Code 1 Transport – Is it worth the risk?

Everything we do comes with risk. Grocery store aspirin can cause GI bleeds, a poorly prepared cannula can cause life threatening sepsis, and the regrettable, but increasingly popular, ‘ondansetron flush’ can give your patient dystonia; it also gives you a chance of winning a staring competition with the 3-year-old in the adjacent bed. 

All of our interventions, whilst potentially beneficial, also come with risk. None more than transporting patients ‘lights and sirens’ to hospital. 

Yes, transporting lights and sirens to hospital is dangerous. We may think that our uniform, reflective delivery van and 4 days of driver training keep us safe, but the reality paints a different picture. You are more than twice as likely to crash going light and sirens compared to driving road speed. Every two weeks a paramedic is seriously injured in a traffic accident in this country. The vehicle fatality rate for paramedics is 11 times higher in Australia compared to all workers. 

Does it really surprise you when you think about some of the code 1 transports you’ve done in the past? It’s 4am and you’re half asleep, you’re distracted by what is going on in the back, you’re doing 30km/hr over the speed limit and running red lights. Up front is probably the most inexperienced driver, and you can almost guarantee the paramedics and the patient are not properly restrained. Take the ambulance out of the equation and this driving behaviour would be considered abhorrent. 

We take on this risk, because we believe that faster leads to better patients outcomes. But how much time are we really saving?

https://www.bbc.com/news/uk-scotland-north-east-orkney-shetland-16623698

Three US studies say about 2 minutes. 

Do you really think that 2 minutes is going to change the outcome?

Lights and sirens transport stems from an era where we could offer very little assessment or intervention to our patients. Times have changed and there are not many truly time critical interventions we cannot offer our patients. 

What evidence base do we call upon when we decide to transport lights and sirens to hospital? What practice guideline exists to identify those patients who actually benefit? To our knowledge, neither exist. 

We have clinical protocols and guidelines to guide our decision making with other interventions. Yet none focus on the risks of code one driving. 

Consider this:

Does cannulation risk killing an innocent family driving home from school? No.

Does an LMA insertion risk seriously injuring our colleagues? No. 

Yet no guideline or protocol exists for what is arguably our most dangerous intervention. 

So how do we get better?

We need to identify the patients who, despite our cares, will truly benefit from getting to a hospital faster. We need to change our culture of ‘just the driver’. If anything, this is the most important role in the team. 

At the end of the day, we all want to go home safe at night; let’s make it happen. 

And please please please, wear your seatbelt. 

To hear more about this, check out Episode 16: Transport to hospital: an intervention that can kill.

References

Lawrence HB et al. Do warning lights and sirens reduce ambulance response times? Prehosp Emerg Care. 2000 Jan;1(4):70-74

Maguire BJ, O’Meara PF, Brightwell RF, O’Neill BJ, Fitzgerald GJ. Occupational injury risk among Australian paramedics: an analysis of national data. Med J Aust. 2014;200(8):477‐480. 

Watanabe BL, Patterson GS, Kempema JM, Magallanes O, Brown LH. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Ann Emerg Med. 2019;74(1):101‐109.

Bledsoe B. EMS Myth #4: Lights and sirens save a significant amount of travel time and lives. EMS World. 2003 Dec. 

Paediatric Red Flags

Using the paediatric assessment triangle

Identification of the critically ill child is a crucial skill every paramedic should have in their tool kit. Moreover, the swift recognition of these patients is paramount to effectively treat and optimise their physiological state. For this reason, we have to become experts in subtly. In essence, our priority is to clinically determine the ‘sick’ vs ‘well’ child.

The paediatric assessment triangle (PAT) is a robust tool for the emergency clinician to quickly assess and formulate an initial impression to guide treatment priorities.

The paediatric assessment triangle:

Initially developed some twenty years ago as a part of education for prehospital providers to assist with quick identification of the ‘sick’ child. This tool employs three components 1. Appearance, 2. Work of breathing, and 3. Circulation. It has stood the test of time and is now used by many emergency physicians. Not only does it identify the ‘sick’ child, but it can direct the clinician to the underlying pathology affecting the patient.

