Journals and Blogs

A while back, I was talking to my partner about something and taught her something new that contrasted with something she had learned in school years ago.  Yay, me!  I love it when that happens.  She asked me how I found new information and kept up with the evolution of medicine.  Simply, I read blogs and journals.  It doesn’t take long – about an hour a week or so, and I think my job is important enough for that time investment to be worthwhile.  Trying to keep up through CE is a joke.  I have to put in the extra work. 

Medicine changes all the time.  I’m thankful for that fact.  I’m thankful that I won’t be bled next time I have a fever, that antibiotics exist, that limbs aren’t commonly sawn off anymore, and that leeches are a minimal part of modern medical practice.  More recently, I’m glad that I neither have to put MAST pants on patients, and that the KED is really just a big flat piece of equipment that can be used however you need it to be used.

With all that in mind, it is important for prehospital providers to stay up to date on current research.  At least a little.  Put a small amount of effort into it.  I wince when I consider how bad a medic I’d be if the only addition to my knowledge base after paramedic school was experiential.  I don’t feel like CE and merit badge classes can keep up with my didactic needs.  Even though most of my practice is based on protocols, expanding my knowledge base with current science is important to keep up.  Finally, let me point out that becoming a subject matter expert is critical to the field of paramedicine being accepted as a career worthy of respect (and pay).  Physicians, psychiatrists, psychologists, biologists, physicists, chemists, dentists, and other professionals keep up with their fields the same way.  Why shouldn’t we, at least within the framework of our career?

So this is how I maintain my knowledge base and interest.  Keep in mind, this is the minimal effort that I will put into my job.  Sometimes I go much further, read new textbooks, and that kind of thing.  Each month I check twelve EMS-related blogs on a weekly basis.  Along with that, I check in with at least nine peer-reviewed journals that relate to EMS.

I read the following blogs once per week.  I usually check in on Sunday, looking for any new posts since I last checked.  Many EMS blogs don’t post on a regular schedule, so I find this is a simple way to keep up.

