What I learned on shift today...

[mct601]

I am making this thread to share a lesson learned/new experience that I had a few days ago while on shift. Feel free to join in and discuss, and even add in experiences of your own- but please keep this clean and polite. For example I am new, and still learning the ways of EMS. I love feedback on what I should have done different, but that can be done without insulting my intelligence or questioning my mandhood.

A few days ago we had a fairly typical day at work. I was working with a medic of nine years, who I have never worked with before. I enjoyed working with her and we had a fairly simple day (3-4 calls). Later that night, approx 10pm we get toned for a car accident a few miles out. Immediately after, we get canceled due to another unit being closer. Within five minutes we are toned out to post at a station in the middle of the county due to the remaining trucks being called out (we are the northern truck). Mind you, our county is fairly big. Its not bad until the fecal matter collides with the wind turbine and we have to run a call cross county. Anyways, we set out to our post when we get toned out to a burn in an area which would typically be in the coverage area of one of the southern trucks. I have not yet worked a burn of any sort, so this entire call is a new experience for me. I also figured it was going to be a simple call (maybe something involving a grill or stove?)..... until dispatch gave us the ETA for the air medic.

The road we are dispatched to is a very long road that runs parallel to the interstate, and is very long. I enter the numerics into the GPS to find out where on the road the call may be, and it points us in the direction of the northern stretch of the road, which isn't far out. We ended up taking a few backroads believing we would end up near the call, but was wrong. This area is very, very rural for our county. We took the road South and finally came up on the call. Had we taken the interstate, probably would have saved approx 10 minutes (+/-). However, I stand by my decision of following the GPS due to the fact that (IMO) it was better to hit the road and run south rather than go all the way down the interstate to risk having to head back north.

We arrive on scene, and by this time the air med was waiting on us at the LZ. Fire trucks and vehicles everywhere, with a fairly big congregation of people across the road from the house fire. I couldn't determine plain clothes firefighters from bystanders. I was being tugged on and asked everything from "Where did you guys come from??" to "What took so long??" to "Where are you going to take them??". Apparently a gas stove had exploded and injured multiple people. I get out immediately and spot the most critical pt wrapped in a blanket on a backboard. I quickly get him on the stretcher, in the truck, and on the onboard O2. My medic went to assess the second pt. She then returns to begin work , attempting IV access and the whole nine yards. This man is burned from head to toe on his front side- the only parts not burned were his pelvic area and feet (assuming he was wearing shorts and shoes). Most if not all of the burned areas are partial thickness, with major loss of the superficial layer of skin. Circumferential burns on arms and legs. Shivering as if it were 10 degrees outside. He has a very low LOC but is somewhat responsive. After a few minutes of work, she discusses something with a firefighter and says shes ready to get the pt to the air medic.

I drive to the LZ, which is a big parking lot of a church. The air ambulance crew flag me in and pretty much jump in as soon as the truck comes to a stop. They take over and go with it. They attempted IV access, and I'm assuming they attempted IO (get to that later), along with attempting intubation. Like my medic, they could not achieve this. They finally got IV in the foot, and knocked him out with some drugs and pushed paralytics (I'm assuming) to attempted intubation. They couldn't get a tube after a few tries. After a few minutes my medic looks to me and says "go put the other guy on a NRB and get a BP". They had the other guy laying in the parking lot, and apparently a second chopper was coming for him. He was not nearly as bad, and was responsive. Once I get him on O2 the medic arrives and wants a line ready as she gets IV access, which I do. Once she gets the line in she moves back to the truck for whatever reason- at this time the second chopper is asking me to get him on a backboard to get him in the chopper. I do, and we load him. As I load him, the first chopper is loading the critical pt. They leave, and we are left with a mess.

