Monday, June 24, 2013

The EMS Engine...How to be an EMS assault team.

The concept of the ALS Engine has been a great posititive impact on the fire service and the communities we serve. The engine's job on an EMS emergency is vital to the patient's outcome and needs to be approached with enthusiasm and preparedness. An engine medic is often on scene as the sole ALS provider for several minutes.  What the engine does in these precious minutes sets the stage for the incoming medic unit and therefore the entire path of patient care. I'm going to talk about the three biggest areas that make a great ALS engine and engine medic: working together as a team, good patient assessment skills and preparedness. 

Organizing The Team:

A suppression piece responding to an EMS emergency needs to be a functioning team. On any given fire event we all have very defined roles. One bucket is the nozzle man, the other is the pipe man advancing hose and backing up the nozzle man. One bucket is hook and can while the other is the irons. We need to be just as specific during an EMS emergency. There are four areas of responsibility in any standard patient care scenario: 1) Patient Assessment, 2) Patient treatment, 3) Patient removal, and 4) Overall scene management. Lets talk about these one at a time.

Patient Assessment:

In my opinion the physical assessment team from the suppression platform is made up of the two bucket people the engine medic and the firefighter.   They work together as a cohesive team performing the physical assessment, attaching the EKG monitor, and obtaining vital signs. Sometimes I walk into an EMS scene to witness  the lonely engine medic up to his elbows in EMS equipment interacting with the patient while the other three members of the crew stand and watch. If you are the firefighter on an ALS engine you play a vital role in all EMS calls. Get with the medic and find out how they operate and how you can be a part of the assessment and treatment team. Below is just one way of approaching the patient assessment of a medical patient. We are not addressing traumatic patients or technical rescue scenes in this article. The following assessment is what I have been teaching ALS interns to do for years. It gives you a good solid framework to operate from. Start by memorizing the steps and you will always be organized in your approach. 

Below are seven general steps to a medical assessment.  Although they are organized in a general sequential order the order may be modified to best address the patient’s specific needs and underlying medical condition.  The items marked with an (*) are best performed by the lead assessor who will be performing the physical assessment and actually touching and interacting with the patient directly.

  • 1) General Impression
            As the assessment team approaches the patient they should ask themselves, does this patient look sick, in distress, bad, or good?  A general impression is a very important building block to the rest of the assessment, but should in no way lead the provider to jump to conclusions and cut corners on the rest of the assessment.  For example, you may have been dispatched to an unconscious diabetic emergency. Upon approaching the patient you see an unconscious person breathing deeply.  This does not mean the providers should jump to obtaining a blood glucose level and then immediately start an IV without measuring vital signs or any further assessment.  Jumping to conclusions and cutting corners is a common provider error during this step.  Neglecting to garner all the other very important and necessary information can lead to wasted time, effort, and improper treatment.  This tactic works most of the time as long as the dispatch information is correct, the patient has no other complications, and the treatment plan is straight forward.  When operating from a suppression platform alone It is much quicker to jump to a conclusion at this phase and perform all the needed ALS skills prior to the transport unit’s arrival thus it is an enticing option, but if we want to be quality EMS providers we need to be well disciplined and assure every patient receives a good patient assessment regardless of any preconceived notions or impressions.  Only after the full assessment is performed should the treatments be initiated.  The general impression phase is when providers very well may jump to a conclusion based on experience and clinical judgment. Instead of immediately acting upon that notion the providers should continue to perform the assessment, gather all the information, and prove the initial impression true or false.  If there are sufficient providers on scene interventions may be assigned throughout the assessment process, but the lead assessor needs to remain on task and complete the assessment to provide a full picture of the patient’s condition.  
  • *2) Airway
            Does the patient have a patent airway? Are they talking? Are there any immediate interventions necessary to improve the airway? Does the patient require an NP airway, an OP airway, suctioning, or supplemental Oxygen?  Does the patient require intubation? Airways requiring intubation should be sized up using the LEMONS acronym. If any airway interventions are required they should be immediately provided.

