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.

Report a 120 over 80 blood pressure to your partner when it’s really 60 over nothing just one time and your credibility as a caregiver is shot. Tell the hospital the patient has a strong pulse at 84 bpm when it’s really weak and irregular at 136 bpm just one time and it will be a long time before they trust your hand-off report again. Medicine is harder when your colleagues don’t trust you.

Everyone has had the experience of not being able to feel a pulse, or hear a lung sound or a blood pressure. Practice your vital signs. Take them diligently and then tell the God’s honest truth about what you find.

Now it’s your turn: Have you ever been tempted to lie about the vital signs? Have you ever done it? What happened?

Read more EMS stuff:

Medicine Between The Frames

Beyond the 1-10 Pain Scale

You Can’t Give Away What You Don’t Have

Waiting Is Serving

Self Destruct

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.

1) The blood pressure starts with a pulse, not a cuff

Most folks put the cuff on the patients arm without much thought to the location. Sure, you were taught how to place the cuff correctly back in school, but, hey, you’ve been doing this a long time so…

I disagree. Cuff placement is important. Start with the brachial pulse. If you have trouble finding the brachial pulse, you can review the location here. The location of the brachial pulse can vary considerably from patient to patient. Don’t assume you know where it is. Find it and place a finger on it while you grab your cuff with the opposite hand. while you’re here, note if the pulse is strong or weak, regular or irregular, fast or slow.

Now place the cuff with the artery label directly above the brachial pulse with about an inch between the pulse point and the cuff. Oh, and this is a good time to make sure you have the correct size cuff. If you have trouble getting a good seal on the Velcro you may need to move up to the big boy cuff. To much overlap may mean you need the Lilliputian size.

2) The stethoscope comes next

Don’t start inflating that cuff yet! Often, folks get the idea that the next move is to start pumping the cuff up to the 200 mmHg range. Hold off their camper.

Place your stethoscope on the patient’s arm and place a bit of pressure on the bell. Now start inflating. Since you placed the cuff and the stethoscope first, now you can listen on the way up. Pay attention to when you start to hear those whooshing Korotkoff sounds. Are they regular or irregular? do they sound fast or slow? Are they loud or soft?

You’re going to know when to stop inflating the cuff because you’re going to hear when the sounds stop. Now you can tailor your cuff inflation to your patient. No more guess work.

3) Nice even drop

With practice, you’ll figure out which needle drop rate is right for you. Too fast and your systolic reading may come out inaccurately low. Too slow and everyone on scene will start tapping their foot waiting for your results. Nice and even.

You’re listening for the first clearly audible whoosh (Or thump…pick your poison.) and the last whoosh before silence. The first clear whoosh is your systolic pressure and the last one represents the diastolic pressure.

There’s some debate over whether the true diastolic pressure is represented by the transition to the fourth Korotkoff sound (deep whoosh) or the fifth korotkoff sound (silence). Don’t worry about it. The current common practice is to use the transition to silence as the true diastolic pressure.

If you want to get fancy you can also grab a quick six-second pulse by counting the korotkoff sounds. Freeze the needle in between the systolic and diastolic pressures, glance at your watch and count how many whoosh sounds you hear in six seconds. Multiply by ten and then continue dropping the needle. Now you’ve got a fairly accurate pulse and a blood pressure all in one.

4) Listen for a blood pressure; don’t look for a blood pressure

The bumping of the needle often seen on the sphygmomanometer (the gauge) during the needle drop may or may not coincide with the audible blood pressure. You can’t take an accurate blood pressure by simply watching the needle. Let me repeat that last line.

You can’t take an accurate blood pressure by simply watching the needle.

It doesn’t work. Believe me, if it was that simple, I’d tell you. The truth is, you may see needle jumps 20 mmHg above the audible systolic pressure or 20 mmHg below. There’s just no reliable correlation. So don’t get fooled.

5) No sound? What now?

OK, so you didn’t hear anything. Don’t panic. It happens to everyone. Start from your ears and work toward the patient.

• Are the ear pieces angled forward into your ear canals or backward against the side of your ear canals? Angle them forward.
• Are there any kinks in the stethoscope tubing?
• Is the bell on the stethoscope turned toward the correct side? Everyone gets fooled by this one occasionally. Tap the business side of the stethoscope and see if you hear clear crisp tapping.
• Feel for the brachial pulse again and place the stethoscope bell directly over it.
• Are you putting too much pressure on the bell of the stethoscope? Don’t let the bell ride to far up under the BP cuff or you’ll invert the bell when you inflate the cuff and muffle the sounds. You want gentle pressure on the bell.

Now inflate the cuff and try again. If you still can’t find it consider trying the other arm or palpating the blood pressure. If the patient is unstable, consider that they may not have a viable pressure. Quit fiddling with the BP and treat for shock.