My medic's attitude spirals downward steadily after the call. Cut a long story about that short, she was absolutely distraught that she was separated from the pt (second guy). Back tracking, remember I said she assessed him earlier in the call and then returned to the truck to work the critical guy. He was not mentioned to me again, so for all I know he is fine and just shaken up. I didn't realize his condition (which was bad, but not critical just yet) until I saw him at the LZ. Apparently what happened was one of the FFs told my medic that they were taking him to the LZ via pickup truck. I know this is a big no-no in EMS, but the LZ was less than half a mile away. Then today as I came in to work I was discussing it with the crew leaving. They said a county supe was on scene and "was not happy about our response time" and had my supe (which I knew nothing about) pulling up run times and mileage. The county blew up suddenly, it happened and there was nothing anyone could do about it. I responded from cross county the best way I could.

Overall, I think I handled myself fairly well. I handled it with urgency, but composed and calm. Despite having multiple people on scene giving me an attitude, I looked beyond it to what mattered and got it done. From an emotional aspect, I was able to focus on the pt's needs rather than focus on the condition (i.e. i can't believe this). I know I could do stuff better, but being my first burn, first time flying out pts, and first time in a situation like that, I think I handled it well.




What I did learn:

A) It can be very easy for the scene to control you- do not allow it.
B) Don't get tunnel vision
C) Garmin is no Christopher Columbus
D) In urgent situations, write down the same info my medic is writing down in case my medic were to lose it.

 

[JPINFV]

Apparently what happened was one of the FFs told my medic that they were taking him to the LZ via pickup truck. I know this is a big no-no in EMS, but the LZ was less than half a mile away.

Any port in a storm, and if you're in an MCI style situation (which multiple patients needing to be shuttled to the helipad with only a single transport resource, I'll consider that an MCI style situation), you should consider any resources available. Should transport by pickup truck be avoided when possible? Sure. Also, hindsight is 20/20 (more like 20/10).

C) Garmin is no Christopher Columbus

Where's that GPS vs map book thread again?

 

[mct601]

Any port in a storm, and if you're in an MCI style situation (which multiple patients needing to be shuttled to the helipad with only a single transport resource, I'll consider that an MCI style situation), you should consider any resources available. Should transport by pickup truck be avoided when possible? Sure. Also, hindsight is 20/20 (more like 20/10).



Where's that GPS vs map book thread again?

Don't get me started on the GPS... much grief.


And I realize that. All in all, there was a total of 4 patients. WHERE the other two came from, I have no idea. I remember working at the LZ and seeing a second truck pass L&S to the original scene and they transported two pts (a female and a pediatric) L&S. The ped transport was simply to be safe, according to what I heard on the radio. I honestly don't think we could have possibly handled a second burn pt in the truck. I mean I KNOW we could have, but the main guy needed all the attention he could get. The second guy was simply given some morphine en route to the burn center and no other interventions were taken, not even airway. So he wasn't too bad off. I'm not justifying what happened, but she completely had a change of attitude after the call. I was ready to get off the truck at that point.

 

[Aidey]

So what happened with the IO? And what type of IO were they using?

 

[mct601]

I'm sorry, it was late yesterday and I forgot to add that last little tid bit of info. Its no big deal, just another piece of the story.

I assumed they attempted IO because the drill was out. Now maybe they got IV access just before they attempted IO, but the equipment was out and open. They attempted this while I was with the other pt. It made its way to the sharps container.


All in all, decon after the chopper left took 10-15 min. Just the amount of trash left behind filled up two large biohazard bags (we threw away the towels and sheets that were used during/after the call, so that was one bag). I'm still waiting to hear what the county supervisor had to say about our response. I missed my supervisor stopping by the station yesterday due to being on a call. I will update that when I get more info.

 

[abckidsmom]

That sounds like a tough call. I remember every one of the severely burned patients I've ever seen prehospitally. I think there's just something about fire that hits a nerve with humans.

I understand the navigational frustrations of doing the best you can and still not being able to make the best response time possible, too. I have had to study and study to get a good working knowledge of the jurisdictions I've worked in. A suggestion? Get a cheap, fold out map of the county and highlight all the major roads. Figure out which end of the roads the numeric 1 is, and what the highest number is on those roads. Study this. Memorize it. Then branch out to the other roads, and so on. It's unfortunate that you had to experience navigational difficulties on such a high-profile call, but let this stress guide you into doing a better job next time, not just being frustrated with the people on the scene.

