By Ben Neal
The tones drop for a 60 year-old female complaining of shortness of breath.
You are met at the door by a frail looking male that simply states, “She’s pretty bad off. Better hurry.”
After carrying your equipment down a narrow hallway, nearly missing the low hanging pictures of a young version of the male in a Navy uniform and countless knickknacks from grandchildren upon grandchildren, you arrive at the patient’s bedside.
She is sitting on the edge of the bed, gasping. Between breaths, she can utter only a word or two. You gather that she has been out of furosemide for “a few days” and has experience decreased urinary output.
You are able to auscultate faint breath sounds, rales. Her pulse oximetry is 86%, her blood pressure is 210/132, and her heart rate is 92.
She reports gradually worsening over the past few days and mild swelling in her lower extremities.
Sidestream EtCO2 is 36 mmHg with a normal waveform and no significant B-C sloping of the waveform.
What’s next for this woman?
Letting go of the ‘load and go’ mentality
Over the past decade, emergency medical services and the tools we use have evolved in ways many never thought were possible. Long gone are the days of funeral homes plucking patients off the interstate and driving fast to an emergency room. The patient, depending on the ambulance crew or hospital staff, might have received two liters of dextrose 5% and half a liter of normal saline.
Although those years have passed, some systems still operate with a “load and go” mentality while not giving themselves enough credit to be intelligent, and are capable enough to handle many emergencies. Beyond that, sadly, many systems have yet to flourish medically and truly engage their personnel to make clinicians, rather than technicians.
Treatment plan for pulmonary edema
Your patient is still gasping for breath. How will you treat her pulmonary edema?
Do you swoop her up like heroes on a network television special, whisk her into the ambulance and drive with your hair on fire to the closest emergency department or do you slow things down and fix the problem?
Of course the answer may be service and protocol dependent, though a good clinician knows what the patient needs. Think past the old dogmas of high-flow oxygen and a diesel bolus.
Does your system have CPAP and nitroglycerin that can be deployed in the home, and the capability to perform a 12-lead ECG?
When do you apply CPAP, administer nitroglycerin, and acquire a 12-lead?
While the urgency to move the patient into a more controlled environment like the back of the ambulance is understandable, how many seconds or minutes will that delay important treatment?
Slow down to provide better care
Aggressive management of respiratory distress is one category of calls that can be managed and treated without the “L” and “G” words. Quality chest compressions is another treatment best performed on scene.
We must slow down. Moving a patient that is in cardiac arrest is detrimental to their survival and the minutes, in the absence of a mechanical CPR device, spent carrying them up or down the stairs and into the ambulance can be the difference between walking out of the hospital or a funeral. Research has shown us that the more time we spend on the scene, doing what the patient needs, the higher the likelihood of resuscitation and survival. There is no magic pill at the hospital that will snatch the patient from sure death; we are that pill.
Barring some catastrophic surgical emergency that requires immediate intervention, we, you and I, are the best chance the patient has. We have to come to terms with this collectively as a profession.
We all know that not every patient encounter is an emergency that requires split-second life or death decisions. Most providers run into those situations rather rarely, unless you are in a high-run volume system that is overflowing with high-acuity patients (if you work in this system, give me a call – I’ll take an application).
For the rest of us, the majority of what we see is relatively benign and simply requires a safe, comfortable ride. After making the same non-emergent runs over and over again, some providers become complacent and even apathetic. They develop the “get on the stretcher and where are we going?” mentality. But is this any different from “load and go”?
Put yourself in this scenario – you are a sleep-deprived EMS provider in a high-volume EMS system in an urban setting. Just after clearing the hospital from your last ‘emergency’, a 22-year-old with a toothache, you are dispatched to a “person down” on the corner near a familiar liquor store. As you approach the scene, you recognize the subject’s jacket as one that is worn by a frequent inebriate you know well. He is face down on the concrete with bottles of beer strewn around him.
When you approach him, he makes the ‘drunken’ moan you are all too familiar with and you notice an abrasion on his left cheek, just below his eye. That’s nothing new - that’s what he does; gets drunk and falls down. You lift him onto the stretcher, put him in the unit and make haste to the hospital where everyone knows his name. Seems like an every night occurrence, right?
Would you be surprised to find out the next day that he is in a coma due to a massive subdural hemorrhage? Regardless of the type of run, failing to slow down and truly assess and treat each patient is categorically no different than “load and go”.
The moral of the story is simple–slow down. We must stop selling ourselves short and rushing to a hospital that may or may not handle the patients’ condition that we could have addressed immediately. We have to assess our patients thoroughly, regardless of what our preconceived estimations may be regarding their condition. We must do what is best for the patient, which is providing a high-level of medical care with the tools and knowledge we have been given. Time is life. Don’t load and go – slow down and fix.
About the author
Ben Neal is a quality improvement officer and cardiac arrest program manager for Louisville Metro EMS. He has have served as a paramedic since joining the system in 2004. Neal’s passions include cardiac arrest management, data collection and analysis, education, emergency management and interdepartmental partnerships.