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.

The Chuck Yeager Voice

Chuck Yeager is a West Virginian pilot who was a fighter ace in World War II, was shot down over occupied France, evaded capture, became a U.S. Air Force test pilot at the very beginning of the jet age, led fighter squadrons and wings over Korea and Vietnam, and became the first pilot to officially break the sound barrier on October 14, 1947.  He performed the last feat hiding a set of broken ribs from his boss and the flight surgeon, and the flight profile didn’t actually call for the barrier to be broken that day.  The man is a genuine badass.  

He touched American culture in another way, however, as explained by Tom Wolfe in his 1979 novel, The Right Stuff:

Anyone who travels very much on airlines in the United States soon gets to know the voice of the airline pilot… coming over the intercom… with a particular drawl, a particular folksiness, a particular down-home calmness that is so exaggerated it begins to parody itself… the voice that tells you, as the airliner is caught in thunderheads and goes bolting up and down a thousand feet at a single gulp, to check your seat belts because 'uh, folks, it might get a little choppy'… 

Who doesn't know that voice! And who can forget it, - even after he is proved right and the emergency is over.  That particular voice may sound vaguely Southern or Southwestern, but it is specifically Appalachian in origin. It originated in the mountains of West Virginia, in the coal country, in Lincoln County, so far up in the hollows that, as the saying went, 'they had to pipe in daylight.' In the late 1940s and early 1950s this up-hollow voice drifted down from on high, from over the high desert of California, down, down, down, from the upper reaches of the [Pilot] Brotherhood into all phases of American aviation. It was amazing. It was Pygmalion in reverse. Military pilots and then, soon, airline pilots, pilots from Maine and Massachusetts and the Dakotas and Oregon and everywhere else, began to talk in that poker-hollow West Virginia drawl, or as close to it as they could bend their native accents. It was the drawl of the most righteous of all the possessors of the right stuff: Chuck Yeager.

Yeager's unconcerned, modulated speech pattern - twang and all - was copied from pilot to pilot until it diffused out of the test pilot program into general aviation, where you have heard it while flying yourself.  And from there it diffused into other fields - like EMS.  This pattern is something that we all should aspire to when on the radio.  Not the Appalachian twang, necessarily, but the calm, unperturbed professionalism.  When I am on the radio or the biophone, I try to make it so that a listener can’t tell if I’m in the middle of the hairiest scene ever or a call we’ve each run three times that day.  I strive for the same calm, clear, professional voice – unruffled, no matter what. 

It takes five seconds to think about what I want to say, take a relaxing deep breath, and make a conscious effort to channel General Yeager.  But those five seconds are a worthwhile investment rather than transmitting a weepy shriek for additional units.  It sets up the rest of the call for success or failure by establishing the mindset for the other involved people. 

“Uh, Dispatch, Ambulance Five.  This will be a MCI with at least four critical GSW victims. Can I get three more ambulances and a supervisor to this scene?  And can you give preliminary notification to the ED when you get the chance, please?”  Modulate the tone to a conversational pattern, speak clearly, and slow your speech.  It is the equivalent of saying, “Uh, folks, this is the flight deck.  Hope you’re having a good flight.  We seem to have had the right engine tear plum off the wing.  So I’m going to have to illuminate the seat belt light and, um, ask you to go ahead and return to your seats…”

When I think about it, it is important to practice this habit beyond radio transmissions and phone calls.  Think about how a family will interpret shouted, excitable orders and big arm gestures versus the calm direction of a scene by a professional who ‘has it under control.’  Think about how a patient interprets: “Jesus, dude! We’re losing him! Put your foot down!” versus asking for a bit more speed in the transport in a conversational tone.  It doesn’t matter what your brain is screaming at you – act like you’ve got everything under control.

I will also admit, when I think about it, that panicked shrieking is helpful in some cases.  In my system, we have the ability to communicate directly to the police on their patrol channels.  For a bunch of reasons, it is best to call for help directly on the police frequency.  Shrieking for help in that case also sets up those personnel with the mindset that I want.  There had better be a really good reason to have every cop in the city speeding to me with their fangs out, cause someone is likely to take a whoopin’.  But those situations do exist, on occasion.

In general, however, sounding all worked up and panicked is definitively not the way to look cool.  And “Look cool” is EMS Rule #2.  So channel “the most righteous of all the possessors of the right stuff” when you’re on the radio – General Chuck Yeager.

Problem-Solution

There was a note in my most recent annual review that made me proud: “Never brings a problem to a supervisor without a specific solution.”

