Difficulty breathing at the nursing home. The officer who arrives on scene tells us to keep coming lights and sirens.
The room in the nursing home is sparse. The patient, a large man in a hospital johnny, is pale and diaphoretic with a low grade fever and edema in his abdomen and extremities. His eyes follow me slowly as I assess him. His lungs are full of rhonci and probably some rales mixed in. It all sounds crappy. I ask him if he is in any pain and he says his back hurts. He says the bed is uncomfortable, and he is too weak to position himself better. With a nonrebreather on he is only SATing at 90%. His heart rate is in the 130's. The nurse comes in with the W10 and I ask what kind of respiratory history he has. None, she says. He has metastasized cancer into his bones. He just came back from radiation. He's only been here a few days. He just started breathing poorly an hour ago, although he has been edematous since he got here. Also, he hasn't peed for a while. And he's a DNR.
Whenever I hear the DNR status, I admit, I feel a small, if sad relief. I won't have to work as hard on this one as I thought, I think. I check quickly through the paperwork, verify the DNR order, and then slip the papers in my pocket. "We'll get you over to my stretcher now," I say, "and try to get you comfortable." The police officer helps us move the man who is quite heavy. I try to get his head under the pillow comfortably, but as it is, his feet are hanging off one end of the stretcher and his head the other. I sit him up to aid his breathing.
When we put him in the back off the ambulance, I look up at him and think for a moment that he has coded. His head is still and cocked slightly back with his mouth open. I see no chest rise. "Stimulate him," I call to our third partner, who rubs his shoulder and he lifts his head slightly and looks at her.
I tell my other partner to just head to the hospital. He is a DNR, but I don't want him to die on us, so I tell him to go lights and sirens, but easy.
And dying is what this man is doing. His breathing is becoming agonal. The light is leaving his eyes. His lungs are slowly filling with more fluid. I can't hear a blood pressure and he only rouses if we stimulate him. I think for a moment about calling the hospital and requesting permission to use some aggression in my treatment, but I can't figure out quite how to ask, plus I know once I mention he is a DNR, they will likely say no because what he needs is to be intubated. He is too lethargic for CPAP, doesn't have the pressure for nitro. My only option is probably dopamine. I use the electronic cuff and it comes back with a BP of 120/90, which I do not believe. I do it again and it reads 80/40. I try a manual again and hear nothing. After I pop in an IV, I look up at the man and his eyes are completely glazed. His mouth is moving in the classic fish out of water manner. I shake his shoulder and ask how he is. He looks at me and just nods.
When I call the hospital, they ask to verify if the man in indeed a DNR. Yes, I say. Very good, they respond and I can tell they are feeling the same as I did initially. Okay, he's really sick, but we don't have to devote full resources to him.
It's awful watching somebody die like this. Wheeling him down the hall, I see nurses and other EMS people looking at the patient. I can see they are thinking. He's not doing too well. One EMT looks at me and gives an expression as if to say, how come I'm not assisting his breathing. "D-N-R," I mouth and he nods.
They assign us a room and I relay the story to the nurse and show her the paperwork. She goes to get a doctor. My partners and I try to get the man comfortable sitting up on the bed. I rub his shoulder and again he opens his now blank eyes. "You all right?"
He nods, gives a small tired grunt and closes his eyes.
The doctor comes in and I haven't gotten thirty seconds into my report when the man's daughter is led into the room by a registrar. The doctor turns to her and she is crying already. He asks what her wishes are and she says she doesn't know. She wants to know how he is, and the doctor says, he is not doing well. The doctor sees that the DNR is only a week old and tells her it represents her father's wishes and that this is probably what they should honor. I'm standing in the corner watching. It is a heartbreaking scene and an urgent discussion, but at the same time I am aware of something else going on. The man is passing. I don't know if he will be dead in the next minute, but I think his ability to respond is slipping away rapidly. I don't want to interrupt the doctor and the man's daughter, while they decide, but I feel I should speak up. The doctor is staring at the woman as she sobs and shakes her head. "I don't know. I don't know," she says.
I wait. I wait.
Finally, I break in. "Excuse me, I hate to interrupt," I say. "Come, take your Dad's hand," I say. "Tell him you're here. Talk to him. He can probably hear you."
She takes his hand. His eyes are closed. His breathing is shallow, irratic. She kisses his head. "Dad. It's me. I'm here. Can you squeeze my hand?"