Physiologic StatesAppearanceWOBCirculation to the skin
Respiratory distressNormalAbnormalNormal
Respiratory failureAbnormalAbnormalNormal-abnormal
Compensated ShockNormalNormalAbnormal
Decompensated shockAbnormalNormal-abnormalAbnormal
Brain injury or dysfunctionAbnormalNormalNormal
Cardiorespiratory failureAbnormalAbnormalAbnormal

Appearance

Observing from a distance enables the paramedic to gain insight to the patient’s overall status without potentially upsetting the child. The mnemonic TICLS summarizes the overall appearance.

                        Tone

                        Interactiveness

                        Consolability

                        Look & gaze

                        Speech and cry

Close attention to how the child interacts with family will give clues to their status. Allowing to assess if they are alert versus reactions from tactile stimuli. The vacant gaze or motionless child is more concerning than that of the moving child screaming. Irritability is an early sign of inadequate brain perfusion. Attention to the pitch of a child cry may also be helpful as it may be signifying their level of irritability.

Work of Breathing

Initially this should be assessed visually prior to getting hands on, as frequently children can become upset with a stranger in their space, which just makes the assessment harder. Note their breathing posture. For example, the tripod or the sniffing positions are portentous signs. However, this assessment is not complete without the chest being unclothed.

Signs of respiratory compromise include:

Stridor

Audible wheeze

Retractions

Grunting

Snoring respirations

Nasal flaring

Signs of impending respiratory failure:

Head bobbing

Seesaw breathing

Respiratory rates are inversely related to age due to the metabolic demands and lower tidal volumes of younger children. Kids function near the maximal tidal volume capacity, so small increases in metabolic demands can elevate breathing rates. Hence, why you can add ~5 breaths per minute for every 1°C above baseline temperatures and be considered appropriate.

Non-respiratory illnesses are identifiable in the character of the child’s breathing. Effortless tachypnoea may be a sign of any shock; deep rapid respirations with normal chest sounds may be compensation for metabolic acidosis. Others include irregular respiratory patterns, which can relate to neurological diseases.

Circulation:

Inspection of the perfusion to the skin provides clues to the child’s cardiovascular performance. Compensated shock is characterized by peripheral vasoconstriction, diverting blood from the skin to the brain and vital organs. The skin will appear pale but warm to touch with a delayed capillary refill time (>2seconds – tip: assess this centrally). If not treated, the patient will become mottled with cold extremities. Do not confuse mottling (random pattern of vasoconstriction) with Cutis marmorata (lacy pattern on the skin caused by vascular irritability in cold environments). The difference being kids will appear well with cutis marmorata, and when the patient is placed in a warm environment, the skin findings will disappear.

Cyanosis may be present normally in kids with congenital heart disease. However, if it is a new finding it is usually predictive of respiratory failure or decompensated shock.

To hear more about this, listen to Episode 20: Pearls of paediatric assessment.

References:

Dieckmann R, Brownstein D, Gausche-Hill M, editors: Pediatric education for prehospital professionals, Sudbury, MA, 2013, Jones & Bartlett.

Ron M. Walls MD, Robert S. Hockberger MD and Marianne Gausche-

Rosen’s Emergency Medicine: Concepts and Clinical Practice

Advice for new Paramedics

“Good judgement comes from experience, and experience comes from bad judgement”

Experience is something that graduate paramedics inevitably lack. However, the perspective that comes with experience can be shared and it can influence our culture, and ultimately what type of people our novice colleagues grow into.

Today, I want to share with you advice that has come from many of our listeners and colleagues, aimed at new paramedics and students. So, if you are new to our business, listen well, as this will not only help you develop into expert clinicians, but also into respected professionals and just good people.

