Street Lessons

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.

15 Comments

  • BH says:

    Unless you plan on carrying said hypotensive patient head-first down the stairs in the scoop, I don’t really see the benefit of one over the other. Either device, used in the normal manner, will still involve a hypotensive patient in a position that is unlikely to benefit them. Necessary, but both equally unhelpful.

    • medicscribe says:

      I agree both have drawbacks, but I think the scoop is less of an upright position and for much less time than the stair chair. Let’s say the person is in the upstairs bedroom or in a bedroom in an apartment building with no elevator. With the scoop, you can carry them supine all the way to the top of the stairs and only then have to subject them to a tilt, which can be moderated. With the stair chair, they go in it right away, have to be wheeled out to the stairwell and then are carried in an upright position. And again now at the bottom of the stairs, with the scoop, they are immediately supine where with the stair chiar they are sitting until they are wheeled over to whereever. None of it is the perfect scenario.

  • BronxMedic says:

    Actually BH, a scoop can help. I recently had a patient in cardiogenic shock who became critically hypotensive when we tried to sit her in the chair, even after fluid infusion. We called for BLS backup, put her in the scoop, and having the two tallest of us hold the the feet end of the scoop above their heads going down the stairs, and the other two bending over carrying the head, we were able to keep her horizontal. Obviously this wouldn’t work in certain situations (extremely heavy patient, tight winding stairs), but the scoop is certainly worth considering.

    • medicscribe says:

      Thanks for the comment, Bronxmedic. It can be a pain, but it is the right thing for the patient. Great job!

  • Kristi says:

    having someone lift over their heads and another bending over to carry doesn’t sound like very good mechanics to me!! That is a great way to hurt yourself and your partner, drop your pt and have them code any way!!!

    • medicscribe says:

      Hi Kristi. We are lucky at times when the FD responds with us, so we have lots of hands to help. You are right, lifts can be challenging, and you have to weigh everyone’s safety. This is the part of EMS that few see, and people are not taught well enough. EMS people who can figure out the best and safest way to extricate are valuable to have as partners.

  • Brian says:

    is an 80yr old not allowed to die?

    • medicscribe says:

      If they are DNR, we don’t work them once they pass, but subjecting them to a move that might assist their passing is not cool.

  • Mac says:

    What if you do not have a scoop stretcher? Not one single ambulance in the province of Nova Scotia has one. Your only option is the stair chair. Not saying your wrong…but what are my other options?

    • medicscribe says:

      That’s too bad. Scoops are great. I suppose you could use a backboard for the extrication or depending on the patient’s weight, a carry tarp.

  • Tampa EMT says:

    Nobody is allowed to die if you can help it. That’s the whole point of being in the medical field, save as many people as possible.

  • Andy says:

    Plus, if they DO code, it’s easier to do CPR when they’re in a scoop, than if they’re in a chair.

  • BH says:

    You keep saying the scoop is better and “its the right thing to do”. I’ve yet to see you tell me why.

    • medicscribe says:

      The scoop enables the patient to be supine for a longer period than the stair chair. A hypotensive patient is better off supine than sitting bolt upright. While the scoop will not be completely supine on the stairs, it will be less upright. Also, you have to figure in the time, the time of transport to the stairs while upstairs, and then the time of transport to the stretcher once you have reached the bottom of the stairs. I am not advocating using the scoop for all extrications, just extrications of patients who will not do well sitting up, such as those with hypotension. I also use the scoops for hip fractures and other scenarios where the patient cannot sit up comfortably.

  • Jay says:

    I agree the scoop is underutilized as an extrication device. The service I work for now in the UK seems to have a habit of carrying everyone in a chair, even cardiac arrest or post cardiac arrest or people in severe pain from hip fractures, and it can be detrimental to the patient.

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