I look down at where she holds his hand. There is no movement.
Friday, September 26, 2008
Saturday, September 20, 2008
Sha La Lala Lala, Live For Today
Elderly man. Alzheimers. DNR. No history of seizures. Had a witnessed seizure at the nursing home. Started with his eyes twitching, progressed to a full gran mal. Now the patient who is normally verbal, isn't saying anything, and has snoring respirations. His pressure is 200/110. I stick an oral airway in after a slight gag, the patient takes it fine and the snoring stops. We start to the hospital no-lights, no siren. I put in an IV. As I'm patching to the hospital, I notice the patient's eyelids are starting to twitch. I get out the Ativan. Like a speeding freight train that you hear coming that you feel the ground shake before it roars into view, so comes this seizure till it is full and upon him, and violent. The stretcher itself is rattling with the force of energy seizing in the man. I draw the Ativan up, but wait a little to see if it will subside on its own, but it is just too violent and I have to try to kill it before it blows this man apart, before the alien force inside him comes out and gets me. I give him one milligram and wait a minute and then give him a second milligram. But he is still seizing to beat the band, so after a few more minutes I draw up another dose, but then the shaking slowly slows inside him until he is still. The monitor shows his heart beating. I can see his chest rise. His body looks really, really tired. In his eyes, it doesn't look like he is even there anymore.
At the hospital, I notice his left arm turning in. Posturing. I overhear the doctor telling his daughter the prognosis is grim. She says she just wants him to be comfortable. I walk by the lighted X-ray viewer on the wall and see a scan of a brain with a large white patch in the middle of it.
***
We're called for an unconscious student at the high school. When we arrive at the classroom, I see a nurse with an ambu-bag in hand, kneeling by a young man who is prone on the floor, jerking asynchronously, arching his back, and slamming his arms against the floor. "He's been seizing for seven minutes," the nurse says. I nod and reach over and touch the student and say "Okay, time to stop." I help him to a sitting position and he ceases his activity. I help him to his feet and over to the stretcher, where my crew buckles him in. He is of course, alert and oriented. His pressure is 120/70. One of his fellow students brings him his jacket from his locker along with a New York Jets cap. On the way to the hospital "DeShawn" tells us his mother is out of the country and he doesn't like his step-father. The young EMT working with me tells the boy at least he probably won't have to go to school tomorrow. I see the student smile.
***
Unconscious elderly man found in a fetal position in his home by a coworker who went to check on him because he didn't show up at work. The officer tells us not to bother with the stretcher. When I enter the house I see why. There is clutter and junk piled to the celling. This is the home of a pack rat. The officer says he is in the living room, but to get to him, I have to snake my way through the clutter in the kitchen. The hallway is completely blocked. I find him amid a fallen pile of magazines. The coworker is as shocked as we are by the surrounding says she has never seen him like this. He is a vibrant man who every year wins sales awards at their office. He looks like a malnourished homeless man. I see a few liquor bottles around -- wine, vodka -- but there is no evidence of recent drinking. And no signs of physical trauma. His eyes don't focus. His grips are equal and there is no facial droop. No arm drift. Could he be a hidden drunk? He certainly manages to hide his clutter habit from his coworker. He struggles to tell me his date of birth. He says he drank last night. But I don't smell liquor on his breath. I wonder if he is also having a head bleed. His blood pressure is 180/110. I pick him up in my arms and carry him carefully through the narrow passages. He seems frightened like a small deer.
***
I take the next day off and take the kids to the Big E -- The Eastern State's Exposition -- New England's big fair. It's a beautiful day so nice I don't even mind the twenty dollar bills flying out of my wallet every time I turn around. Bumper cars. The Fun House. Smoked Turkey Legs. A midget roller coaster. Mini Doughnuts with cinnamon powder. The water gun races to see who pops the balloon first. Fresh squeezed lemonade. The barkers selling kitchen cleanup supplies. Miracle mops and knifes that never dull. I win a Yosemite Sam doll when the man fails to guess my age within two years. Throw the rings at the bottles to try to win an I-pod. More bumper cars. Watch chicks hatch from their eggs. See the sheep, cows and horses. The Haunted House. Knock over the milk cartons. Ride the Ferris Wheel as the sun sets. The Petting Zoo where you can feed the billy goats and a Camel.
