May 21, 2012

Case Review: 23-year-old with chest pain

Here’s an interesting case to wrap your head around:

EMS is dispatched to a residence code-3 for chest pain. On arrival, the crew finds a distraught young man waving them inside the residence. He stated that he and his 23-year-old girlfriend were arguing when she suddenly started to complain of severe chest pain. The girlfriend is in the fetal position on the ground crying and grabbing her chest. It is difficult to obtain any information out of her as she is hysterical and won’t answer any questions. The paramedic on the ambulance kneels down to try and calm the patient and get her to talk, while the EMT partner questions the boyfriend.

The patient starts to calm down and tells the paramedic that her chest hurts and is interrupted by the EMT who yells from across the room that the patient has an internal defibrillator. The paramedic turns to his partner who explains that the boyfriend just said that the patient was grabbing her chest saying that her defibrillator shocked her. The patient tells the paramedic that her defibrillator shocked her “a bunch of times”. He instructs his partner to place her on oxygen while he places her on the ECG monitor. Before he can get all of the leads on her, she screams in pain and says “it shocked me again”.

The ECG monitor is applied and shows sinus tachycardia a rate of 112. The crew places her on the gurney and obtains a quick set of vitals. NIBP = 142/72, Sp02 = 99%, HR = 112. Just as the crew prepares to leave the house, her internal defibrillator shocks her again while the paramedic was watching the monitor. The paramedic now suspects that the defibrillator is malfunctioning as she still had a narrow complex rhythm when it shocked her. He asks her if she has a magnetic device to disable the defibrillator. She states that she lost it a long time ago.

The crew loads the patient into the ambulance and begins towards the nearest cardiac facility code-3. While en route, the defibrillator shocks the patient again, only now the patient’s rhythm converts to ventricular tachycardia.

Have you ever run into a scenario like this? What would you do for this patient?

Stay tuned for a follow up post.


A Guide to Radio Reports

Radio reports or “call ins” can be a bit of an art. Finding that happy-medium between too much and too little information can be difficult. People starting out in EMS often have trouble adapting to formal lines of communication like radio systems as getting the most information out with the least amount of words is an acquired skill. If you have never worked in a setting that utilizes formal radio traffic then naturally, you want to speak just like you would in any other conversation. But in the name of formality and time savings, you have to learn to kick proper English to the curb. In this article, I will go over some tricks that I have learned over my years in EMS and hopefully break the barrier that many of us have when it comes to giving reports over the air.

Time

Different systems may require different amounts of information, but the expectation that your report will be short and thorough typically remains the same. A good rule of thumb for a desired length is less than 30 seconds. If done correctly, that should be ample time to deliver a good report.

Minimizing the amount of time your report takes helps to ensure that you aren’t tying up the base-station radio for other crews that may need orders or have a critical patient to call in. It also frees up time for patient care and you don’t lose the attention of the staff on the radio. As silly as it may seem, try practicing reports with a timer. You will find that it doesn’t take long to improve your technique and shorten your reports.

Content

You are the eyes and ears of the ER staff until you arrive at the hospital, so it is your job to paint the best picture you can of the patient’s current condition. Now this doesn’t mean that you have to tell a long winded story of what led up to this event. All that does is lose the attention of the ER staff. Remember, all of that information can be relayed once you arrive at the hospital. The staff is pretty much looking to either give orders or assign a priority to your patient, so you really only need to give them the information necessary to achieve those tasks.

Here is a list of essential information that should be included in your report:

  • Age
  • Sex
  • GCS
  • Chief Complaint
  • Pertinent Positives or Negatives
    -Example: Shortness of breath associated with chest pain.
  • OPQRST (if applicable)
    -Example: This can be used to clearly paint a picture of chest pain being cardiac vs non-cardiac, or to paint the picture of a patient with abdominal pain having probable appendicitis.
  • Vital signs (including skin color and lung sounds)
  • History, Allergies or Medications (if pertinent to the chief complaint)
  • Any treatment or interventions along with response.
  • Any other information that may help paint a clear picture of the patient’s condition.

There are always exceptions to these guidelines. You may be required to provide certain information in order to activate a STEMI, Trauma Code, or Stroke protocol. I typically prefer to add this information to the end of my report under “other information”. Do what works best for you.

Gathering Information

In order to provide an adequate amount of information, you must first gather that information. In order to do this, I find it best to maintain an organized system of writing down information that I will use during my call-ins. Some people write on their gloves, some people carry a notepad and some people are talented enough to go completely off memory.

When you are going through your questioning, assessment, etc, try writing down your findings in the order that you give your radio report. For example, if you are writing on a notepad, write the age, sex, GCS on the top line, the chief complaint on the second line and so-forth. This way you can essentially read right off your notepad from top to bottom when you do your call-in. This helps to avoid long pauses, repeating yourself or leaving out information.

To help facilitate gathering information in an organized fashion, I created a simple document that you can print on any 3×5 card. I typically clip a bunch of these together and carry them in my shirt pocket. When I call in my reports, I read from left to right, top to bottom. This way my reports are consistent and I minimize the chance of leaving anything out.