• Rogue Medic is a controversially-written (argumentative may be a better way to describe it) website, but also more intellectually stimulating than the average.  (Much more stimulating than my blog, for example.)  As the author says: “The purpose of this blog is to frighten, intimidate, or cause emotional distress to those who intend to keep EMS from improving.  If we are interested in the truth, we should question everything – especially anything we take for granted.”  He questions epinephrine, quality assurance, pseudoscience, training programs and merit badge courses, immobilization, and so on.  The great part is that the author backs up his assertions with research.  Sometimes I read this and think, “Jesus.  Is there anything we do that works?!?”  Great stuff to make you think.
• Dr Smith’s ECG Blog is written by Dr Stephen W Smith from Hennepin County Medical Center in Minneapolis.  As the title suggests, it is a great way to improve your ECG skills.  His posts are case studies that illustrate a specific point.  This isn’t a blog to improve your differentiation of sinus versus a-fib, though.  The ECG topics here are more advanced.  His explanations work to make it accessible to anyone with a basic ECG foundation.
• EMS 12-lead is similar to Dr Smith’s blog, but the posts are less regular.  The topics are still advanced level, so it maintains my interest.  One part that I like about this blog is that there are case studies without answers, so you can work out your own response before reading the author’s answer.  I only wish the answer was posted more regularly to the initial post – like 24 hours after, or something.  Sometimes the answer comes a week or more later, so I have already forgotten the original case.  But it is still very much a blog that is worth your time.
• Amal Mattu’s Emergency ECG Video of the Week is posted by Dr Amal Mattu, from the University of Maryland.  His posts are similar to Dr Smith’s, but are posted as YouTube videos.  If you enjoy ECG work but don’t like to read, this is the site for you.  His pearls are phenomenal and I have learned a lot.
• Mill Hill Ave Command is written by Dr Brooks Walsh, from Bridgeport Hospital in Connecticut.  Dr Walsh looks into research as it relates to EMS.  For example, he is currently working through the evidence behind Cyanokit and whether it has been clinically shown to save lives.  This, along with Rogue Medic, is a good site to begin to get into reading research.
• The Ambulance Chaser is written by a licensed Texas paramedic who is also a licensed attorney and unlicensed barbeque critic.  That last one needs to go on my resumé – awesome.  The blog’s point of view is patient oriented, but also gives some legal background without delving into legal advice.  I only found this blog recently and like it a lot.
• EMS Patient Perspective is written by Bob Sullivan, who is an educator in a paramedic program and working paramedic.  His posts focus on EMS as seen from the patient point of view.  These are phenomenal reads.  I hope more EMS providers like Bob start getting their point of view out to the public.
• Captain Chair Confessions unfortunately seems to be dying out.  The blog is a collection of stories that make a point.  Its pretty good reading for funny situations, peeves that hit us all, and a few rants.  The posts make for short reading.
• A Day in the Life of an Ambulance Driver is written by Kelly Grayson.  This blog covers Kelly’s interests, which include firearms and (luckily) EMS.  This is a blog that is similar to Captain Chair Confessions, in that there are short articles telling stories about calls, making points (like his article on dumb EMS sayings), and that kind of thing.
• Burned-Out Medic is grouchy, as his blog title suggests.  The stories and anecdotes here have a more negative tone, which make them funnier to me.  Even if you don’t like his tone, his points are valid and insightful – nurses can be bitchy and patients can waste our time.
• Street Watch: Notes of a Paramedic looks at topics like why we start IVs, presentations from the Eagles conference, and such.  Intelligent, short reads with a academic foundation.  It has the EMS blog shortcoming of being a little streaky, however.
• EM Lyceum is another blog that I only discovered recently.  It is written by a group of physicians at Bellevue Hospital Center.  This is emergency medicine-focused, but there is a lot of information that could inform your prehospital practice.  Each topic is posted for two weeks.  Topics are stuff like upper GI bleeding, or abscesses, or intracranial hemorrhage.  One week will post several questions on the topic and the next week will offer the answers.  This would be incredible for interns in an EM rotation or EM residents.  It can be pretty interesting for medics, too, depending on the topic.

The nine journals* are:

• Prehospital Emergency Care  This is the official journal of the National Associations of EMS Physicians, State EMS Officials, EMS Educators, and EMTs.  It is one of my favorites, and usually generates a few articles from each edition.  It is published four times per year. Essentially every article in the journal relates to EMS practice. The only reason that I don’t read them all is based purely on my own interest level. 
• Prehospital Disaster Medicine This is a journal with a more international flavor, published by the World Association for Disaster and Emergency Medicine.  This is published six times per year, and is most interesting for disaster medical response articles and mass gathering research.  There can be some really good stuff, especially if you are into disaster or large event planning. 
• Annals of Emergency Medicine  This is the official journal of the American College of Emergency Physicians, and it is published monthly.  Many of the articles are focused on emergency department administration and emergency department care, with a small subset looking at prehospital topics.  Example articles include stuff like “Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay” but there are also EMSey articles like “Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: A systematic review and meta-analysis.”  This is one of the primary journals that your ED physicians are reading.
• Academic Emergency Medicine  The Society for Academic Emergency Medicine puts out this journal on a monthly basis. The articles here can be kind of dense and…  um, academic.
• American Journal of Emergency Medicine  This journal doesn’t seem to be specifically related to an association or group, but tries instead to blend academia and practicality on a monthly basis.  It is pretty similar to Annals. You can usually find something good to read from here.
• European Journal of Emergency Medicine  The European Society for Emergency Medicine puts out this periodical on a monthly basis.  It is very similar to Annals and American Journal, as well.  The articles can be pretty good, but be careful about applying all of the information to your system – EMS system design can be pretty different in Europe, with physicians staffing ambulances, and such.
• Western Journal of Emergency Medicine  This journal comes out of California, with associations like California ACEP, UC Irvine School of Medicine, and the California Chapter of the American Academy of Emergency Medicine, along with the American College of Osteopathic Emergency Physicians.  The best part of this journal is that it will occasionally review a topic, like a textbook would, except updated with current data and science. 
• Circulation Arrhythmia and Electrophysiology  The journal Circulation is an important journal for cardiologists, but most of the articles involve cath lab techniques and genetics.  Crazy hard stuff that doesn’t relate to EMS really at all.  The subjournal (for lack of a better term) Arrhythmia and Electrophysiology focuses on the ECG.  Most of the articles revolve around atrial fibrillation, but you can find good stuff about ECG findings here.  I’m an ECG nerd, so this is up my alley.
• Air Medical Journal  Five air medical transport associations combine to publish this periodical.  The focus is, of course, on air medical transport.  But there are good articles about pathophysiology, case studies, and other topics that I enjoy reading.  There are good literature reviews in this journal, as well.  It is probably second to Prehospital Emergency Care in the list of my favorite journals.

