Size Up

This is a call I did a few months back. I wrote about it then, but didn’t post the story. Part of the reason I didn’t is because while I want to write honestly about being a medic, I have some restrictions. I can’t trash the company I work for or anybody who works for it, and I guess I also can’t really trash myself. I can point out my failings, but sometimes it takes a little while to see the failings.

The call and my feelings about it are not straight forward, but since I have been writing about lights and sirens, I want to address it now. There is not a simple moral here because there is a fair amount of gray involved, although some of it, is fairly straight forward. Enough with the rambling, here’s what happened:

***

We were sent lights and sirens for a five car MVA. Our staring point was a distant hospital so it took us a good fifteen minutes to get there. I pride myself on being cool on a scene, quickly sizing up what needs to be done, and allocating the proper resources. When we get there it is dark and rainy. There were a number of cars in the road. It is a good bangup, but one car has no injuries, there is no fifth car, and the other three looks managable. A man holding his chest with a nonrebreather on, but alert seems to be the most seriously injured. Another man wanders about with general body pain. The woman who apparently lost control and came across the median stands by her car claiming she is a diabetic and that she is about to pass out. She has a baby in the backseat in a car seat and the baby is fine. A second ambulance — a BLS ambulance — is already on the way. I decide to take the guy with chest pain and the other guy, while leaving the woman and the baby for the BLS crew. I tell an officer we should be all set, and have my partner let dispatch know we’re all set. We c-spine the two men and get them in the ambulance. It is then, as I climb in the back that I hear on the radio another medic signing on to head to the five car crash. I can hear his siren in the background of the radio transmission. I tell my partner we don’t need a medic, we are all set as soon as the BLS crew got there. He comes back and says the PD is requesting another medic. I tell him to tell the other car not to kill itself getting there, everything is in hand.

The BLS car finally arrives and we take off — not on a priority because by now I realize the guy with chest pain, while hurt is not as seriously hurt as I first thought. He just seems bruised. The trauma center is about eight minutes away so there is clearly no need for lights and sirens. Everyone is stable. Plus I am standing in the back with two boarded patients and I don’t want get throw all over the place.

We get to the hospital, unload our patients. I keep waiting for the other car to show up to see what the deal is — why the cop wanted the medic. I find out later that the BLS crew waits for the medic, and then the medic goes lights and sirens to the further trauma hospital on the far side of town.

This all annoys me because A) I didn’t request another medic, B) I said he didn’t need to come on a hard priority and (C) he ended up transporting on a priority.

A good part of this is my ego. I am supposed to manage the scene, but it didn’t go like I say it should.

I get some of the story later. The cop called for the medic because the woman said she thought she was going to black out. When I saw the basic crew I told them I didn’t ask for a medic. They said, well, it was good one came because the woman had an irregular heart beat. Irregular heart beat? I’m thinking com’on. That’s some BS. This woman completely struck me as someone trying to get out of a ticket. I asked for more details. They couldn’t explain the irregular heart beat, but they said the medic had to run two large bore IVs wide open, but they say all she had otherwise was shoulder pain, and the baby didn’t even get transported. The father showed up at the scene and took him home. The female patient’s vitals were fine and she was alert the whole way. When I saw the medic later he told me she had a funky heart rythmn that was going from 40 to 90 and back(on the monitor which records in very brief intervals). A Sinus Arrythmia with all kind of blocks. He showed me a strip, but it was not very convincing. I didn’t see any blocks and I didn’t see any long periods without a beat, enough to make someone pass out. And why go on a lights and sirens priority to the distant trauma hospital if he was so concerned? Why not the closest hospital? And what was up with the two large bore IVs wide open. Shoulder pain with stable vitals?

BS, I think, a load of BS. I think a lot of times how a medic is sent to a call determines how they handle the call. Being sent lights and sirens We Need a Medic Now for a Five Car MVA seems to make a medic more inclined to go lights and sirens two Large Bore IVs Wide Open We Need the Trauma Room where if you just look around and settle down, you see things really aren’t that bad. I know when I first started I went lights and siren two Large Bore IVs Wide Open for lots of stuff that today I would go on a non-priority, and certainly not Two Large Bore IVs Wide Open.

