The next time you’re in the middle of managing a difficult head injury patient, I want you to think about two things.

There are limited things that we can do in the prehospital setting to fix a closed head injury. They need to be transported to an appropriate trauma facility. Our care is centered around managing them until we can get them to the definitive care that they need. With that in mind, here are the two cardinal sins of closed head injury care. These are the two things that need to be avoided at all costs.

Two things…

First thing. Never, ever, ever let a closed head injury become Hypoxic.

Hypoxia will make a bad head injury become worse in a big hurry. Remember that respiratory status can be a moving target in the closed head injury patient. Anything goes with the rate and depth of respiration as a patient intra-cranial pressure rises. And things can change fast. Be very agressive in the airway management of this patient. If their breathing is adequet, keep them on high flow oxygen. If they vomit, roll them and suction them aggressively. (Keep the oxygen flowing during suctioning.)

Manage hypoventilation immediately. Have the BVM standing by and use it as soon as they need it. Get those BLS airways out and use them. If the patient has a gag reflex, use a nasopharangeal airway. If they don’t have a gag reflex, use an oropharangeal airway and get an advanced airway in as soon as possible. (Intubate if you can, use a King airway or other dual lumen device if you can’t.)Ventilate the patient, but don’t hyperventilate them. Hyperventilating head injury patients is old school. Use capnography if you have it and keep that ETCO2 at a low-normal level. No capnography? That’s OK. One breath every six seconds. (Hint: It’s slower than you think.)

I know that new CPR guidelines are de-emphasizing airway management. This is not the case with head injury’s. Make the airway your number one priority and don’t neglect it for a second.

Second thing. Never, ever, ever let a closed head injury become Hypotensive.

Research tells us that even one episode of hypotension can be devastating in the presence of increased intracranial pressure. Start IV lines and administer fluid as needed. Use the shock position, but not trendelenburg. Preventing hypotension begins with aggressive monitoring. If you have an auto-cuff set it for every two minutes. This will give you almost constant blood pressure monitoring. Auscultate that pressure if anything on the monitor looks sketchy. No auto-cuff? That might be better. Wrap a coff around the patients arm and palpate the systolic pressure every few minutes. Auscultate if you find it trending toward hypotension territory.

When you call in to the hospital, the patients most current blood pressure should be the second thing you report on (Right after the status of the airway.)

When you keep these two things primary in your mind, your care priorities will become more obvious regardless of the complexity of the patients presentation or how rapidly their condition changes. Focus on the airway, monitor the blood pressure and transport to the appropriate facility. Everything else is but a footnote.

Now it’s your turn: I left several important notes regarding the care of head injuries out of this article. What other tidbits do you have on treating this challenging patient group? Leave a comment and let us know.

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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.

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There’s an interesting little bit of behind-the-scenes information about how I started the tradition of saying these two things before I left a patients room. I picked up the idea of always saying that I was glad to be of service to the patient early on while working at Pridemark Paramedic Services.

Jeff Forster, the organization’s CEO, was the first EMS leader I encountered who really challenged his people to take their service level up a notch and maintain a patient-needs-first focus.

Years later I had a partner named Will Dunn. Will went on to be a popular EMS instructor in the mid-west region as well as a paramedic supervisor and education coordinator for Eagle County Ambulance District.

Years after our partnership, Will and I were having lunch together when he brought up how he’d picked up on my habit of leaving each patient with a hand-shake and warm goodbye. He told me that he had been doing it ever sense our partnership. I respected Will as an excellent paramedic and I was proud to know that I had influenced his care in that way.

Then he told me about how he always asked if there was anything he could do for the patient. I really liked the idea and started trying it out immediately. I’ve been doing it ever since.

I was influenced by Jeff, then Will learned something from me and then I learned something from Will and now, perhaps, you can learn something from all of us. It’s amazing the way we influence each other, isn’t it? I hope you’ll try this out and I hope you enjoy the video.