I realize that journals can be hard to find, especially if you are a poor paramedic.  Even googling the journal name will usually get you to the current issue’s table of contents, with access to the abstracts.  That’s what the links lead to, above.  One of the best ways to get full-text access is through library systems.  I use the local college library’s website, but public libraries could probably get access too.  Even college libraries, like I use, are usually open to the public in person, and maybe you can get web access from the librarian.  All that means is that you stop by once per month or so.  But if you can find full-text web access, that is certainly easier.

(Side rant.  Many studies are publicly funded, or run from public organizations.  Open the access to publicly funded articles!  Make science accessible!  Rant done.)

I scan through the journal’s table of contents and download interesting articles to read later in the week.  My threshold for readable articles is simple – does the title seem like something that would interest me?  From there, I read through the abstracts to check whether the information will be helpful.  Small studies, simulator-based studies, and self-reported qualitative studies are less interesting.  So I don’t go nuts reading dozens of articles per month.  I end up with ten or fifteen interesting articles from which I read the abstract.  Three to five result in my reading the whole thing.  A few times per year, something pings my interest so well that I end up reading other articles from the bibliography. 

One more note about reading and interpreting research articles: Use caution applying the results of studies to your daily practice.  Your job shouldn't change based on one study.  Rather, use journal readings to inform your knowledge base and understand the direction that medicine is taking.  This helps you to understand protocol changes when they happen.  Applying research to practice is difficult and filled with pitfalls (see therapeutic hypothermia, for example).  Your medical director is trained in this, plus can apply his/her experience and professional insight to protocol changes.  Unless you are an unusually educated medic, be careful citing research.  Look here for a painfully truthful article about the inappropriate application of current research.

Hopefully you will find the time to peruse some of the links above and take control of your own continuing education.  Hopefully, also, the links in this article work.  Pick a topic you like and dive into it!

*JEMS isn’t on the list, is it?  Hmm.

I Deserve a Friggin' Oscar

The field training program wasn’t especially easy for me.  I didn’t have an especially hard time meeting expectations, but the Denver Paramedics was pretty different from the agency in which I began my EMS career.  I started in a private service that transported for an ALS fire department.  So I was skilled at quietly affecting a call without taking it over: “How do you guys feel about an amp of D50 before Fred intubates him?”

When I went to Denver Health, I discovered the joys of a pure ALS service with a BLS fire department.  One of my two biggest problems that the field training program beat out of me was the ability to be in charge of everything on the scene.*  I recall one of my first calls; we arrived to a dyspneic patient who was tripoding and two or three word dyspneic.  The BLS crew was on scene, but oxygen hadn’t yet been applied: “How do you guys feel about giving him some oxygen?”  The firefighters looked at me with very uncomfortable expressions - this was a situation that they weren't used to.  Someone asking them what to do?!?  What I should have done is taken charge of the scene: “I need him on a non-rebreather. Get my wheels, please, and set me up for a line and a 12-lead.”

