With every trauma call we run, there are two things that are almost absolute certainties. And I don’t mean that in the tongue-in-cheek sense, like, “We are certain that the elderly fall victim will live on the third floor and the elevator will be broken or nonexistent.” or, ”We are certain that the nursing home C.N.A. will call for that extended inter-facility transfer 12 minutes before the end of our shift.” type of certainty. I mean…even more certain than that.
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When people call us for trauma, these two things are certain.
1.) Two objects collided with each other.
2.) Someone called 911.
When we put these two certainties together, we can make some fair assumptions about trauma calls. Objects colliding with each other aren’t such a big deal. It happens all the time. If my fingers weren’t colliding with the keys on my computer keyboard, you wouldn’t be reading this right now. But nobody’s running off to call 911.
It’s the second certainty that gives us pause. You see, people don’t start activating 911 until things collide in uncontrolled ways. Trauma calls happen when things collide together in unexpected ways and with unexpected velocity. It’s as simple as that. Now that I’ve said that, it sounds so profound that I want to write it down again and put my name under it. Here:
“Trauma calls happen when things collide together in unexpected ways and with unexpected velocity.”
- Steve Whitehead
Doesn’t it sound more profound in quotes? I agree. …Lets move on.
As obvious as it sounds, it bears repeating for one simple reason. If all of our trauma calls originate with two or more objects colliding with each other, doesn’t it make sense to spend a little time learning the nature of how objects in our universe behave when they collide with each other? Regardless of what two objects collide, whether it be Grandma Smiths hip and her linoleum floor or a minivan and an SUV, there are some elements that are always true about the way things collide. When we understand them, we can better predict the potential for damage.
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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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“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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I first heard the BCAPBTLS acronym sometime around 1998 while helping a group of EMT’s practice their skills. I hadn’t been involved in EMT education for several years and I had missed the whole inception of the DCAPBTLS acronym. Dutifully, each aspiring EMT moved from the head to the neck, shoulders, chest and abdomen. Each student verbalized their assessments as they went along and sounded off the acronym in turn.
“I’m exposing the chest and looking for DCAPBTLS.” “I’m checking the abdomen for DCAPBTLS.” On 
and on it went until I finally interjected, “What is this word you all keep using?”
“What word?”
“That word. The Dee Cap something.”
“Oh yeah.” They chimed in and began explaining the purpose of the DCAPBTLS acronym. If I remember correctly, there may also have been a “TIC” component added on to the end as well. If there was, the TIC part has been lost to education history. The students explained that DCAPBTLS was an acronym that was designed to help them remember the various abnormalities that they were looking for during the assessment. Then the funny part happened.
Collectively the students tried to recall all the elements of the acronym. “Deformity, contusions … uh … abrasions.” The room fell silent. “Uh … the T is tenderness.”
“Don’t forget bruising.” Another student chimed in. “Oh, yeah. Bruising.”
By the time the students collectively produced all eight elements of the acronym, several things were clear. The eight elements of DCAPBTLS was not one of them. Before we get in to that, let’s set the record strait. DCAPBTLS stands for:
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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 three
different 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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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 five 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 five, “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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