I am annoyed by this five car crash call. Annoyed as I said before and for all the reasons I listed above. But I am also annoyed because I didn’t do my job properly. I just eyeballed the lady — a decade of being a medic told me it was BS. But after all she did cross over the median. Was she going to fast and lost control? Did she skid on the wet pavement? Or did she pass out because of a heart rythmn? That’s her story now.

Nobody died. Everybody got to the hospital. But I was too quick to size things up. I could have gotten burned.

Experience can enable you to cut through everything and see the immediate need, the truth at the center of a call, but it can also make you miss. I am not because of this going back to doing everything by the book. Now I do much of my work by the book, but not everything because the book is made for the class, made for when you need a map to see your way through, which I often do. But I do need to be more careful.

**

Reviewing what I have written now months later, two things strike me, both involving the other medic’s two large bore IVs wide open treatment for a patient with stable vitals and only shoulder pain, and no significant trauma?

1. Conditioned Response: I wish you could do an controlled experiment where medics were sent to the same call. Half the medics are sent lights and sirens and told it is a really bad crash, the other half are sent nonlights and sirens. Same crash, same patients, same injuries. My guess is that the medics sent lights and sirens will be more aggresive in their treatment, will put in more IVs, run more fluid, and go to the hospital on a priority more than the medics sent on a non-priority. I say this because in the past and maybe even sometimes now, how I get sent ramps me up, and I let it affect my treatment. I can think of several times I was sent lights and sirens to a crash, did the rapid extrication, short scene time drill, only to realize half way to the hospital that my patient really wasn’t hurt very badly at all.

2. Old Dogs(mas): I recently overheard an experienced medic tell a paramedic student that he always establishes two large bore IVs and start running fluid on all trauma patients to “stay ahead of the game.” That’s what we were taught ten years ago. Not today. All the studies show aggressive fluid management may not be the best thing for trauma patients, it may in fact be harmful. The AHA 2005 Guidelines for trauma say:

Aggressive fluid resuscitation is not required for trauma patients who have no evidence of hemodynamic compromise. Recommendations for volume resuscitation in trauma patients with signs of hypovolemic shock are determined by the t
yp
e of trauma (penetrating vs blunt) and the setting (urban vs rural). A high rate of volume infusion with the therapeutic goal of a systolic blood pressure 100 mm Hg is now recommended only for patients with isolated head or extremity trauma, either blunt or penetrating. In the urban setting, aggressive prehospital volume resuscitation for penetrating trauma is no longer recommended because it is likely to increase blood pressure and consequently accelerate the rate of blood loss, delay arrival at the trauma center, and delay surgical intervention to repair or ligate bleeding vessels.4,14,22 Such delay cannot be justified when the patient can be delivered to a trauma center within a few minutes. In rural settings, transport times to trauma centers will be longer, so volume resuscitation for blunt or penetrating trauma is provided during transport to maintain a systolic blood pressure of 90 mm Hg.

-AHA 2005, Part 10:7

And the other day a medic student told me about a code he had just done where they tried pacing the patient in asystole. The new AHA guidelines, which are already protocol in our region, have eliminated pacing in asystole. Don’t do it, it doesn’t work.

Pacing in Arrest
Several randomized controlled trials (LOE 2)99–101 failed to show benefit from attempted pacing for asystole. At this time use of pacing for patients with asystolic cardiac arrest is not recommended.
-AHA 2005, Part 7.2

Three randomized controlled trials (LOE 2)140–142 of fair quality and additional studies (LOE 3 to 7)143–149 indicate no improvement in the rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted to provide pacing in asystolic patients in the prehospital or hospital (emergency department) setting. Given the recent recognition of the importance of maximizing chest compressions as well as the lack of demonstrated benefit of pacing for asystole, withholding chest compressions to attempt pacing for patients with asystole is not recommended (Class III).
-AHA 2005, Part 5

I have heard many older medics badmouth the new AHA guidleines. What’s wrong with the old way? they say. These new guidlines are a bunch of BS by people who have never worked the street, the medics say. And these “medics” are passing on their knowledge to new medics.