And then I think I see him. A young man in a New York Jets hat. I think that little shit. I push through the crowd. I call his name "Hey DeShawn!" The young man turns, but it's not my patient from the previous day -- the boy who faked the seizure to get out of school. It's someone else.
But then I think, hell even if it was him. Can I blame him?
Everybody ought to enjoy a fair in their lives. As often as they can.
Eat the mini doughnuts.
At the hospital, I notice his left arm turning in. Posturing. I overhear the doctor telling his daughter the prognosis is grim. She says she just wants him to be comfortable. I walk by the lighted X-ray viewer on the wall and see a scan of a brain with a large white patch in the middle of it.
***
We're called for an unconscious student at the high school. When we arrive at the classroom, I see a nurse with an ambu-bag in hand, kneeling by a young man who is prone on the floor, jerking asynchronously, arching his back, and slamming his arms against the floor. "He's been seizing for seven minutes," the nurse says. I nod and reach over and touch the student and say "Okay, time to stop." I help him to a sitting position and he ceases his activity. I help him to his feet and over to the stretcher, where my crew buckles him in. He is of course, alert and oriented. His pressure is 120/70. One of his fellow students brings him his jacket from his locker along with a New York Jets cap. On the way to the hospital "DeShawn" tells us his mother is out of the country and he doesn't like his step-father. The young EMT working with me tells the boy at least he probably won't have to go to school tomorrow. I see the student smile.
***
Unconscious elderly man found in a fetal position in his home by a coworker who went to check on him because he didn't show up at work. The officer tells us not to bother with the stretcher. When I enter the house I see why. There is clutter and junk piled to the celling. This is the home of a pack rat. The officer says he is in the living room, but to get to him, I have to snake my way through the clutter in the kitchen. The hallway is completely blocked. I find him amid a fallen pile of magazines. The coworker is as shocked as we are by the surrounding says she has never seen him like this. He is a vibrant man who every year wins sales awards at their office. He looks like a malnourished homeless man. I see a few liquor bottles around -- wine, vodka -- but there is no evidence of recent drinking. And no signs of physical trauma. His eyes don't focus. His grips are equal and there is no facial droop. No arm drift. Could he be a hidden drunk? He certainly manages to hide his clutter habit from his coworker. He struggles to tell me his date of birth. He says he drank last night. But I don't smell liquor on his breath. I wonder if he is also having a head bleed. His blood pressure is 180/110. I pick him up in my arms and carry him carefully through the narrow passages. He seems frightened like a small deer.
***
I take the next day off and take the kids to the Big E -- The Eastern State's Exposition -- New England's big fair. It's a beautiful day so nice I don't even mind the twenty dollar bills flying out of my wallet every time I turn around. Bumper cars. The Fun House. Smoked Turkey Legs. A midget roller coaster. Mini Doughnuts with cinnamon powder. The water gun races to see who pops the balloon first. Fresh squeezed lemonade. The barkers selling kitchen cleanup supplies. Miracle mops and knifes that never dull. I win a Yosemite Sam doll when the man fails to guess my age within two years. Throw the rings at the bottles to try to win an I-pod. More bumper cars. Watch chicks hatch from their eggs. See the sheep, cows and horses. The Haunted House. Knock over the milk cartons. Ride the Ferris Wheel as the sun sets. The Petting Zoo where you can feed the billy goats and a Camel.
And then I think I see him. A young man in a New York Jets hat. I think that little shit. I push through the crowd. I call his name "Hey DeShawn!" The young man turns, but it's not my patient from the previous day -- the boy who faked the seizure to get out of school. It's someone else.
But then I think, hell even if it was him. Can I blame him?
Everybody ought to enjoy a fair in their lives. As often as they can.
Eat the mini doughnuts.
Sunday, September 14, 2008
Run Forms
A fundamental tenet of the street medic is that you do not criticize another medic if you were not there on the call yourself.
Countless times I have had people come to me and tell me what so and so medic did on a call and can I believe how stupid they were.
But most of the time when you actually talk to the medic and hear first hand what actually happened, there is quite a different spin on the story.
The other problem with criticizing another medic is it always seems that shortly thereafter fate whips itself around and you find yourself in a difficult situation, doing something foolish yourself, and as it is happening, you know deep down it is payback for your dissing another.
