Situational Awareness and Responding to an Ambulance Call

No doubt you have read about the Northwest Airlines jet that sort of missed their airport by a few miles. By now, they are saying stuff about laptops, schedules, and what not. So they were not paying attention, and I have to ask the question-

“JUST WHAT IN THE **** WERE YOU GUYS THINKING UP THERE?”

There. Done.

OK. So what does that have to do with situational awareness (SA)? Actually, nothing. But one of the fire service blogs I read from time to time tried to compare the Northwestern incident to situational awareness back before we found out they just were not paying attention.

There are a lot of definitions out there of SA. Having read them, to me SA can be defined as a combination of knowing and understanding what is happening around you, being able to predict how this activity may/will change what is going on around you, and understanding how that (those) change(s) will affect you. There is also the essence of “being at one” with your environment and the dynamics that are driving it.

The military learned a long time ago that sometimes fighter pilots were overwhelmed with everything going on around them. Think about it. For a fighter pilot in an F-15 or F/A-18 in level flight there is a lot going on. There are all sorts of inputs that provide information to the pilot. Now, throw in a couple (or more) enemy aircraft, maybe a SAM or two, and the dynamics of the situation have changed. Dramatically. And the pilot has to be able to manage all of that information in order to keep flying and neutralize these threats. Being over loaded with input had some detrimental effects on SA. So the military did some things to alleviate it, in a fashion. As an example, the “heads up” displays in the cockpit were a part of this situation.

Now, operating an ambulance is not as dramatic. Or is it? Think about it- when we are responding to a call we have all sorts of information that is being fed to us, whether we are paying attention or not. From the driver’s perspective, think about these-

1. The vehicle’s instrumentation. There is the speedometer (hopefully you are paying attention to this), the tachometer (can tell you a little about your vehicle’s performance; pay attention), the fuel gauge (which you should have been paying attention to before now), the oil pressure gauge, temperature gauge, and volt meter (you need to pay attention to them, too).

2. The radio (not the AM/FM). Hopefully there is information coming to you this way, whether it is from the dispatcher, the first responders, or other EMS units that are on scene.

3. Your partner. He/she should be calling out traffic situations on his side and to the front. He/she should also be paying close attention to the radio (you have your hands full driving the vehicle).

4. Your own senses. Obvious you have to be keeping a sharp lookout to your side, to the front, and to the other side, as well. After all, you are the driver and you are responsible. There are things you hear (radio, your partner calling out traffic, other vehicles’ horns or sirens, etc.)

In my EMS system, we also have a mobile data terminal (MDT) that provides in-vehicle navigation (IVN) and computer-aided dispatch (CAD) interface. IVN is a good tool, and the program we use is OK, to a point. I think there are some things that could make it better, but that is another day. Also, the CAD interface we have can provide good information, at times, but there are some things that need to be improved with there, also.

So with all of this information coming in, you have to sort it out and prioritize it. If you are driving, you have to ‘limit’ your ‘heads up display’ so to speak (no, we do not actually have a HUD and I would hate to see the incarnation of it on an E450). When I am driving, I concentrate on six things- the traffic on my left, the traffic ahead, the speedometer, the traffic on my right, my partner, and to a degree my other instrumentation. When I am riding in the right front seat, I limit my attention to the traffic on my right, the traffic ahead, the radio, and the MDT. If I need it, I also concentrate a map book (but I always know where I am going BEFORE the ambulance moves).

Yes, there is a certain amount of overflow between the driver and the passenger. I guess that is a way of the two positions becoming “one with the situation”. But I am amazed at the low level of overflow when each is maintaining their own ‘sphere of responsibility”. For example, if I am driving, I always look right, even when my partner calls “clear right”. I may not take a long look, because I am depending on them, but I at least take a quick look. It’s the safe and prudent thing to do.
But back to the subject, what are some of the things that can be challenges to SA?
Well, there is the siren. No, I am not talking about the big screaming Q2B found on most fire trucks around these parts. No, I am talking about the multi-tone, multi-position electronic sirens that most ambulances use. You know, the ones with wail, yelp, phaser, hi-lo, ex-wife nagging, screeching cat-in-heat, etc. A lot of times the driver seems to want to control the siren. To me, that is a no-go. First, both of your hands should be on the steering wheel. Second, your gaze should be focused on traffic, the speedometer, your gauges (occasionally), and traffic. You are responsible for moving 15,000+ pounds of steel, aluminum, plastic, rubber, and my flesh and bones through traffic. Safely. So, if you are working the siren (and you shouldn’t be if you have a partner up front, set it on wail and forget it. It is one less thing to distract you from what is going on around you.

MDT updates. I know not everyone has MDT’s, but my system does. And they have two annoying habits. First, they are ‘updated’ every few moments, which requires you to depress a button on the screen to get the latest information (which may or may not be relevant). Second, there is a lot of other stuff that comes up on the screen that is totally irrelevant to what we are doing. The reason that I say this is distracting to the driver is that we have a natural tendency to want to know what is going on; what kind of information is being passed along. Is it now a ‘code’? Are police on the scene? What’s going on? It’s distracting. I try and always turn the MDT away from me when I am driving. And if I have to view it for directions on IVN/MARVLIS, I STOP THE TRUCK. What more can be more distracting to my situational awareness as the driver than looking at a computer screen?!?!?

