Street Lessons # 6 Don’t Always Believe Your Own Eyes
When I was a new EMT, I responded to a call for an unconscious person. In the basement of a house, I found a woman in her thirties unconscious of the floor and her husband shouting frantically that his wife was dying and that he had in fact done CPR on her for several minutes. “Help her,” he demanded. “I am,” I said. I was kneeling beside her and feeling her pulse, and watching her breathe. While she was in fact unconscious, her breathing was even and her pulse was steady. Her skin was warm and dry and she didn’t have a scratch on her.
My partners had told me stories of people doing CPR on living patients and always laughed at them, and while in my career I would encounter this phenomenon again and again, this was first time seeing it, and I thought, I am an EMT, the person is breathing and has a good pulse. This man is just a layperson who is very panicky and I think it is a good bet she did not actually need CPR when he was pounding on her chest. Perhaps she is on drugs. Her husband denied that when I asked. To this day, I am surprised he did not beat me for suggesting it. I guess he was clinging to the belief that maybe I could help her.
Well, we got her on the stretcher and out to the ambulance, and wouldn’t you know, ten minutes later, she stopped breathing and we were doing CPR.
A wise person told me once when I arrived on scene to always acknowledge the first responders or the bystander if there were no responders and get a report. Some reports would be excellent, some would be crazy. The point the wise man made was to simply show respect. “I did CPR on her for a couple minutes and then she came around,” the woman would say. “Great,” I would respond. And then get on with managing the syncopal victim with the now bruised sternum.
But let me tell you this now. I would add a caveat to the acknowledge the first responder advice, and that caveat would be “Listen to them.” I know sometimes in the past, while pretending to give my full attention, my mind has been going yadeedaa.
Now I say this because in my career, while I have had first responders or bystanders describe what seemed like crazy things compared to what my eyes were seeing when I arrived. I have had those same seemingly okay patients suddenly revert back to what the bystander or first responder described. “Sure, you were doing CPR, great Job!” I’d say, thinking that’s a laugh, only to find myself doing compressions five minutes down the road. Or to have the responder describe the crazy seizure they witnessed, only to have the patient startle me with the same earth-shaking tonic-clonic seizure later on down the road.
Don’t assume because the person is fine now, that they were fine when 911 was dialed.
I am not saying to take everything a first responder or lay person says as gospel, only to consider it. Never dismiss any information outright. If someone says the little girl with the polka dot dress’s head spun around three times and fire came out of her mouth, I will store that nugget in a small, but retrievable place.
In EMS the hierarchy on a call goes something like this. Bystander, first responder, EMT, paramedic, with each higher level of care assuming command as they arrive. The hierarchy continues at the hospital. Nurse, Doctor. Although some of us paramedics would argue the nurse is not above us, most hospitals are structured where the paramedic turns the care over to the nurse, who makes the decision where the patient goes next – a regular room or a critical care room.
Has it ever happened to you where you have described the extremely sick patient you encountered who now seems fine, and had the triage nurse or the doctor be somewhat dismissive of your account because of what their own eyes are telling them? I am sure it has if you have worked any amount of time.
Doctor, he was pale and diaphoretic. Nurse, she was in full seizure. Doctor, he was completely unresponsive. Nurse, he was blue. Doctor, I know it isn’t on yours, but I have ST elevation on my 12-lead.
Waiting room. Or a bed in the hallway.
Later, you hear: Hey your patient coded in the bathroom. Or they found your patient seizing by the coke machine. Or perhaps: Yeah, didn’t you hear? The hospital burned to the ground with only one survivor, a little girl in a polka dot dress standing in the midst of the rubble, unharmed.
Street Lessons #5 The Hand Drop Test
Anyone new to EMS is likely as amazed as I was at how many patients feign unresponsiveness. We all likely have had a moment when a more experienced responder has demonstrated the “Hand Drop Test,” where they raise the patient’s hand over their face and release it. If the hand smacks the face, they pass the test and truly are unresponsive. If the hand stops or is moved to the side to avoid contact, then the patient fails the test and is a FAKER. Or so it goes. The best FAKERS, I was told, know our tricks and so let their hands smack their faces because they are wise to what we were trying to prove. I was told to look out for these master fakers.*
There is a second more valuable lesson than the Hand Drop Test, a lesson that comes later and often comes painfully to your own performance as a paramedic. And that lesson is just because a person is aware enough to move their hand to avoid their face, doesn’t mean they can’t also be really sick.