I write all this as an introduction to a situation I find myself in that is a key part of my new part-time job as an EMS clinical coordinator. It is now my job to read run forms.
The run form police? Me? Oh my.
How do I handle this? How can I do one job and yet be faithful to my street medic creed?
This is how I am trying to handle it.
I say aloud, "I was not there. I do not know what happened. I cannot judge on what actually happened. But I can judge on the story you have written. You may have provided great care and I respect you for that, but what you have written here does not tell the story of your heroism, and we need to work on that."
I actually am enjoying reading the run forms. I do so at lunch. I go up to the cafeteria, get myself a turkey and bacon sandwich on rye with a slice of jack cheese and a leaf of lettuce, a bag of mesquite barbecue chips and a Diet Coke over ice and then back at my desk, I pull out the stack and I read.
I don't read the run forms red pen in hand. I read them as a true fan of EMS. Others may pop in DVDs of old episodes of Emergency, me I prefer (my eternal love for Dixie McCall aside) these yellow or pink carbon copies that tell tales of true life.
A well-written run form puts me right there on the scene. I see the sixty-three year old man, sitting upright, struggling to breathe. I can hear the rales in his lungs. Feel the edema in his feet and see the JVD in his neck. I am worried by the low pulse sat reading, the high blood pressure. When the medic squirts the nitro under his tongue it is as if I am doing it myself. I cheer as an IV line goes in on the first try and rise applauding as the medic straps on the CPAP, and the patient almost instantly begins to relax. Well done! Well done! Bravisimo!
The stories I have read! The medic does a 12-Lead. Huge ST-elevation and then a mad dash for the hospital ensues. The patient codes at the hospital door, but the medics are quick with the defibrillator. Boom! Boom! and a perfusing rhythm returns.
While others may talk about the latest episode of ER or what happened at the Olympics or the political convention speeches, I wish they could read what I have read so I could say "How about that call on the highway? Or the 3rd Degree heart block? Or can you believe the story of the unsigned DNR?
What is even better is if the patient was delivered to my hospital, I can -- right from my desk access the ED records -- to read the next episode -- what happened to the patient in the ED.
I hope the medics are learning not to run in fear from me as I pursue them, calling after them, "We must talk about that call on Main Street."
I don't want to get on them about how they left out the time of their 2nd set of vitals or how they misspelled "consciousness," I want to tell them what happened to the characters. He had a 95% occlusion of the LAD or she had a sub arachnoid bleed. Or she got a pacemaker and is doing fine. Or after ten days your cardiac arrest patient walked out of the hospital on his own.
What delight I get when I read a great case I can later share with all the medics at case reviews!
But sometimes I do have questions. I was reading your story and you gave your patient atropine. I couldn't quite follow why. Part of the narrative must be missing. Or it says you got a refusal, but you left out my favorite part where you try to convince them to go and you detail all the things that can happened to them if they don't. You might think it is boring, but I love that part!
I have never been the greatest run form writer myself, but I find that reading other's run forms is helping me improve the writing of my own. I am reading both masterworks and stories that should never leave the slush pile. Now on days when I am back on the street I am thinking of someone else reading my form and I am trying to do my best to tell them the complete story to make them feel as if they were right there beside me at the patient's side.
Countless times I have had people come to me and tell me what so and so medic did on a call and can I believe how stupid they were.
But most of the time when you actually talk to the medic and hear first hand what actually happened, there is quite a different spin on the story.
The other problem with criticizing another medic is it always seems that shortly thereafter fate whips itself around and you find yourself in a difficult situation, doing something foolish yourself, and as it is happening, you know deep down it is payback for your dissing another.
I write all this as an introduction to a situation I find myself in that is a key part of my new part-time job as an EMS clinical coordinator. It is now my job to read run forms.
The run form police? Me? Oh my.
How do I handle this? How can I do one job and yet be faithful to my street medic creed?
This is how I am trying to handle it.
I say aloud, "I was not there. I do not know what happened. I cannot judge on what actually happened. But I can judge on the story you have written. You may have provided great care and I respect you for that, but what you have written here does not tell the story of your heroism, and we need to work on that."
I actually am enjoying reading the run forms. I do so at lunch. I go up to the cafeteria, get myself a turkey and bacon sandwich on rye with a slice of jack cheese and a leaf of lettuce, a bag of mesquite barbecue chips and a Diet Coke over ice and then back at my desk, I pull out the stack and I read.
