It Depends

An emergency doctor friend of mine has a great lecture called “It Depends…” He says that for many EMS patient care questions he is asked, the answer is “It depends…:” But there are other questions where it does not depend, he points out. For instance, when your patient suddenly goes into v-fib. There is no “It depends.” You defibrillate. Your patient is in severe anaphylaxis. It does not depend, you give them epinephrine.

When I analyze a call now, I try to follow the decision making. Did it depend or did it not depend? and if it did depend, what did it depend on?

Here is a question that I recently considered. If you have a critical patient who you are worried may crash, when do you do the IV? At the patient’s side, on scene in the ambulance, or en route to the hospital? The key is that you need to have the IV when you need it. What is my thinking as I consider this question?

Well, it depends on whether or not I am going to be able to do anything for the patient and can the hospital do something that I can’t that will make a different in outcome. For instance, a gunshot to the torso. The patient needs a surgeon. My IV is not going to offer me much avenue to help. I would elect to do the IV en route once I have taken care of other priorities.

Now how about a pale, diaphoretic patient in ventricular tachycardia with a pulse? This of course raises the question of shocking or giving meds. Another it depends question. Let’s say I choose to shock first and it is unsuccessful. Back to the IV question. For me there is no more it depends. It doesn’t depend, I need the IV right then. I will go for the IV right at the bedside because I will be able to deliver amiodarone and if the patient codes, other ACLS drugs (for what they are worth). Bottom line, I won’t wait till the ambulance to get my IV.

Now let’s say the patient has sepsis and hypotension. Here my IV can be an avenue to give this patient needed fluid. While fluids may be life-saving the IV is less moment dependent than in the previous case, so depending on the surroundings in the home (lighting, space, etc), I may wait to the ambulance, and then depending on whether or not I think I can get the IV easily (or who is driving) I may elect to do the IV enroute or try first in the parked ambulance if the patient has poor vasculature and my partner is a rough driver.

Most every EMS call has many “it depends” moments. Here is one I am thinking about now. You are alone in back and your patient goes into sudden cardiac arrest. Ventricular fibrillation. You shock once with no success. What do you do? Do you have your partner continue to drive to the hospital while you try to manage the code or do you have him pull over and help you out in back?

What does your decision depend on? How far are you from the hospital? Can you effectively deliever quality compressions, manage the airway, and deliever quality care by yourself? How far away is help? Is it safe to pull over where you are? Does the screaming family member in the front seat affect your decision? I would lean strongly to pulling over at the first safe spot and getting assistance to work the code right there.

Tough calls. Tough questions.

And the answer? I think when deciding if it depends or does not depend, the answer must always be — When it comes to what is best for the patient, it never depends.

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Peter Canning

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