If I am not driving, the MDT is turned towards me. I’ll call out directions.

The radio can be distracting. Sometimes the radios are on scan. In my system, it is desired that we switch at least one portable radio over immediately to the appropriate TAC channel. But then someone else may say something on the main channel that your mobile is still tuned to, that is not relevant to your call, but sounds like it is, then you get distracted, then you are filling out incident reports on the wreck you just had. Some people may disagree (and that’s alright, you can’t help it), but I work to set all of the radios to the assigned TAC channel. Leaving the main radio on the dispatch channel can even be distracting to me in the passenger seat. Nothing like turning your head and saying “What did they just say?” as a minivan plows into your side.

I won’t even mention much about cell phones, iPods, and Blackberries. Unless God personally is calling you, you do not need to be talking on some other
communication device while you are driving my ambulance ‘hot’ to anywhere.

So much for SA while driving. I could talk more, but you get the idea. Do what you can to make your job SAFE. Your ultimate goal must always be going home at the end of your shift. All other concerns are secondary.

M914

A picture is worth a thousand words...

A picture is worth a thousand words. And the last thing that I want is for you or me to be the subject of a picture like this. All it takes is a few seconds to make sure you have a safety blocker in place, or at least on the way.

Vests, flares, traffic cones, flashing lights, and chevrons make you visible. To the driver who is paying attention.

But what about the one(s) who is not paying attention?

What would the result have been if this car had struck the ambulance? Especially if you and your partner and a couple of first responders were loading a patient into the ambulance.

On arrival at a scene like this, pull ahead. This allows the fire truck that arrives after you do to pull into position between you and the motoring public. If the fire guys are already there, pull around in front of them.

Either way, you have something between you and the motoring public. 

Rituals can be a good thing...

Contrary to some belief, I think some 'rituals' are a good thing, even here in EMS. Sometimes those rituals get us into good habits. And as long as they are based on sound goals and objectives, well, they can be good.

Checking-off the ambulance at the beginning of your shift is an important thing. It is a ritual of sorts. We should be doing it at the beginning of every shift. I guess in a perfect world you could trust your off-going shift to be diligent in ensuring that you and your unit can take that call that comes in immediately after you go on duty. But usually, that is when I get my nastiest surprises. You see, as much as I like them, sometimes, well, they forget stuff. Or in some cases, they just don’t care. Yes, I have worked with some of those people during my career.

So I take matters into my own hands. Some surprises are good, but others are not. First thing, you need to arrive at work with enough time to check a few things before going on duty. So, if your shift changes at 0800, then you need to be at work NLT 0730. Change at 0700? Be there at 0630. No, you are not going to get paid for it. Not money, anyway. But it can pay you dividends that you can appreciate it. More on that in a few minutes.

The first thing I check is the main onboard oxygen cylinder. The second thing is the defibrillator batteries (those actually in the defibrillator and the spares). The third thing is my portable oxygen. A quick look around the unit to verify that things seem to be in place takes care of my ‘initial’ check.

The next thing I do is change the portable radio batteries (unless I know that they were changed just prior to me receiving the radio).

I try and get some sort of turnover report from the off-going crew, then, I or my partner start on the complete check-off. If we get a call in the middle of it, then, my partner or I can continue the check-off while the other is completing the report at the ED.

There are things that you can do to make the check-off easier. At my service, we seal certain items with a numbered seal tag. The things we seal are the ET kits, the pediatrics bag, our drug box, and our Mark I kits. Other things could be sealed, like cabinets with little-used items (OB kits, burn sheets, etc.).

The rest of it is just a matter of finding things on the checklist and then finding them in the unit. Of course, after only a few days you should know where just about everything is, so it should not take a lot of time.

And somewhere up there at the beginning, before the other shift leaves, I like to verify my narcotics and controlled drugs. There is nothing quite like discovering a morphine or fentanyl that has not been accounted for. After the other shift has gone home. And of course, no documentation is available, and the last shift’s call reports are in the ‘HIPAA box’.

But back to the check-off. Usually, it can be done before or shortly after our official shift begins.

So what other benefits can be gained by this? Well, if you establish the standard, maybe the other crew(s) will reciprocate. After all, if you are there at 0730 and a call comes in at 0745, then you should take the call. Again, you probably are not going to get paid for it, depending on your agency’s HR policies or your union contract. But the other crew does not have to take that late call, and they should be appreciative. Enough so to return the favor the next day. I know I would, since

I really hate those 0745 calls. Seems like they only come in when I have to be somewhere at a specific time.

But what if they don’t return the favor? Well, several of the crews I work with are like that. And that’s OK. At my old service I always tried to arrive between 0730 and 0740 for an 0800 shift change. My new job has an 0700 shift change, and I want to be there between 0630 and 0640. It hasn’t worked out thus far since the other half and I have been down to one vehicle for a little while now. But as soon as I get the 9E1-mobile back, then I will be leaving home at 0620-ish.

