Noncompliance

When I was an angry, angry captain responsible for quality assurance, working in a basement dungeon and rarely being allowed out in public, I found out that there were three main reasons for not complying with a directive.

Dunno, can’t, and won’t.

Dunno encompasses all of the times that an employee “don’t know” something.  When an employee doesn’t know that something is required.  When an employee doesn’t know how to do something.  When an employee doesn’t know how to use a piece of equipment.  When an employee doesn’t know how to document that s/he did what was required.  Some people are just a wee tad hypocognitive and need to be reminded more than once. 

Most of the dunnos are corrected in paramedic school – a medic learns to run an arrest, intubate, start an IV, and that kind of crap.  Then they are hired into a job and an HR person goes over the other requirements, so they know how to wear the uniform, how to clock in, and how to call in sick.  Finally, a field training program of some sort covers a whole bunch of the other dunnos (and correct some of the stuff learned in school).

After all of that, though, there are still requirements that change, new procedures, and new equipment that have to be learned.  Anytime something changes, drops, or is adopted there is someone who is slow to get the proverbial memo.  Hell, I still occasionally think of Bretylium, bicarb in arrest, and MCL1 from time to time.  It took me a year or so to remember to use aspirin when we first got it.

I am optimistic that there is a bright and happy future where I
am embarrassed at being so old as to even think of this.  Credit

The “can’t comply” form of noncompliance occurs when an employee knows about a directive, but systemic factors are standing in the way.  For example, you can have a standing order that says an employee must complete the PCR before leaving the ED, but if there is another call for them that dispatch is nagging about, the run sheet is probably not going to be left. 

Another good example of this was back when we adopted waveform capnography.  End-tidal CO2 must be documented for all intubated patients.  All employees were told about the new requirement.  But even after allowing time for adoption, re-explaining the requirement, and pulling my hair out, there was still embarrassingly low compliance.  Then one day a medic explained it to me, like I should have known about it all along.  See, the EtCO2 equipment was hidden away.  Thus, it was a pain in the ass to get out and use when you had a patient sick enough to require a tube.  I don’t know why the capnography adapters were so hard to find, but all it took was moving the equipment to the airway cabinet for compliance to shoot up.  The medics wanted to comply, but there were problems standing in their way. 

If an employee knows that something is required, knows how to do it, and there is nothing standing in their way, then all you are left with is that they “won’t comply.”  Employees that truly won’t do what is asked of them shouldn’t be employees for long.  But most employees aren't actually willfully disobedient, so this is rare, and a topic for another time.

One of my biggest flaws as a manager (and, I freely admit, there were many) was that I was habitually too quick to assume “won’t” when “dunno” or “can’t” actually explained what was going on.  If you find yourself in a management position, please make sure to always look for the can’t and the dunno first.  One of the major roles of managers and supervisors is to get rid of the can’ts and dunnos in your organization and allow good employees to be good employees.

Bumsicles

Two weeks ago was the first real cold snap of the season.  It got butt-ass cold.  Cold like a well digger’s brass bra cold.  You know the cold that is so cold when you inhale through your nose and can feel the boogers freeze?  Or when you climb in your car and it creaks and crunches like an arthritic old man?  Cold like that.  The second day of the cold had a high of 7°F, but that was the high for the day.  When my shift started at 6 AM, it was much, much colder. 

Ever been in cow-freezing cold? I have - goose hunting in Wyoming...
Public domain, NOAA, via Wikimedia Commons

The city is generally good to the homeless on nights like that.  At night, most of the shelters toss out the rules and throw their doors open.  Most shelters normally don’t accept intoxicated people, but when it gets so dangerously cold outside they drop that rule.  "Come on in drunk, if you need to.  If you are a needle drug user, please try to keep it to that corner over there."  But not everyone gets into a shelter, and many shelters close first thing in the morning.  Everybody gets kicked out for the day.