6) Palpation, how do you do that?

Palpation allows you to quickly get a rough estimate of the systolic pressure without the use of a stethoscope. When monitoring critical patients, when time is of the essence and trending vitals is a frequent task, palpating the pressure is a great tool.

Correctly apply the BP cuff and grab a radial pulse. Inflate the cuff until the radial pulse goes away and then slowly deflate the cuff. When the radial pulse returns, that’s a fair estimation of the systolic pressure. it’s worth noting that palpated pressures tend to be about 8-10 mmHg lower than the true systolic. when documenting palpated pressures note the systolic pressure as assessed and replace the diastolic pressure with the letter “P”.

There you have it. The basic blood pressure technique is just like the basic vegetable chop. But there’s a lot more skill to taking a solid accurate blood pressure than initially meets the eye. Just like there’s a lot more to chopping vegetables than just the basic slice. Just ask any teppanyaki chef.

Now it’s your turn: What are your favorite blood pressure tips and tricks?

Read more EMT skills stuff:

The Ultimate Guide to EMT Vital Signs Part 1, The Pulse

The Art of Using Trauma Shears

Remembering The Glasgow Coma Score

Beyond The 1-10 Pain Scale

5 Assessment Findings That Should Concern You

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.

1) Know where to check for a pulse. (And why)

There are a bunch of places to obtain a pulse and good reasons to use each one. Here, our collapsed young runner shows us the seven primary pulse points that every EMT should know.

Recall that the pulse is felt when we trap an artery between our finger (or fingers) and a bone lying beneath the vessel. There is some technique to this. It requires a firm, gentle, accurate touch. There’s only one way to develop this skill. Take a lot of pulses. Let’s look at each one of these pulse points in a little more detail.

We’ll start at the top and work our way down.

The Carotid Pulse

The carotid pulse is found by palpating the external carotid artery on the side of the neck on either side of the trachea. The carotid is a very central pulse and should be easily palpated with somewhat deep pressure. Feel for the side of the trachea and then press posterior into the neck.

This is the classic CPR pulse check site and well known to the lay public. It is often used by runners and athletes to assess their own heart rate. A palpable carotid is the current tipping point for rapidly deciding if external chest compressions are indicated. Until a more definitive measure of cardiac output is available, in the absence of a carotid pulse, CPR is indicated. (Presuming the patient is unresponsive.) This site can also be used to assess the effectiveness of CPR. During adequate chest compressions, a carotid pulse should be palpable. If not, it might be time to switch rescuers.

The Brachial Pulse

Felt on the inner aspect of the arm on babies and small children and commonly found on the medial aspect of the antecubital fossa in adults, the brachial pulse should be the starting point for each blood pressure check you perform. Find the brachial pulse and line the artery arrow on the BP cuff up with the pulse point about one inch above the elbow joint.

The brachial is the primary pulse check point for infant CPR, it’s also often overlooked as an easily accessible pulse point when the radial pulse is inconvenient or painful to use. Feeling a brachial pulse requires a bit more pressure than the average radial pulse. Brachial pulses are often present even when a radial pulse is not discernible. If you are ever unable to palpate a radial pulse, the brachial should be your next stop.

The Radial Pulse

Conveniently located and easy to palpate on the anterior / lateral portion of the wrist (thumb side), the radial pulse tends to be the classic point for checking heart rate and rhythm in the conscious patient. More convenient than a carotid, less personal than a femoral, the radial pulse is far and away the most common pulse location in use.

The absence of a radial pulse is a fairly reliable indicator that the systolic blood pressure has fallen below the 80 mmHg mark. Unequal radial pulses can signify a variety of conditions, including aortic abnormalities, vascular compromise, atherosclerosis and compartment syndrome. In the presence of shoulder or upper arm injuries, an accurate blood pressure can still be auscultated at the radial artery, providing that the cuff is properly fit to the forearm and applied correctly over the artery.

The Femoral Pulse

After the aorta passes through the retroperitoneal cavity of the abdomen it branches into the left and right femoral arteries. These arteries can be palpated in the crease between the upper thigh and the lower pelvic area, where the lower abdominal quadrant joins the leg. Palpate deeply in the crease about midway between the iliac crest and the groin.

The femoral artery is a very central section of vasculature which makes it a popular point of access for insertion of cardiac stents and other invasive procedures that require surgeons to operate within the vasculature. It is also a great spot to check the effectiveness of CPR compressions. Due to its location, femoral pulse checks are reserved for unconscious patients. Like its centrally located brother, the carotid, femoral pulses can sometimes be felt at systolic pressures as low as 50 mmHg.

The Popliteal Pulse

Possibly the hardest to locate of the bunch, the popliteal pulse is useful in assessing vascular compromise in the presence of a knee or femur injury. In significant leg injury it can assist in determining the location of vascular compromise and is a good secondary location for distal circulation checks when using a traction splint, which covers both of the primary pedal pulse locations.

