The Illussion of Control

Part two of a two part series on scene presence. Part one is here.

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.

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Mastering The Head-To-Toe Assessment

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.

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Treatment of Head Injury

Part three of a three part series

In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.

There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability. 

These are some guidelines when sizing up and prioritizing your care.

Airway Management:

Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.

In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.

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Understanding Combative Head Injuries

Big biker dude strained against the double layers on tape across his forehead and it occurred to me that the act of c-spine seemed pointless if the patient insisted on fighting violently against the tape and straps. Three firefighters were still holding big biker dude (BBD) down and the firefighter closest to his head was yelling, “calm down. … CALM DOWN!” This wasn’t working, but I understood. Sometimes the urge is irrisistible. For his part, big biker yelled back in disorganized consonants and vowels, “uaaaaghhh”.

BBD had laid his Harley down just before an intersection at the corner of our district. Medic units from threedifferent providers would be responding to the intersection to establish who’s patient he really was. This was often a recipe for conflict, but not tonight. The second medic on scene was happy to assist me with setting up IV’s and the third drove by without stopping. From his position in the road, BBD clearly wasn’t in my response area, none-the-less, big biker dude was all mine.

Maybe it was all the leather, or perhaps it was the Harley, or the time of night, but I assume from their demeanor that most folks on scene thought that big biker dude was really drunk or really mean or both. In reality he was neither. Big biker dude had a closed head injury and he was in his combative phase. Combative closed head injuries can be easily mistaken for aggressive patients by emergency responders and, if we’re not careful, the confusion can lead to incidents like this one and profoundly inappropriate care.

So what makes closed head injury patients fight us?

I found surprisingly little information addressing this specific question. While there is plenty of information to be found regarding the debate over how to treat these challenging patients, exactly why they fight is left unexamined. The reasons for combativeness are primarily theoretical. They are likely a combination of the following:

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5 Big Trauma Scene Mistakes You Can Avoid

We all have our good calls and our bad calls. Don’t we? Sometimes things just flow. Sometimes the patient, the bystanders, the crew members, everyone just clicks. And it’s beautiful. It’s like that perfect drive off the tee box that keeps you coming back for another round. The three point jumper that makes you wonder if you should have tried to play college ball.

Unfortunately (perhaps) it is the rare scene that runs flawlessly. More often than not we look back on our calls and think about the things we could have, and should have done better. Of course, that’s how it should be. Without those moments we don’t grow or become better. Some EMT’s carry the philosophy that we should emerge from our field instruction with flawless medicine. Nothing could be further from the truth.

Here is my list of six common trauma scene mistakes I have encountered frequently in my career. I am guilty of doing all of these, some with painful frequency. In those moments of personal scene review, I rank these as my top six, “I wish we had done that differently.” items.

#1 Failing to manage the scene.

We learn a lot about patient care in school. Unfortunately our education regarding management of the scene may be limited to being taught to blindly recite the words, “Scene safe, BSI” as we enter our skills stations. Scene management can be hard. Especially management of big scenes with multiple priorities like calling for more resources, assessing hazards, protecting bystanders, interacting with family and friends of the injured and triaging multiple patients.

On these scenes, patient care suddenly becomes a warm comforting blanket. Caring for one patient seems so much more manageable. Patient care priorities like holding c-spine and doing an assessment call to us like a sirens song. Don’t do it! It seems obvious but, when it’s your job to manage the scene, manage the scene.

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