What do you mean? They have an intracranial bleed? They failed the hand drop test!
What do you mean? They are in acute renal failure? They failed the hand drop test!
I was burned by this early in my career, but never again.
All a person needs to fail the hand drop test is a smidgeon of consciousness, and a quarter ounce of remaining strength. It merely tests for a smidgeon of consciousness and a quarter ounce of strength. It does not provide proof that a patient is not sick or injured.
Also, if the results of all your other assessment capabilities still leave you wondering, and you just have to do the hand drop test, make certain that you protect the patient. A paramedic caused bloody nose should not be considered collateral damage from having to do the hand drop test.
* I no longer feel it is my job to unmask fakers. If I suspect someone is faking, I find it easier to just pick them up, put them on the stretcher and take them out to the ambulance, than to try to prove to the surrounding crowd that the patient is conning everyone.
Street Lessons #4 Carry Your Gear
Always carry your gear into calls. I know it can be a pain to do, but nothing is worse than suddenly needing your equipment and not having it.
A woman calls 911 and says “my baby is sick!” You get dispatched for a sick baby. You think if it is a sick baby, what do you need equipment for? Most likely the baby is not really sick, but if the baby is really sick then you can, as my preceptor once said to me, “O.J. it.” This of course was when O.J. Simpson was known for running and leaping faster than any other human and not known for slashing throats. “O.J it” meant grab the baby and run for the ambulance.
Many times in my early years as a medic I “OJed” it with sick kids, sometimes doing CPR and tiny breaths as I went, hurtling toward the ambulance, my office where the gear that made me a medic was stowed. Aside from that clearly not being the ultimate way to resucitate a baby or anyone for that matter, the “sick baby” call doesn’t always turn out to be a sick baby. The sick baby can be anything from a 300-pound fifty-two-year old son in cardiac arrest to a vomiting parrot. The 300-pound son you clearly wish you had your gear for. The vomiting parrot? Well, that’s another story.
When I started there was one paramedic who always carried all his equipment in on every call. Back then we had a black hard suitcase called a biotech for the meds and IV supplies. We had an intubation kit, we had a large house bag with the oxygen and bandaging supplies, and we had the Life Pack 5 and then the Life Pack 10 monitor. We also had an orange tackle pedi-box.
Now this medic didn’t bring the pedi-box in on every call unless it sounded like it might be a pedi. For the sick baby that turned out to be the 300-pound fifty-two-year-old son, he would have had the pedi box there along with everything else where other medics would have had to send their partners running back down to the truck.
He also-- and this is what impressed me the most -- he always carried the portable battery-operated suction machine in. Every call. Me, I only bring it in to a known cardiac arrest, and I can tell you to my embarrassment, two of the last three difficulty breathings I’ve been too have turned out to be cardiac arrests where my preceptee has said, “I need suction!” when he has put the larengyscope in and seen nothing but murky waters. “I need suction now!” On its way. but not here yet.
We had a paramedic here who was fired for not bringing equipment in. She sometimes brought equipment in. Say it was a known cardiac arrest, she would put a larengyscope, a tube and a 10 cc syringe in her pocket. I kid you not. She also downgraded a stabbing because the hole in the chest was "just a little hole." Lazy paramedic. Bad paramedic.
I carry in the house bag and the monitor, and the 02 if the fire department hasn’t gotten there yet, although there have been times when I have climbed up three flights of stairs only to find the fire department also didn’t bring in their 02. I hate not being prepared.
