because I am not really typing the narrative.  All I am doing is changing the “normal” findings to whatever abnormalities I found.  Second, note the importance of pertinent negative findings.  In addition, notice that it is all spelled correctly and is grammatically (generally) correct.  Finally, notice that I took the CAPS LOCK off.  It is not hard for me to briefly press the shift key with my pinkie finger when it is appropriate. 

Spelling and grammar are important.  What do you think of the intelligence and skill level of a medic who wrote something like this: “CALLED TO ADRESS ON A ROLLOVER ON ARRIVAL WE AN FD ON SCENCE FD IS TRYING TO GET PT OUT OF CAR. NOTE: PT CAR IS ON IT’S ROOF HEAVY DAMAJE TO CAR FRONT RIGHT AN LEFT SIDE AND REAR OF CAR AND ROOF PUSHED DOWN ABOUT 1 FOOT PT LEGS IN DRIVERS SEAT AN DTOP HALF OF PT IS IN BACK SEAT…”*  It doesn’t reflect well on the provider, does it?  He or she (face it, though, a narrative like that comes from a dude) may be a phenomenal caregiver.  But the impression gained from the narrative is a negative one.  Quit shouting a people with all-caps.  Use a period once in a while.  I have read PCRs about “nife wounds to rists”.  Use the spell checker, or ask your partner how to spell knife.
Luk out! It's a nife! Watch yor rists!
(Public domain via Wikimedia Commons)

Narratives are a very personal thing to a medic, and they don’t change a whole lot once the habits are set.  Hopefully, though, there is an idea or two in my narrative that you can steal and use in your future narratives. 

*Invented narrative, but it is pretty close to other narratives I have had the pleasure of reading.

October 11, 2014

The Ampule of Doom

Last week, my trainee partner and I ran on a crazy person who was escalated to the point of needing some help in calming himself down. Some haloperidol-type help.* The patient was recently released from a long-term psych facility and his behavior had been escalating over the last few days. This morning he had decided to lie in traffic in an effort to either end it all or go back to his nice, safe psych facility. When the police put a stop to the killing himself plan, the patient became loudly and floridly angry. 

The patient was restrained on the bed in the back of the ambulance, shouting about whatever he was shouting about, and my partner got himself a glass ampule of Haldol. He struggled for a few moments trying to find a 4x4 gauze pad, finally found one, and used the 4x4 to break the amp.
Justin Urgitis [CC-BY-SA-2.5], via Wikimedia Commons
I may have rolled my eyes. 

In drawing up the medication from the amp to the syringe, the medication spilled, so the whole process needed to be restarted. I told the trainee to just let me do it.

I explained in my most authoritative field trainer voice that the 4x4-wrapping-the-amp technique was taught to me in paramedic school too, but it is a waste of time. In almost 20 years of EMSing, I’ve never had an amp shatter and cut me. Just tap the medication out of the top half and break the amp. Like this.

Snap.

Except it wasn’t really a snap sound. It was more of a crunch sound. The top half of the amp shattered. About a quarter of the glass shards fell into the medication and another quarter fell on the floor. The remaining half of the glass shards were embedded in my now-bleeding thumb.

Dammit! Why must the EMS gods punish me whenever I confidently say something out loud?!?


I have to give my partner credit. Most other medics would still be laughing and talking shit.

*Personally, I slightly prefer droperidol-type help in calming down.  But apparently, it is impossible to get for reasons that are confusing to everyone. Either droperidol or Haldol is better than an 80kg dose of Brutacaine per police, though.

Slumper Car

“Ambulance 1, code 10 to eastbound Main Street east of Broadway.”
“Main and Broadway, 10.”
“Down party, slumper in a vehicle.  Fire’s going, police have it but nobody is assigned yet.”

I hate to run on slumpers in a vehicle.  A lot.  Hate.  They are one of my least favorite calls, as a matter of fact.  I hate slumpers in a vehicle for two main reasons.

