Taking Care of People…

Over on The Happy Medic, San Francisco Fire Department Paramedic Justin Schorr writes about his family’s recent experience with a child’s medical emergency. And of course, Justin zeroes in on some EMS related issues. Be sure and go over to read his blog. Good stuff, it is.

But anyways, it kind of got me to thinking. How well do we really take care of people?

It depends upon what you think it involves. Of course, we have protocols to follow, skills to do, and on and on and on. But there are other things that we need to do that are just as important. And they have nothing to do with starting an IV, reading a 12-lead, or any of that other stuff you learned (hopefully) in paramedic (or EMT) school. It’s all about how you take care of people.

Justin mentioned something in his blog about warming a stethoscope. So just how many times do you take the time to warm up a stethoscope before you place it on a patient? Especially in the winter time when it has been hanging in the back of an ambulance, probably on that catch-all-netting at the head of the bench. Even when it is wrapped around your neck it gets cold. Little kids and elderly patients are kind of sensitive to that cold stethoscope. And guess who makes up a large number of our patients? Yep, you got it. So take a few seconds, tuck the bell under your arm. Probably would be a good thing to do when you are introducing yourself to your patient. You do introduce yourself to your patient, don’t you?

Over on 9-ECHO-1, I mentioned that the entrance to Walmart is smoother than the entrance to most of this area’s Emergency Departments. So, do you take it easy over those entrances, or just bump on across? Based upon what I have seen, most of us just bump on across. Probably feels really good with that broken hip, bone cancer, or any one of many maladies that hurt when you move. 

And when entering the ambulance entrance to several of the area EDs, it seems that the worse part of the trip is when you are turning into the ED. And we know doubt know it since we do it enough. So how many of you just turn on in, bumping and swaying? And how many of you think about your patient (and partner) in the back of the specialty vehicle you are driving that is NOT known for its smooth ride? If you are the one that just drives on in without consideration for your passengers, I bet you are the one that does not slow down and ease across railroad tracks as well.

But what about other things along the lines of ‘taking care of people’?

Do you explain what you are going to do and why you are going to do it? As I get older I am exposed to the healthcare system just a little bit more. At my colonoscopy I saw a wide variety of ‘explaining’ and the lack thereof. The nurse that started my IV had a good technique (well, her tourniquet technique sucked) but she barked out orders like Gunnery Sergeant Hartman- “Put your arm down”, “Make a fist”, “Hold still”. And when she was done she just walked away. Oh yeah, and there was that introduction- “I’m gonna start your IV”.

Well, she did tell me what she was going to do. And what do to. In no uncertain terms. But ‘why’ would have been nice. So would a personality.

I always tell my patient (even if they are unconscious) what I am going to do, why I am doing it, if it’s going to hurt, etc. And you should too. It is part of the reassuring process. For a lot of people (I like to think most of them) the whole process of getting hurt or sick and calling 9-1-1 is a pretty stressful and frightening event. A big part of our job is reassuring them and alleviating their fears. And to do that you must tell them what you are doing, why you are doing it, and quite frankly, if something is going to hurt. Before we do it.

And how well do you ‘relate’ to your patient? You know, that rapport that you have to establish early on to gain their confidence. I have seen some people that are really good at it, while others…well, some people are really good at it. It’s all of the stuff above, and a little more. In my old system we used Panasonic TOUGHBOOK laptops to complete our call reports. And there was a natural tendency to type as you rode. And that is OK if you can pull it off. By 'pull it off' I mean that you have to maintain that rapport, that relationship, with the patient. And that means you have to talk to them. Pay attention to them. And, egads, reassess them.

Reassess means more than let the Zoll's blood pressure monitor recycle every few minutes and take a look at the pulse oximeter reading every few minutes or so. It means talking to them. It means asking them if they feel better, if the oxygen is helping them. Of if they’re feeling worse. And you CAN’T sit in the ‘captain seat’ and do that. And sitting in that captain seat, typing away, and asking your patient, from behind them, without making eye contact, if they are OK, to me, is worse.

Taking care of people is a total package. Sure, starting that IV and reading that 12-lead is important. But being nice (because nice matters) is just as important. Maybe more so. In the end, it is the total package that matters. It is the total ‘A’ game.

And you have to bring that total ‘A’ game to every call, every time.

Anything less is not doing your patients (or their families) any favors.

Stroke stuff...

Don't you just love it when the powers-that-be try to make everything fit into a simplified process? Kind of like everyone thinking that the Cincinatti Stroke Screen is the end-all and be-all to assessing a potential stroke patient.


"A good man's got to know his limitations" H Callahan.

Well, it IS useful. And pretty good to use MOST of the time. But it does have it's limitations. Seems that there are those other times, that, well, just tend to screw up plan A.

Over on Ambulance Driver's site, he recently entered this reminder that everybody does not fit into the 'normal' parameters and sometimes, well, you just gotta think about stuff.

Over on Paramedicine 101...

...there is a good post about professionalism. Mostly, it is about how we conduct ourselves in front of our patients. It is must reading for all of you.

WAIL-YELP-WAIL-YELP-WAIL-YELP-CHIRP-CHIRP-CHIRP-WAIL-YELP-WAIL-YELP

This afternoon me and my other half were out and about. At one point we were sitting at a stop light in the second biggest city in our county, in front of the great big mall. Now we were sitting on the front row at the stoplight when I saw RESCUE 2 coming down the road with red lights going. There was a moderate amount of traffic and on their approach they went to the outside lane (passing on the right). As they approached, out of curiosity, I turned down the radio.

After they passed, I asked the missus when she heard the siren. The same time that I did- after they were already in the intersection.
Later, we were in another one of the smaller towns, sitting at another stop light, when I heard a siren approaching from the rear. I looked in my rear view mirror and saw a deputy sheriff approach from behind. As he approached he came up on my left, stopped, then eased out into the intersection before proceeding.

I heard him coming from a distance of about one and a half football fields.
The difference? The fire unit had their siren on yelp. The deputy had his on wail.

And we had the radio in the Tahoe turned up so we could listen to the hockey game when the deputy approached.

I don’t know the science behind it. But at some point we were taught that this crap of changing tones and stuff made us more easily heard. That it would move traffic out of our way better. That it was safer.

Purely anecdotal evidence at this point, but it holds up time after time after time.

I know. I harp on this. A lot.

But it is amazing how many wrecks involving emergency vehicles I have heard of that the other driver “never heard them coming”. On yelp. Or phaser. Or that cutesy switching back and forth stuff.

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.