Think L-E-M-O-N-S When Assessing an airway that may require intubation. 
Look externally. There may be some physical clue or foreign object that portends difficulty.
Evaluate using the 3:3:2 rule. Can the patient fit three fingers between the incisors? A mouth that can open that far has good temporomandibular joint mobility. Is the mandible length three fingers from the mentum to the hyoid bone? That's a nice, normal length; either shorter or longer makes ventilation or intubation trickier. Last, the distance from the hyoid to the thyroid tells you something about neck length--two fingers' distance is ideal.
Mallampati classification. If the patient can cooperate, ask her to stand or sit up, open the mouth, stick out the tongue, and say, "Ahh." The structures that are visible compose Mallampati class I (the easiest airway), II, III, or IV (most difficult). If you see the tonsillar pillars, that's Mallampati class I. If all you can see is the palate, that's class IV.  In order to gain any beneficial information from this assessment tool you need to perform this while the patient is still conscious so you need to 
The classification correlates with the Cormack-Lehane laryngoscopy grades. A Mallampati class I will be a Cormack-Lehane grade I in 99%-100% of cases. You can proceed with paralyzing the patient to establish an airway without any concerns.
A Mallampati class IV always will be a Cormack-Lehane grade III or IV. This is going to be tough, and you need to be thinking about what your alternatives will be.

Obstruction. Look for anything that might get in your way. The enemies of airways include soft tissue swelling from smoke inhalation, burns, broken necks, trauma to the face or neck, foreign bodies in the airway, and excessive soft tissue from obesity.
Neck mobility is desirable. Unfortunately, many patients who need resuscitation in the emergency setting require cervical collars or have compromised neck mobility, and you may not be able to move them into preferred positions for establishing a definitive airway.
Emergency providers have the luxury of thoroughly evaluating only around a third of patients who need an airway established, because most are too sick or injured to allow much evaluation.
Most important, ask yourself, "Will I be able to ventilate this patient" with a bag valve mask? Also ask yourself, "Will I be able to intubate this patient? Could I do a cricothyroidotomy if I needed to?”
Saturation:  What is the patient’s O2 saturation? Are they on supplemental oxygen? Be sure to preoxygenate with an NRB and a NC with ETCO2 monitoring.  Keep the NC in place during intubation as this will provide passive oxygenation and help maintain the patient’s O2 saturation during intubation.
Even a thorough advance evaluation will help you identify difficult airways only about 50% of the time, so be prepared in any case (Boschert, Norris)
  • *3) Touch patient, radial pulse (skin color, temp, moisture)

            This is the time to introduce your team and ask permission to touch the patient if necessary.  A good beginning is to feel the patient’s radial pulse.  By just taking a radial pulse you can determine if there are signs and symptoms of shock.  Is the pulse fast or slow? Are they cool and clammy to the touch? Is there skin moist or dry?  Is the radial pulse even palpable?  If not, do they have a brachial or carotid pulse?  Are the pulses equal in strength on both sides?  At this point you should have enough information to form a good impression of the severity of the patient’s condition.

  • *4) Check eyes for reactivity and conjunctiva.

            Ask the patient to close their eyes.  This will tell you if they have the ability to follow simple commands.  Then ask them to open their eyes.  By doing this, most times you can see the reactivity of the pupils without using a pen light.  If needed use a pen light to measure the pupillary response.  While you are examining the eyes pull down the lower eyelid and examine the conjunctiva. Is it pale (hypoxia), pink (normal), jaundice (hepatitis/liver failure), or is there any subconjunctival hemorrhaging (severe vomiting or choking).

  • 5) Gown the patient at this time if feasible

            By putting the patient in a gown now you will have full access to the upper part of their body to listen to lung sounds, apply EKG electrodes, and perform an abdominal assessment.  If there is no gown readily available then take this time to expose the chest as necessary to perform the assessments.  This step is particularly important for pediatric or infant patients as it gives us the opportunity to expose the patient and examine the entire body for signs of abuse or neglect.  With an infant patient remove all the clothes. Remove and examine the diaper for saturation or signs of abuse or neglect.  Then work with the caregivers to replace the diaper.  This will build a good rapport with the caregivers and allow you the opportunity to thoroughly examine the patient. 

  • *6) Count Respirations and Auscultate Lung Sounds

            Listen in three places in the front and at least 4 places in the back.  The right middle lobe is best heard with your stethoscope directly under the right breast midaxillary. Most disease processes are present in the lower lobes which are best heard from the posterior as these lobes overlap the frontal lobes with the largest part of the lobes taking up the majority of the posterior side as you can see from the illustrations below. 

  • 7) Obtain vital signs and perform diagnostic tests: 
B/P, Pulse, Resp, Temp, SAT, Dexi, EKG, 12-Lead EKG

Patient Treatment
The treatment of the patient is dictated by local protocol and directed by the lead medic on the scene.  Just as the Medic and firefighter are the assessment team they are also the primary treatment team. More critical calls such as a cardiac arrest may call for the driver to become engaged in patient treatment as well, but the treatment of most emergency patients can be handled very well by the bucket medic and firefighter team. 

