Pre-Hospital Blog

My friend Nick Hoskin has just completed a collection of short stories titled Saving Lives, Living the Dream.

I worked with Nick in Boulder for a few years, and he was one of my first Paramedic field instructors.  He’s a great Paramedic and an even better guy.  Congratulations, Nick!

The book relates the stories of EMS professionals and is targeted at people in the business, their families who are looking for more understanding of the profession, and anyone considering a career in the field.

Check out the site for a free sample chapter with a good story in it, and to buy a copy (print or download).

You have a huge opportunity to learn from critical calls during your turn-around time at the hospital.

After a critical call, while still at the hospital, take 5 minutes to debrief the call and review any lessons learned. This might include cardiac arrest, critical trauma, severe illness, and any call that requires lots of work and critical thinking.

In my experience, most EMS systems offer the ability to take a third rider into the hospital with the ambulance to assist with care of a critical patient.  Typically this will be a firefighter or two from the fire crew you ran the call with.  This results in everyone with whom you ran the call being at the hospital afterward (the fire engine often follows the ambulance to the hospital to pick up their missing crew member)  This means you have a great opportunity to sit down with everyone who ran the call for a few minutes and go over it.

We can learn things from any call.  Critical patients offer not only the best chance to make errors (I’ve made plenty), but also the best chances to learn from them.  Research has shown [sorry, no link] that the best time to review and retain information is one to two days after first introduction of new information.  Typically, if I review these calls at all with anyone besides my partner, it is in one of two settings (outside the call to my training guy with a stream of questions): M&M review or a call into a CQI meeting.  These trainings usually occur 1-2 months after the call: far too long to retain anything important.

So when it is possible, take an extra 5 minutes at the hospital to go over things with everyone involved.  Get permission from your supervisor or from dispatch if necessary.  Everyone will have ideas about what went wrong and right.  Some will have misconceptions about what happened that can be cleared up right then – offering understanding all around and maybe the opportunity to stop a call to your quality manager.  Everyone will have a chance to learn more about that patient and their condition.

It can be difficult to create an environment in these situations where everyone feels comfortable speaking frankly.  I’ll offer some guidelines gleaned from my organizations M&M review own guidelines(themselves taken from the Massachusetts Medical Society and an article from the Journal of Academic Internal Medicine).  All are aimed at creating a comfortable environment.

1. Make sure that everyone understands that all questions will be respected.
2. Limit who can participate only to those who were there.  This Any other ambulance crews or hospital staff who are interested in participating should be asked to leave.
3. Be sure that everyone is comfortable having this discussion.
4. Most M&M reviews also involve the understanding by participants that nothing leaves the meeting.  Since this is not an official, sanctioned type of meeting involving medical directors and other higher-ups, I really don’t think this is advisable here.  Any significant clinical issues should be brought to the attention of the appropriate people immediately.

Also, if you are the one organizing the discussion, you have the role as moderator.  In addition to creating a comfortable environment for everyone involved,you should strive to:

1. Keep the discussion limited to he call.
2. Start with what went right and give credit to everyone involved for their role.
3. Identify problems without assigning blame to specific individuals.  For example, failure to give a medication in the appropriate amount of time is not solely the fault of the person giving the medication.  Blame lies with the person running the call, the person holding the drug kit, the person giving the medication, the person starting the IV, and the atmosphere of communication among the group in general: EMS calls are a team effort.  Caveat: don’t let this become the excuse for poor performance.

Learning from your calls does not have to be limited to that provided by the clinical education staff months later.  It can happen in just a few minutes following the call.   Whether it was run-of-the-mill, or the best/worst call you have ever run, you can learn things here. Give it a try.

I’ll be checking these guys out from time to time. They seem to have a very well-structred and varied website with some gret news items and articles.

Check it out!

There’s lots of ‘em. It is criminal how many people die each year in the US from air medical crashes. These kinds of death rates among normal road ambulances would spur all kinds of investigation and industry upheaval.