The popliteal artery can be felt behind the knee and is easiest to reference when the knee is slightly bent. Place both of your thumbs on the knee cap and feel in the pit behind the knee at the mid-point with the fingers of both hands.

The Dorsalis Pedis Pulse

While its location can vary considerably, the dorsalis pedis pulse can often be felt on the dorsal (top) region of the foot just medial to the bony prominence above the instep.

The dorsalis pedis is the most commonly used pulse when assessing for distal circulation in lower limb injury.  Once you find it, mark it with a pen for future reference. (Note the “X marks the spot” markings on the feet of the patient at left.)

The Posterior Tibial Pulse

Due to the infinite variations of splinting options in lower limb injuries, it’s often helpful to have an alternate spot for distal circulation checks. The posterior tibial pulse is located behind the bony prominence on the distal end of the tibia. (The medial ankle bone.)

It’s also a handy location to check is the sometimes elusive dorsalis pedis pulse cannot be located. Often patients with a difficult to locate dorsalis pedis pulse will have a strong posterior tibial pulse and vice-versa.

2) Know what you’re checking

As previously stated, there’s a lot more to that pulse check than heart rate. Circulation compromise, cardiovascular status as well as acute and chronic conditions can all be assessed if you’re paying attention to the rate, quality, rhythm and equality of the pulses.

An exact heart rate is actually pretty low on my pulse check priority list. Before that, I primarily want to know if it is fast or slow, strong or weak, regular or irregular. Most of the really important stuff can be figured out in the first three seconds of your pulse check.

3) Put the pulse in context for the patient

This is often overlooked and one of the harder things to grasp for newer EMTs. The pulse, just like everything else you assess, needs to be placed in the context of the overall clinical picture.

An EMT student might ask, “What if I can’t find a radial pulse?” Hoping for some definitive response to the “no pulse” situation. The answer is always the same. “What’s the patient’s mental status? What does their skin look like? Do they have a brachial pulse? Do they have a radial on the opposite side?” The answers to these questions and a bunch more will determine the proper next step.

A friend of mine recently assisted a dentist who was doing CPR on a conscious combative male who had collapsed at a local pool. The fact that he couldn’t feel a carotid pulse was the only thing that mattered to him. The rest of the clinical presentation, including the victim’s cries of protest, didn’t matter to the dentist. He insisted bystanders help restrain the patient while he continued CPR. Sometimes, even people with advanced medical training have a hard time considering the whole clinical picture.

The presence or absence, rate and rhythm, equality or inequality, strength or weakness all need to be put into the greater context of the patient presentation. They don’t stand alone.

4) Really take a pulse

I don’t mean take a long time. I mean focus. Pay attention to that pressure wave beneath the skin we call a pulse. We check pulses so routinely, we often fall into the habit of not paying attention to other stuff while we check a pulse. Allow me to elaborate.

Have you ever checked your watch and had someone else who saw you checking ask, “Hey, what time is it?” …and you have no idea? That’s because you were performing a routine. You weren’t really focusing on the time, you were just checking because that’s what you do.

We do the same thing with pulses. We check it, we find it, we hold it for a few seconds and then we move on. If someone sees us check and asks, “What was the pulse like?” we might know, we might not.

Don’t get stuck in that rut. Feel the wave. Visualize the heart beating withing the patient, sending a wave of pressure through the vessels. Feel for its regularity, equality, strength and rate. Ask yourself what it means. Now you’re on your way to becoming a virtuoso.

Now it’s your turn: What’s your favorite pulse check trick?

Read more skills stuff:

Mastering The Head-To-Toe Assessment

CPR Right Now

The Art of The Pulse Check

Get Anyone To Go With You To The Hospital

How To Make Sure Your Hand-off Report Gets Heard

]]> http://theemtspot.com/2010/05/22/the-ultimate-emt-guide-to-vital-signs/feed/ 13 http://theemtspot.com/2010/04/03/the-c-spine-helmet-issue/ http://theemtspot.com/2010/04/03/the-c-spine-helmet-issue/#comments Sat, 03 Apr 2010 12:00:23 +0000 Steve Whitehead http://theemtspot.com/?p=2812 The good news in the world of head trauma and brain injury is that we’re seeing a lot more folks putting on helmets before they go out and do potentially dangerous, head crushing stuff. The good/bad news is that we’re encountering more patients who are wearing helmets and need to be placed in full spinal immobilization. This brings up a controversial decision. Should we remove the helmet or leave it in place?

The leave it or remove it controversy has been around for as long as I’ve been in EMS and, like most controversies that remain unresolved for years, there are merits to both options. In these instances, it’s easy to create blanket rules and then follow them mindlessly.