What kind of system are we perpetuating?

I think as medics we need to approach each call fresh and we need to approach each new development fresh.

No preconcieved notions.

Assess and evaluate – size up – everything with an open mind.

Whether it is a woman at a scene who says she is going to pass out or new research that says we need to do some things differently.

We have to always ask ourselves: What is the right thing to do?

Yes, this patient needs to be taken seriously — fully assessed — even if our gut tells us she isn’t really sick.

But no, she doesn’t need 2 large bore IVs.

We don’t need to go lights and sirens.

5 Comments

  • Anonymous says:

    I was talking today with one of our local ER docs. He was reading about fluid in critical care. There’s a lot of discussion in some circles, particularly military, about using hypertonic solutions.This guy is extremely well-read. I like to think that I keep up on current trends, but he’s got me beat in every area, and he covers many more areas of interest.Anyway, that deal with fluid resuscitation is a good one. There’s a lot of talk that hypertonic solutions, like 7.5% NS, can be given in MUCH less amounts. There’s some promise for people that are hyponaturemic, and CHFers were you want to draw some of that fluid into the vasculature. Hypertonic solutions seem to have less of an inflammatory response, leading to better long-term outcomes.I hope the doc goes ahead with this one a few trauma patients. I’d like to see what effect it would have.I’ve seen fluid challenges change over time. I’m pretty green, so I have to consult older texts and people to hear what’s changed. Just like at one time people popped bi carbs routinely, there may be a day when 100 mL of 7.5% NS with dextran will suffice.

  • Anonymous says:

    Sounds like a problem of relative inexperience, too many ALS medics with too little work and a medical director/management system that fails to address clinical decision making concerns.Our system isn’t perfect, but peer review, a positive and proactive Medical Director and a realistic attitude that acknowledges more often than not it doesn’t matter if it takes 5 minutes or 50 minutes has to make our resource poor single provider model more user friendly for all.

  • PC says:

    Thanks for the comments. I have read about the hypertonic solutions and will try to do some more research and post about it.As far as there too many medics with too little experience and too little oversight in our system, you are right on. While we have excellent medical control doctors, the system isn’t well set up for them to review the individual medics because the number of medics is too high and the number of calls too great. We have what is called a sponsor hospital system, so there is one doctor employed by the hospital who oversees all the ambulance companies affiliated with the hospital, in addition to all his clinical and administrative duties at the hospital. I think the services need to aggresively take on the QA role. I envy those services that have peer review and other QA programs in place.Thanks again for the comments,PC

  • CBEMT says:

    Further proof that the push for all-ALS systems is a really stupid f-ing idea if a majority of the medics we’re churning out every 18 months can’t think for themselves.I’m an ALS provider with probably a quarter or less of the education time that a medic gets even from a crappy school, and I know better than to blast fluid into a patient that barely even qualifies for a TKO line. Sheesh.

  • Chris says:

    1. Being a medic is about playing the odds, and from what you describe, I see no problem with the judgement call you made. If you’d done the big detailed assessment on the diabetic lady, then you might be sitting there now, regretting that you spent too long on scene while the guy with CP was having a giant MI… or if you hadn’t told the 2nd unit to back it down, you’d feel responsible when they t-bone’d a minivan at an intersection. 2. I agree with you absolutely about a lights+sirens response influencing pt care. Furthermore, I’ve noticed that when I end up as driver on the way to the scene, and then end up taking pt care, I have a hard time getting my adrenaline from the response under control. It would be neat to see if there was a statistically significant difference in care on calls where the AIC also drove on the response. (short/longer scene time, large bore IV’s, O2 by NRB, etc). 3. I agree there is a world of bad als providers out there. QA and involved OMD’s should help, but I’ve seen some piss poor QA programs, and some OMD’s who were willing to grant frightening amounts of leeway to their EMT’s.

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