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

Square Breathing

Last winter I ran a lady who slipped on some ice, landing on her outstretched hand. The fall hyperextended her right elbow and she felt pain in that joint. There were no other injuries, including her head and neck. She passed my amateur distracting injury test. I examined her right elbow and found pain and tenderness both in her distal biceps and proximal brachioradialis muscles. The elbow joint itself was stable, as was her humerus, radius, and ulna – as far as I could tell. The biceps muscle had a lump in the distal end that gave a step-off appearance and it was already starting to bruise.

From Gray's Anatomy (1918) via Wikimedia Commons

I felt like she tore her biceps, at least. I mean, you could pretty much see it.  The brachioradialis may have been torn, as well. I was also suspicious of an elbow sprain and kept the possibility of fractures in mind. My plan was to start an IV, dose her up with some fentanyl, splint the arm, and then take her to the hospital. She was in a significant amount of pain, however, and it would take me a couple of minutes to start the IV. I needed to distract her.

“Listen, Sally,” I told her. “I know your arm is hurting really badly right now, so I am going to give you some pain medications that will make you more comfortable. While I do that, I need you to slow your breathing.”

She nodded and did what almost everyone does – she slowed her breathing by taking very deep breaths.

“That’s good, Sally. Believe it or not, slowing your breathing will help your arm hurt less. But I have a great technique I want you to try. It helps a lot. Are you willing to try it out?”

She nodded, with tears in her eyes.

“Cool. The technique is called square breathing. Have you heard of it?” She shook her head no. “That’s alright. It works really well. As a matter of fact, snipers use the technique to control their nervous systems. It is really simple. Are you ready?”

Sally nodded, paying attention.

“It is based on the count of three. We are going to breathe based on a three-count. Inhale for three, hold it for three, exhale slowly for a three count, and then hold your breath empty for three. Got it? I will count.”

I began a slow count: “Inhale, two three. Hold it, two, three. Exhale, two, three. Hold it out, hold it out, hold it out. That was great, Sally. Here we go again.”

I began the counting pattern again, while I started the IV.

The technique works as a distraction. The need to count and maintain a pattern focuses the patient’s attention on counting and breathing, rather than on what’s hurting. Instead of focusing on the anxiety of an injury, the pain it is causing, and the fear of what is going to happen, I can often get a patient to focus on breathing through a three count. My goal is to stretch the three-count to fours. Fives would be great, too. The pattern is easy enough for me to quickly explain. I can count out the pattern while my attention is on starting the IV, or drawing up analgesia, without distracting myself too much.

It probably doesn’t work as well as I think it does, but it is better than doing nothing and watching a patient hyperventilate. At least, it is a good second-line action. The best thing for a patient like this is opioid analgesics, of course.

As for Sally, I maxed out her first dose of fentanyl as soon as I started the IV. I like to start with two mikes per kilo IV as the initial dose, except in the case of elderly people. Sally handled the analgesia well, relaxed a bit, and continued the square breathing pattern while I splinted her arm.

*Edit: The incorrect dose units in the last paragraph has been changed...

Chargeshockchargeshockchargeshock

Years and years ago, I ran an interesting cardiac arrest. Well, I’ve run a few interesting cardiac arrests, but there is one that I would like to tell you about today. It involved a fifty-something male who had chest pain, waited too long before calling, and attempted to treat the pain with Pepto Bismol or some such ineffective remedy. So he eventually arrested and fell down, which notified his family that something bad was happening. The family was on the ball. 911 was called and his adult son began effective CPR immediately.

Besides his son slamming away with some good, rib-cracking CPR, this patient had an ambulance and a fire truck relatively nearby. So the professionals (plus me) had a quick response time. Let me tell you how this went, so you can see how long ago this happened…

The paddles were gelled and pressed against the patient’s bare chest. VFib was identified. Charge to 200 joules, clear, shock. I kept watching the monitor postshock and the patient was still in VFib. Click the thumb dial to 300, charge, clear, and shock again. Still VFib. The 360 joule shock resulted in asystole. A firefighter got back onto the patient’s chest and I intubated him. My partner started an IV and pushed a milligram each of epi and atropine.

See? Long, long time ago.*

Anyway, this arrest was like a demented ACLS megacode run by an idiot who had never seen an arrest before but had read about the rhythms once. The patient kept switching rhythms like the ACLS instructor had just bought a new rhythm simulator and was just randomly pressing buttons. The epi and atropine changed the asystole to a pulseless IVR and more epi turned that into VFib again. Shock, asystole, meds, IVR, meds, VFib, repeat. I recall there was at least some VTach mixed in and there may have been a significant run of PSVT.

Bad for the patient.
By Jer5150 (Own work), via Wikimedia Commons

In any case, I found myself chasing rhythms while transporting. (Because back then we felt like we could do effective CPR in a moving vehicle, so we gave dead people a final cruise through the city.) On the way to the hospital, I contacted my base hospital to have them set up the receiving hospital. I was transporting to Hospital A, but I called my base physician at Hospital B so s/he could call Hospital A for me. Its our system. I got a certified legend on the phone.