Its funny – it is unintentional on my part, at least when I am dealing with supervisors.  I suppose what they mean is that I call them and say something like, “I’m out of narcotics, so I need more.  If you’re nearby I can meet up with you, but otherwise I will need to go back to the garage.”  Problem, solution.  I don’t just call and tell them I am out of narcotics.  When I was a supervisor, it was certainly my preference because I didn’t have to absorb the information, decide on what the real problem was, prioritize the problem among my other issues, and work out an appropriate solution.

I see this as being similar to my expectations when I am on a call.  When I ask for additional units, for example, I have a specific job for them and specific instructions as to what I want them to do.  I would never call dispatch and say, “There are four patients here.”  I would ask for what I need: “I need another nonemergency ambulance.  Have them access from the north and park behind my bus.”  I guess that habit kind of carries over.

I also follow this pattern when making base contact to consult with a physician.  It would be especially unusual for me to say, “I have a patient with Symptom X. What should I do?”  My normal pattern is to explain the issue and then explain my plan.  I end it with something like “How does that sound?” or “Do you have any other ideas that I am missing?” (I'm trying to stop, but sometimes I just pause when I am done talking.  If they don't speak up, I take that as their approval of my plan.)

It should be noted that I am open-minded.  Another plan can certainly replace mine.  This is true when I’m letting a supervisor know about an issue I’m having, as well as on a scene or on a phone call with a base physician.  If someone else has a better plan or more information that I don’t have, let me know; we’ll work it out.

I began to watch how often other providers act like this.  The results are mixed.  When they personally need something, medics will ask for it specifically – like with schedule changes, for example.  If a medic needs a day off, they will tell the supervisor about the wedding they need to attend and ask to be removed from the schedule on that day.  This doesn’t hold as true for other systemic issues, equipment issues, and the like.  Some will explain both the problem and solution and others will just explain the problem. 

I have heard way too many examples when it doesn’t happen in exchanges with dispatch, which is one of my pet peeves.  If you’re the provider on scene, tell dispatch exactly what you need.  Don’t tell them your problem, tell them your needs.  I am not talking about “I need you to get a phonebook, call every Jones in there, and ask if they own a red car.”   I’m talking about normal, everyday issues.

How often have you heard, “Nobody is making themselves known”?  Okay.  And?  Do you want dispatch to confirm the address?  Call the reporting party back?  Are you going in service?  What do you need?  Tell dispatch what you need to accomplish your assigned duties.

Dispatch doesn’t need updates.  They don’t need to hear, “We have a child care issue.  There are a lot of children on scene.”  A better way to word that request is to actually make it a specific request: “I need either an EMS supervisor or police officer, whichever is faster, to respond emergency to this scene.  The patient needs to be an emergency transport, and there are five children on scene who will need some supervision until the patient’s sister gets here.”  There are some days when I may not even explain why, but that is probably less optimal than having dispatch understand the issue that they are being enlisted to help me solve.

When you explain the problem only, you put the solution in someone else’s hands.  In that case, you are hoping that the solution they come up with is in your (and your patient’s) best interest.  I’d always rather have the solution come from me.

Check yourself over the next few shifts and see if you are giving general updates or specific requests.  Are you explaining both the problem and solution, or just the problem?  Try to increase your specific request rate.  

Emotions, Or The Tale of the Three-Legged Lab

I get emotional on calls.  It is one of my issues, I’m aware of it, and I monitor myself for it when I can.  What can I say – I’m a passionate man.  My emotions aren’t sad emotions.  I am unlikely to cry with a patient or anything like that.  My issue is with angry emotions.  Let me give you an example.

I was sitting at a southeastern post late one night with one of my favorite partners.  It was a pretty quiet night and so we were just hanging out.  For some reason, we were monitoring the police radio traffic in the northeast part of the city.  I think they may have had something interesting going on, so we were just eavesdropping a little and never shut it back off.  In any case, we heard a call go out:

Dispatch: “Car 54, 100 Main Street on a checkwell.*”

Car 54: “100 Main Street.”

Dispatch: “The female party that lives in that house is a diabetic.  She was in a verbal phone argument with her ex-husband and stopped responding to him.  Phone hasn’t been hung up.  The ex would like you to check on her.”

Car 54: “Okay.  Are the paramedics responding too, or is it just us?”

Dispatch: “Stand by, I will check.”

It wasn’t 2 minutes later that I got an emergency call to 100 Main Street.  According to my dispatch, the police were requesting emergent EMS for a diabetic problem.  That was the beginning of my problems.

I was fired up.  I had just heard a simple question from the police, the correct answer to which was “No medics, just you.”  Instead, I have to drive across the city with lights and siren for a welfare check that should have been handled by the police!  The cops weren’t even on scene yet!  The responding officers hadn't asked for EMS!  The woman was probably just angry and went for a walk without hanging up the phone!  Communication failed to occur in the communication center again!  Fire and brimstone!  Dogs and cats living together!

