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!

The Craftsman Clinician

Below is a guest post from Garrett Chism, MBA, EMT-P. Garrett has been in EMS for 25 years. He currently works as a Paramedic for Denver Health and Adjunct Faculty for Metropolitan State University of Denver. I hope you enjoy his thoughts as much as I did. 

-Bill

Things I love: Hearing Garrison Keilor tell a story; the pianist carefully choosing the perfect note; the movement of a brush on canvas; the sound a perfectly sharpened hand plane makes on hardwood… And the moment a new clinician runs their perfect call and knows it. The smile and confidence they have at that moment is worth it all.

In my older age I have become slightly obsessed with craftsmanship. I spend a fair amount of time reading, watching, and listening to different forms of craftsmanship. Recently, I sat in the front of the ambulance and thought about what makes a craftsman? Do I, as a clinician, act as a craftsman?

Merriam-Webster defines craftsman as “a worker who practices a trade or handicraft; one who creates or performs with skill or dexterity especially in the manual arts.”

I find that definition to be inadequate. The difference between a craftsman and a dilettante amateur is the pursuit of perfection. As I ponder this I am preparing to teach a new employee. I have taught for most of my career. I used to think I was fairly decent at it; however, age has given me a clear lens to the mistakes of my male, egotistical youth. So as I prepare to teach again, I began to think, “What would a craftsman clinician do differently?” I ask myself how to pass on the experience of my chosen craft… not the drama, not the ego, not the inflated stories, but the really important lessons that others wiser than me have taught me. Here is my list of what makes the first cut. I hope you find this helpful, add on to it, and pass it on.

1. Be the patient’s advocate. This takes many forms, I am sure you've heard them before, be their advocate… many times you are the only one who is. The craftsman clinician makes all decisions based on this golden rule.

2. Communicate like a human being. Listen, don’t hear. Clinicians who are craftsman aren’t rapid firing questions at patients to get the quickest answer possible, only to be forgotten not ten seconds later. A craftsman clinician listens, with the intent to learn and understand. Talk to patients like they’re a friend or family member… because they are someone’s. 

3. Stop making assumptions. When I moved into a position in the hospital, I was amazed on how little I knew, how often EMS is wrong, and how much larger the patient experience is beyond the walls of the Emergency Department. I often say that even the best clinician can never be as good as the one that has been a patient before. Craftsman clinicians don’t pretend to know everything. Rather, they actively educate themselves on different areas of medicine with an open mind of what EMS can do to make the total patient experience better.

4. Focus only on the things that matter and spend lots of time perfecting them. Practice perfecting every detail of your craft. Hone a complete patient assessment, the perfectly executed treatment plan, the clear transition to the next clinician. 

5. Care. Beyond caring about your patient, care about the work you do. Care about your peers and students, as well. It’s great to practice medicine, but practice with the intent of improving every single time. Craftsman clinicians care so much about perfecting their craft that the end result is the best possible experience for a patient.

Craftsmanship takes time. It takes generations to develop. It takes constant pursuit of perfection in the tools, the education, the mentors… especially the mentors. Craftsmen dedicate their lives to their craft, love their craft, perfect their craft, and want nothing more than to pass that love on to the next generation.

Garrett Chism