Below is a blank view of my 3×5 report card:

When I use this format, I fill in all of the pertinent information prior to making my call-in. Any information that I don’t plan to pass along over the radio is skipped over. For example; A patient complaining of chest pain would most likely require every field to be completed while a complaint of general weakness would not require the OPQRST.

The medical history, allergies and current medications are generally skipped over during the call-in, but written down to reference for documentation and the formal report given at the bedside.

The “TX/Other” section is utilized for treatment, response to treatment, mechanism of injury (for trauma calls) and anything else that might be needed to paint a clear picture.

This card is available for free download on this site.

Calling in the Report:

This is the part that requires some time and repetition to get right. This is where you need to learn to minimize the amount of words that you use in an effort to keep your report brief and formal. Remember, it should only take 30 seconds or less to deliver a brief but thorough report.

When reporting a chief complaint, stick to only the necessary information. Rambling on about things like the patient’s last doctors visit will eat up that 30 seconds and lose the attention of the staff on the other end of the radio. Here is an common example of “rambling” on the chief complaint:

County Hospital, Medic 325, Paramedic Eddy en route to your facility with a 57 year-old male with a GCS of 15. The patient states that he started complaining of chest pain this afternoon. He also states that he is short of breath and nauseous. He was seen at Dr. Smith’s office today and is now being transported at the request of the physician to rule out a possible MI.

In the above example, I told the hospital that the patient is being transported from a physician’s office with a complaint of chest pain with associated shortness of breath and nausea. While this does help to paint the picture of a cardiac event, it can be done in much less time with fewer words. The following example delivers the same message with less than half of the words:

County Hospital, Medic 325, Paramedic Eddy en route to your facility from Dr. Smith’s office with a 57 year-old male complaining of chest pain, shortness of breath and nausea. Physician on scene requesting transport to rule out MI.

On a chest pain call like this, it would be wise to include the OPQRST, as that information can be useful to the base facility to differentiate between cardiac and non-cardiac chest pain. Here is an example of how you can deliver that information in a brief and effective manner:

County Hospital, Medic 325, Paramedic Eddy en route to your facility from Dr. Smith’s office with a 57 year-old male complaining of chest pain, shortness of breath and nausea. Physician on scene requesting transport to rule out MI. Patient’s pain is with a gradual onset, non-provoked, dull in nature, non-radiating, 7/10, times 2 hours.

In the above example, we have told the base hospital everything they need to know about the chief complaint and we can now move on to the vital signs. Any other information in regards to the complaint itself can be relayed once we arrive at the hospital. At this point we are about half way done with our report and have probably only taken up about 10-13 seconds. All that’s left to cover is the vital signs, treatment and ETA. Here is an example of the complete report:

County Hospital, Medic 325, Paramedic Eddy en route to your facility from Dr. Smith’s office with a 57 year-old male complaining of chest pain, shortness of breath and nausea. Physician on scene requesting transport to rule out MI. Patient’s pain is with a gradual onset, non-provoked, dull in nature, non-radiating, 7/10, times 2 hours. Blood Pressure is 146/82 with a strong radial pulse of 90, non-labored respirations of 16, sating 98% on 2 liters, and sinus on the monitor with no ectopy. Skins signs pink, warm and dry, lung sounds clear. History, allergies and meds on arrival. Pt has received 1 aspirin and 2 nitros with no relief. IV is established and our ETA is 10 minutes. Any questions or orders?

This example is actually on the longer end of the spectrum as far as radio reports go. For calls that don’t involve pain, you can skip past the OPQRST and probably come in around 20 seconds for the entire report. Chest pain, vehicle collisions, and others that require special protocols (STEMI, Stroke) are going to be the longer reports, while most other medical complaints will be rather short.

When it comes to radio reports just remember; short, sweet and to the point.

Examples:

Here are a few examples of some radio reports for different types of calls:

Trauma

County Hospital, Medic 325, Paramedic Eddy en route with a 25 year-old male involved in a 2 vehicle collision. Pt was a restrained driver of a small-sized sedan traveling approximately 30mph when striking another vehicle from behind. No LOC, passenger space intrusion, or airbag deployment noted. Pt complains of lower back pain with no obvious deformities. Blood pressure is 126/74 with a strong radial pulse of 80 and non-labored respirations of 18. Skin signs pink, warm and dry. Lung sounds clear. History, allergies, meds on arrival. Pt is in c-spine and we are utilizing BLS interventions only. ETA is 5 minutes. Any questions or orders?

-Note: Trauma is the only time that I skip straight to MOI prior to the chief complaint. I know of several paramedics that prefer to leave it at the end. Do what works best for you.