Leave a comment and let me know how it goes. It’s been a pleasure being of service to you today.

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:

“I am on a tactical medic team.  The temperatures here have dropped recently (as they always do this time of year). We recently had a call out. Most all of our medics have an entry bag that stays in their vehicle and a main bag that stays in the response vehicle. As you can imagine, neither of these are heated or cooled, “temperature controlled” environments.”

“On this call out, we had an officer who was walking through the neighbors yard to provide perimeter security when he obtained a fairly significant laceration on his lateral right leg. As most officers would, he brushed it off, vowing to deal with it after the incident. After about 45 mins he finally called for a medic. We replaced him with another officer and escorted him back to the command post. “

“The officers leg from the laceration down was soaked with blood, pant leg, sock, everything. This officer was being particularly hard headed and said he would go get it looked at in the morning and asked us to simply bandage it for him. My partner was able to talk him into an IV because of the blood loss. I was focused on bandaging his leg while my partner started a 500 cc normal saline bag. I left to go back to the perimeter after finishing with the bandage and my partner stayed back to monitor him and finish his IV. “

“I was at the perimeter for all of 20 minutes when I was called back to the command post for assistance. When I got back the officer was lethargic, his extremities were cold to the touch his teeth were chattering, and he was slightly confused. “

“My first thought after, “Oh shit!” was shock, but I had a brief moment of sanity before the panic set in. I took my partners glove off and told him to grab the IV bag. As you guessed it was freezing cold to the touch. He had put the officer into hypothermia by giving him a sub-zero fluid bolus. “

“We quickly called for a unit, covered him up, took vitals and proceeded through our hypothermia protocols. “

“It had not even occurred to my partner that his IV equipment has been in his freezing cold trunk all night, and even when the patient went down hill, he didn’t see the obvious signs of hypothermia. In treating this officers laceration he nearly caused a more serious medical emergency. “

“Most agencies keep their trucks in a climate controlled bay or have a solution to heat their units or bags. However there are some that don’t. I thought this might be worth sharing with you. “

Thanks for the story Scott. And yes, it is worth sharing. I’ve mentioned before the importance of keeping trauma patients warm. As winter sets in here in Colorado, I can imagine all kinds of scenarios where this mistake could play a significant role in the patients outcome. Our medic units use warming plates for our IV bags, but the one in the kit remains unheated.

I also consider how many times I’ve started IV’s on the side of the road in a snow back or deep in the back-country. IV bags get left outside on special events and coverage situations like the one Scott describes here all the time. The next time you’re outside in the cold or pulling an IV bag out of a kit, don’t forget to feel that solution. Induced hypothermia does have its applications, but most of our patients will benifit from warm fluid.

Thanks for the tip Scott.

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?

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.

3) The official obstetrical term for the mother’s water breaking is “rupture of membranes”. It can be documented with the abbreviation ROM.

4) Unlike the Glasgow Coma Score, you can’t just guess that a healthy baby gets an automatic 10 on the APGAR score. Most healthy babies are born with a score between 8 and 10. In some regions of the United States very few babies are ever scored a 10 at birth.

5) You won’t remember the APGAR score when you’re holding a newborn baby in your hands. Write it on your OB kit.

6) All things considered, moms tends to be the best judge of when labor is eminent.

7) In your EMT class we drilled on the idea that mom should be laid on her left side. More recent research has indicated that getting mom on her side is the important part. Whether she’s on her left side or right side makes no real difference.

8.) Designate the person with the least to do as the official time keeper. Make sure they have access to the most accurate clock available.

9) 600 ccs of blood pass between mom and baby every minute. Mom can loose 1,000-1,500 ccs of blood before she becomes symptomatic. Typical postpartum hemorrhage should be in the neighborhood of 500 ccs.

10) Delay transport if delivery is eminent. Don’t delay transport for delivery of the placenta. It can take hours. Once baby is out, package for transport.

11) Aggressive (uncomfortable) fundus massage is still the best method to slow postpartum hemorrhage.