First, slumpers never work out to be a medical problem requiring EMS.  In my experience, slumpers are people who fall asleep, DUI drivers, and people broken down on the side of the road.  The logic behind running emergent to a slumper doesn’t hold up – sorry, but people don’t die in their car without crashing into something.  They take their foot off the brake and roll forward until something stops their car.  Waste of a response.  I don’t have stats to back up my experience, but I stand by my opinion.  You can probably come up with that “…one time, five years ago, when that one guy was sort-of hypoglycemic…” and I still don’t care.  I’ve run dozens of slumpers since then, all with nothing really wrong.

Second, slumpers are dangerous.  Not many paramedics and EMTs recognize the danger in approaching a car.  It is similar to a traffic stop, with the added fun of waking someone up.  People wake up confused.  According to the FBI, almost 100 police officers were killed and more than 4,000 were assaulted during traffic stops between 2001 and 1010.  Even when a person isn’t specifically trying to hurt you, you can get hurt approaching a slumper car.

Imagine falling asleep in your car at a traffic light.  You aren’t doing anything wrong, you’re sober, just tired after a long day.  Suddenly, you are woken by tapping on your window.  Or the car door being pulled open.  There are bright flashlights and authoritarian voices.  People panic and do stupid things.  Some people floor it.  Some people fight.  Some people grab the pistol between the driver’s seat and the center console.

Traffic stops suck.  No, really, they suck.  Suh-huck.  

So, to me, running a slumper in a vehicle is the worst of both worlds.  Bad things happen, and the most common outcome is that I shouldn’t have even been there.  I’m not a police officer and I resent it when I am expected to act like one.

There are things that we can do that help to mitigate our risk on these calls, however.   I divide up the process into two phases – Before contact and making contact.

Before contact.  This is when you pull up behind the slumper in his crappy sedan, parked at the light.  What should you be doing and what should you be thinking about?
  • The first step is to realize that approaching a slumper in a vehicle is not a run of the mill job.  Pay attention to your safety and the safety of other team members.  Start with the right mindset. 
  • This is not a routine call!
  • You are essentially performing a traffic stop!  Ever been trained to perform a traffic stop?  Nope, me neither.
  • Like with a traffic stop, you don’t know who is in vehicle, what is in vehicle with them, what their intentions are, and how they will react to your presence.  Add into the mix that people know when they are pulled over that a police officer will walk up to their window.  Half-drunk guy who fell asleep at the traffic light isn’t expecting to see you.
  • Position your vehicle well.  Look at police cars at traffic stops.  The cruiser is usually placed so that it is closer to the road than the stopped vehicle.  This is to give the officer room to work at the side of the stopped vehicle.  Our process should be similar.  Take a lane to work in, and more if you need to.
  • Get yourself plenty of light.  Turn on everything.  Add spotlights and flashlights.  Light helps you see.
  • Consider the small details.  How many people are in the vehicle?  Is it running?  Is a window down? 
  • Update dispatch on what is going on.  Include a description of the vehicle with the make, model, and color.  Give out the license plate and describe the vehicle’s occupant as best you can. 
  • Position yourself well.  Do not stand in front of the vehicle.  You will be run over if a foot comes off the brake, or if the confused person inside decides to take off.  Do not stand behind the vehicle.  Same reason.  Stand on the sides of the slumper car.
  • Never stand between two vehicles.
  • As you walk past the trunk, press on it to make sure it is closed.  This is important to cops, for some reason.  I don't really understand it, myself.  But it seems like a ton of cops have made this a habit.  So it must be important on some level, right?
  • Stay behind the rearmost person in the vehicle, as much as you can.  If there is only a driver, use the B-pillar to mark your furthest forward point.
  • Use your flashlight and see what is going on before you begin an interaction.  Take a few seconds to check where the person’s hands are (and what’s in them).  Are the keys in the ignition?  How do the doors unlock (slide things or little posts at the windows).  Are there weapons visible?