Respiratory

County hospital, Medic 325, Paramedic Eddy en route with a 36 year-old female GCS of 15 complaining of difficulty breathing x 2 hours. Pt presents with labored respirations, retractions and speaks in 1-2 word sentences. Blood pressure is 146/82 with a strong radial pulse of 120, labored respirations of 26, sating 93% on 15 liters and is sinus tach on the monitor. Skin signs pink, warm and dry. Lung sounds reveal wheezing in all fields. History of Asthma, further history, allergies and meds on arrival. Pt has significant breathing improvement post 2 Albuterol treatments and .3mg sub-q Epi. IV is established and our ETA is 8 minutes. Any questions or orders?

Cardiac Arrest

County hospital, Medic 325, Paramedic Eddy en route with a 58 year old male GCS of 3. Pt found pulseless and apenic, downtime of approximately 5 minutes prior to EMS arrival. Pt has sustained asystole post 3 rounds of Epi and Atropine. Pt is intubated and an IV is established. Continuing ACLS protocol en route. ETA is 10 minutes. Any questions or orders?

-Note: The hospital will be busy getting a bed ready for your arrival. The faster you get the report done, the faster you can get back to working and the hospital can start working.

Conclusion

These guidelines have worked well for me during my career as a paramedic. These guidelines are meant to be flexible and should work on pretty much any type of call. If you have a format that works well for you, I would love to hear from you and try it out.

Feel free to e-mail me with any questions, comments or suggestions.


Next generation EMS

So there I was, sitting in the back of the ambulance cleaning up after running a combative patient that was under the influence of meth-amphetamines. My partner and I were wading through the wreckage that this outstanding citizen caused. Kind of like people do when their homes get demolished by tornadoes. I looked at my partner – who happens to be brand new – and told him that he did a good job on the call. He looked up at me with a confused stare and replied, “are you being scarcastic?” I explained to him that he stayed calm and did a great job with getting the restraints placed on the patient in a timely manner.  ”Um….thanks, nobody ever gives me feedback so I don’t really know if I’m doing a good job or not”, he replied.

After speaking with him for a while, I realized that he is afraid to ask any senior medics or EMT’s for advice. This really troubles me for many reasons. For starters, the majority of my family lives in this town and if a new EMT wants to better himself and learn from the more experienced medics, then I want that opportunity to be available to him. If he runs my family, I want him to be competent and comfortable with his skills.

Back in my night-shift days – before giving in to the call to promote to middle management – we used to all sit around the crews quarters and talk about our calls while finishing up our PCRs. Everyone talked about scenarios, asked questions and offered advice to the new guys. Nobody was afraid of being perceived as an idiot or a bad medic. We were all there to learn from each other and grow as professionals.  Nobody was out to be the “best medic”.

We owe to our newcomers to flood their brains with tips and information, whether they ask for it or not. Every time I see a teaching opportunity, I jump on it. Likewise, I take advantage of every learning opportunity that comes my way. Just remember, in time our “FNG’s” will become the senior providers. At some point in time, my health will get the best of me and I will require EMS. The same “new guy” that nobody wanted to bother with may end up coming to my aid. I don’t know about you, but I want him to have the benefit from learning from all our years of experience.


Do as I say, not as I do

I was teaching a CPR class a couple days ago to a group of EMT students. While I was explaining the 30 compressions to 2 breaths ratio, a student raised her hand and asked me if I actually count or even follow the AHA guidelines when working in the field. Believe it or not, this is the first time any student ever asked me that. I was honest and told the group that I do not always follow compression ratios. As a matter of fact, I probably never do. As you can imagine, the class was full of comments and questions after that answer.

Of course, I explained the science behind the AHA guidelines and why they recommend fast and hard compressions. The hard part was explaining why me and most of my coworkers don’t follow them. Being a paramedic, It’s easy to explain that my focus is around ALS interventions. Being that I have plenty of BLS providers on scene with me, I don’t typically have to worry about doing CPR. However there isn’t really a good excuse as to the large number of EMS providers that just “pump and blow”. It kind of makes me wonder how much of the Heart Associations studies actually included pre-hospital cases. More importantly, it makes me wonder if it really makes a difference.

….which brings me to my next point.

It seems like every time I teach a class, whether it be CPR or an EMT class, I always find myself having the “when you get into the field” talk. There seems to be this big separation of what you learn in the classroom and what you learn on the streets. I get that there are many things that experience teaches you that a textbook just cant. But why can’t our education be more realistic? It almost seems that we do everything BUT prepare our EMT and Paramedic students for real life scenarios.

We don’t tell people in CPR classes that bagging patients for any period of time usually leads to abdominal distention and regurgitation. Sure if you “properly ventilate”, that shouldn’t happen. But throw in the “bouncing ambulance” factor and the “2 people trying to do five things” factor and you got yourself a gurney caked with used hot dogs.

We don’t seem to tell our paramedic students that Mr. Homeless on 4th street only calls 911 complaining of chest pain because he knows you will give him Morphine, a bed and a hot meal. Is it that the people writing the books are so far disconnected from pre-hospital medicine? Or do we just think it’s too “politically incorrect” to tell our students that our patients lie to us?

All I’m trying to say is that we as EMS educators and providers need to put more emphasis on teaching our students the reality of working in this field. I would like to see us try and close this gap between classroom and field learning.

Anyone beg to differ?