“Always leave the helmet in place, unless it obstructs the airway.”

“Always remove the helmet before you put them on a backboard.”

You’re going to hear some folks spout these rules off like they’ve been long established treatment guidelines, written in stone and backed by The American Board of Something Technical Sounding. They’re not. Whether you decide to remove a helmet is, and should be, a matter of clinical judgment. You’re going to need to decide for yourself, using your own good judgment and assessment findings.

Let’s help you sharpen your decision making scalpel so the next time you encounter a helmeted patient, you can proceed with confidence.

1) Helmets protect the head. They do not protect the neck.

If anything, that big helmet may have increased your patients risk for a neck injury. Don’t fall into a false sense of security when you see a helmeted patient walking around on scene. They’re still going to need a thorough evaluation of their neck and neurological status.

2) Athletic pads may need to remain in place or be removed in conjunction with the helmet.

This goes primarily for football players or anyone wearing shoulder pads or padding across their upper back. The back padding will often be equal to the added occipital padding that a helmet creates.

So if you decide to remove the helmet, take the pads off with them. If the helmet stays in place, leave the pads behind. This is going to help you find that neutral position for the neck when the patient lays down supine.

3) If you leave the helmet in place, everything covering the airway needs to go.

On some motorcycle helmets, this may be as easy as flipping up the face piece. Other helmets have the face guard integrated into the helmet. If the helmet permanently covers the mouth, it needs to go. Not, “If there’s a problem,” before there’s a problem.

You don’t want to have to figure out how to get a helmet off after the patient starts puking or becomes apnic. You want to get that airway uncovered beforehand.

3) Trainers may have a bunch of useful tools for removing face-plates and helmet garb.

So if you’re responding at a sporting arena, try to get the trainer to stay around and help out. If you’re going to want to leave the helmet on, ask them early if they have tools to remove the face-piece. They usually will.

They also know how all the pads lace and unlace so if you want to remove patient protective gear, get their advice. “Is there any way to remove these while he’s lying down? Where does that thingy tie?” The trainer can be a really useful person to have helping out. And they usually appreciate not being ignored.

4) Evaluate how well the helmet fits.

There’s no sense in securing the patients helmet to a board for c-spine if their head is rattling around inside the helmet like a pinball between two bumpers. If the helmet doesn’t fit sung, it’s no good for c-spine. However, it will probably be a cinch to take off.

5) You need two people to take a helmet off.

It’s not a one man job. You can do it on your own, but you can’t do it right. Here’s the technique.

I find it easier to do with the patient lying down. Have one rescuer hold the helmet from above while a second rescuer positions themselves at the patient’s side, facing the head. The second rescuer places their hands on either side of the patients neck and slides their fingers up inside the helmet toward the patient’s ears. When the second rescuer feels like they have a good grip on the patients head they can let the first rescuer know it’s OK to remove the helmet.

With the head secured by the second rescuer, the first rescuer pulls out on the helmet at the ears and slides it up and off the patients head, then returns to help secure the head to the board. Most open faced motorcycle helmets will need to tip slightly back during removal. Football and full-face helmets tilt slightly forward.

Olay! Your helmet worries are over.

Hopefully, the next time you encounter a c-spine/helmet dilemma, you’ll feel a little more at easy evaluating the situation and making a decision to leave the helmet on or take it off.

Now it’s your turn: Do you have a hard and fast rule about helmet removal? What things do you consider when faced with the c-spine/helmet dilemma?

I Want More! ….OK:

Mastering The Head-To-Toe Assessment

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The Art of The Pulse Check

Remembering The Glasgow Coma Score

While we’re talking about scene presence, I think it’s important to bring this one up. I’ve hesitated to talk about the illusion of control on the blog even though it’s a learning point that I invariably discuss with new students on the rig in the first one or two shifts. The illusion of control is deeply applicable to learning scene presence, but, quite frankly, it contradicts something I’ve preached here on The Spot for some time.

It contradicts my advice to always be authentic. When it comes to authenticity, the illusion of control is the exception to the rule. I suspect that some of my regular readers may have take issue with that. It’s OK, I’m a big boy. I can handle it.

In the world of scene management and scene control, the illusion of control is a metaphor for how we should respond when things don’t go the way we planned.

There is an awkward and embarrassing moment that we all have to deal with while running calls. It helps to think it over before it happens. If you’ve been in EMS for any length of time, it’s already happened to you. So let’s talk about it now. How do you react when you make a mistake during a call? What do you do when things don’t go as planned? How do you respond when you make an outright flub, guffaw or blatant error right there for everyone to see?

My answer, “The illusion of control.” Allow me to explain.

Once you’ve made a mistake, you can’t rewind time and redo it. (Oh, but we wish we could.) You can only respond. At that moment you can certainly respond in ways that make the mistake worse or amplify the error. Or you can respond in ways that minimize the error and move on. Given a choice, I would chose to minimize the error and move on…most of us would. But that isn’t our natural instinct.