12) Cut the cord between the clamps. (Seriously…it happens.)

13) When delivering twins, both babies will deliver first. Both placentas will deliver after. Any other ordering is an obstetrical emergency.

14) Fetal trauma cannot be ruled out in the prehospital setting. Lack of vaginal bleeding or pain on palpation does not rule out fetal trauma. Pregnant mothers who have suffered any significant mechanism to the abdomen should be transported for evaluation. (They will typically be observed for 12-24 hours.)

15) Don’t forget to prepare for two patients.

Now it’s your turn: What OB tips would you add to the list?

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“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.

In truth, they weren’t. Bunch them all close together and the tiger would surely escape. Space them randomly across the gap and you’d get the same result. In fact, even the slightest alteration in the spacing between the bars would produce the same result. Free tiger.

While we tend to pay attention to the bars, it is the space between them that contains the power of the tiger.

If you’d asked me what saved me from becoming a tiger snack, I would have undoubtedly pointed at the bars. We tend to focus on what we can see. We are drawn to the obvious. The necessary perfection of the spacing would have never crossed my mind. And so it is with our job skills.

If you told me about an EMT that you know who is really good at what they do, undoubtedly, you would tell me about how they perform on calls. You would tell me stories about their great patient assessment skills or their ability to ask that just-right question in that just-right moment to bring the whole call together. You might discus the way the interact with people or their superior clinical skills.

You would point to the things they do from the time the call drops to the time they place the patient in a hospital bed.

Hard evidence. Strong proof.

You would point to the bars.

While it is their performance during a call that defines them as great, it is what they do in between the calls that makes them great. We tend to pay attention to what they do during the calls. It’s what they do between the calls that contains the power of their skill set.

The next time you have an opportunity to work with someone you feel is really good at what they do, pay attention to how they use the space between their working time.

Notice if they leave the hospital room immediately after giving a report  or if they linger and listen to the questions the hospital staff ask and talk with the doctor about their impression of the patient.

Notice how they check out their rig before their shift.

Notice how they respond when they encounter information that they are unfamiliar with.

Notice what they do when they make a mistake. (Yes, they do make mistakes.)

Notice if they spend time on continuing education, or research.

Notice the million little things that they do to prepare themselves for the next call.

What they do on the next call will be the thing that people talk about. What they do before the next call is every bit as essential. I imagine it’s the same for just about anything.

What about you? What do you do with the space between?

With that in mind, it’s worth considering how we might shift our ideas about trauma care to a more global perspective. When you look at the mortality time curve in traumatic injuries you see that patients tend to die in three time windows.

Put simply, when people experience significant trauma, they tend to die in about two minutes. If they don’t die in two minutes, they tend to die about two hours later. In most urban settings this means that they die on a trauma surgeons table in the middle of damage control type cut-and-run surgery. If the patient is fortunate enough to survive the surgery, then they tend to die about two weeks later. Two minutes, or two hours or two weeks.

Here’s the big get it. In each of the mortality time windows, the patient dies for different reasons. But…

The stuff we do on scene, in the first two minutes, effects all three time windows.

Wrap your brain around that for a minute. We do stuff on scene that effects the patients mortality in the first two minutes. This is what we often think about the most when we think about our trauma care. Crash medicine. Down and dirty airways, immobilization, rapid transport. But what we do also effects the two hour survivability significantly. And, believe it or not, we can have a huge impact on the two week survivability as well.

To be able to treat the patient in all three windows, we need to know what kills trauma patients in two minutes, two hours and two weeks.

I was first introduced to the concept of addressing trauma care from the 2/2/2 perspective by a fantastic trauma and burn surgeon named Dr. Bradley Philips who practices at Swedish Medical Center in Denver Colorado. Here’s Dr. Philips analysis of why trauma patient’s die in each of our three time windows.

1) Patient’s die in two minutes from: Airway and breathing compromise and hypovolemic shock.

2) Patient’s die in two hours from:  Hypovolemic shock.