My first call was right out of the garage.  A homeless man was forced to leave a shelter when it closed.  He had immediately developed chest pain.  I am not going to make any statement about his chest pain or the fortuitous timing of the pain.  The second call was for a different urban outdoorsman in a wheelchair inside a convenience store.  He had been hanging out inside the store and when he was asked to leave, dude had a seizure.  He only had socks on his feet – the hospital socks with the plastic tread on them.  I am not going to make a statement about the nature of his fortuitously timed seizure.  The third call was for a undomiciled lady who began to cause a scene in a coffee shop when she was asked to leave after hanging out for an hour or so.  There was really nothing wrong with her, except for being loudly and profoundly upset about having to be out in the cold.  She complained that she moved here for the legal weed, but didn't realize how cold it could get.

It was, all in all, a frustrating morning.  It was a waste of EMS resources.  It is not what I imagined when I began my EMS career.  (In my imagination, my job involves crawling through the broken window of an upside-down sorority bus with a laryngoscope and an ET tube during a nocturnal thunderstorm.  Lightning flashing, thunder roaring, that kind of hero thing.  My job is pretty badass inside my head.)  It is also a waste of hospital resources.  I pretty much guarantee that taking care of a cold bum with “chest pain” isn’t why the doctor got into med school.

You know the most frustrating part?  There is no answer to the problem.  I would have chest pain too, if I had to spend my day outdoors with a high of 7°.  Hell, I would jump in front of a bus if I had to, in order to get indoors.  What’s the answer?

I decided that it is okay that I don’t have the answer.  It is not my job to solve this problem.  My job is to make each patient’s day a little bit better.  When it is cow-freezing cold out, I can do that with a ride to the hospital.  I get paid hourly.  I don't get a bonus based on how many people I transport are actual, imminent emergency patients.  All I have to do is give someone a ride to the hospital, their situation is better than when I found them, and my job is done. 

Listen, schizophrenics stop taking their meds.  Women go back to physically abusive boyfriends.  Alcoholics continue to drink.  Homeless people are homeless.  These are complex problems that are multifactorial and difficult to solve.  It doesn’t help for me to get frustrated or angry about the situation.  I didn’t cause it and I can’t fix it.

I have to give credit – I usually hate it when my patient goes to the waiting room when we arrive at an emergency department.  But on this day there were hospitals sending me to the waiting room.  Once there, the triage nurse would ask whether the patient wanted to get checked in with a problem, or if the patient just wanted to sit in the waiting room until they were ready to leave.  The hospital had no problem if they sat in the waiting room quietly.  Several patients took advantage, without getting checked into a room for a full evaluation.  There is a balance there: You don’t want to turn the waiting room (where my family would wait) to turn into a shelter, but kicking people out will probably result in higher evaluation costs and uncollectible future toe removals.

Toes, twelve days post frostbite injury.
By Dr. S. Falz (CC-BY-SA-3.0), via Wikimedia Commons, with permission

The ED staff didn’t have answers for the problem either, so they just concentrated on helping people.  Focus on making the day of the person in front of you a little bit better.  Isn't that one of the main reasons you're in EMS?

The Art of Confusing a Customer

This week I had to go to the tire shop to get a little puncture in my tire repaired.  While I was hanging out waiting on the work, I overheard one of the salesmen explaining tire options to a lady. 

Apparently her Mercedes sedan used 225/45-17s on the front and 245/40-17s on the rear wheels.  But if she wanted, she could go with the 225/45-18s on the front with 245/35-18s on the back.  But then she would have to get eighteen inch wheels, which shouldn’t be a big deal if she traded in her 17s.  The Yokahamas were studless winter tires, but cost about $50 more than BFGoodrich’s speed rated tires.  Did she know about speed rated tires?  No?  Don’t worry about it.  Anyway, the Bridgestones had a longer warranty, but cost $20 more per tire and would need different wheel-mounted pressure sensors.  There was a cheaper Bridgestone tire, but it wouldn’t work on the eighteens they were talking about.

Something like that.  The dude went on offering confusing options for about fifteen minutes.  I quickly became confused by all of the jargon and choices.  Apparently the customer did, too.  (You did too, I bet.  Didn’t read all of that paragraph, did you?)  She extricated herself from the salesman, saying something about needing to sleep on it.  I bet she just went to another shop where someone competent helped her.