The transition from “How do you feel about…” to “I need…” was a hard one for me to make, believe it or not.  There I was, 25 years old and a little more than a year out of paramedic school, expected to be in charge of a whole team of public safety providers.  In my head, I knew that I was an idiot who knew next to nothing.  The other people on scene had been doing this for decades in some cases.  Some were as old as my father!  (And try ordering him around, I dare you…)  I rarely had a firm grasp on what was going on.  I shouldn’t have been in charge of my own checkbook, let alone a cardiac arrest or a multiple vehicle car crash.  Didn’t everyone know that I was grossly incompetent?!?

I found success by acting.  Pure method acting.  Faking it.  Completely fraudulent affectations.

By Amaranthe26 via Wikimedia Commons, with permission and modified.

Now for the really embarrassing admission: I would talk to myself in the side view mirror on the way to calls.  “Who’s in charge? You!  You got this, Bill!  You can handle it!  Nobody will doubt who is making decisions!  Hooah!”  Like the daily affirmations of Al Franken’s Stuart Smalley, or something.

I had to make a conscious and continuous effort to act like a paramedic.  I didn't feel like a paramedic.  I made the effort to act like I knew what was going on.  I didn’t feel like I knew anything.  I made an effort to act like I could handle whatever I found on the call.  I certainly didn’t feel that way.

Nobody knew it was an act.  I doubt they would have cared, because the job was getting done.

As time passed, I became more skilled as a paramedic.  Sure, I worked at increasing my didactic knowledge base.  Experience helped immensely; there is no substitute to running thousands of calls.  Nowadays, it is a rare call that offers something that I haven’t seen before.  I have made mistakes and learned from them.  I obsess over my shortcomings and try to fix them.  So the need for acting has decreased, but it has never gone away.  I don’t think it ever will.  I have come to the realization that a large percentage of prehospital medicine is pure acting.

I act like I am interested in the patient’s mild nausea symptom.  
I act like I am interested in what kicked off the patient’s anxiety attack.  
I act like the patient has my full attention.  
I act like I am not hangry.  
I act like the patient shouldn't be embarrassed about what is currently stuck in his rectum.  
I act like I have heard of the patient’s weird disease and then secretly look it up behind them in the ambulance.  
I act like I remember the patient’s name, but am only asking again because I want to make sure of how it is spelled.  
I act like chronic fatigue syndrome isn't really a psychiatric issue.
I act like it matters to me that the patient doesn’t refuse transport.  
I act like I got enough sleep last night.  
I act like this call won't emotionally scar me and give me nightmares in the future.  
I act like my back doesn’t hurt.  
I act like the story my partner is telling me is a good one.  
I act like I care about what the receiving nurse thinks the patient being transported to her hospital.  
I act like I am calm when I am on the radio.  
I act like I’m not hungover.  
I act like I’m more than happy for the biophone physician to talk to the patient (on my cellphone).  
I act like other people call 911 for similar problems all the time.  
I act like my mood is a positive one.

Don’t misunderstand me.  My concern for a patient isn’t an act on every call.  Neither is my interest in my partner, for the most part.  My confidence isn’t an act all of the time, or even most of the time.  But all of us have off days, irritating patients, irritating partners, empty bellies, occasional hangovers, bad weather, our own health problems, off-duty relationship issues, and other distractors.  All of us can be confronted with a call that makes us feel overwhelmed and incompetent.  The patient, their family, and other agencies and providers don’t especially care (if they say they do, it is likely an act on their part).  We have a job to do.  If acting advances the call more than the truth does, act.  You may be surprised at how acting a way results in it becoming true.

My acting continues to this day.  You know you’re a pretty skilled medic when people rarely know you’re acting.

*The other challenge was alternative call dispositions.  An ambulance service isn’t really paid for refusals.  So transports are important to the financial viability of a private company, where as a third service (or hospital based pseudo-third service) has other concerns along with finances.  Concerns like keeping ambulances in service.  So dispositions are relatively much less important in the privates, at least 15 years ago, so it was a skill that I didn’t have enough practice to be good at.