Our nature is to focus on the error, the mistake or the embarrassment. It comes crashing to the forefront of our minds and completely derails our plans. There are a lot of behaviors that will only amplify our mistakes and they all seem like the right choice at the moment.

• We get angry
• We get embarrassed
• We talk about it
• We cuss
• We blame someone or something

Here’s a different idea…an idea counter-intuitive to your natural response. Act like it happens all the time. No really…this works. Be casual and continue on like that stuff just happens (because it does.)

You see, we have a very powerful tool on our side and we don’t recognize it. The patient doesn’t run emergency calls every day. The patient doesn’t have training and experience in what we do. They don’t know how many times it takes to start an IV on average. They don’t know how long it takes to untangle an oxygen cannula or any of that stuff. They can only gauge the appropriateness or inappropriateness of our care by our reactions to our own behavior. So, if things aren’t going as planned, don’t announce it!

Carry on and keep moving in the right direction. Miss the IV? “Well that one didn’t work, let’s take a look on the other arm.” Need your kit, but you left it in the rig? “I have just a few more questions while my partner runs out and gets some equipment that we’re going to need.” Drop the patient? “Terribly sorry about the rough landing, let’s get you the rest of the way to the pram.” I’m not saying you can’t acknowledge that things could have gone better. You just don’t have to advertise it to everyone.

Let me put it another way. When you go to see a magic show, you know there’s some behind the scenes shenanigans going on right? (Well, I’m sorry to spoil the show, yes…there is.) But you don’t want the magician to tell you all about it. If two bunny rabbits were supposed to come out of the hat and only one shows up, he’s not going to stomp his feet and declare, “Damn it, there were supposed to be two!” He’s going to hold up the one rabbit and say, “Ladies and gentlemen, behold my amazingness!” Or something like that.

The illusion of control is about presentation. It’s about having a little bit of showmanship. It’s about style. The show must go on, so continue in style. You’d be amazed at what your patient will usually let you get away with if you simply do it with a little grace and casual style.

So the next time things don’t go as planned, don’t lose your cool. Take a deep breath. Maybe smile just a little bit. Apologize if necessary. And announce what you’re going to do next.

Ladies and gentlemen. Behold my amazingness!

Now it’s your turn: How do you react when things go wrong? What’s your traditional response? Does it work for you?

Read More Cool Posts:

Safe At Home

Passion Counts

What Is Ketosis Anyway?

Wrong Medicine

The Art of The Pulse Check

]]> http://theemtspot.com/2010/04/01/the-illussion-of-control/feed/ 6 http://theemtspot.com/2010/03/30/its-not-my-emergency/ http://theemtspot.com/2010/03/30/its-not-my-emergency/#comments Tue, 30 Mar 2010 12:00:29 +0000 Steve Whitehead http://theemtspot.com/?p=2718 Part one of a two part series on scene presence. Part two is here.

A regular reader of The EMT Spot asked a great question recently. (Thanks Timothy.) “How do I keep my cool and not loose my head in stressful situations?” I want to give you a tip that has worked well for me in the past. It’s a phrase I learned as an EMT and it’s helped me on countless occasions.

“It’s not my emergency.”

I know. I know what you’re thinking. On the surface, “It’s not my emergency.” sounds like a very callous and uncaring thing to say. But give me a chance to explain.

I was taught the phrase, “It’s not my emergency.” by a talented young paramedic who was a mentor in my early years in EMS. Since I first learned it, I’ve heard it used in a much more callous and uncaring form. More often than not, when I hear people say this catch-phrase it’s said in a dismissive manner. “It’s not my emergency” has become, “It’s not my problem.” or worse, “I don’t care about your emergency.” It never meant that to me. That’s not how I learned it.

For me, “It’s not my emergency.” is a mantra that helps us remember our role in the trial and tragedies that befall our patients. It reminds me of my place in the human drama of EMS. My role is that of the caregiver, not the patient. And, until the day that I pick up a phone and dial 911, that’s how it shall remain.

This is what “It’s not my emergency means to me:

I am part of the solution. I am not here to be a part of the emergency. This is another person’s problem. I’m here to help solve it.

It’s important to keep our perspective about what role we’re playing in the emergency medicine show. We are the solution. We don’t serve the public interest or our patient by becoming a part of the emergency. And, believe me, there are lots of ways to contribute to the emergency.

Here are a few:

• Freelancing
• Being emotional to the point that we become ineffective
• Becoming injured
• Bringing our personal biases, prejudices, politics or psychological traumas to the scene
• Adding to the sum total of stress and high energy
• Making bad decisions
• Sticking to our bad decisions and ignoring (or feeling threatened by) helpful input
• Conflicting with the leadership on scene.