I explained what was going on, what I had done, my plan (keep on doing what I had been doing), and that we were 5-7 minutes away from Hospital A. He stopped me and gave me instructions: “Bill, listen to me. This is what I want you to do. I want you to deliver three shocks at 360 joules to the patient as quickly as you can. Don’t even look at the monitor, don’t do anything but charge and shock. Charge-shock-charge-shock-charge-shock as quickly as the monitor will do it. I will wait on the phone so I can hear you do it. Give him all three now.”

Okay. That algorhythm wasn’t in any ACLS class that I’ve taken.

Old-school defibrillator paddles, for those who have never seen them.
By User:Tirante (Own work), via Wikimedia Commons

So I did it. booooOOOOOOOOOOOOOOOO BLAM. The firefighter on CPR leaned forward to restart CPR and I told him to hold off. booooOOOOOOOOOOOOOOOO BLAM. Number two. “What the hell are you doing?” the firefighter asked. I grinned at him wildly with a gleam in my eye and a frantic giggle. I hit the charge button again. booooOOOOOOOOOOOOOOOO (“No, please, stop! What are you doing to him! It smells like burning and hatred!”) BLAM. The very confused firefighters looked as though the first thing they were going to do when the call was done was to make sure I was charged with assault. I checked for a carotid pulse.

Well, holy shit. The patient had a pulse. He kept that pulse all the way to the hospital and maintained a decent blood pressure.  A 12-lead in the ED showed an apical MI. I later found out the patient had a CABG or four, got to know the MICU nurses, and was eventually discharged to home. He had close to 30 minutes of prehospital CPR, total.

I’m still not totally clear on how the triple shocks worked. I think each shock lowered the resistance for the next one. Keep in mind the LifePack-10 I was working with didn’t throw biphasic shocks. One way or the other, the physician on the other end of the call saved the patient’s life from miles away. If I’d have called the receiving hospital directly, those shocks wouldn’t have been delivered.

Sometimes you contact base with one expectation and get help you didn’t even know you needed.

*I still remember the VFib jingle I learned in my first-ever ACLS class in paramedic school: Shock shock shock, everybody shock. Little shock, big shock, mama shock, papa shock… For the youngun’s among my readers, that results in a stack of three shocks – 200, 300, and 360 joules. Everybody = epi. Little = lidocaine. Big = bretylium tosylate. Mama = magnesium sulfate. Papa = procainamide. You gave a 360-joule shock and an epi between each of the other meds. That’s how it went…

Weightlifting, 2-Man Coverage, and EMS

A couple of years ago, I took up weightlifting. I am lucky to work out in a gym that provides trainers and coaches who work to improve my form. They also watch out for my safety. I wouldn’t have thought it, but picking a weight up from the ground and lifting it over your head is complicated as hell. Details matter. How far apart are my feet? Are my feet parallel or toed out? Ankle position. Knee and hip relationship. Hamstring tension. What is the position of my femur relative to my pelvis in three dimensions? It goes on and on. Even my thumb position relative to the rest of my hand matters.

It isn’t a matter of “…try not to curve your lower back.” Picking up something heavy from the ground is something cavemen did, but it is extremely complicated to do well.

Not me...
By Sasan-sj [Public domain], via Wikimedia Commons

Recently I ran across an article that explained one of many football defensive coverage schemes: 2-man coverage. Check it out – the detail is incredible. And this is a basic look at what football players deal with dozens of times per game. This barely gets into the physical aspect of football defense – a cornerback’s hip position, whether a linebacker’s break uses his left or right foot. This just explains some of the intellectual concepts that go into the coverage scheme. An example quote (because I don’t really expect you to read the article):

As you can see, both safeties will gain depth at the snap to play from a deep-half alignment. This allows the free and strong safety to drive downhill (top-down) versus the deep dig (square-in), 7 route (corner), post, etc. while also having the ability to get over the top of the 9 (fade) route or overlap the inside seam.

Huh? Can you go over that again, slowly? I knew football was more complicated than John Madden let on during a game (“The best way to gain more yards is advance the ball down the field from the line of scrimmage”), but aren’t football players supposed to be dumb? A person with the ability to understand play concepts like that isn’t dumb.

How about fly fishing? Want to hear about the details of thumb and wrist position during a backhand cast versus a roll cast? How about different flies, or how barometric pressure affects fish, or which caddis fly is hatching, or different ways to read a stream? There are anglers who work on the details of elbow position for months, to make their cast slightly better.

It is easy to spend time focusing on the details of hobbies we choose to do. When you love something it is fun to work on improvement. All it takes is finding a coach or mentor with knowledge, the willingness to share that knowledge, and hours upon hours of hard work.

Do you spend as much time or burn as many synapses improving the tiny important details of your EMS game? Or did your knowledge base peak on the day you got out of class? How aggressively are you challenging yourself to improve?