Pronouncement Done. More Work to Do.

I remember the first pronouncement I was involved in.  It was at my first job, for a private EMS service in the burbs.  It was early one morning that we worked a 60-year old female who ‘woke up dead.’  I was so new that I was third-riding as an EMT; I wasn’t even partnered with a medic at that point.  Even at that shiny, new part of my career I remember thinking that our crew had performed the process wrong.

The patient was worked in a bedroom while the family sat in the living room waiting.  She was probably an asystolic arrest that we gave a round or two of meds to before calling it – I don’t know, like I said, I was a new EMT.  I remember that the medics and firefighters pronounced the patient, cleaned up their mess, and began taking equipment out to the bus.  Through the living room.  Past the patient’s family.

Before we notified them of the negative outcome of our efforts.

When one of the paramedics did tell the family about the patient’s status, he told them that she had “moved on.”  I recall vividly that her husband asked where she went.  He wanted to meet her there.  I think in his mind, the experts arrived because his wife wasn’t breathing.  Then the experts were leaving, so she either was better or was transported – maybe out through the bedroom window or something?  Brains don’t always make sense under stress.

In the years since, I had two main points that I taught to new medics.  My goal was to avoid situations like this.  First, don’t ease into it.  It is easier for providers to have a little throwaway conversation before we get to the hard stuff.  The problem is that introductory conversation to a medics involves something like, “So, has she been sick lately?”  You have just tied any answer that the family member has to her death.  “Oh, God, I knew I should have made her get checked out!  This is my fault!”  The second main lesson that I pushed is to use the word “dead” at least three times.  Dead, death, or died are your only choices.  Don’t use euphamisms like “gone to a better place” or “no longer with us.”  Be clear, say dead, and it takes three times to sink into a grieving brain.

'Inconsolable Grief, oil on canvas by Ivan Nikolaevich Kramskoi (1837-1887). Public domain.

A few years ago, however, I ran across the GRIEV_ING mnemonic.  It works similarly to what I was doing.  Gather.  Resources. Identify. Educate.  Verify. Space. Inquire. Nuts and bolts. Give card.

Gather: Get all of the family together.  Ensure that everyone is there and optimize the environment.  Make sure it is quiet and private.  Have everyone sit down – fainters are hard to preidentify.  Get at their level.  Make eye contact.  Gather yourself too – tuck your shirt back in, wipe the sweat off your forehead, and slow your pulse rate if needed.  You are transitioning from hardcore street medic to comforting social worker.  Lower your voice to that of normal conversation.  Speak clearly.

Resources: I think this one is out of order.  This step is to call for additional support resources, like chaplains, other family, etc.  To me, this should be after the Inquire step, but then the mnemonic makes no sense.

Identify: Tell them who you are and identify the patient by name.  “My name is Bill, and I am a paramedic with the city.  I was in charge of taking care of Joe.”  Use the patient’s name; never refer to the dead as another word: the arrest, the patient, the body, your mom, whatever.  He is Joe and that is how you should refer to him.  I hope that is common sense.  But it really is important to be able to use the deceased’s name.

Educate: Update the family about what was found and what was done.  Explain that you found them without a pulse and not breathing.  “We performed all the same treatments that would occur in any hospital.  We put a tube in his lungs to breathe for him, performed CPR, and gave him powerful medications.”

Verify: Use the word “dead” or “died.”  I still go with the three times rule: “I’m sorry to tell you that even with all that, Joe has died.  All of the treatments we performed could not save his life.  Joe is dead.  It looks like he died peacefully in his sleep during the night.”  (If it doesn’t look like he died peacefully, don’t say that.  Trust me.  Experience talking here.)

Space: Give them space to absorb the information.  Don’t leave, because they will have questions.  Just shut up for a while.  Be a professional, sit there, and console them one human to another.  Put your hand on theirs.  Put a hand on their shoulder, maybe.  Even just sit there and witness their grief, if that is all you can muster.  However their bereavement manifests, do not take it personally.  Some people wail, some people strike out, some will throw themselves to the floor, and some people just stare.  Do not restrain them unless they are a danger.