Rituals can be good. As long as we have solid goals behind our rituals.

The Code Commander

I remember back when we in EMS did not do anything like ICS. Hell, we did not do anything like ICS in the fire service, either. And looking back I come away with two thoughts. First, it's amazing we did not get more of us killed and hurt. Second, it was pretty damn funny to watch.

But then Chief Bruno wrote his book and it all changed. Maybe not overnight, but it did change.

Well, not quite.

How many resuscitations have you seen that were 'less than organized'? There was a lot of yelling going on, a lot of equipment being thrown around, but not much getting accomplished. Yep, I have seen a plenty of them, too. Even participated in a few of them.

Well, the answer is right in front of us. Apply the concepts of ICS and designate a Code Commander.

No, we do not need any special hats, vests, or badges. The code commander is the one watching the monitor. Calling the shots. Making sure stuff is getting done.

And the concept works.

Your system's design will determine hwo the concept works for you. In ours, we have resources. Lots of resources. Most of the time.

Usually, fire units arrive first. Most of the time the first arriving fire unit brings at least three personnel to the scene (in some instance two, in others four or more). They initiate chest compressions and early defibrillation (if indicated).

The next arriving unit is typically an ambulance, staffed with at least one paramedic. That's your initial 'code commander'. The code commander is tasked with making sure that adequate chest compressions are ongoing and makes sure the monitor is attached to the patient. If ALS resources are initially short, the first arriving paramedic can place the IO.

Place the King airway. In our system EMT-Bs can do this. Attach the ETCO2 and verify the waveform.

Sit back. Oversee.

Other resources will arrive. In our system at least a second ambulance, a district supervisor (EMT-P) and/or an additional supplemental response vehicle paramedic.

If desired, the code commander role can be transferred to another arriving paramedic. But if the first person is getting it doen, then leave it alone. No sense fixing something that ain't broke.

One code I worked recently found the patient on the screened in back porch. Resources arrived quickly and everything was getting done. I was the code commander, so when our medical director arrived (he checks in on calls, drives a marked response vehicle, etc.) there I was, sitting in a chair, LP12 in my lap, good view of the scene, and my feet propped up on an ottoman. All that was missing was a drink and someone to fan me!

The concept works.

And something else that helps is the 'checklist'. Below I have the 'cardiac arrest checklist' that is in use in my system-

Cardiac Arrest Checklist:
____ Code Commander is identified
____ Monitor is visible and a dedicated provider is viewing the rhythm with all leads attached
____ Continuous compressions are on-going
____ O2 cylinder with oxygen in it is attached to BVM
____ Mask travels with bag, regardless of what airway is in place
____ EtCO2 waveform is present and value is being monitored
____ ITD is in place if appropriate
____ Access has been obtained (IV or IO)
____ Gastric distention is not a factor
____ Esophageal temperature probe is in place and temperature is visible
____ D50 and sodium bicarbonate have been considered and/or administered
____ Tension PTX has been considered
____ Family is receiving care and is at the patient’s side

I'llget pictures up pretty soon. More later on the whole checklist thing.

Good morning...

So here we are. Blog #2.

I have really enjoy doing the 9-ECHO-1 blog. But like I said over there, there is something I wanted to do that really would not fit, at least I didn't think so, on the 9E1 pages. So here I am.

Most everyone knows what 9-ECHO-1 stands for and where the name comes from. BUt where does MEDIC 914 come from?

Several years ago I was a volunteer paramedic with my town's rescue squad. We all had individual radio numbers assigned, and mine was 914. When my agency began providing paramedic level service, I would use the call sign MEDIC 914 whenever I was communicating on a non-unit level.

At that time, the concept of Incident Command had not caught on much. OF course, that led to some pretty darn humorous stuff on the radio. And so, in the interests of being the "class clown" and calling attention to myself, a lot of times, when my unit arrived on the secene of some "less than life threatening medical situation" you might here something like "MEDIC 9 on scene, we have a two story wood frame apartment complex, nothing visible from the outside. MEDIC 9 has Butterfly Apartments Command, we're investigating, Sector 5". And always, I would get a chuckle or some sort of remark from the 9-1-1 center personnel.

Everyone thought that was kind of funny, the way I did that. But of course, when I rolled up on the "thoroughly life threatening medical situation", it went something like this "MEDIC 9 on scene, we have a single vehicle rollover crash. I have multiple patients in the north and southbound lanes. Traffic is blocked in both directions. MEDIC 914 has I-95 South Command at MEDIC 9. I need 10 ambulances to the scene and 10 helicopters to the pad".

Let me clarify one thing. This took place back when we thought helicopters were life saving creatures. Back when all things in a resuscitation effort ceased while the paragod paramedic intubated the patient. Back when MAST trousers were life saving pieces of equipment. You know, just a few short years ago.

But anyway, I hope you enjoy the new blog. Don't forget to check out the other one, but keep coming back to this one. And please, offer comments, ask questions, or argue.

I love a good argument.