Be respectful

  1. “It may not be an emergency to you but it is to your patient and their families”
  2. “Always ask yourself, what would I expect if it was me. Then this is what you should give your patient”
  3. “Listen with open ears and an open mind. Treat as you would want to be treated”
  4. “Always remember the patient’s name
  5. If you struggle, write it down. You will lose trust from the patient and their family if you have to keep asking”
  6. “Be kind and apologise if you make a mistake”
  7. “Just because the body is old, doesn’t mean the mind is. Treat our seniors with respect and they may allow you to have theirs”

Be a measured clinician

  1. “Just because you can, doesn’t mean you should”
  2. “There is no such thing as a shit job. Every patient presents an opportunity to practice and hone your skills and you might get a surprise by what you find”
  3. “Keep a notebook, or a list on your phone, for anything you come across during your shift that you don’t know about. Write it down and look it up later”
  4. “You never know enough. Ask questions. Know your truck thoroughly, and keep studying”
  5. “What makes you great at your job is basic skills and comprehensive assessments”
  6. “Listen to every chest, and do airway skills on as many jobs as you can”
  7. “Complacency kills patients; train, train and train some more”
  8. “Gather as much information as you can to make good decisions”

Communication

  1. “If you don’t know something, speak up”
  2. “People forgive stupid questions. Stupid mistakes because you didn’t ask a stupid question are a different matter”

Self – care.

  1. “Always pack a lunch”
  2. “Mistakes happen, learn from it and move on”
  3. “If you get angry, it’s time for a break”
  4. “Slow down when driving”
  5. “Build a solid foundation of support and watch out for your mates”

So if you are a new paramedic, I hope you heed these words of wisdom. They have come from experience, which has involved plenty of mistakes.

For us seasoned practitioners…let’s lead by example and ensure that we are practising what we preach. It is a privilege and an honour to work with the amazing people that we do. Thank you for being just that.

Traumatic Cardiac Arrest – A paradigm shift: Part 2

You arrive on scene to find a car that has had a frontal impact with a gum tree. The engine bay is wrapped around the tree trunk, horn blaring. The patient is slumped over the steering wheel, with a weak carotid pulse that dissipates immediately. Are you confident with your next step? What are the priorities here? Do we declare them or work on them? Well, luckily, you’ve read Traumatic Cardiac Arrest Part 1, so you know that this is game on.

We know that there are four primary pathologies that we can potentially treat. But how do we do this?

Hypoxia is the end result of a broad range of underlying insults. However, it doesn’t matter whether the cause is airway obstruction, brain impact apnoea, or a lung pathology, the fix all starts the same – basics. The term basic, however, is a misnomer. The ability to use a bag-valve mask effectively is a skill that will serve you well in your career, whether it be a failed airway algorithm or trying to judge your priorities in a traumatic cardiac arrest. Practise this skill ‘til no end. Whilst these patients do benefit from a definitive airway, the initial goal is all about air in and out.

The management of tension pneumothorax and cardiac tamponade conceptually is easy…decompress them. However, pre-hospital medicine is far from simple. Anyone can be taught how to place a needle into a set location. But what happens when it does not work? Mastering your practice is more than learning the fundamental skill. It is about understanding when to do it. It is about picking up on the cues that suggest that it will be ineffective. It is about knowing what the patient needs, and the options that are available to get the patient what they need – even if it is not in your tool kit. So how do we deal with these pathologies? We know our equipment, we know our procedures, we know our fail safes, and most importantly, we know our limitations.

Bleeding is undoubtedly the elephant in the room. It causes the greatest number of traumatic deaths that were potentially reversible. Therefore, we need to be experts at dealing with it. Many ambulance services now have a repertoire of options to treat external haemorrhages. Ranging from basic and modified pad and bandages, to haemostatic dressings and tourniquets. Junctional haemorrhage is an important subgroup of these patients that we are learning a lot from the military. They present a unique challenge due to the pairing of vulnerable major vessels with inconvenient locations. However, let us not forget about internal haemorrhages. Potentially amenable locations include long bones and pelvic regions. However, looking to the future, and in some cases the present, we have more dramatic methods of controlling other forms of internal haemorrhage such as REBOA and thoracotomy.

There is ongoing controversy about the role of cardiac compressions and adrenaline in the traumatic arrest patient. On one hand, it makes no physiological sense to perform compressions, and doing so may interrupt more important interventions. The counter to this is that not all traumatic deaths are equal, and it’s hard to generalise the priority of an intervention, with such vast aetiologies. Arguably, the greatest concern is if this apparent traumatic arrest, actually had a medical origin. Isn’t that one to think about. That patient that wrapped his car around the tree… could he have had crushing chest pain and a VF arrest prior to the car leaving the road?