Inquire: Ask if they have questions about the situation and if there is someone you can call for them.  “Is there anyone that I can call to help you, like a minster or a family friend?”  They may have questions that you can’t answer, like what caused their death.  Don’t guess – say you don’t know if you don’t know. 

Nuts & bolts: Explain the process from here.  This is system-specific, so make sure you know your jurisdiction’s rules.  In my system, any out of hospital death needs police involvement and a coroner’s consult.  Explain that to the family.  I explain that “the police are well versed in the process and will take good care of them.  Joe will probably have to go to the medical examiner’s office.”  Explain that your treatments have to stay in place for now, so the IV line and breathing tube are still there. 

If the police officer is good with it, give the family a chance to go sit with Joe and say their goodbyes.  In my system, the ability to do this is dependent on factors that the police know, but I don’t.  So I leave it up to the cop.  It’s something that I wouldn’t have realized, not wanting to do it myself, but it can be deeply helpful for some people to be able to say goodbye directly to their loved one.

Give card: This step is really more for victims’ advocates who deal in death notification.  If you want to give a card, knock yourself out.  But one way or the other, I would replace this by handing off the care of the family to another professional.  Introduce them to the police officer.  Wait on scene with them for the officer to arrive, if need be, and introduce them. 

Relating back to the pronouncement I explained at the beginning of this post, don’t start moving equipment or responders out until at least the ‘Space’ step.  Duh.

Good things to say:

“I can’t imagine how difficult this is.”

“I’m so sorry for your loss.”

“It must be hard to accept.”

“How can I help?”

“I know this is very painful.”

Dumb things to say:

Anything religious: “This is a blessing because…”

“You’re lucky that at least…”

“Get a hold of yourself.”

“You don’t need to know that.”

“I can’t tell you that.”

“Things always work out for the best.”

“I know how you feel. My __ died last year.”

Many articles that explain the death notification process suggest allowing the family to view the resuscitation process.  It makes some sense, theoretically, in the right setting.  Even a fairly incompetent resuscitation seems skilled to a layperson.  The family gets a feeling that “everything possible was done.”  They probably won’t know that you can’t get the tube unless you say. “Dammit, I can’t get this tube!”  It makes me a little uncomfortable, though.  My practice is to update the family at several points during the resuscitation if I can.  There can be times when we’re just waiting for the 2 minute cycle of CPR to get done and can go give a situation report to the family then.  Think of this as prepping them for the potential notification.

The final point I want to make: Don’t be a wimp.  This is part of your job.  Hitch your big boy or big girl pants up and go do it.  Do not transport futile resuscitations in order to pass off the notification process to an ED.  Family members of pronounced patients report who were transported report less positive interactions with providers and more anxiety rushing to the ED than did pronounced patients.^1,2  You’re giving the family hope when you drive off with their loved one, sirens wailing and lights flashing.  Remember, no notification is easy but you have one of the relatively easier ones.  Picture how much more difficult it is to a police officer who has to knock on a door, wake someone up, and start from scratch.  Surprise!  And then throw in body identification.  Picture how much more difficult it is for a physician to explain brain death versus death death to someone grieving.  Or organ donation requests right after the notification. 

Your skill at giving death notifications has a huge impact on how the deceased's family will process the change in their lives.  Do it right.

1. Edwardsen A, Chiumento S, Davis E. Family Perspective of Medical Care and Grief Support after field termination by EMS Personnel: A Preliminary Report. Prehosp Emerg Care. 2002;6: 440-444

2. Schmidt TA, Harrahill MA. Family response to out-of-hospital death. Acad Emerg Med. 1995; 2(6): 513-518. 

Big Room Reports

A couple of months ago, I took a patient to one of the local Level I trauma centers.  I put the patient into their assigned room, told the receiving nurse about the patient’s abdominal pain of three years, or something, and was headed back out to the ambulance.  At the same time, a crew from another local EMS agency rushed in after an emergency transport.  Their patient was immobilized, with IV bags and other accoutrements of trauma care piled on the patient’s legs.  The trauma team was all fired up, ready to go and awaiting their arrival.  I slowed out of a mixture of jealousy and curiosity to hear their report.