3) Patient’s die in two weeks from: Septic shock.

Often, we run our trauma calls from the two minute perspective and we don’t really consider the other two time frames. Perhaps, we’ve been taught that our job is to simply get the patient to the trauma team alive and everything else is their problem. It’s easy to think that way. Once the patient is out of our hands, who are we to be concerned about their long term survival? Isn’t that some doctor’s job?

As is the case with many questions in medicine, yes…and no. If the patient dies on the operating table because they were given so much saline in the prehospital setting that they were unable to coagulate their blood, we played a significant role in their death. If we let a trauma patient get cold and that hypothermia contributes to their abnormal coagulopathy and hypovolemia, our care played a significant role in their death. If the pseudomonas bacteria on our gloves is transferred to the patient’s wound while we are packing it and the patient dies two weeks later from a pseudomonas infection, our care played a role in the patient’s death.

I understand that this is a less comfortable way to look at trauma care. The get-them-there-and-forget-them strategy is more comfortable. It relieves us of our responsibility to be concerned about the patient’s survival after they have left our direct presence. And it keeps the game on our playing field. Let’s face it, getting trauma patient’s to survive the first two minutes is easier than getting them to walk out of the hospital. However, for the patient and their loved ones, dead is still dead.

What’s an EMT to do? When you walk into your next trauma scene, ask yourself, “What will kill this patient in the next two minutes?” Then ask yourself, “What’s going to kill them in the next two hours?” and then ask yourself, “What’s going to kill them in the next two weeks?” Here are some more specific guidelines.

First: Control the Airway (2 minutes)

The first big killer immediately following a major traumatic event is airway compromise. Get in there and get aggressive. Use those BLS airway adjuncts early to improve your efforts to assist ventilation. You were trained to use them for a reason. Use them. If the patient can take an OPA without gagging, they need a more definitive airway. Get out your king tube or Combitube or whatever more advanced airway you have and use it.

If you have the ability to intubate and the skill to do it quickly, do it. Be honest with yourself about that second part. I know you think you’re fast when it counts, but very few of us really are fast enough to not bog down a trauma scene with our intubation attempt. If your intubation attempt delays the transport of the patient one second, it wasn’t worth it. You should have stuck with the BLS airway.

Second: Let Them Breathe (2 minutes)

Pay attention to the patient’s lung sounds and, if you suspect they have a pneumothorax, vent the chest. If pleural decompression isn’t in your scope of practice, get that patient to someone who can vent their chest. It’s a horrible thing to watch someone suffocate in from of you. It’s even worse to let them suffocate and not recognize that you could have saved them with a simple procedure. Figure out a way to get the chest decompressed.

Also make sure that you stabilize any paradoxical motion of the chest wall and keep the breathing patient on high flow oxygen. Think carefully about how yo utilize interventions that impinge upon breathing like shock position and the Kendrick extrication device. These interventions have a role, but we need to consider effective breathing first.

Third: Stop the Bleeding (2 minutes and 2 hours)

This is relatively easy and we suck at it. Often times we let people bleed to death. Fear of tourniquets is part of the problem. Not being aggressive enough with out direct pressure is another part of the problem. There are three things we can do to prevent our patient’s death from hypovolemic shock.

1) Be really aggressive about bleeding control.

That means pack wounds with dressings, Gauze, Kerlix, whatever you have and then put real pressure on it. If you see someone assigned to bleeding control gently holding a dressing on a wound while blood oozes from underneath put your hand over their hand a squeeze like you mean it. Also put their free hand on the closest pressure point and squeeze there as well. If it doesn’t work, start thinking about a tourniquet.


2) Keep the patient warm.

We let most of our trauma patients get hypothermic and we rarely pay close attention to this detail. The good news is that we’re exposing people appropriately. The bad news is that even a small drop in core temperature can significantly impair the patient’s clotting ability through three different mechanisms. If they are going to survive surgery, we need to keep them warm. Cover them when your done with your assessment and kick the heater on high.