Traumatic Cardiac Arrest – A paradigm shift: Part 1

Evolution is a natural, and essential, part of medicine. During the 18th century, blowing tobacco smoke into the anus was believed to be an effective treatment for drownings. Whilst this is a time in history where we can look back and question logic – bloodletting was common too – we need not jump onto our high horses about previous practices, but rather stimulate introspection about how we currently practice medicine. Are we ourselves practising medicine in manner that will be considered comical in 100 years’ time?

Historically, traumatic cardiac arrest was mostly thought to be a futile condition. Once a traumatic pathology had progressed to the point of cardiac arrest, it was a common belief that the patient could not survive. However, thanks to the modern era of evidence-based medicine, we have re-shaped our perceptions about these patients – there are survivors. The question remained though, who are they, and how do we save them? 

The most compelling arguments originally came from post-mortem studies where the cause of death was derived. The results were profound. What we saw, was that there were a significant cohort of patients who could have been saved. These were the patients who had died from:

  1. Hypoxia
  2. Hypovolemia
  3. Tension pneumothorax
  4. Cardiac Tamponade

In modern trauma systems, we are seeing survival rates anywhere from 5% up to 27%. These are big numbers, particularly when we take into account that the vast majority of the trauma patients are younger, fitter and healthier individuals compared with their medical cardiac arrest counterparts.

That being said, we do need to recognise that a large cohort of patients will have catastrophic injuries and will inevitably die. The challenge that has faced clinicians and researchers over the years, is how do we predict patients with such injuries.

What we have learnt is that there are very few predictors of futility in traumatic cardiac arrest. Signs previously thought to be synonymous with death, such as asystole and fixed dilated pupils, have since been debunked. Current recommendations for withholding resuscitation are centred around:

  1. No signs of life within the preceding 15 minutes;
  2. Massive trauma incompatible with survival, such as decapitation and loss of brain tissue.

There are some pretty impressive injuries that fall outside of these categories that previously would not have been worked on. It makes you think, doesn’t it?

So what is the paradigm shift? It’s a mentality.

Let’s not throw the baby out with the bathwater. Let’s resuscitate these patients. We’ll throw everything at them and try and capture the ones that can be saved, and accept those that cannot be. Be an advocate for your patient.

To hear more about this, listen to Episode 14: Traumatic Arrest – A Paradigm Shift.

Bias – Does it influence your judgement?

Does this sound familiar?

It is 4am and the pager goes off. You see “75-year-old with a sore leg” or “65-year-old vomiting and diarrhoea” or an 18-year-old female “drunk”.

What would be your immediate reaction?

Be honest….

You probably, (myself included) have descended into the five stages of grief. Denial, anger, bargaining, depression, and hopefully, acceptance. Why? Because, whether we are aware of it or not, we believe that jobs like these aren’t what we should be going to. When university courses, TV shows, news articles and self-proclaimed “health advocates” on twitter focus so much on the high end of our work, why should we?

We believe our role, where we can practice our craft, is in the big work. We start to perceive our identity based on this belief.

When we associate this identity with an expectation and that isn’t met, we become discouraged, demotivated, and a little angry. And who do we blame? The person responsible for creating that feeling…the patient who called us.

So why could this be detrimental to our patient care?

An internal dialogue that starts with “We shouldn’t be going to this”, can easily lead to “I don’t think this patient requires an ambulance”. And because they don’t require an ambulance, my next thought might be, “this patient can’t be sick”.

This is the kicker. Based on little information, we have concluded that “this patient is not sick”

This is dangerous. This is bias.

Bias stops us from considering all the possibilities. Bias stops us from looking further once we have reached a decision. Bias makes us focus on the variables that affirm our belief that someone isn’t sick and ignore the variables that contradict it.

The sore leg can be septic cellulitis, the diarrhoea and vomiting can be acute adrenal crisis, and the drunk teenager can be having a stroke.

I’m no saint, and I will happily put my hand on my heart and say I am guilty of this. But being aware of your thoughts is the first step to correcting them. So next time you get a sore leg, or drunk at 4am, pause, acknowledge the bias, and try and approach the patient with an open mind.

Remember, to you it’s just another job. To the patient it may be the worst day of their lives.

To learn more about bias,

Check out Episode 5 – Deadly D and V