My latest Remember Two things video is posted over at EMS1.com. In this episode I discuss a crucial moment in patient care that is often overlooked. I’m talking about the moment we say goodbye to the patient after we’ve dropped them off at the hospital or their designated destination.
It’s an important moment because it’s an opportunity to make a very real, human connection with our patient and leave them with a positive impression of their experience with us and our service organization.
Any kid who has ever drank a Slurpee too fast on a warm day, and found themselves shivering and chilled, knows that cold fluids can be remarkably effective at cooling the human body. I had this leason reinforced while I was working as a consultant for a bio-tech company. The company was looking for methods to induce and maintain therapeutic hypothermia.
I can disclose much about the different methods and results that the engineering team experimented with, but I will tell you this, if you want to drop someones core temperature fast, nothing is quite as effective as a quick, two litter bolus of cold saline. This is why most therapeutic hypothermia protocols begin by inducing hypothermia, not with some fancy cooling blanket or external cooling device, but an infusion of 37 degree saline.
With that thought in mind, how important should it be to keep the saline we infuse into our patients whom we want to keep warm at something close to body temperature? I hadn’t really given the question much thought until I got an email from Scott.
Scott’s one of those SWAT medic types. He works with his local SWAT team to provide on site medical interventions if the need arises. Scott had an interesting experience with an accidental infusion of ice cold saline. I’ll let Scott take it from here:
The EMT Spot needs your tips and tricks! I’m collecting the very best tips and techniques for nailing the IV every time. What have you got to add? What are your very best techniques for making sure you get the IV started when it counts? What’s the best IV starting advice you ever received? Now that you know, it’s time to help your fellow EMS brethren on their way to IV mastery.
Send me your contribution and, if you make the final cut, you’ll see your advice immortalized right here in a future post. This is your chance to contribute to the ever-growing database of EMS knowledge that is The EMT Spot. I’d love to put your name right here, along side many of the industry’s top educators and EMS practitioners.
Send your IV starting advice to steve@theemtspot.com, send me a tweet @SteveWhitehead or click on the comments section and add your advice right here and now.
This post won’t be awesome without you. What are you waiting for?
Posted 4 months, 4 weeks ago at 9:04 pm. 10 comments
There’s something about the patient in labor that makes my palms sweat. I’m not alone. Most of us EMS folks get a little anxious at the idea of delivering a baby. Obstetrical calls can go very right and they can go very wrong. The stakes are high.
Here are a few things to consider before you run your next obstetrical call.
1) At full term, pregnant females have a heart rate 10-15 beats per minute faster than when they were prepartum. (Psst…Before they were pregnant.) They also have 25%-30% higher stroke volume and 30%-50% higher cardiac output.
2) Pregnant females will tolerate significant blood loss before they become symptomatic. Once they are symptomatic, they will decompensate rapidly.
“It’s the space between the bars that holds the tiger.”
-Zen Koan
How does anyone become really good at what they do? Is there a magic recipe?
From the opposite side of the bars, an adult Bengal tiger studied me from his resting spot. He was big, topping out just over five-hundred pounds. He was also strong. Pound for pound a tiger is four times stronger than a man. Our guide explained this to me while she pointed out some of the finer elements of the great cats stalking behaviors.
The Feline Conservation Center in Rosamond, California, isn’t like a typical zoo. There are few barriers that prevent guest from reaching inside the cages if they chose to be so foolish. Hence our watchful guide. At the observation end of the enclosure, thirteen bars kept me from becoming tiger lunch. Once the great cat fixed on me, they seemed hardly adequate.
Once you understand the protocol / skill connection you might come to see a host of problems with the way we develop, use and teach our protocols. I’d like to tell you about two biggies.
As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.
The problem with our protocols is that they were written with the expectation that everyone would use them the same way.
The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.
Let’s look at both of these problems a little more closely.
If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.
Such is the nature of growing things.
It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.
This is probably a good time to bring up the number one rule of vital signs. Remember the movie Fight Club? Everyone knew the first rule of fight club was to never talk about fight club. Now let me give you the first rule of vital signs. Burn it into your memory.
Never lie about vital signs.
Oh, I know. You think you’d never lie about vital signs. You’re an honest person right? Why would you lie about something as silly as vital signs? And yet, it happens…a bunch.
There you are deflating that blood pressure cuff. Everyone’s looking at you, waiting for your report, and you hear . . . . (wait for it) . . . (wait for it) . . . nothing! everyone is waiting. And you did see the needle bounce right around 120 and stop bouncing right around 70. The BP must be normal right? Couldn’t you just make it up and save face?
Don’t do it. It’s hard to admit when you just don’t hear the BP or can’t feel the pulse, especially when you think it’s something you’re doing wrong. It’s easier…and very tempting, to fake it. Don’t do it. You only have to make up incorrect vital signs once to completely blow your credibility.
I love teaching each new EMT class cycle how to take a blood pressure. It’s fairly simple and strait-forward, but there’s also a real art to it. Folks who are good at it wield their blood pressure cuff like a teppanyaki chef wields his knife. You can tell they’re good by watching the confidence in their movements, the order that they perform the steps, and the attention they give to the details.
There’s a big difference between the guy who chops vegetables down at the local Denny’s and the chef at the Benihana. Same tools, different level of skill. You see what I mean right? If your blood pressure skills are still somewhere in between the short order cook and the teppanyaki chef, here are some tips to getting better.
There are few things that EMT’s should claim as their domain. There are certain skills that the EMT provider should simple dominate. Vital signs are one such skill. No medical provider anywhere should be able to hold a candle to the EMT when vitals signs are the name of the game.
Vital signs are, to the EMT, what sharp shooting is to the sniper; what the fast ball is to the closing pitcher; what swordsmanship is to Zorro. It’s the EMT bread-and-butter skill. And yet…so many EMTs fumble through vital signs like it’s amateur hour. No more. Over the next few weeks we’re going to break down vital signs here at The Spot and make every one of our trusted and loyal readers a vital sign virtuoso.
Are you ready? Carnegie Hall awaits. Let’s start with the pulse check.
Some EMT’s can take 30 seconds to a minute to check a pulse. When they’re done they have one single piece of clinical information to pass on, the heart rate. Others can feel a pulse for 3 seconds and tell you much, much more about the patient’s cardiovascular status. What’s the difference? Practice and focus. If you’d like to be the second EMT, here’s how.