I carry my controlled substances on me when I go into a call. While there is some lack of clarity as to what exactly the rules are in our state governing the securing of controlled substances -- it ranges from they must always be secured doubled locked in the ambulance unless you have the intention to use them to its okay to secure them on yourself as long as you are on the clock and capable of being dispatched to a call where you might need them. The issue here is: what if you respond for a person vomiting and after wheeling your stretcher down many halls and up a couple different banks of elevators in a big insurance company, you find your patient is actually seizing? You can either 1) Put the patient on your stretcher and wheel them seizing all the way back out to the ambulance. 2) Give the controlled substances keys to your BLS partner and tell him to get the kit and hurry. 3) Or you can take the controlled substances kit out of your own pocket and stop the seizure now. I hate being without my gear when I need it.
Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched -- the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, "he's up on the 2nd floor." We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with gurgling respirations and an ever growing pool of blood around his head. "He got the shit kicked out of him," the cop says -- "steel toed boots." "Uh-o," Steve says to me. "Go get the gear," I say to Steve.
We work together the next week. No "uh-o" moments we both agree. We'll bring the gear in on every call. First call of the night is for a "woman drunk wants to go to rehab." This is a call we do all the time too. We walk in, meet the patient, who says, "I want to go to rehab." And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door -- also up on the second floor. "My daughter is an alcoholic," he says. "She needs to get cleaned up. I don't think she's breathing." Uh-o. Go get the gear.
I know the gear is heavy, but look at it this way, you are in physical training. Carrying all that gear up and down stairs will get keep you in shape and keep you young. Do enough calls, walk up and down enough staircases and you can skip the gym after work and spend the time with your family.
Street Lessons #3 Know Thy Patient
Ahh, the simplest things. You need the patient’s name, date of birth, and social security number if possible. The name is most important. If the name is John Smith or Juan Martinez, the date of birth helps.
I was a brand new spanking EMT and we had a patient in classic CHF -- I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum. We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out. No name, no DOB, no social, just the address we picked him up at. Chalk that one up to two excited rookies.
On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you. In the past, I didn’t often bother with this information if the patient was talking to me. I figured I could get it out in the ambulance. I look at the elderly patient and say “You know your date of birth and social security number?” The patient looks me right in the eye and says “yes, sir.” Very good.
On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth. “Yes, sir!” he says. Same answer to social security number. I ask him his name. “Yes, sir!”
Always get the name and social.
I am in the nursing home and the nurse hands me the envelope. I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it. Check. Check. The patient is unresponsive. Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition. I notice then that patient’s name is Mary Wilson. The problem is the patient is a man. I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.
Here’s one. Nursing home patient is unresponsive. Ambulance crew takes patient and paperwork. Patient’s blood sugar turns out to be 29, but he is not a diabetic. They give him D50, and he comes around, but is still somewhat confused. At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic. Plus he is still confused. He won’t answer to his name. Later that night, the hospital gets a call from the nursing home to check on the patient. Who? The hospital says, we have no one by that name here. Later the hospital calls the nursing home back. We do have someone here from your facility named Edward Thomas. Ahh, no you don’t. Edward is right here next to me in his wheelchair. Whoops. No wonder the man in the hospital bed won’t answer to his name. Turns out the patient is a diabetic after all.
You have to check the name. If the patient can’t confirm it, check for a name bracelet. No bracelet? Get a nurse to verify the patient and paperwork are one and the same.
You’d think it would be easy, but it’s not. The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder's previous patient, and not this current one. The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper. Not the patient in front of me.
I try hard now. I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name. Mistaken identity can lead to serious errors, and those we always want to avoid.
Street Lessons #2 Troubleshooting the Monitor
In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments. Simple enough. If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag. Some might say you should also be bringing in your suction --anything you might need. You never know what you are walking into. But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you. (At least in cases A-D). Here’s where the problems begin.
Problem A
Both batteries are dead. You checked them this morning and you swear they both had four bars. Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead. What happened? Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down. I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.” What do you do? If you are still in the truck when the battery is beeping, you change the batteries out. Simple enough. But let’s say they are both dead and you don’t notice until you are in the house. You take the spare battery out of the back. How do you know you have a spare battery? Because this has happened to you before, so you always keep a spare battery in the back now. Always.