Contact.  This is when you ‘break the egg.’  You are going from looking at a dude in his car to contacting the dude.  Unfortunately, in the worst cases, he is locked in a car with all the windows up.
  • Let dispatch know that you are approaching and if you don’t check back in within 60 seconds, they should call out everyone.  Cops, more medics, National Guard, jets flying over, swimming ducks, dogs and cats living together, everyone.  If I have not checked back in, dispatch had better get friggin’ Seal Team 6 fast-roping into the intersection cause things have gone sour…
  • You and your team should have three main goals.  Hands. Ignition.  Out. 
  • Hands means to know what is in the patient's hands - nothing, gun, penis, whatever.  Optimally, I would like to control the slumper’s hands. Don’t let them go for waistbands, shift levers, or the gap between the seat and the console. 
  • Get the ignition shut off, along with putting the car in Park.  Cars roll less when they aren’t running and are in Park.  When cars roll less, they run over fewer people.
  • Finally, get the slumper out of the car so we can revert from a police-type call to an EMS-type call. 
  • To me, the trick is to make sure that everyone on my team knows my goals.  We can all work toward the same end points.  In order to get to hands, we need to get the car open.  If a window is down, the first action should be to unlock all the doors.  Once we start, the process needs to be pretty smooth and rapid. Car door open, get hands, partner shuts off car from the passenger side, say reassuring things to the confused person, get them out of the car.
  • Break a window? Probably best to get the cops there for that, unless I can overtly see that there is obviously a medical problem going on.


If nothing else, I hope this post makes you think about the fact that approaching a slumper in a car is not a run of the mill thing.  What do you do if they try to drive away?  (I let them – I don’t endanger myself by trying to stop them.)  What do you do if they are drunk, but only drunk?  (Not a medical problem – now I have to wait on the cops.) 

These are not routine calls.  Make sure to keep yourselves safe.


Seriously, I am not paid enough to do this in the real world.
By U.S. Navy [Public domain], via Wikimedia Commons

October 4, 2014

Aphasia

You are assigned to the report of a CVA in a skyscraper downtown. You arrive on scene of the 23rd floor to find a 64-year-old attorney complaining of a headache and difficulty speaking. She seems to start sentences, try to think of the right words, fail to find the vocabulary, and shake her head in silent frustration. There are no deficits to her grips, no arm drift, and her speech is clear. There is no recent history of head trauma, car accidents, falls, shark attacks, or bar fights. She just doesn’t seem to be able to find the right words and it is pissing her off.

What's going on? Are you worried?

Aphasia is a general term that describes language problems that range from mild to severe. It is related to brain damage (as compared to mouth or other damage), usually involves the left hemisphere, and may affect any form of communication. Aphasia means that a patient can have problems with speaking, comprehending speech, writing, reading, and even gesturing.

Language comprehension arises in two main areas of the brain. Broca’s area is in the inferior-posterior portion of the frontal lobe. It is important in the translation of thoughts into speech. Wernicke’s area is involved in understanding speech and writing, and is located in the posterior portion of the superior temporal gyrus. Both areas are located in the dominant hemisphere of the affected patient, which is usually the left hemisphere.
Public domain, via Wikimedia Commons

Aphasia can be chronic or acute. Chronic aphasia usually involves tumors, infections, and dementias. That isn’t what we are talking about here, though. Acute aphasia is usually the result of acute processes, such as CVA, migraine, or head injury. The patient in the scenario, being a working lawyer, is experiencing acute aphasia. She uses verbal and written communication in her job on a daily basis. She doesn’t report recent head trauma, so the likelihood of stroke or migraine being the cause of her aphasia increases. 