Patient Removal
The driver of the engine is in the best postion to be in charge of the removal of the patient from the scene. As the assessment and treatment team go to work they can be be scoping the best and easiest way to extricate the patient from the home. They should meet the incoming EMS transport unit and communicate any equipment needs for removing the patient from the scene giving the EMS crew a short briefing on the location and general condition of the patient.  Regardless of the driver's level of EMS training he can tell if the patient is really sick or doing ok, and the driver will know if a stair chair is needed, what the best entrance to the home to use, etc.  

Overall Scene Management

Overall scene management and safety is the job of the engine officer.  The engine officer should be interacting with the family in a positive manner, taking notes on the assessment findings for the assessment crew, and keeping a wary eye out for any safety concerns. 


The engine medic may find himself in some precarious remote locations rendering patient care such as upside down in a car, over an embankment 20 feet below the road, in the middle of a creek bed, or behind mounds of personal belongings in a horder's home.  Sometimes its difficult to carry all of our equipment and bags to such areas.  A prepared engine medic has all the essential assessment and treatment equipment close at hand at all times.  Ask yourself, what do I need to fully assess someone and save a live in the first 5 minutes of an emergency.  The best engine medics I know carry some sort of small personal go bag packed with all the essentials.  Below are pictures of one such bag. 
The contents of mine are what I need to assess a patient, some PPE, and items to bandage and control minor to severe bleeding.

Assessment Tools
Adult B/P cuff
Small flashlight (Penlight)
Finger Pulse Ox
Safety Glasses
Surgical Masks
N95 Masks
Hand Sanitizer
Bleeding Control
a 5x9
a tourniquet

Below are pictures of one such bag carried by a top notch engine medic from the Fairfax County Fire Department in Virginia.  What are your thoughts and feelings on tricks of the trade, methods, and techniques on how to be a better engine medic? Comment below.


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Saturday, March 2, 2013

Oh the Humanity...Hauling the Homeless

Each patient, whether you work in a 911 system and encounter repeat callers or you work in a non-emergency transport system where you routinely ferry patients to and from nursing homes, requires your utmost attention. Be ever diligent. Anyone can be a good paramedic on the good days. You need to be a great paramedic every time you begin a new patient encounter, regardless of the number of patients you have already seen in the shift, regardless of the number of meals you have skipped, regardless of the time of day or your fatigue level.  Never forget the person in front of you is much more than just a patient. They are someones mother, father, sister, or brother. There is someone in the world who loves them very dearly, with all of their heart, and you should imagine that person is looking over your shoulder demanding your best at every turn. Treat every patient as if they were one of your own family members.  Remember the little things. Sometimes a smile or simply being treated like a human being is the greatest and most important treatment the patient can receive. This is the philosophy I use to stay focused and try to give everyone I encounter everything I have to offer.  Sometimes it's not easy, but you have been called to a vocation that is best developed with humanity, intelligence, compassion, and respect for our fellow man. With this in mind I would like to describe a patient population in the City of Fairfax I encounter on a regular basis which is a good example, the homeless.

The City of Fairfax and Fairfax County, Virginia collectively have the second highest homeless population in the National Capital Region second only to the District of Columbia.  A large number of the Fairfax County homeless population are arrested at one time or another and charged with some sort of misdemeanor alcohol related offense.  They are taken to the Fairfax County Jail by their arresting officer.  After spending a warm night in jail they find themselves walking out to a bright and sunny morning smack dab in the middle of the City of Fairfax. They discover two major issues at that particular time in their lives.  They are hungry and they are shockingly sober.  In their minds these two situations require immediate attention.  So what to do? Hit up one of the many 7-11 convenience stores for problem number one.  But what to do about food? If they pay for food then they won't have enough money later for another trip to 7-11. Either by experience or by talking to one of their peers they learn of an establishment that feeds the homeless during the day.  This establishment is actually providing an amazing service to the community. They are a church based group that has daytime hours.  They offer food, showers, christian counseling, and help to get a man, down on his luck, back on the right path. They discourage drunkenness and offer a helping hand to any in need. God Bless them. A byproduct of this service, however, is after the doors shut and the sun goes down where does a guy get his next meal? Best bet is to just wait until morning for breakfast when the doors open up again. This behavior has created transient pockets of homeless tent communities throughout the city. Not everyone who frequents this establishment meets the description above, but I wanted to give a good descriptive example of one possibility as to why a small city in the suburbs of Washington D.C. could have such a high homeless population. 

