Friday, March 25, 2011

Ready or Not?

So here we are, a small fire department in a tiny town, out here in the middle of nowhere, far from any hospital.  We're non-transporting, so we have automatic ALS back-up from the ambulance service in a nearby larger town.  This is a good thing, right?

Who are we kidding?  
Automatically toned when we are, so they are on their way without us having to call them in, which saves time.  Always ALS because that's how they run.  Highly skilled medics, most of whom we know and work well with.  Sometimes two medics, depending on who is on shift.  Other times, the medic's partner will be certified at a lower level, but they'll have a lot of experience.
It's a GREAT thing!

Isn't it?

The answer is a little complex.

Yes, it's great. From the patient's perspective, knowing that the ambulance is on the way can only be a good thing.

But I think sometimes, if we aren't careful, it can lead to some things that are NOT good.  Habits that are, at best, non-productive. At worst, potentially disastrous.

Let me give some examples, and a little explanation, of what I mean.

We live in a strange part of the EMS world, being non-transporting.  

A typical scene goes something like this:
We are toned.
We go to the station, then to the scene.
We make patient contact and begin an assessment.
IF we have more than one person on scene, someone can be getting a med list, getting demographic info, and getting some history if the patient can't provide it. 
If not, we generally have time to check ABCs, get oxygen on them if necessary, get a general idea of what is going on, and the ambulance crew shows up.
That's if we get there first.
Most of the time, we may have about five minutes on scene before the ambulance arrives.  Sometimes less.  Occasionally, more.
They may get toned the same time we do, but they are already on the road most of the time. They don't have to wake up, get dressed, go to the station, etc.  And sometimes, for certain things, they hear about it before we are toned.

We don't usually have time, before the medics are there, to get to a second set of vitals- if we even have time to get to a first. There are calls where they do all the patient care. We don't have a stretcher, and don't generally lift patients much. We don't do radio reports much at all, except for a brief update to the incoming ambulance on some calls.

We still do paper PCRs, and are likely to continue to do so until the state absolutely mandates differently.  We don't have the technology to do ePCRs.  No accessible computers.  What this means is we have to hand write the PCR, on scene, really rapidly, in time to hand off the back copy to the ambulance crew before they leave.  This can be a challenge.  The sicker the patient, the less we can get on that piece of paper before they are transported because we are BUSY. We don't get the chance to sit down after a call and construct a well-ordered PCR narrative.  The very best narratives we do are on the refusals!  No copy needs to go anywhere, so we have all the time in the world for those.

What these things mean is that there are a bunch of things that we get little to no experience with on scene. And if we aren't careful, we can become accustomed to that, and not practice those things at all.  It is very easy to become complacent.  To adjust to the situation. To count on that back-up getting there quickly.  To feel like they will bail us out if we get into trouble, if there is something we don't have experience with. To get used to the ambulance crew taking over, controlling the call.

It is imperative that we DON'T allow that to happen.

Here are some examples:

We had a call for difficulty breathing, on the near end of town.  We arrived moments after the ambulance.  Okay, so they will do all the patient care, and we will assist them with getting information, moving the patient, carrying their gear, opening the back of the ambulance, etc.  No problem.
So what did we carry in with us?  Our usual equipment? No.  It would just be in the way, since we wouldn't be doing the patient care.
The patient crashed shortly after we got inside.
We learned NEVER to assume that just because the ambulance is there, they will do all the care.  Even though most of the time, they will.  Doesn't matter. We need to be prepared for whatever MIGHT happen, not for what USUALLY happens.

We had a call for a woman who had fallen from standing.  Possible public assist only.
Okay, no problem.  We happen to like helping little old ladies up.  It's one of the calls where we actually can be sure we helped someone.  And they are generally relatively low stress, as well.
So we get on scene, and sure enough, a lovely older woman had fallen. From the doorway, she didn't appear to be injured, and told us so.  Just needed a hand up.
Until we started the assessment.  Tachychardic, irregular heart rhythm, tachypneic, low BP, and she said that she had "felt a little dizzy, maybe" before she thought she "slipped."  She wasn't sure, really. Couldn't remember. She also had been feeling a little sick, but didn't want to worry anyone.
The ambulance, assuming a public assist, was coming from further than usual, and not hurrying.
Our "bail out" was a little further away than we would have liked, for sure.
Then we found out that they had gone towards the wrong location, there being highways here with similar numbers, towns with similar names, and once in a while, some confusion from dispatch. That never happens, right?
Now they were really delayed.
So much for counting on ALS to swoop in and save the day.
Sometimes, they don't swoop so much.
We don't ALWAYS have a short period of time on scene before they get there. We need to be prepared to handle any situation for a more extended period of time.

We had a call for an incident with several patients.  Two went in the ambulance. One went by personal vehicle.  After the ambulance left, we listened to their radio reports to the ER.  They didn't mention the third patient.  We ended up radioing the ER, to let them know they had three patients coming in, not two.  A tad unusual situation, but there it was.  It happens.

My point is this:
I love that we have such great back-up.  It helps keep us calm on scene to know that we aren't alone out there. It provides high quality continuation of care for our patients.  It means we have paramedics on scene on every call, even though we don't have any medics out here in our department. It means we have providers on scene who have much more experience than any of us have. People we can count on, and learn from.

But complacency is a very real danger.
The moment we lose sight of that, that we begin to assume they will take care of things, that we don't keep our skills up to the level we'd want them to be if we were the ONLY providers, is the very moment something will happen to prove to us that we can never be ready enough.


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  2. Great post.
    Complacency is a subtle, ever-threatening and deadly enemy.


  3. Nice post and very well laid out. We have a similar problem, but we are a transporting FD. Many of our EMT's rely on that ALS backup to both confirm their assessment and provide support. On the rare occasion when ALS has no units available, these same folks find themselves in deep poop. Too many still rely on following protocols without making any decisions on their own. They expect the protocol to make the decision for them, and we all know that this isn't how it works.
    I look forward to reading more from you. I'd love to know what county you are in, just in case it's a place I visit.

  4. @UU Exactly. They confirm our assessment, which has been very helpful, really, through our early learning curve phase. But continuing to COUNT on that would be a huge mistake.
    My goal is to know enough to be able to pick up on things the medics might miss, so that we are helpful to them, rather than always the other way around.