This salesman offered her too many choices, based on technical information that she didn’t understand.  There is no way for her to understand the relative benefits, costs, risks, and sizes in all the different combinations.  Nor did she need to understand all of that.  Do you know why she doesn’t need to understand all of that?  She isn’t a tire salesman!  That’s what we pay tire salesmen for!

I’m not a tire expert.  The last time I had to buy tires, the salesman asked what kind of tire I wanted.  I said, “Black ones.”  My knowledge was exhausted at that point.

Dude, I don't even know.  Is that the right size for a Honda Civic?  I mean, at least it's black and all...
By Greencolander, via Wikimedia Commons

The salesman should have learned what the customer needed and then offered his recommendation.  Did she drive long distances at highway speeds, how much winter driving did she expect to do, that kind of thing.  Using that information, he (the expert) could know the two or three best options for the customer.  The customer still gets a choice, cheaper with short warranty or more expensive with long warranty, that kind of thing.  But the lady wouldn’t have been overwhelmed.  If the two or three options he offered didn’t work, move to the fourth one.  He shouldn’t have shotgunned choices at her.

The same thing happens in EMS.

We need to inform people of technical information all the time.  But most of our patients are not medical experts. It is difficult for a non-expert to accurately weigh the risks and benefits of a given choice, multiplied by the relative odds that condition such-and-such is even what they have going on.  When you add in fear, uncertainty, embarrassment, and pain, the ability to make complicated choices becomes nearly impossible. 

People get confused.  Experts need to de-confuse people by giving them simple information. 

I use this phrase all the time: “If it were me…”  Repeat after me: “If it were me…”

“If it were me, I would stay home, rest, and take some ibuprofen.  There is always a slim chance that something terrible is going on, like a one in a million broken neck.  But in my opinion, based on everything I see here, the risk of that is really low.  It is common to be sore after a jolt like this and it usually better after a day or two of rest, ice, and ibuprofen.  How’s that sound?”

“If it were me, I would send him to the hospital in the ambulance.  This could be something minor like a breath holding spell, but I don’t like to mess around with breathing.  Breathing is important, right?  If you let me take your son, I can keep an eye on how he is breathing and intervene if it comes to it.  How’s that sound?”

“If it were me, I would probably get my wife or a friend to drive me to an urgent care.  They can shoot an x-ray and take care of it if it is broken.  It would be a lot cheaper that way, too.  But if you want come with me to an ED, it is probably more expensive but I can give you some painkillers to help you feel better on the way.  It’s up to you, based on how much pain you are in.  But one way or the other, you need to get to a joint with an x-ray.  What do you think?”

Give people your honest opinion.  You are an expert.  Work in their best interest.  You have an opinion.  Let them know that it is your opinion by using the phrase “If it were me.”  But you have to give people your expert opinion of what is going on.  Tell people what they should do.  If you don’t know something, tell them that you don’t know. 

Base your opinions on what would be in the best interest of that patient.

People still make choices opposite my opinion all the time.   I’m actually okay with that.  Information is what patients deserve, so that they can make decisions.  Give the information, show them the best path based on your training, knowledge, and experience, and let them make their choice.  Don’t be the tire salesman, spreading confusion in your wake. 

Injuries

I’ve only had a few injuries at work.  Mostly, I’ve had to deal with soreness from a standing fall on an icy driveway, or that kind of thing.  I get soreness at my low back and SI joint when I carry obese patients down narrow circular staircases.  Doesn't everyone?  I’ve only had two injuries that have made me stop patient care, though.

My first needle stick was a scary event for me.  I was an EMT and starting a line on a patient on the way to the hospital.  I can’t even remember what was wrong with the patient.  I got the IV catheter inserted and reached across the patient to my left for the sharps container.  It was on the wall by the back door then.  There was another needle that hadn’t been completely swallowed by the red box.  Doink!  A jab in the thumb.  

I went through a range of emotions.  Elisabeth Kübler-Ross should have watched an EMT get a dirty needle stick, rather than study grief.  Confusion – what was that?  Irritation – dammit, that was a needle.  Pondering - which patient was that needle from?  Different confusion – wait, we haven’t used a needle this shift.  Fear – whose needle was it, then?  Hope – maybe it just hurt and didn’t break the skin.  Disappointing return to fear – nope, that is blood on my thumb.