It really sounds like you did the best job you could. There were other providers on the scene before you, right? They made the pickup truck decision...in an MCI situation, I do agree that crazy things sometimes happen. Hopefully, in your system, they can come up with a way to "declare" an MCI, kinda like the dispatchers specify that they are using the emergency rule if they aren't able to follow the standard protocols.

You're right, this has been a complete learning experience. I like your list of take-home lessons. What do you plan to do with them next time?

 

[Veneficus]

Short of instantaneous or faster than light travel, nobody will ever think you get to the scene quick enough.

I am much more fond of maps than GPS. Are they better? Depnds on who you ask, but one of the things i can do with a map is judge the total distance.

The good part is you had a rational reason to make the decision you made. Some will agree some will not.

an MCI is defined as having more patients than resources. I think your call definately fits into that category. Triaging at night is also very difficult.

I once was the last unit on scene of an MCI (5 people rolled a car, 3 ejected, and one crawled to a house to call 911 or nobody woul have known)

Long story short, 2 people were airlifted, and as fate would have it, somehow the sickest of the bunch wound up in the truck with me. (the girl who crawled)

I think the most important thing to lear from this is:

If everything went exactly by the book, then there wouldn't be an emergency. Welcome to EMS.

 

[lightsandsirens5]

Any port in a storm, and if you're in an MCI style situation (which multiple patients needing to be shuttled to the helipad with only a single transport resource, I'll consider that an MCI style situation), you should consider any resources available. Should transport by pickup truck be avoided when possible? Sure. Also, hindsight is 20/20 (more like 20/10).

Exactly. We had an MCI MVA recently. All four of our ambulances were out (two on other calls, two on the MVA). And the next nearest transport ambulance was 45-60 minutes out. We were loading people into fire engines to transport them to the LZ and hospital. WA RCWs say that in the event that a transport licensed vehicle is significantly delayed and the pts life will be in danger if transport is delayed, any vehicle can be used for transport of the pt to a higher level of care and/or to rendezvous with a transport vehicle be it ground, water, or air. So basically, whatever works.

Mct, sounds like you did well. Burns are terrible anyhow and the way you found yourself in that situation only added to the stress I'm sure. And with two critical pts it would have been nice to have two ambs, but that is the whole idea behind triage. Sounds like you and your partner chose the most critical pt to work first.

About the people asking what took so long, happens all the time out here. With a two hour response time to the northeast corner of our district in bad wtx..........yea. We had one guy who would call, go listen to his scanner, and as soon as we were paged, start a stopwatch. When we'd show up, he'd be all like "You all took 12 minutes longer than the last crew, what took so long?" Used to drive me crazy! You get used to it. Lol.

 

[mct601]

That sounds like a tough call. I remember every one of the severely burned patients I've ever seen prehospitally. I think there's just something about fire that hits a nerve with humans.

I understand the navigational frustrations of doing the best you can and still not being able to make the best response time possible, too. I have had to study and study to get a good working knowledge of the jurisdictions I've worked in. A suggestion? Get a cheap, fold out map of the county and highlight all the major roads. Figure out which end of the roads the numeric 1 is, and what the highest number is on those roads. Study this. Memorize it. Then branch out to the other roads, and so on. It's unfortunate that you had to experience navigational difficulties on such a high-profile call, but let this stress guide you into doing a better job next time, not just being frustrated with the people on the scene.

It really sounds like you did the best job you could. There were other providers on the scene before you, right? They made the pickup truck decision...in an MCI situation, I do agree that crazy things sometimes happen. Hopefully, in your system, they can come up with a way to "declare" an MCI, kinda like the dispatchers specify that they are using the emergency rule if they aren't able to follow the standard protocols.

You're right, this has been a complete learning experience. I like your list of take-home lessons. What do you plan to do with them next time?