I don't read the run forms red pen in hand. I read them as a true fan of EMS. Others may pop in DVDs of old episodes of Emergency, me I prefer (my eternal love for Dixie McCall aside) these yellow or pink carbon copies that tell tales of true life.
A well-written run form puts me right there on the scene. I see the sixty-three year old man, sitting upright, struggling to breathe. I can hear the rales in his lungs. Feel the edema in his feet and see the JVD in his neck. I am worried by the low pulse sat reading, the high blood pressure. When the medic squirts the nitro under his tongue it is as if I am doing it myself. I cheer as an IV line goes in on the first try and rise applauding as the medic straps on the CPAP, and the patient almost instantly begins to relax. Well done! Well done! Bravisimo!
The stories I have read! The medic does a 12-Lead. Huge ST-elevation and then a mad dash for the hospital ensues. The patient codes at the hospital door, but the medics are quick with the defibrillator. Boom! Boom! and a perfusing rhythm returns.
While others may talk about the latest episode of ER or what happened at the Olympics or the political convention speeches, I wish they could read what I have read so I could say "How about that call on the highway? Or the 3rd Degree heart block? Or can you believe the story of the unsigned DNR?
What is even better is if the patient was delivered to my hospital, I can -- right from my desk access the ED records -- to read the next episode -- what happened to the patient in the ED.
I hope the medics are learning not to run in fear from me as I pursue them, calling after them, "We must talk about that call on Main Street."
I don't want to get on them about how they left out the time of their 2nd set of vitals or how they misspelled "consciousness," I want to tell them what happened to the characters. He had a 95% occlusion of the LAD or she had a sub arachnoid bleed. Or she got a pacemaker and is doing fine. Or after ten days your cardiac arrest patient walked out of the hospital on his own.
What delight I get when I read a great case I can later share with all the medics at case reviews!
But sometimes I do have questions. I was reading your story and you gave your patient atropine. I couldn't quite follow why. Part of the narrative must be missing. Or it says you got a refusal, but you left out my favorite part where you try to convince them to go and you detail all the things that can happened to them if they don't. You might think it is boring, but I love that part!
I have never been the greatest run form writer myself, but I find that reading other's run forms is helping me improve the writing of my own. I am reading both masterworks and stories that should never leave the slush pile. Now on days when I am back on the street I am thinking of someone else reading my form and I am trying to do my best to tell them the complete story to make them feel as if they were right there beside me at the patient's side.
Sunday, September 07, 2008
Straps
I may have mentioned recently that I started a new part-time job. I'm an EMS coordinator at a local hospital. I'm still keeping my full-time medic job, only I won't be working so much overtime. I haven't written yet about the new job -- I need to think more about the proper way to write about it. I obviously will have to keep the same confidentiality and fair play standards I have tried to keep when writing about EMS calls. In the meantime, the job affects this blog in that it I have less calls to chose from by only working the street 40 hours instead of 60-70, and I have less time to write. I hope to still post at least twice a week with at least one post being street material.
***
Today, I'm going to resort to an old trick that served me well as far as material in the past. Instead of posting a comment on another blogger's site, I'm going to use his post to riff on my own.
Again I turn to one of my favorite bloggers, Baby Medic, who recently posted Points of View, a thoughtful account of doing a great job medically, getting a STEMI patient to the cath lab, only to return to his ambulance to receive a "ticket" from a supervisor for not using all five straps (leg, waist, chest with connection to right and left shoulder) to secure the patient on his stretcher.
In general, I sympathize with Baby Medic on this. He did an awesome job, helping save a patient's life only to be met with demerits for not using all the straps. On the other hand, (maybe it is my new position talking), if you have policies, and you are going to enforce those policies, you have to be even-handed about it. You can't ticket only medics you dislike or only medics who provide inferior care if you are going to let medics you like and medics who provide great care get away with violating the policy. And far as policies go, if 5-straps are the safety standard, then you have to encourage the application of that standard.
Again on one hand, I understand the need for patient safety. Heaven forbid, you have a rollover and your patient is not properly secured. On the other hand, had that supervisor witnessed nearly every patient I have brought in for however long back, he wouldn't have enough ticket books to write me up with. I am, you see, a chronic violator of the 5-strap rule.