See where it says 'Lift to Assure Disposal'? The ass who had my bus last didn't do that.
(By BrokenSphere, Public Domain, via Wikimedia Commons.)

I was just stuck by an unknown needle.  Well, the brand new second patient in the back of the bus with the bleeding thumb had just been triaged pretty high by this EMT at that point. 

Glove off, peroxide being poured everywhere, alcohol rubbed into the (admittedly very minor) puncture, muttered curses and oaths, and wishing I had bleach to soak my thumb in were the steps I followed, rather than continue whatever patient care I had in mind before the event.  I’ve had five or six other needle sticks in my twenty years of EMSing, and my personal self-treatment protocol is pretty much unchanged.

Needle sticks suck, but the other time I stopped patient care was especially stupid.  I was transporting an extremely ill CHF patient to the hospital.  She needed to be intubated, but was conscious, so blind nasotracheal intubation was the choice.  No problem, the patient was sitting as upright as the pram would go and I nasally intubated her. 

I had the grand idea to stabilize myself while I was doing this two-handed procedure.  In order to be properly stable, one needs three points of contact with one’s surroundings.  My normal procedure in this setting is left foot (one), right foot (two), and my hips (three) against the back of the upright bed.  My spectacular idea this night was to not use my hips as the third point of contact. 

I used my head.

That isn't a figure of speech.  You see, I pressed my head against the ceiling of the ambulance.  Two feet, one head: three points of contact.  I am a little taller than the inside of the bus, so it worked fine.  I was stable.  It was awesome – so much better than being bent over.  Bending and hunching always killed my back (and still does).  I think I may have wondered why ambulance manufacturers didn’t set this up with a head-shaped cup on the ceiling.  Awesome!

The patient was intubated, the placement was confirmed, and I was tying the tube down when we hit the speed bump.  Apparently, my partner didn't see it in the dark.  So we crashed into it at 40 mph or so.  I think we got air.  

My neck crunched and I was blinded by pain.  I might have peed myself a little.  My arms went numb.  I sat down into the captain’s chair and rested myself.  I had never felt so stupid.  I realized why people didn’t brace themselves like that.  I could move my arms, but my neck was pretty stiff and I couldn’t feel anything from my upper extremities.  The firefighter who was riding in with the patient and me saw me flop into the chair and probably thought I was really relived to have the patient intubated.  I just sat there to the hospital while he squeezed the football.

After arriving to the ED, I got myself out of the bus, walked into the ED, gave my report, and wrote my PCR.  I got myself some ice from the lounge, put it on my neck, and went back in service. 

I didn’t tell anyone about my neck pain.  I was too embarrassed.  I still haven’t (until now).  My arms were numb for two days and then got better.  My neck bothers me from time to time, but not bad enough to get it checked.  I know that I got lucky.  I don't know which was stupider, crunching my neck in the back of the bus or not telling anyone (or even getting it checked out).  Wait, yes I do.

Anyway.  Lesson: Look at sharps containers and don’t wedge yourself in the back of the bus with your head. 

What is a Distracting Injury?

This is probably one of those posts where I point out that I am not your medical director, I don’t sign your paycheck, and I have nothing to do with whether you continue your employment or not.  So use your own best judgment and do what you think is right.  With that being said…

You are sent to the riverside bike path on the report of a bicycle crash.  Of course, it is like any call on a path away from road signs – it takes forever for the caller to figure out enough landmarks for you to find the call.  In any case, after your irritatingly long response time, you arrive to find a 50-year old male who was spending his morning riding several thousand dollars of carbon fiber.  For whatever reason, he was forced to swerve at speed off of the concrete path.  Off the path, he struck a bench and was thrown forward off of the suddenly stopped bicycle.

You find him awake and alert, but in obvious distress.  He is cradling his right arm and complaining of severe right shoulder pain.  Making a long story short (because you don’t want to spend all day reading this), he has a demolished right shoulder – probably a fractured clavicle, maybe dislocated, and maybe humeral or scapular fractures.  It is all a tender, swollen, discolored, and abraded mess.  His distal sensation and circulation are intact, but the shoulder is just wrong.  Interestingly, his helmet is rather abraded and cracked, as well.  The patient denies loss of consciousness, and additionally denies neck pain or tenderness. 