I am learning the area better. I do not yet have a map of the county (gonna get one when I get time), but I DO have a nifty iPhone GPS app that shows me the destination, and a B-line straight from my location to the destination. I can then determine the roads I need to take from there. I can't use it while driving, but I can make mental notes of what roads to turn on, etc. It helps.

I honestly am not sure about the MCI thing. I'm sure there is, but I don't know what it would take to activate it. We have a trauma system (i.e. Alpha and Bravo patients) that works pretty well, don't see why we don't have an MCI system. We just didn't know what we was getting into till we got on scene.

The notes? I've began practicing them in every call. The tunnel vision note wasn't so much a problem I had on scene, but I could see how one could allow tunnel vision to make over in such a situation and focus on one aspect of the call instead of the entire call. I won't let it happen.

On calls that are more on the hectic/high stress side, I have begun jotting notes even if my medic is or not. Names, dates, ages, medications, injuries- any pertinent info to the pt or call. My medic I am with now religiously writes everything on a notepad so I won't really have to deal with him writing it on his glove and throwing the glove away, like what happened on the scene of this burn. But just in case.

and as far as the scene - I just plan to step up and play more of an assertive role in triage, handling the bystanders, etc. Once again, the scene really didn't control us, but I could easily see how something could get out of hand, and I won't allow that to happen.

Short of instantaneous or faster than light travel, nobody will ever think you get to the scene quick enough.

I am much more fond of maps than GPS. Are they better? Depnds on who you ask, but one of the things i can do with a map is judge the total distance.

The good part is you had a rational reason to make the decision you made. Some will agree some will not.

an MCI is defined as having more patients than resources. I think your call definately fits into that category. Triaging at night is also very difficult.

I once was the last unit on scene of an MCI (5 people rolled a car, 3 ejected, and one crawled to a house to call 911 or nobody woul have known)

Long story short, 2 people were airlifted, and as fate would have it, somehow the sickest of the bunch wound up in the truck with me. (the girl who crawled)

I think the most important thing to lear from this is:

If everything went exactly by the book, then there wouldn't be an emergency. Welcome to EMS.

In my opinion, this is what EMS is about. Why my medic had such a poor attitude afterwards, is beyond me. I had little to no lingering stress once the call was over. Just a huge sigh of relief.

Exactly. We had an MCI MVA recently. All four of our ambulances were out (two on other calls, two on the MVA). And the next nearest transport ambulance was 45-60 minutes out. We were loading people into fire engines to transport them to the LZ and hospital. WA RCWs say that in the event that a transport licensed vehicle is significantly delayed and the pts life will be in danger if transport is delayed, any vehicle can be used for transport of the pt to a higher level of care and/or to rendezvous with a transport vehicle be it ground, water, or air. So basically, whatever works.

Mct, sounds like you did well. Burns are terrible anyhow and the way you found yourself in that situation only added to the stress I'm sure. And with two critical pts it would have been nice to have two ambs, but that is the whole idea behind triage. Sounds like you and your partner chose the most critical pt to work first.

About the people asking what took so long, happens all the time out here. With a two hour response time to the northeast corner of our district in bad wtx..........yea. We had one guy who would call, go listen to his scanner, and as soon as we were paged, start a stopwatch. When we'd show up, he'd be all like "You all took 12 minutes longer than the last crew, what took so long?" Used to drive me crazy! You get used to it. Lol.

I forgot to add in

The nearest truck was at the nearby hospital dropping off a pt when we went on the call. When the pediatric and female pts were reported (which we had no idea they were around, I guess the fire dept seen they were not serious and held them for the next truck and allowed us to take on the critical pts) dispatch sent that truck to pick them up. 4 pts total, 2 flown out by us, 2 transported to a facility ~1hr away by another truck. Hell on Earth haha.


I have been trying to get updates on the pts and the call itself. Everything is vague so far, but one of the lifeflight guys was on a scene of an MVA w/ entrapment last week with us. He said he was not on that call but heard about it- and the most critical guy had over 70% burn. I have also heard that the incident has turned into a big legal battle. Nothing involving EMS, but something to do with the explosion.