3) Go easy on the IV fluids.

It’s time to move away from the mindset that more fluid is better. Permissive hypotension is the new name of the game. To much saline impairs the patient’s ability to clot. If the patient’s is oriented and their systolic pressure is above 90, you probably aren’t doing them a favor by dumping more saline into them. Do them a favor and back off on the big fluid challenges.

Fourth: Keep it Clean

Sterile gloves are the most underused piece of equipment on the ambulance. Those sterile gloves are for more than delivering babies. If you’re working on open wounds, burns on invasive procedures, you should be pulling on those sterile gloves. It’s not a big production. Just pull a pair over your non-sterile gloves. If you’re packing and working with a significant wound, you may need to layer up several sterile gloves while you work. Using sterile dressings isn’t enough. To many of our patients end up with extended hospital stays and increased mortality due to the infections we give them in the field.

If you don’t think that using sterile techniques is important, you’re not paying enough attention to sepsis mortality rates. The patient might not die in your care, but dead is still dead.

What do you think?: Should we treat trauma patients with the 2/2/2 mindset? Leave a comment and tell everyone what you think.

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Someone told me this once and I did choose to believe it. I earnestly began trying to answer the question. And it worked for me. When I came up with the right answer, and it wasn’t even the perfect answer, it more than doubled my income.

Now you want to know the question right?

If you want to double your income, seek to answer this question relentlessly: “How can I be ten times more valuable to my employer and my industry?” That’s it.

If you relentlessly seek to add more value for your employer and your industry, you’ll make more money.

Your first reaction may be one of frustration. You may feel like the question is some sort of scam. That’s understandable. There are a lot of people out there trying to scam you. Skepticism is a rational response. I don’t blame you if you’re thinking, “That’s impossible!” If you believe it’s impossible that just means that you haven’t come up with the right answers yet.

Granted, it’s a hard question. If it was an easy question it probably wouldn’t have the power to double your income.

Here are a few of the wrong answers people get stuck on. (There are many.):

1.) Earning a degree. – Earning your degree might make you appear more valuable. It might qualify you to perform a more valuable role or function in some organizations. It certainly enriches you. But a degree, in-and-of-itself, does nothing to add real value to your work for anyone other than you. Your patients won’t pay more money for a ride to the hospital from you simply because you have a degree in your pocket. It’s a piece of paper.

2.) Working more hours. – Doing more of the same thing that you’ve already been doing is the easiest and most obvious answer. This is why I asked you to focus on being ten times more valuable. It rules out the easiest answer. You couldn’t possibly work ten times more hours or run ten times more calls. Yet, some will try.

The problem with doing more is that there is a point of diminishing returns. As you work more hours, your free time becomes more and more valuable. At some point the trade off isn’t worth it. Time is a precious asset and most of us in EMS spend to much of it in our ambulances. You need a better answer.

Here are a few good answers. (There are also many.):

1.) Increase employer recognition. – I don’t mean send your boss a thank you card. I mean, go do some stuff that makes people look at your employer in a favorable light. If your patient says, “Thank you.” at the end of the call, you’ve provided the value you are already paid to provide. If the charity event that you’ve organized makes local news stations show up in from of the local Save-Mart to talk about the great things the local ambulance service is doing for the community, now you’re adding more value.

2.) Increase employer services or reduce expenses. – If you design a method to expand your existing infrastructure to provide medical billing for three more companies or tap into a new transport market or reduce vehicle service and maintenance expenses or turn your continuing education program into a paid online CE provider or help your organization become a critical care transport service provider, now you’re providing real value.

3.) Become a knowledge matter expert. – If you become the local WMD expert or Hazmat trainer or street drug recognition expert or online education specialist or social media PIO, now you’re providing real value.

None of these things increase your value ten fold. You can’t do that over a weekend. You’ll have to be tenacious. You’ll have to show up and do it again and again. And each time that you do, you’ll become more and more indispensable to your employer. Before you know it, your paycheck will reflect your value. It works like magic.