Do you immobilize him?

The spinal immobilization criteria in my system are pretty similar to the NEXUS criteria.  We don’t need to immobilize if there is no focal neuro deficit, no midline spinal tenderness, no altered consciousness or intoxication, and no distracting injury.  He has no neuro deficits, no spinal tenderness (or pain), and is not altered or intoxicated.  Does he have a distracting injury?

The NEXUS literature defines a distracting injury as “a condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury.”¹  The Canadian C-spine rule describes distracting injuries as “injuries […] that are so severely painful that the neck examination is unreliable.”²  Common examples include long bone fractures, visceral injuries requiring surgical consultation, large lacerations, degloving injuries, crush injuries, large burns, and injuries producing acute functional impairment (whatever that is).  Okay, we got it – stuff that hurts.  Heffernan added any painful chest injury³ and Konstantinidis showed that the 4% of patients with painless neck fracture all had rib fractures and/or severe chest tenderness.  So add chest injury to the description of distracting injuries, I guess. 

Everything in this video would result in a distracting injury to me...

All of the listed injuries above vaguely irritate me.  The authors made a good faith attempt to objectively describe injuries that are likely to distract a patient.  And I think that they failed.  They failed because the task is impossible.  I get that a femur fracture (long bone fracture criteria) is probably a distractor.  But what about a distal tibia fracture?  I drove myself to the ED four hours after fracturing my distal tibia – I wasn’t distracted.  How severe does a burn have to be?  How much degloving do you need?  What is "severe chest tenderness"?  Are pelvic fractures (not being long bones) never distractors?  What the hell constitutes a “large” laceration?  Speaking of hell, what the hell is acute functional impairment – an injury that the patient doesn’t want to move?!?  

If you ask me, “any testicular injury” should be on the list of distractors.

Jackie, I thought you were better than that...

Everything is still subjective.  Sorry, but you still have to make a decision.  Is the patient distracted by his/her other injuries?  Answer the question.  A distracting injury is something so painful that the patient can't pay attention to other injuries.  They feel nothing but the distractor.  It has 100% of their attention.  So how do we decide where that line is?

I have an idea.  This is something that I have done for years.  It is not supported by literature, but see if it makes sense to you.

Check if the patient is distracted. 

Do this in blunt trauma, because who still immobilizes penetrating trauma?  So what you want to do is pinch one of the patient’s fingers without them being able to see the finger.  They have to feel the pinch.  Cover their hand with a blanket, cover their eyes, whatever makes sense to hide their fingers.  Squeeze a finger, about as hard as you do when you check capillary refill and hold it.  Ask the patient which finger you are squeezing.

If they get the answer correct, especially if you repeat the test with lighter and lighter touch, they can separate the pain from their other injury from their other neurologic inputs.  They are also likely to be able to recognize midline cervical tenderness when asked.  They are demonstrably not distracted.  Thus, if they can identify which finger your are touching, they probably don’t have a distracting injury. 

What do you think?  Does this make sense to you? 

The patient described in the beginning of this post passed the squeeze test.  He could even identify which finger was being lightly scratched with a fingernail.  I decided that even in the face of a destroyed shoulder and cracked helmet, I felt like I could trust his denial of spinal tenderness. We had a talk about immobilizing him, paralysis, and distracting injuries while I was starting an IV.  He agreed that immobilization was unnecessary.  So I didn’t immobilize him.  There are other patients who are in such pain that they can’t even pay attention to the fact that you are trying to test them, however.  Those patients have distracting injuries and get immobilized in my bus. 

If you are concerned that a distracting injury is present, check if the patient is distracted. 

1. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM 2000;343:94-99.

2. Stiell IG, Wells GA, Vandemheen KL, Clement CM, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

3. Heffernan DS, Schermer CR, Lu SW. What defines a distracting injury in cervical spine assessment? J Trauma 2005; 59: 1396-1399.