But you can avoid all of that. It’s all packaged up nicely into something I like to call scene presence. Develop your scene presence and you won’t have to worry about this stuff. You will always remain a part of the solution.

When we’re part of the solution, we focus on our role on scene. That means if the scene needs us to be in command, we remain in command. If the scene needs us to do patient care we do patient care. We are able to remain focused on our assigned tasks without becoming overwhelmed.

When we’re part of the solution we approach human distress with compassion and empathy, but we never allow our emotions to overwhelm us or cloud our decision making or add to others distress. We can make human connections with others without adopting their emotional state. This is their moment for grief, not ours. We can have our moment later.

When we’re part of the solution we place our safety above all else, knowing that nothing will cause the scene to devolve faster than an injured responder.

When we’re part of the solution we leave our psychological crap at home. It doesn’t matter if our friend was once killed by a drunk driver or the guy in the bar fight reminds us of a bully back in grade school or if our father abandoned us as a child because of his heroin addiction. We all have our stuff. Our patients are bound to stir up that stuff within us. The patient has their own stuff to deal with. They don’t need ours.

When we’re part of the solution we remain calm and professional. Sometimes it seems like yelling, running, barking commands and being visibly stressed is the best thing for everyone. It’s not. It never is. Once people see the ambulance crew looking overwhelmed they start to lose it. Your affect is a catalyst for everyone else on scene. That goes for your co-responders as well. You are the calm at the center of the storm.

When we’re part of the solution we make good decisions. Good judgment is the hallmark of good EMS. It isn’t good knowledge. It isn’t good skills either. It isn’t strong protocols or fancy equipment. It’s good judgment. Make good decisions and things will go well. And know how to ask for help making good decisions when you need it.

When we’re part of the solution we recognize that everyone on scene is a resource. We don’t need to have the right answers all the time, we just need to know how to use the team around us. Let go of the idea that your performance needs to be perfect. Be fallible. Be authentic about your abilities and limits with the other responders on scene and use them as a sounding board. They’ll help keep you out of trouble if they know you want their help and input.

When we’re part of the solution we understand that it’s our job to support the leadership on scene. It doesn’t matter if we like the person in charge. It doesn’t matter if we agree with them. We support them. If they make a mistake, we have their back. When we feel we have valuable input, we give it in a respectful way. We take care not to undermine the trust in the authority on scene, with the team or with the public.

“It’s not my emergency” has served me well over the years. I’ve said it to myself in the back of my rig alone with a patient who needed more help than I could offer. I’ve said it to myself on scenes with way too many patients and way too few resources on hand.  I’ve said it to myself with news helicopters circling overhead on incidents that you’ve heard of and probably watched. I’ve even said it when it was my emergency. And it works for me.

See if it works for you.

Now it’s your turn: How would you answer Timothy’s question? How do you keep your cool?

Read more EMS awesomeness:

Trust Is A Currency

Be Remarkable

Five Rules For One Shift

Unconventional Thoughts on EMS

Patients Define Their Emergencies

]]> http://theemtspot.com/2010/03/30/its-not-my-emergency/feed/ 10 http://theemtspot.com/2010/02/08/mastering-the-head-to-toe-assessment/ http://theemtspot.com/2010/02/08/mastering-the-head-to-toe-assessment/#comments Mon, 08 Feb 2010 21:46:07 +0000 Steve Whitehead http://theemtspot.com/?p=2599 You probably practiced your head-to-toe assessment a bunch in your EMT class. Maybe more than any other skill in the EMT curriculum. If your class was or is anything like mine (as a student or a teacher) you performed the head-to-toe assessment again and again.

As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.

That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.

I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.

1. Do head-to-toe assessments frequently.

I mean more frequently than you’re doing it right now. You have a lot more opportunities to do a a good head-to-toe than you’re currently taking advantage of right now. Drop the surprised expression. This is just you and me talking here right?

That infant in the car seat involved in the fender-bender could have used one. That trip and fall at the mall would have been prefect too and so would that dude punched in the bar fight. You let them all go without a top-to-bottom physical exam. The more you do head-to-toe exams, the more comfortable and efficient you’ll become.

2. Be systematic.

It’s called a head-to-toe for a reason. No, that doesn’t mean that you need to start at the head every time. (In fact, with kids, I recommend starting at the feet.) But you do need to have a system and stick to it. If you make up your physical exam each time you do it you’re never going to be smooth. When an emergency is in full-swing, the assessment won’t come naturally.

People tried to teach me this lesson for a long time and I don’t know why I was so slow to learn it. I guess it just seemed silly to force myself to do the assessment the exact same way every time. I’m glad I finally relented. Now I understand. If you want to be efficient when it counts, you have to be systematic.