But you have to make the first move. You can’t decide you’re going to become more valuable after you get paid more money. That’s what everyone thinks. It doesn’t work. You have to begin.

So begin.

I’d like to know what you think about that. How will you add ten times more value?

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Where Do You Put The Fear?

Ten years after Denver General changed it’s name to Denver Health Medical Center, Dr. Pons was still referring to the institution as D.G. and still answering the bio-phone with his same, hallmark gruffness. Any medic who worked in the Denver metro area from the mid 1970s till very recently was accustomed to the short, intolerant voice of Dr. Pons on the bio-phone and the feeling his presence often induced.

There was a lot to like about Dr. Pons. As a physician, he was as good as they come. And he didn’t tolerate bad medicine or poor performance from anyone. If you fumbled through your bio-phone report or didn’t know what you were calling for, Dr. Pons would make you hang up, think about what you wanted to say, and call back. No kidding. He also helped to write one of the best EMT textbooks on the market.

I wish we had more docs like Dr. Pons. We’d all perform better medicine and we’d also probably be a lot smoother on the bio-phone. Here are a few tips to help you stay relaxed on the bio-phone so your next report can be a well-organized exercise in smoothness, instead of a fear inducing drama. With any luck, you’ll never get the hang up treatment, even from the gruffest of E.R. docs.

1) Think about what you’re going to say before you call.

Domenic, a paramedic friend of mine, had a great story about Dr. Pons giving him the callback treatment. Dominic got off balance during a call-in report and stumbled over his words. He got nervous and disorganized and, before he knew it, the whole report feel apart. Dr. Pons interrupted. “Look, this is what you’re going to do. Hang up the phone. Think about what you want to say to me. When you know what you want to say, call back.” Click…the line went dead.

And so he did.

Domenic’s next call was much smoother and he eventually got the medication order that had prompted his call. We could all take Dr. Pons advice on this one. Before you make the call to the hospital, think about what you want to say. You don’t need to rehearse it. It isn’t a Broadway play or anything like that. Just consider why you’re calling and what you want to tell the doctor or nurse on the other end of the bio-phone. How are you going to describe the patient? What re the key elements you need to include?

2) Know why you’re calling. (And ask for what you want.)

In most EMS systems, the vast majority of call in reports are to let the hospital know you’re coming. These reports are typically simple and strait-forward. They’re also a great opportunity to practice for the more stressful reports like medication orders or medical refusals.

If you’re calling to notify the hospital that you’ll be arriving soon with a patient, they want to know when you’ll be there, what bed they need to get ready and if they need any additional resources standing-by when you get there. These calls are a great opportunity to practice painting clear, concise pictures of the patient in front of you in a low stress situation.

When the patient is an against-medical-advice refusal (A.M.A.) let the doctor know why you’re calling and tell him your impression of the patient’s right to refuse before you launch into your story. Don’t make the doctor guess at what you’re thinking. They’ll tell you if they agree or not.

If the call is for a medication order. Tell the doctor what medication you’re calling to request before you start your report. Let them hear the report in the context of the medication order being requested. Often, our failure to get the drug order filled is a simple matter of not giving the doctor enough insight into what we wanted in the first place. Even worse, sometimes we never get into the habit of asking at all.

I listen to medics get upset at the darn doctor who wouldn’t give them their medication order, “I can’t believe Dr. MacGregor didn’t give me a Morphine order on my chest pain patient!” The truth of the matter is, they never asked. They gave the report, they sounded uncertain about what to do next and they left an awkward pause at the end of the report. If you give that sort of report, don’t be surprised if you hear a polite voice on the other end of the radio say something like, “Thank you and continue transport. We’ll see you when you get here.”