In fact, in the middle of writing this post, in which I will finally come down on the side of needing to properly secure patients, I did a call (an OD), in which I only used two of the 5 straps. I try not to be a do as I say, not as I do guy, but sometimes, it is what it is.
When I started in EMS in 1989, we only had two straps. Sometime in the early 90's we got three. We went to five sometime back -- I don't know maybe five or six years ago. I had a hard time with that new third strap. I have a really hard time with the 5-straps. By hard, I mean hard time complying, not hard time understanding the need. (I do love the five straps on boarded patients -- keeps them from coming off the board on decelerations).
Here's why it is hard. I work in high volume systems where care is largely provided during transport. Not just rare lights and sirens transports, but routine no L&S emergency transports. I get the patient, I get them in the ambulance, we get on the way to the hospital and I do what I have to do. It is hard for me to properly assess a patient with the five straps on, sitting them up to listen to lung sounds, getting an accurate 12-lead, or keeping them in a comfortable position when they are having a hard time breathing or are nauseous. This isn't to say, it can't be done, it is just often difficult. The same goes with the seat belt around my waist, which I confess I don't wear much either.
Maybe I need to change my ways. Maybe I need to do as much care as possible in the driveway or at curbside, and then when all is done, strap everyone up and say to my partner. We're all set. I do this only on occasion when I have certain unnamed drivers who I deem to be lead-foot, herky-jerky, take-my-life-in-their-hands drivers.
If I do use all five straps, I'll get one of those few movie, or coffee and doughnut coupons I have heard they at times pass out to people who bring in their patients in with the proper straps as a reward incentive. While at the same time, I'll be arriving at the hospital five or ten minutes later than I might have otherwise. In most patients, that won't make a difference, but in a STEMI like Baby Medic's, it may in fact make a big difference.
Years ago I use to work in a hardware factory on an assembly line. They run assembly lines at a speed a little faster than comfortable, which is the most efficient speed. Just enough to keep you working at your peak. Too slow and it is unproductive, too fast and it falls completely apart. We had three bosses -- each of which had different agenda. The time keepers wanted things done the fastest, the quality control person wanted them done the best. And the line supervisor wanted the best done product in the shortest amount of time.
One of our many projects was assembling door knobs and screws on a large paper sheet (30 or so door knobs to a sheet) that was then heat-wrapped and chopped into 30 individual door knob units all ready for sale.
The conflict came when the time keeper was on me or my co-workers to be more efficient in our movements, which to satisfy him, invariably led to poorer quality (the knobs would be laid down slightly off-centered), which caused the line supervisor to get angry because we'd have to rerun the sheet.
Me, I'd just shrug when they yelled at me and say, "I'm doing the best I can." If pressed, I would freely admit I preferred to err on the side of quality. (F- the time keeper.)
We do -- in this job of taking care of people -- the best we can. We need to do our best to do what is best for their safety. In almost all cases that will involve using those troublesome straps. But if I have a STEMI right now and I need a good 12-lead or set of lung sounds or whatever, I can tell you I will likely unsnap those top straps and may not get around to resnapping them. But I will try. I make that resolution today.
***
A question has been raised in the comments about how do we know the five point straps are actually safe. I admit I was taking that on faith alone. I have just looked up the web site of the noted ambulance safety expert Nadine Levick and found the following from one of her handouts:
"Firmly secure patients with over the shoulder harnesses. If medically feasible, have them sit as upright as possible for safety."
Here are two links:
Best Practices Interview
Objective Safety Home Page
Check Nadine Levick out, and if you ever get a chance to hear one of her lectures and watch some of her videos on ambulances classes, they will chill you to the bone.
Here's some comments of mine after attending her lecture in Baltimore last year:
Funk
***
Today, I'm going to resort to an old trick that served me well as far as material in the past. Instead of posting a comment on another blogger's site, I'm going to use his post to riff on my own.
Again I turn to one of my favorite bloggers, Baby Medic, who recently posted Points of View, a thoughtful account of doing a great job medically, getting a STEMI patient to the cath lab, only to return to his ambulance to receive a "ticket" from a supervisor for not using all five straps (leg, waist, chest with connection to right and left shoulder) to secure the patient on his stretcher.