3. Pay attention to the patient’s facial expressions during your assessment.

Sure we ask the patient if it hurts, but you’ll pick up on a lot more if you pay attention to the patients face. Are they distressed or relaxed? Are they paying attention or distracted? Do they wince or grimace during palpation? There are many reasons why a patient might try to conceal their discomfort and if you are in the habit of only looking at the body part you’re checking, you’re going to miss some stuff.

4. Interact with the patient.

I don’t just mean, breathe deep, does this hurt, yada, yada. That’s the patient interview. But it isn’t real interaction. Talk to people while you’re assessing them. Family doctors have mastered this skill, and for good reason. There’s a wealth of patient assessment information to be gained by just talking with folks about what happened, where they were going and whatever else is on their minds.

You don’t need a fancy mental status exam to figure out if people are oriented and responding in context. Just talk to them. If their brain isn’t working right you’ll figure it out.

5. Visualize the structures beneath the skin.

This requires you to know your anatomy. If you’re palpating parts of the body and you can’t visualize the structures beneath the skin, go back to your anatomy text book or try to find a cadaver lab to attend.

It’s a worthwhile skill to be able to visualize what lies beneath the patients skin and it’s essential when we are calculating the possibility or probability of injury and developing a differential diagnosis.

6. Feeling, really feeling, is harder than you might think.

Of course, we feel the patients body. Palpation is feeling. What else would we be doing? Actually most of what’s going on is looking and asking. Things that we see like bruises and abrasions are rarely missed in a proper physical assessment. Pain and tenderness is also pretty easy to pick up on. Push, “ouch”, got it.

But things that we need to feel. Things like crepitus or masses, or fever or coolness or rigidity. Those things tend to get missed. we miss them because it’s easy to go through the motions of palpation, but it requires some mental energy and practice to really feel for abnormalities.

It’s also something we never really get to practice until were doing real-deal patient assessments. In class we get in the habit of looking and pushing but you can’t really feel abnormality on a mannequin. They feel hard and plastic every time. When you’re palpating a human, focus on what you’re feeling.

7. Be confident.

Have you ever watched an ER physician do a physical exam? Pay attention the next time you get an opportunity. Watch not only the types of assessments they do but the manner in which they move from one assessment to the next, interacting with the patient, describing the needed behaviors or responses.

ER physicians do thousands of patient assessments and it shows. They don’t need to think about the next step in the process. They just do it. It’s the same way a short order cook doesn’t need to think about the ingredients in your Denver omelet. It’s the same way a professional baseball pitcher doesn’t need to think through the steps to throw a slider. They have reached a level of unconscious competence.

When you’re working on your head-to-toe technique, strive for that level of unconscious competence. Where you are confident in your ability because you know what comes next without ever needing to think about it. At that level of ability you can really focus on what you’re seeing, feeling and hearing.

I said it at the beginning but it bears repeating. Your physical assessment skills are one of the defining qualities of your patient care ability. When I’m evaluating a new EMT or paramedic, one of the first things I want to see them do is perform a complete head-to-toe assessment.

Performing that skill well, with calm confidence, is one of the hallmarks of a good EMS provider. It is an essential, foundational skill that speaks volumes about your ability. Could yours use a tune-up?

Now it’s your turn: Have you ever known a really good EMT who couldn’t do a near-perfect head-to-toe assessment? Have you ever known a really bad one who could? What are your tips for mastering this skill? Other readers would like to know. Leave a comment and help make this post even better. 

Read More Goodness:

Test For Unconsciousness: The Hand-Drop

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The EMT Code of Ethics

Beyond The 1-10 Pain Scale

All the shears I’ve ever owned have come and gone. I don’t have a particular set that I’m really attached to right now. I’ve had some great sets of shears over the years. I think my longest running favorite pair lasted around five years. I don’t remember the brand now, but they were good. Black handle with a bit of cloth tape for grip. (I know it isn’t a bio-friendly practice.) Nice tight feel to the action.

Like all shears I eventually lost them. Some scene was moving along and I handed them off to someone in the rush of delegation to strip a patient down and they never returned. Equipment comes and goes. It’s the way of things.

The truth of the matter is, it doesn’t much matter how good or bad the shears work. The guy (or gal) wielding the shears is the deciding factor in how fast a patient gets stripped. I can strip a human in seconds with a wobbly pair of $2.00 knock-offs. The shears just don’t make that much of a difference. It really comes down to technique. Here’s the skinny on how to take a patient from their winter-best to fully naked in seconds.

Shoes:

Try to slip shoes off before you cut them off. Many will just come right off. If they don’t, try to slip the scissors inside the laces. This works sometimes but not often. If you can’t easily get under the laces and you’re in a hurry to lose the shoes just cut the instep.