I know, it can be intimidating to put yourself out there in front of our medical control and say, “This is what I want to do.”, but it’s important. If there is any single defining factor that differentiates the EMTs and medics who get their medication orders filled regularly from those who don’t, it is this; medics who ask for their orders, get their orders. “Dr. Bergner, this is EMT Hansen, I have a 68 year old male with chest pain and I’m calling for an order to administer nitro. This patient is currently…” or,  “Hi Dr Kanowitz, this is Steve, the paramedic on medic 42 this evening. I’m calling for an order for Amiodarone and possibly a cardioversion on an adult male in v-tach. This is what I have…”

3) Ask if they can hear you.

Now that most facility communications have moved to cell phones, many providers have dispensed with this courtesy, but I still find it a useful way to start a report. “Good evening Memorial, this is Steve on medic 42, do you hear me alright?” A communications check will give the doctor or nurse a moment to grab a pen and compose themselves. Just because they answered the phone doesn’t mean they’re ready to record your report. Ask if they can hear you, then give your report. You’ll find that you’re asked to repeat yourself a lot less often and the call-in will progress smoother if you use this common greeting.

4) Use the same format every time.

I use the same format in every report I give. It doesn’t matter if I’m writing a patient care report or talking to a doctor on a bio-phone or delivering a verbal report to a crowded room in the middle of a trauma activation. I start with the patient age and a brief summary of what happened. Then I tell a detailed story followed by a description of my assessment findings and then my treatments so far.

The content and details for each report may differ drastically depending on the type of report and patient condition. A bio-phone report won’t contain nearly as much detail as a hand-off report in the patient’s room and that report won’t contain all the details of my patient care report, but the format never changes. If I get off my format, I forget stuff, and things go badly. Find a format that works for you and stick to it.

If you’re thinking that my format sounds a lot like the S.O.A.P. format, you’re right. Your own style will dictate the format that works best for you. So will your system. When I worked out in the California desert, the hospitals in Lancaster were crazy about the Glasgow Coma Score. They had to have it, and if you didn’t say it, they were sure to ask for it. I prefer to give a more detailed description of the patients level of consciousness, so I rarely reference the Glasgow and nobody seems to care. Out in sunny California, it was an essential component of every report.

5) Keep it conversational.

A little informality can do wonders for your report. This is like the old advice about talking to one audience member at a time when giving a speech or pretending an interview panel is wearing their underwear. If you can keep things informal, you’ll be less nervous and you’ll perform better.

Whether you’re on a radio or speaking on a cell phone, when the hospital answers, just talk to them. Just speak like the two of you are talking about a patient you had last week. Learn your format and know what you want to say, but before you launch into a Gettysburg address type formal dissertation, relax and just talk. The hospital will be more apt to ask questions and even cut you a little slack if you forget a detail or two.

6) Know how to ask for a mulligan.

Sometimes, reports just go badly. Unfortunately, it tends to be at the worst possible times. The more people listening and the more critical the patient, the more nervous you get and the more likely that the report will start weak and devolve into a jumbled mess of information. It’s OK. It happens to everyone. When things go down bad, don’t stand there and pretend you were spot-on. Everyone knows that you weren’t.

Ask for a mulligan. You know what a mulligan is right? In golf, a mulligan is the ability to retry your first tee shot if the first one goes poorly. A mulligan is a do-over. You can ask for a do-over. Nobody’s going to take away your birthday. When the report goes wrong, fill in the details as best as you can and then say something like, “Wow, that was kind of a jumbled mess. What did I miss?” Smile. Laugh at yourself. Start again if you need to.

Once you’ve asked for a mulligan and found that most nurses are more than happy to help you piece back together the missing elements of a bad report, you’ll be more relaxed for the next time. When you’re more relaxed, your reports will get better. As your reports get better, you’ll find that you need to ask for mulligans a lot less often. I’ll see you on the tee box.

Now it’s your turn: What are your tips for a flawless hospital report?