Every year at some point, someone in the news media remembers how bad this is and there’s a series of articles like this one decrying the problem and hi-lighting the FAA or the NTSB’s commitment to solving the problem. And then nothing.

If anyone can offer some realistic statistics on this issue, with numbers adjusted for the growth in air ambulance programs each year, please offer some guidance in the comments. Any realistic analysis of current work towards federal, state, or local regulation changing this would interest me as well (not just CAMTS compliance, either. I believe that while CAMTS is a good start, the solution to his problem will be broader). I’d like to know more about how bad this issue really is and what is being done about it.

http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.763011v1?papetoc

Submitted on December 27, 2007, Accepted on February 20, 2008, Published Online on May 5, 2008

Hands-On Defibrillation. An Analysis of Electrical Current Flow Through Rescuers in Direct Contact With Patients During Biphasic External Defibrillation

Michael S. Lloyd MD*, Brian Heeke BS, Paul F. Walter MD, and Jonathan J. Langberg MD

From Emory University Hospital, Atlanta, Ga.

Background-Brief interruptions in chest compressions reduce the efficacy of resuscitation from cardiac arrest. Interruptions of this type are inevitable during hands-off periods for shock delivery to treat ventricular tachyarrhythmias. The safety of a rescuer remaining in contact with a patient being shocked with modern defibrillation equipment has not been investigated.

Methods and Results-This study measured the leakage voltage and current through mock rescuers while they were compressing the chests of 43 patients receiving external biphasic shocks. During the shock, the rescuer’s gloved hand was pressed onto the skin of the patient’s anterior chest. To simulate the worst case of an inadvertent return current pathway, a skin electrode on the rescuers thigh was connected to an electrode on the patient’s shoulder. In no cases were shocks perceptible to the rescuer. Peak potential differences between the rescuer’s wrist and thigh ranged from 0.28 to 14 V (mean 5.8±5.8 V). The average leakage current flowing through the rescuer’s body for each phase of the shock waveform was 283±140 µA (range 18.9 to 907 µA). This was below several recommended safety standards for leakage current.

Conclusions-Rescuers performing chest compressions during biphasic external defibrillation are exposed to low levels of leakage current. The present findings support the feasibility of uninterrupted chest compressions during shock delivery, which may enhance the efficacy of defibrillation and cardiocerebral resuscitation.

Diana Neubecker, RN,BSN,EMT-P

EMS System In-Field Coordinator

NWC EMSS, Arlington Heights, IL

Another great week of the EMS Garage Podcast. Fun discussion of response times, cardiac arrest outcomes, medical directors and rabid raccoons.

Listen in.

I’d rather have a Paramedic who runs 1500 calls per year arrive at my emergency in 15 minutes than a paramedic who runs 500 calls in 5 minutes.

because I am crotchety

I had the good fortune the other day of being on the EMS Garage Podcast with Chris Monterra, Dave Ross, and Thom Dick. If you don’t know these guys, they are all hard working, huge minds in EMS and I have no doubt you’ll run into them eventually.

The topic is motivation issues in EMS, along with the now usual chat about current EMS news items. It was a great to be involved in the discussion and to learn a thing or two from these guys. Take a listen.

I will toot my own horn for a second: I took a semester each of college level Anatomy and Physiology, including 5 hours per week in a cadaver lab before I went to Paramedic school.  I have found that this knowledge has been some of the most valuable possible for me moving forward in my paramedic career.

I now see many Paramedic programs that teach A&P with a coloring book and open book tests.  I have a hard time thinking that this is an area where you can cut corners.

Do yourself a favor: if you haven’t, go to your local community college and take a semester’s Physiology You’ll balk at how much it does for your understanding of your patients problems and what the drugs are doing for them. Also, contact your local community college or medical school (if there’s one nearby) and find out about opportunities to get into a cadaver lab. I can show you a picture of where the spleen is, but the value seeing it in a real body is impossible to reproduce.