Slid you scissors into the shoe at the medial aspect of the foot just under the ankle and cut downward into the shoe. Now pull it off. Voila! Still no luck? Make the same cut on the other side too.

Pants:

Don’t try to cut a pair of pants completely off. It takes forever. The secret to rapid removal of pants and shirts is to primarily tear them off, using the scissors to get the cut going.

To get an idea what I’m talking about take a look at my highly technical drawing at right. Cut the bottom cuff of the pant leg then grab the fabric on either side of the cut and tear it. Jeans tear like gang-busters. Stretchy fabrics take a bit more work. Motorcycle leathers are a pain. You may need to actually use the scissors all the way up.

Keep the scissors handy to go through the waistband and the belt at the top.

Shirt:

Just like the pants, remember you’re ripping. The scissors are just giving you the assist. Don’t cut like a kid in kindergarten doing a craft. One nice cut, then tear em’ like you mean it.

If you look at my handy shirt drawing you’ll see the fast three cut pattern that even works if your patients left arm is substantially longer than their right.

Shirt fabric also bunches better than pant fabric so keep in mind that you can often save some time by grabbing the fabric you intend to cut in one big bunch and then cutting through it. You can cut a t-shirt from waist to neck by gripping it in one bunch and then cutting it.

Snip, tear, tear. Snip tear, tear. It probably goes without saying, but this is all much easier with a sharp pair of scissors. My nostalgic story aside, there’s something to be said for not getting too attached to a good pair of scissors. All of them get dull and loose after a few years of use. Some much sooner. (And there’s no faster way to dull them up than to cut up pennies for amusement.)

While this last point should be obvious, we all need to be reminded. We are granted tremendous trust from the public. There are very few instances when people are allowed to strip strangers in the middle of the street. (Except maybe in Las Vegas.) So don’t forget that it’s a three part process, strip, assess, cover. Or, when possible, strip, cover, assess. Protecting peoples dignity is part of our job as well.

I collected a few more tidbits from the EMS folks on twitter. Thanks to @Jeramedic, @DG_Medic, @RVaEMSExaminer and @RicAnderson.

• Look out for ECG wires when cutting. They’re expensive to replace. (I’ve had this happen as well.)
• When cutting the shirt, cut the collar down to avoid cutting toward the patients face and neck.
• When cutting a man’s pants, stay toward the outside seams to steer clear of sensitive anatomy. (Ouch)
• In rural areas you may want to consider cutting along the seams. Some folks who are gifted with the sewing machine will sew their clothes back up. (If you’re in downtown Manhattan don’t bother.)
• There is debate over the proper way to cut off a down jacket. My advice is to avoid it, if it is humanly possible. If you must cut through a down jacket, do it on the street, before you load the patient. If you cut up one of these pretty little fashion statements in the back of your rig you will be cleaning up feathers for weeks. No, seriously…weeks.
• Ask an officer how his or her bulletproof vest comes off before you lay into it. Most of them Velcro on the sides.

So there you have it. Everything you need to know to get the patient fully exposed in a hurry. Now go find a trauma patient and show em your stuff. But first …

Now it’s your turn: Do you have any good tips or tricks for exposing a patient fast? What techniques do you use to get the job done. What else did we leave out? Leave a comment before you move on.

Other Articles Worth Your Time:

The Art of The Pulse Check

The Art of The Nasopharyngeal Airway

Remembering The Glasgow Coma Score

Six Techniques to Nail The IV Every Time

Understanding OPQRST

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

I also hope that after you’ve read the e-book, you’ll come back here and post a comment, or send me an e-mail, letting me know what you thought about it.

I look forward to your comments, I look forward to providing you a behind the scenes look at the web site in the monthly newsletter and I look forward to continuing to provide you with quality content right here on the blog. Thank you for stopping by.

Now it’s your turn: Will you be signing up for the e-book and newsletter? Why or why not? If you’ve read the book, what did you think? Leave a comment before you go.

My first E-book is scheduled for release on January 21st, one week from today. The e-book will be free and it will be available right here at The Spot.

The Book is called The Non-Conformists Guide to EMS Success. This book is the culmination of two decades of EMS experiences, mistakes, failures, trials, and errors that lead to my ultimate success. My goal was to write something that would be useful to EMTs at any stage in their career. And I didn’t hold anything back. This is my road map to finding true success and fulfilment in EMS work.

I started at the beginning and kept typing until every ounce of useful information was on the screen. Over 15,000 words and 50 pages later I closed the largest writing project I’d ever undertaken. And now you can have it for free.

The book release will also coincide with the launch of Splatter, a brand new bimonthly newsletter for regular readers of The EMT Spot. Splatter will be the behind-the-scenes, insiders guide to The Spot. You’ll get the e-book and the newsletter all in one go. And it’s all going to happen right here. So mark your calendars. I’ll see you back here in a week for the ribbon cutting and the cake.