“Hi.  This is Evelyn.  She is allergic to, um, penicillin…”

I’m out.  I no longer cared.  Neither did the trauma team.  From their point of view, they knew that they would be starting from scratch.  With a report like that, the paramedic didn’t give the impression that he knew what was going on.  That’s how fast you can lose your authority and their attention.  The trauma team in a ‘big room’ wants to hear from an expert on that specific patient, briefly, and get to work.  They truly want to know what happened to the patient, what injuries occurred, and what was done about it.  But that feeling is contrasted with the need to get to work applying their prodigious skills immediately.  If the reporting medic doesn’t give the impression of expertise, the team isn’t able to trust anything they say.

Big room reports take training and practice to do well.  It is a critical prehospital skill that is absolutely integral to our job.  I’m in no way perfect, and I have screwed up a lot of big room reports, but I think I have learned what the hospitals in my system are looking for.  Big room reports are weird; you’re used to giving a report to a nurse with (maybe) a doctor, but now you’re giving a report to ten or fifteen people.

This can be a scary place, both for the patient and for you. (Scripps Mercy Hospital trauma bay, San Diego CA)
Courtesy: Walleigh via Wikimedia Commons, with permission.

Overall, any big room report should be loud and clear.  That is for several reasons.  First, it gives the impression of confidence.  You want to give the impression (whether it is true or not) that you have a handle on this patient.  You know all there is to know and you are here to give the trauma team a head start.  You’re the closest thing that they have to an expert regarding what happened to this patient; they want to listen to you if you give them the chance.  Second, everyone involved on the team needs to hear your findings.  EMS is important, and prehospital findings affect care decisions.  Let everyone in the room hear you, but do it without bellowing as though you’re at a Metallica concert.  Finally, you need to be clear with your language.  Communication does not occur with mumbling or vernacular terms that not everybody understands.

I divide big room verbal reports into three types.  Each has different requirements.

Emergency trauma reports to a trauma team have five parts:

• Title: This is the one-sentence description of the overall patient.  Include the age and mechanism.  A title is what your answer would be if a coworker asked what the last call was when you were too rushed to answer fully; something like “Thirty year old male, gunshot wound to the face.”
• Findings: Run through a brief list of pertinent findings on your secondary exam.  Include very pertinent negative findings, but make it short.  There is no need to point out each abrasion.  Don’t forget to include a description of vehicular damage and any pertinent bystander reports, such as reported seizures, loss of consciousness, and that kind of thing.
• Vital signs: Give the team your most recent set of vitals, plus a quick description of any changes.
• Non-obvious treatment you’ve provided: There is no need to tell the trauma team that the patient is immobilized. They can see that.  They can’t see that you give the patient 300 micrograms of Fentanyl.  Make sure to tell them.

When that is done, I ask for any questions and let them get to work.  I love seeing that process.  It looks like hyenas on a fresh zebra kill.  Really skilled and educated hyenas, but still.  I wander over to the charting nurse to make sure that s/he got all of the information and to give him/her specifics about IV sizes and such.  The charting nurse cares more about scene gossip than the surgeon does.  Make sure admissions gets any demographic information that you have – knowing who the patient is seems unimportant to us, but is critical for the hospital and the patient’s care.

Trauma arrest reports are much shorter in my system:

• Title
• Time of arrest: The trauma team’s treatment decisions depend on the duration of arrest and mechanism.  Give them either the exact time that you recognized loss of pulses or the exact duration of pulselessness.  (It is important to glance at your watch when you note the patient has arrested.)  For example, “She lost pulses 4 minutes ago” or “She arrested at 7:03…”

That’s it.  Let the staff get on it.  Hang out and answer their questions as they give them to you, but a trauma arrest only needs the mechanism and time of arrest.  Wander over to the charting nurse and admissions clerk to help them out, as with any big room report.