Problem B
The batteries are good, but when you attach the electrodes, nothing reads on the screen. You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change. Still nothing. You take the electrodes off and apply some new ones from the same open bag, and still nothing. You blame the monitor. Is it the monitor? No, some of you may have guessed from your experience or from what I have written that reveals the clue. The problem is the electrodes are from an open bag and they are dried out. You were smart enough to switch electrodes, but you took the new ones out of the same open bag. Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem. I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this -- from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.
Problem C
You need to do a 12-Lead. Whoops, you have the regular cable, but the 12-lead attachment cable is missing. It fell out and no one noticed or you forgot to check carefully this morning. Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic. What do you do? A modified 9-Lead. This is how we did 12-leads before we had Life-Pack 12s. Take the left leg lead -- the red lead, and move it to the V1 position. Run Lead III in diagnostic mode. Repeat with V2, V3, V4, V5 and V6. Label each lead as follows: McL (modified chest Lead)1, McL2, McL3, etc... While not exact replicas, they do passably well. You do this and see hyperacute T waves in McL3 and McL4 and McL5. Call in a STEMI Alert.
Problem D
This time you have your 12-Lead cables, but that is all you have. You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables. Your patient is alert, but very clammy and you can’t feel a pulse. What do you do? Take out the defib pads, and apply them to the chest. Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set. If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print. If it is a sinus, well at least you know that.
Problem E
Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor. D’oh! What happened? Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh! I was lucky enough that my call was not a chest pain, but a BLS call. Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept. Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed. Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.
I am introducing a new series. I am calling it Street Lessons, but I could just as well call it any of the following:
Things They Didn’t Teach Me in Paramedic School
Things They Might have Taught Me in Paramedic School, but I Was on a Bathroom Break.
Oh Shit!
Things I Learned The Hard Way
Trial and Error
Eureka! or Light Bulb Moments
***
Street Lesson # 1
Don’t Carry Hypotensive Patients in a Stair Chair
Over the years, I have had five patients go into cardiac arrest while I carried them in a stair chair. What does that tell me? It could mean that I carry a lot of patients in stair chairs. It could mean there are not very many elevators in the city I work in. It could mean I have done a ton of calls in my twenty plus years in the field. All would be true. And I can say I have never had an ambulatory patient go into cardiac arrest on me -- at least not while I have been ambulating them. My first words to my partner on arriving at patient bedside are usually, “Get the stair chair.” The old saying "ABCs - Ambulate Before Carry" - it is not in my book of sayings.
Still five patients coding on the stair chair seems like a lot -- certainly enough for me to wonder whether their coding was in any way related to their being on the stair chair.
So why might they code on a stair chair?
They are sick and dying and called 911, and if we hadn’t arrived as soon as we did, they would have gone into cardiac arrest at that precise moment anyway.
They are sick and dying and the fact that they were being carried down steep creaky stairs scared the last bit of life out of them.
Or maybe they were hypotensive and when we sat them up, their weak hearts couldn’t compensate, and that little extra bit of stress was enough to push them into the void.
I cannot remember the details of all five cases. But I can remember each of them dropping their head back or dropping it forward in a manner that indicated they no longer had muscle control. Sometimes they took a last gasp or two, sometimes not. I am a big believer in working a cardiac arrest right where they code, not losing a precious second in poor or absent CPR. Still it is hard to just stop carrying someone mid-stair case and start rescusitation.
“You know what just happened?” I will say to my partner.
“What?
“The patient just coded.”
So what is the lesson in all of this (Besides, expect if you do enough calls and carry enough people some will code on the stair chair)?
My lesson is -- if the patient is hypotensive while supine or borderline hypotensive and they are sick, consider carrying them in a scoop stretcher.
A 20-year-old with a pressure of 80 due to vomiting may be less at risk that an 80-year-old cancer patient with altered mental status, tachycardia and a pressure of 100. If a patient gets dizzy sitting up, then don’t use the stair chair. It may not spare you having them arrest on you during extrication, but it will be less likely to cause harm.