Read more EMS awesomeness:

The S.O.A.P. Reporting Breakthrough

What We Need Most

Eight Tragic EMS Flaws to Avoid

Ten Things You Can’t Learn About EMS From Your Computer

The Protocol / Skill Connection

]]> http://theemtspot.com/2010/12/02/mastering-the-bio-phone-report/feed/ 5 http://theemtspot.com/2010/10/17/the-protocol-skill-breakthrough/ http://theemtspot.com/2010/10/17/the-protocol-skill-breakthrough/#comments Sun, 17 Oct 2010 19:35:00 +0000 Steve Whitehead http://theemtspot.com/?p=3814 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.

1.) The problem with our protocols.

Your protocols were developed by a group of physicians who were trying to give direction to a competent EMT or Paramedic provider. Remember the competent caregiver? She’s the one who feels safe operating inside of her protocols and still depends primarily on rules, guidelines and routines.

This Goldilocks approach to protocols is neither too hot nor too cold but it leaves a large segment of caregivers wanting something more. Our novices want more detail. Our advanced beginners want more structure to the prioritized treatment lists. Our proficient caregivers want to be able to operate outside of the protocol with less formality and scrutiny and our experts want to work without the protocol book at all.

This can also create problems if your quality assurance manager has an idea that everyone should adhere to the protocols as if they were an advanced beginner. If the care provider is an advanced beginner, that level of compliance may be entirely appropriate. If the caregiver is proficient, there are going to be some problems.

With both of these situations, the clear answer is to build protocols with detailed direction meant to guide the caregiver through an example of what ideal care might look like with an emphasis on flexibility. Protocols should guide appropriate care; they should not dictate appropriate care.

The necessity of that guidance will change as a caregiver’s skill and knowledge advance. When we are reviewing field care, we should always focus on the appropriateness of the care given, not the strict adherence to protocol directed treatment. If our field personnel are giving appropriate care that falls outside of the protocol, the problem is with the protocol, not with our providers.

2) The problem with our field education.

In the documentary movie Hearts of Darkness, Francis Ford Coppola describes his frustration with actor Dennis Hopper’s improvisation from the script. Hopper would want to enter the scene and just begin filming and see how the scene flowed from there. For a brilliant (Read expert) actor like Hopper, this type of improvisation was appropriate.

There was just one problem. Hopper hadn’t read the script. Coppola and him would have yelling matches with each other where Coppola would lament, “You can’t improvise from the script if you don’t know the script!” Well said Francis.

As new providers enter the field we need to account for the fact that they will be highly dependent on their protocols. They need to learn the script. A certain level of protocol dependence needs to be OK…in fact, in needs to be emphasized.

The problem we can run into here is when we take on a new trainee and we have an expectation that they will act as a proficient provider immediately. The new provider needs to know the rule book before they can deviate from the rule book. As field instructors, we can’t rush into demanding improvisation from the script until we have emphasized the need to learn the script.

We need to teach the script. And we need to recognize that it can be hard to teach someone a script that we haven’t been using for years. It’s easier to just say, “Do it the way I do it.” But that is a recipe for disaster.

If we are the new trainee we can also get ourselves in trouble by wanting to eschew the formality of protocols when we haven’t yet developed the skills to do so. This isn’t a field known for attracting people who are willing to take the long slow approach. That just isn’t in our DNA. But skill development in something as dynamic as EMS is a long slow process. It flies in the face of our impatience.

When we put our protocols in the context of the Dreyfus skill acquisition model our view changes dramatically. We change our perspective and recognize that protocols are not a one-size-fits-all endeavor. We change the way we see this essential element of EMS care. Hopefully this model will eventually change the way we write protocols, the way we perform quality assurance, the way we educate our EMS novices and the way we use the protocol book during patient care.

All of these changes can start with you.

What do you think? Are these the two most significant challenges to our protocol use? What are the others? Does the Dreyfus model change the way you see your protocols? Leave us a comment and join the discussion.

Read more stuff like this:

The Protocol / Skill Connection

What is an EMS Nonconformist?

Why Do Bad Ideas Stick Around?

Written Protocol vs. Common Sense

Quality Assurance in EMS