Any kid who has ever drank a Slurpee too fast on a warm day, and found themselves shivering and chilled, knows that cold fluids can be remarkably effective at cooling the human body. I had this leason reinforced while I was working as a consultant for a bio-tech company. 
The company was looking for methods to induce and maintain therapeutic hypothermia.
I can disclose much about the different methods and results that the engineering team experimented with, but I will tell you this, if you want to drop someones core temperature fast, nothing is quite as effective as a quick, two litter bolus of cold saline. This is why most therapeutic hypothermia protocols begin by inducing hypothermia, not with some fancy cooling blanket or external cooling device, but an infusion of 37 degree saline.
With that thought in mind, how important should it be to keep the saline we infuse into our patients whom we want to keep warm at something close to body temperature? I hadn’t really given the question much thought until I got an email from Scott.
Scott’s one of those SWAT medic types. He works with his local SWAT team to provide on site medical interventions if the need arises. Scott had an interesting experience with an accidental infusion of ice cold saline. I’ll let Scott take it from here:
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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.
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If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and 
the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.
Such is the nature of growing things.
It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.
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Part 1: The Pulse
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.
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I helped teach CPR to our latest EMT class this past week. This class is always a good reminder of how fast emergency medicine changes.
Here in their first week, the new students are beginning to hear our warnings.
“You are going to hear about many different ways to perform this skill. Some are older methods than the ones we are teaching you today. Some are newer. Some things you are learning will quickly go away. New methods, new machines and new research are all in progress. That doesn’t mean what you are learning right now is wrong. It is an imperfect method. Prepare for change.”
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Sure, this site isall about being a better EMT, but perhaps you’ve asked yourself, “Why?” OK, granted, it was probably one of your more cynical moments. Perhaps you had a bad day, a couple of frustrating calls or a less than optimal interaction with a patient, your partner, another agency, your boss … or
perhaps all of the above.
Then you went out and threw down your stethoscope. Or maybe you didn’t throw it down because you remembered it was a Littmann and a gift from your aunt, but you raised it over your head and thought about it. And while that stethoscope dangled over your head in your clenched fist you thought, “Why? Why do I work so hard to try to be better at a job that pays so little and offers so little in return?”
“Why?”
We’ve all had these moments. Moments when we contemplated, “Why don’t I just phone it in? The bad EMT’s make the same amount of money as the good ones. I clearly already meet the minimum standard. Nobody’s really pushing me to be any better. Nobody seems to recognize my growth or effort. So why do it?”
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C-spine immobilization is not a benign procedure.
It’s not something that’s always worth doing “just in case.” It’s not risk free, comfortable or even practical. And, now, recent research from the Washington University School of Medicine suggests that it may not even do such a good job of keeping the patient’s head still.
Does anyone else agree that we’ve seen enough bad news about c-spine now that we can stop the massive overuse that plagues our industry? Can we start evaluating people and deciding who does and doesn’t meet criteria for spinal immobilization. Please?
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I get a bunch of E-mails from people just starting their EMT education who want advice on how to excel in their programs. “How should I prepare? What books do you recommend?” The questions vary but their is always the familiar flavor of enthusiasm and the same basic question, “How do I do this well?”
Success in this field is fairly predictable. Use the right recipe and you’ll get there. I think the hierarchy of EMS success looks like this:
1.) Attitude
2.) Motivation
3.) Tolerance for repetition
4.) Goal orientation
5.) Strategy and tactics
6.) Performance
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“But … It Was In My Hand-off Report“
Every EMS responder who delivers patients to the emergency room has experienced the frustration of feeling like the ED staff didn’t really get the whole picture. You came in, you told the story and you said your goodbyes, but somewhere along the way it felt like there was a disconnect.
Now, some excellent research out of Harvard tells us exactly how much of the EMS hand-off report is really making it into the patients chart and being used in the clinical decision making and care of the patient. I’m sure the study findings are going to have a bit of a “duh” effect on responders who give routine hand-off reports to ER staff, but it is nice to feel that your impressions have been validated by some objective measure.
Researchers decided on 16 prehospital data points that were considered to be significant in effecting patient outcomes in level one trauma activations. Then they had a panel of trauma physicians watch videos of the EMT-to-trauma-team hand-off reports and checked off when the data points were actually communicated in the verbal hand-off report. Next they checked the patients medical record to see how many of these data points had been recorded in the patients chart.
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If I may start with a sweeping generalization, we EMS folk maintain an odd and somewhat dysfunctional relationship with our gear. We love our gear, but we hate it. We chastise others for carrying to much stuff. We chastise ourselves for not carrying enough. Or just not carrying the thing that we could really use right now. (Read vomit bag, seat beltcutter, flashlight.)
There’s a commonly held belief that the longer you’re in EMS the less stuff on you tend to carry around with you. this observation is sometimes extended to paid vs. volunteer personnel as well. I’m not so sure that’s true. There are, however, clearly different styles.
Lately I got to thinking about what kind of stuff the typical EMT responder carries around with him / her. What is considered kosher and what’s excessive? Are there things we can all agree should be in your pocket or on your belt. Are there any equipment gems that I might be overlooking?
To that end I asked a whole bunch of EMS responders from around the Internet and around my system to tell me what they were carrying in their pockets. After editing out some of the more obvious or personal findings (Wallet, keys, Britney Spears fan club cards) here are my not-so-scientific results. Ask your doctor first, results may vary. Here’s what the folks who know are carrying with them.
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