Inevitably the fire department becomes involved in the lives of the homeless when they become too inebriated to walk or go to jail.  They may trip over a curb, discovered sleeping in the park in a near comatose state, or worse, involved in a traumatic accident.  When this occurs in rush the firemen and paramedics who encounter a great number of different homeless personalities on a regular basis. Sometimes the same personality two or three times a day every day for several weeks or months. As a paramedic you often get to meet people on the worst day of their lives. The homeless population seem to have these days on a regular basis.  

Regardless of their present physical condition, the fact they are alcoholics or mentally ill, homeless people are patients too, but above all else they are human beings and should be treated as such. They have all the same medical issues any other human being may have except all the signs and symptoms are clouded by alcohol and poor hygiene. Their lifestyle places them in a much higher risk category for all the major illnesses.  What I hate to see is a paramedic becoming complacent with the local drunk and overlooking a major medical emergency.  Paramedics dealing with a homeless population need to be ever diligent all the time. Regardless of the number of times you may have transported Otis to the hospital he requires, no he demands, your full attention because without another full patient assessment you have no idea what is transpiring with his current medical condition. 

The astute homeless immediately complain of chest pain when aroused by local police. Many times this pain is non-existent or actually upper abdominal pain from an overworked liver or pancreas, but it is not our place to assume this is the case. I have discovered more than one case of V-Tach and more than one acute MI from just such a situation. If I had just assumed Otis was drunk again and trying to avoid arrest I would have missed a serious emergency and provided a horrible service to the public. 

It's easy to be a good paramedic on a bright sunny spring day when all of your patients are pleasant and personable. The best paramedics are great all the time regardless. The next time you feel the pangs of burnout as you dread the next call or a certain type of patient remember what I have said and be a great paramedic, one that your mother would be proud of. 

Sunday, February 24, 2013

The Paramedic's Most Important Job

The single most important role a paramedic can play in any patient's healthcare experience is to properly set the stage.  Yes, we must all be proficient in the recognition and treatment of immediate life threatening conditions, but that is just the beginning. Unfortunately this is the area most paramedics mistakenly concentrate all of their efforts. Have you ever heard a paramedic say something like this with a confident tone, "Nothing to that one! Show me something like V-Tach or SVT and you will get my attention." This attitude couldn't sicken me more. Every patient should have all of your attention for the entire incident.  The most underutilized skills I see in prehospital medicine are compassion and a good thorough patient assessment.  The topic of compassion is for another blog.  Today I want to talk about setting the stage and patient assessment. Setting the stage is done by performing a good patient assessment and interview, observing the surroundings and living conditions of the patient, and passing along the information, as well as, your opinion of the underlying cause to the receiving physician.  Paramedics were intended to be the eyes and ears of the emergency physician and I think we have strayed from that mindset.

The future of EMS is bringing the emergency room the the patient's living room.  With overcrowded hospitals and wait times growing we need to train the nations paramedics to think and act like physicians.  When an EMS provider examines a patient in their home they need to have a high index of suspicion for any condition that warrants further evaluation in the hospital setting.  When paramedics transport a patient to the emergency room they need to observe the initial actions and evaluations of the receiving physicians.  If the paramedic's assessment did not agree with the physician's assessment then I can guarantee you one thing.  One of them has something to learn.  If the physician performs any treatments or interventions in the first five minutes after paramedics transfer the patient then ask yourself, "Should I have done that? Is that something we can incorporate into future EMS protocols?"  The profession is it's own worst enemy.  I have heard too many paramedics say, "Why do I need to know that? It won't effect my treatment of the patient."  A more detailed medical education may not effect what treatments we allow paramedics to perform in someones living room, but it will give paramedics the knowledge to assure no patient is left at home with a potentially life threatening condition.

I just read this blog on Facebook from

Its an interesting EKG but all I see is that paramedics let a STEMI walk out their door.  Why did that happen?  Was their index of suspician high enough for this situation? Should they have performed a more detailed patient assessment? Should they have asked different questions or performed more diagnostic tests?  I think in hind sight we can all answer these questions.  Don't let it happen to you.  Be curious! Be inquisitive! Ask more questions more often! Don't rest until you understand!