In general, I sympathize with Baby Medic on this. He did an awesome job, helping save a patient's life only to be met with demerits for not using all the straps. On the other hand, (maybe it is my new position talking), if you have policies, and you are going to enforce those policies, you have to be even-handed about it. You can't ticket only medics you dislike or only medics who provide inferior care if you are going to let medics you like and medics who provide great care get away with violating the policy. And far as policies go, if 5-straps are the safety standard, then you have to encourage the application of that standard.
Again on one hand, I understand the need for patient safety. Heaven forbid, you have a rollover and your patient is not properly secured. On the other hand, had that supervisor witnessed nearly every patient I have brought in for however long back, he wouldn't have enough ticket books to write me up with. I am, you see, a chronic violator of the 5-strap rule.
In fact, in the middle of writing this post, in which I will finally come down on the side of needing to properly secure patients, I did a call (an OD), in which I only used two of the 5 straps. I try not to be a do as I say, not as I do guy, but sometimes, it is what it is.
When I started in EMS in 1989, we only had two straps. Sometime in the early 90's we got three. We went to five sometime back -- I don't know maybe five or six years ago. I had a hard time with that new third strap. I have a really hard time with the 5-straps. By hard, I mean hard time complying, not hard time understanding the need. (I do love the five straps on boarded patients -- keeps them from coming off the board on decelerations).
Here's why it is hard. I work in high volume systems where care is largely provided during transport. Not just rare lights and sirens transports, but routine no L&S emergency transports. I get the patient, I get them in the ambulance, we get on the way to the hospital and I do what I have to do. It is hard for me to properly assess a patient with the five straps on, sitting them up to listen to lung sounds, getting an accurate 12-lead, or keeping them in a comfortable position when they are having a hard time breathing or are nauseous. This isn't to say, it can't be done, it is just often difficult. The same goes with the seat belt around my waist, which I confess I don't wear much either.
Maybe I need to change my ways. Maybe I need to do as much care as possible in the driveway or at curbside, and then when all is done, strap everyone up and say to my partner. We're all set. I do this only on occasion when I have certain unnamed drivers who I deem to be lead-foot, herky-jerky, take-my-life-in-their-hands drivers.
If I do use all five straps, I'll get one of those few movie, or coffee and doughnut coupons I have heard they at times pass out to people who bring in their patients in with the proper straps as a reward incentive. While at the same time, I'll be arriving at the hospital five or ten minutes later than I might have otherwise. In most patients, that won't make a difference, but in a STEMI like Baby Medic's, it may in fact make a big difference.
Years ago I use to work in a hardware factory on an assembly line. They run assembly lines at a speed a little faster than comfortable, which is the most efficient speed. Just enough to keep you working at your peak. Too slow and it is unproductive, too fast and it falls completely apart. We had three bosses -- each of which had different agenda. The time keepers wanted things done the fastest, the quality control person wanted them done the best. And the line supervisor wanted the best done product in the shortest amount of time.
One of our many projects was assembling door knobs and screws on a large paper sheet (30 or so door knobs to a sheet) that was then heat-wrapped and chopped into 30 individual door knob units all ready for sale.
The conflict came when the time keeper was on me or my co-workers to be more efficient in our movements, which to satisfy him, invariably led to poorer quality (the knobs would be laid down slightly off-centered), which caused the line supervisor to get angry because we'd have to rerun the sheet.
Me, I'd just shrug when they yelled at me and say, "I'm doing the best I can." If pressed, I would freely admit I preferred to err on the side of quality. (F- the time keeper.)
We do -- in this job of taking care of people -- the best we can. We need to do our best to do what is best for their safety. In almost all cases that will involve using those troublesome straps. But if I have a STEMI right now and I need a good 12-lead or set of lung sounds or whatever, I can tell you I will likely unsnap those top straps and may not get around to resnapping them. But I will try. I make that resolution today.
***
A question has been raised in the comments about how do we know the five point straps are actually safe. I admit I was taking that on faith alone. I have just looked up the web site of the noted ambulance safety expert Nadine Levick and found the following from one of her handouts:
"Firmly secure patients with over the shoulder harnesses. If medically feasible, have them sit as upright as possible for safety."
Here are two links:
Best Practices Interview
Objective Safety Home Page
Check Nadine Levick out, and if you ever get a chance to hear one of her lectures and watch some of her videos on ambulances classes, they will chill you to the bone.
Here's some comments of mine after attending her lecture in Baltimore last year:
Funk
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