What makes a great EMT or a great paramedic? I’ll start of with some common and easy answers –compassion, impressive medical knowledge, outstanding airway and IV skills, cool head under crisis.
I could go on. While this would clearly make a great subject for another post, what I want to talk about today is a skill that is rarely talked about, but nonetheless extremely important. I’ll call it scene management.
Let me set the stage.
2nd floor. Several rooms deep into the cluttered apartment. Man in and out of consciousness at the dinning room table. Cool, clammy, extremely diaphoretic. He says he feels terrible. He can’t even hold his arms up. If his wife were not holding him up, he would keel over. You can’t feel a pulse. The blood pressure is 70/. It’s just you and your partner. You have all your gear with you.
What do you do? And in what order?
You have to treat the patient and you have to get him out of the house, hoping he does not code.
I periodically find myself on calls like this. You can call for help, but help is not always around the corner, and sometimes even if you have say, a first responder with you, it is still a bit of a challenge.
I usually start by telling my partner, “Get the stair chair.” While he does that, I slap the patient on 02, try to get vitals and a quick 12-Lead. Then the fun begins. I usually, if its just two of us, take the patient off everything, tie him into the stair chair and make a dash for it, and then once I get him in the ambulance, I start working him up, while my partner retrieves the equipment, and gets whatever information I didn’t already get or forgot to get on the patient – today it was name, social security and meds.
I always feel awkward going down the stairs with a patient like this, trying to spin the corners, not fall over, constantly making certain the patient hasn’t coded. (I have had several patients code over the years half way down the stairs as we carried them).
Today’s call went okay – the patient didn’t die – but I was thinking during the course of it – even though I have been doing this for years – this type of extrication is really often at the heart of what we do, and it is not well taught or practiced. You need more hands than you have, so you have to make some compromises. The patient comes off the monitor and off the 02. I suppose if you have an oxygen shoulder bag, you could keep them on the 02. If I have a third person I sometimes have them carry the 02 behind the chair as we go down the stairs. That still leaves the monitor detached, and the house bag up in the room. Sometimes I’ve had my partner bring that down when he goes for the stair chair, but never on critical patients like this one.
(I'm from the school of if they code, I work them where they dropped, but if they are a possible pending code, I like to get them in the ambulance if I can before they arrest.)
Even though I think I do it pretty well, I often feel fairly incompetent during this type of extrication. I wonder how it would look on a video camera. This morning we burst out of the apartment building, and then set the man down , both of us had to stretch a little to get the kinks and strains out before we unbuckled the patient, and then lifted him up onto the stretcher, which my partner – the mark of a seasoned EMT -- had put in the down position with a sheet on it and straps undone. So here was our patient (not on any oxygen) bare-chested – I’d removed his shirt to do a twelve lead -- diaphoretic, groggy, too weak to lift his arms up from the sides of the stretcher where they now hung down – out in the morning chill as we quickly pulled his arms up to his side, tossed a blanket over him and then without even strapping him in, raised the stretcher up and high-tailed it over to the ambulance, where I found a new non-rebreather and put it on him, running off the onboard 02 and waited for my partner to come back with the monitor -- and the house bag. In the meantime I took another blood pressure, did a head to toe and started an IV of saline.
My partner came back with all the equipment and then slapped down a piece of paper with name, DOB, SS #, and a second sheet with the med list. Everything I needed. (When I was a brand new EMT, my also brand new EMT partner and I once had a bad CHFer with pink frothy sputum. We did a stair chair and run only to get to the hospital realizing we didn’t even know the guy’s name, much less his DOB and SS or any history. On other scenes, I’ve left my intubation gear). He closed the door, got in front and we were off to the hospital.
So the bottom line of this all, a good medic or an EMT, is isn’t just someone with good skills, medical knowledge, and compassion, it’s someone who knows how to extricate a patient, get moving quickly, efficiently, and without forgetting anything. It is a little appreciated art, but something when we do it well we should be as proud of as hitting the diagnosis on the head, or getting a difficult IV or tube.
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Just after posting this, another medic handed me a brochure for a Nurse to Paramedic Bridge class that consists of 96 hours of instruction, 72 hours hospital clinical and 96 hours ride time. Many years ago around here, you had to have at least a year of EMT experience in the field before they would even let you apply to medic school. Now many go right from EMT school to medic class. It doesn't matter really what you are -- nurse trying to be a paramedic or new EMT making the jump to medic school, there are certain things with any job that come only from experience. If you don't have it, hope that you have a partner or veteran first responders who can lead you through the "field" part of EMS -- the part that isn't taught in a classroom.