Medical big room reports are more extensive and less structured.  They are both tougher because they are more complex, as well as easier because they are closer to a normal handoff report.  I teach new paramedics about the ‘fish hook theory.’  Your report should perform the same job that a fish hook does.  Sink it into the receiving team’s cheeks.  Pull the line exactly to what you want the receiving staff to know about.  Don’t be afraid to tell them exactly what you think is going on, or what you’re worried about.  Diagnose, at least in a preliminary way: “I think she is having a lower GI bleed.”  It’s fine.

Make sure to include the same points that you would include in a normal hand-off report: complaint, onset, provoking/ameliorating factors, quality, radiation, severity, time, associated complaints, pertinent medical history, secondary exam findings, and vital signs.  All the stuff that will go into your written report’s narrative.   A big room report in this case is the same verbal report that you would normally give.  The only difference is to use the report like the fish hook.  Drag the listeners right to MI, or lower GI bleed, or stroke, or whatever.  Rearrange the order of your information to facilitate the fish hook.

“Sixty-five year old female, normally lives alone with normal mentation.  Found this morning with profound facial droop, left-sided weakness, and aphasia.  I am worried she is having a stroke.  She has a history of…”  After reading that, do you have an idea of what is wrong with this patient?  Lay it out for the receiving team so they end up with the same worries and differentials that you have.

Three final points: 

First, give the shortest report that you can, making sure it contains all of the necessary information, and then… Shut.  The.  Hell.  Up.  There is no need to make these reports especially long.  In many cases, the more critical the patient the shorter my verbal handoff report is.  Work needs to be done and work doesn’t involve listening to me.  

Second, this is how big room reports work in my system.  Your ED physicians, specialists, and surgeons may have other expectations.  Ask them what they would like to hear.  

Third, these reports are what the trauma team needs to get to work.  I hang out, wash my hands, talk to the charting nurse, and those kinds of things in order to make myself available for any questions that come up.  A lot of times, I find, only the critical information in my report is heard the first time around.  Specifics are missed, or aren’t important initially.  When the team cares about the specifics, I am there to fill them in.

So how does all this work out?

“Hi everyone.  I have a thirty-year old female, ejected from a highway-speed rollover.  She’s been conscious the whole time I’ve been with her.  She has the big lac that you can see to her left arm, plus crepitus to her left midaxillary chest wall.  Her breath sounds are clear, though.  She has no cervical pain and is moving all four extremities.  Blood pressure one-ten over sixty, pulse one-twenty, respiratory rate twenty-four.  Any questions?”

“Everyone here that needs to be here?  Good.  Seventeen-year old male, gunshot wound to the face.  He initially had a GCS of eight, but is now unresponsive.  The wound to his left temple is the only one I’ve found.  One-ninety over one-ten, heart rate sixty, respiratory rate of six before I intubated him.  Any questions?”

“Evening.  Mid-twenties male, GSW to the anterior chest.  Lost pulses enroute [look at watch] three minutes ago.  Get ‘im…”

“Hi everyone.  Edith is seventy-seven, found lying on her right side after not being heard from for three days, covered in urine and feces.  She is complaining of a headache, but is perseverating and altered to everything but her name.  It looks like she spent three days on the floor, with deep carpet impressions all on her right side.  Everything is tender, wherever I touch her.  I can’t find any specific deformity, bruising, or crepitus except for generalized tenderness in the secondary, though.  There was a strong smell of ammonia in her house, like from her urine.  Blood pressure seventy-six over fifty, pulse irregular at about one-ten, respiratory rate of eighteen with clear breath sounds and sats in the low nineties on the non-rebreather.  A-Fib on the monitor with a little ventricular ectopy.  Anything else I can tell you?”