There are a ton of different aphasias:
  • Expressive aphasia is the inability of a patient to speak or write. It is the inability to put out language and is related to damage in Broca’s area. It is a problem with the brain, not with the tongue, mouth, or vocal cords.
  • Receptive aphasia is also known as Wericke’s aphasia or sensory aphasia. It is characterized as the inability to understand spoken or written language. Patients with receptive aphasia speak normally; they just don't understand you. (Think about how frightening it is to have everyone around you look like you expect, but speak in an unintelligible foreign language.)
  • Anomic aphasia is characterized by the inability to remember certain words or names. Patients with anomic aphasia will sometimes talk around a subject in order to describe it (i.e. describing big white ducks that honk rather than quack, rather than using the word ‘goose’).  It is odd to see someone not be able to recall the word 'pencil'.  It is scary to them, too.
  • Global aphasia is the combination of receptive and expressive aphasia, meaning that patients experience difficulty with both speech and understanding at the same time. It is usually the result of widespread left-sided damage (sometimes described as a ‘left-side blowout’).
  • Conduction aphasia is pretty rare. It is characterized by difficulties in repeating speech. Patients can speak their own thoughts without difficulty, and they understand everything that is said to them. But there are problems with speech repetition.
  • Primary progressive aphasia is a form of chronic aphasia related to dementia. It presents with gradual problems with object naming, problems with simple math, and changes in abilities to execute learned movements (like writing or walking, for example).
  • There are others. A lot of others. A whole metric ton of others. But concentrate on the ones above. Especially the first three or four.

There is a lot of research that looks at how rehab reverses aphasia, and long-term topics like that. There isn’t a whole lot of research on acute aphasia that relates to the prehospital setting.
  • Laska and a bunch of others1 wrote up a study of 119 consecutive patients with aphasia. They found that about one-third of stroke patients presented with some form of aphasia. Eighteen month mortality was twice that of non-aphasic patients, and atrial fibrillation was associated with worse outcomes. There is about a 25% rate of complete recovery at 18 months. 
  • Pedersen’s group2 looked at almost 900 consecutive stroke patients, specifically looking for aphasia. About 38% of stroke patients had aphasia at admission and 18% of stroke patients had aphasia at discharge.
  • Berthier3 performed a review of aphasia. The important finding here is that aphasia is present in 21-38% of acute stroke patients, plus is associated with increased morbidity, mortality, and costs.
  • Tsouli, et al.4, reported on 2,300 stroke patients in Greece.  Of those, 35% had aphasia. The authors found that increasing age, atrial fibrillation, worsening severity of the stroke, and hypertension were associated with higher rates of aphasia. This study indicates that the presence of aphasia was an independent predictor of dependence at one year.

In the end, there are a few main lessons about aphasia for you to remember. First, acute aphasia should equal stroke in your mind, especially in the absence of other causes. It is a big deal. Second, it is also a big deal to not be able to use language or otherwise communicate. It is part of what makes us human. It takes a significant lesion in the brain to remove this ability from us. Keep in mind that a person has to be really, really deeply drunk to lose the ability to speak, right? Essentially people become unconscious before they quit being able to talk. So the inability to talk is a big deal. The inability to understand is worse. And finally, aphasia is deeply frustrating and frightening to patients, as well as being irritating to medics. The inability to speak is terrible. Be patient, calm, and reassuring with these patients. Just because they can't speak doesn't mean that they don't understand.


1. Laska AC, Hellblom A, Murray V, Kahan T, VonArbin M. Aphasia in acute stroke and relation to outcome. J Intern Med 2001;249(5): 413-22.
2. Pedersen PM, Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Aphasia in acute stroke: Incidence, determinants, and recovery. Ann Neurol 1995 Oct;38(4):659-66.
3. Berthier ML. Poststroke aphasia: epidemiology, pathophysiology and treatment. Drugs Aging. 2005;22:163–82.
4. Tsouli S, Kyritsis AP, Tsagalis G, Virvidaki E, Vemmos KN. Significance of aphasia after first-ever acute stroke: impact on early and late outcomes. Neuroepidemiology. 2009;33:96–102.