The long response had the result of getting me more worked up than would usually be the case.  I had five or six minutes to get myself all worked up, rather than just having a minute or two.  In addition, my partner was not especially the kind of partner to put the brakes on my emotions.  I don’t exactly remember, but it was likely that he was adding his own rants to mine.  Just picture two angry men driving fast, shouting about the nefarious plot to ruin our shift, amplifying each other.

We arrived to quite a scene.  Three police officers were standing on the hood of a cruiser.  One had a fire extinguisher-sized bottle of pepper spray.  One had a taser in his hand.  The last had his sidearm out. 

On the sidewalk next to the cruiser was an old yellow Labrador retriever.  You can tell when a lab is old because of the grey “spectacles” shape on its face and nose.  And this one had three legs.  It was acting just like a lab would when it gets to meet new people.  It was wagging its tail so hard that its whole body was wagging from side to side.  Its tongue was out so it looked like it was smiling -  just a happy, old, three-legged yellow lab.

Remember, I’m angry.  So I am not thinking as clearly as I should.  I was sincerely concerned at the nightmares that would follow a cop shooting this dog.  It was something that I felt the need to put a stop to.  I said to my partner: “What the hell is going on here?!?  They can’t shoot that dog!  I’m going to put a stop to all of this.”

Partner: “Bill, you should wait in the bus until we figure out what’s going on.”

Angry Idiot: “F**k that.  I’m not letting them shoot that dog.” 

Partner: “Well, I’m going to wait right here.”

I got out of the ambulance and walked up to the happy, old, three-legged yellow lab.  It looked even happier and older up close.  I knelt down and talked to it with a baby voice.

“Whuzza matter, are those big tough poweece officers afwaid of you?  No, you’re a sweetie, aren’t you.  Is your name Twipod?  Tell doze tough poweecemen to come down, you wanna pway…”  

The dog nuzzled up to me, still wagging its whole body, and I gave it a good petting.  I got my face licked, even.  At that point, the officer holding his pistol spoke up: “Here he comes again.”

My stomach dropped.  My taint tingled with fear.  I looked up the street behind me and initially thought a bear was charging me.  It was a brown blur, headed right at me.  Foam was flying and whatever it was was roaring.  Not barking.  Roaring like a bear, or a lion, or something.

It was the aggressive Chow that the cops had been macing for five minutes.  Oh, shit.

I looked up hopefully at the cruiser. 

The officer with the taser smiled: “No room up here, dickhead.”

I panicked and took off across the front yard at full tilt, headed for a six-foot cedar fence leading into someone’s backyard.  I had a fleeting hope that there wasn’t a Doberman in the yard closest to me that I was heading to, but mostly it was just an adrenaline-filled, high-stepping sprint for safety.  You've seen shows with a celebrity who volunteers to wear the bite suit and get taken down by a police dog.  It was like that, but with more panicked shrieking and no bite suit.  The Chow was right on my tail across the yard, roaring and foaming.

To this day, I don’t recall how I cleared the fence.  I probably just hurdled all six feet of it like Carl Lewis.  The dog, probably blinded by enough OC to clear a riot, crashed into the fence right behind me.  As I caught my breath, I climbed up a little to look over the fence.  The police were falling over each other laughing.  It was apparently the funniest thing they had ever seen.  If the Chow had turned on them, I don’t think they could have defended themselves for the laughter.  The Chow, who positively reeked of OC, was barking and snapping at me from the base of the fence.  My partner had climbed out the window of the ambulance to look over the roof. 

“See?” He shouted at me, “I told you to wait in the bus!”

So to finish up this story quickly, I had jumped into the backyard of 100 Main Street.  Her back door was unlocked and I found her on the kitchen floor in insulin shock.  Her blood sugar was under 20.  There was an alley behind her house that I told the cops and my partner about, so everyone came into the scene from the back.  We fixed the patient up and took her to the hospital, or whatever.  We just ignored the crazed Chow and old lab out front.

As far as I know, those two dogs could still be terrorizing that neighborhood – ten years later.

So, the lesson.  Can you see how my negative mindset put me on the path to failure?  I guess it wasn’t a complete failure of a call, but if I had controlled those emotions the call would have gone very differently.  I understand that angry emotions are something to watch out for, and I think I do a better job now of controlling them.  We all have constraints put on us through our personalities.  It is important to understand those constraints or pitfalls and avoid them, not to necessarily change who we are.  Who we are sets the context through which we view and affect the call.  Getting fired up about nothing is one of my (many) pitfalls to watch out for.

My hope is that each of you can take a good look at yourselves and pick out the pitfalls of your emotions.  Watch out for them and get yourselves under control.  Otherwise you may find yourselves running for your lives from bear-dogs.

*Checkwell is a welfare check.