EMTs: Don't just do something, stand there

In every resuscitation room at one of our local emergency departments, there are large, comfortable wooden rocking chairs. They aren't for family or mothers comforting their children. In fact, they look like they belong on the front porch of your local Cracker Barrel, occupied by elderly folks playing checkers while they digest their meals.

They are not something one expects to find in a modern emergency department decorated in glass, tile and stainless steel. But they have a very real purpose.

During a cardiac arrest or critical trauma, the physician sits in the chair and manages the resuscitation. They don't actively participate, unless the resuscitation requires a procedure only a physician can perform. The chair allows them to be objective and dispassionately consider what needs to be done next, without being tied up in the mechanics of how it gets done.

One of the best emergency physicians I have ever met works a resuscitation by standing off to one side at the foot of the bed, arms folded across her chest, sometimes speculatively tapping her chin with a finger. Rarely does she do an intervention herself.

The respiratory therapists intubate, nurses get the vascular access and provide most of the interventions and care. Occasionally, she'll step out of her place at the foot of the bed and start a central line or insert a chest tube. Mainly, she quietly asks questions and gives orders, occasionally pointing at someone like a maestro conducting a symphony.

She does not raise her voice. There is no drama, her voice as even and conversational as if she were ordering lunch at her favorite bistro. It would probably make for very boring television, but I could easily envision her in one of those rocking chairs, orchestrating a complex resuscitation while she knits a sweater.

She knew that often, the best approach is not to just do something, but to stand there.

When I wrote about being the stand-back, big-picture, non-interventional paramedic, I pointed out that the maturation of an EMS provider is often reflected in the restraint he practices, but let's not forget the first two parts of that description: stand back and big picture. A brief pause in the doorway to dispassionately consider what you're seeing and what needs to be done is more important than doing something immediately. If your role on a scene is to be the EMT in charge, you're being paid for what goes on between your ears rather than what you do with your hands.

Don't just do something, stand there
In my experience, that seems to be one of the biggest hurdles for new medics to clear; how to transition from being one of the dancers to choreographing the entire routine.

What got me ruminating on the subject was a story related by a colleague, who was called to back up a flight medic and a ground crew on a challenging call. What he walked in on was a call about to go south in a big way, and much of it due to the proposed course of treatment by two experienced, otherwise talented paramedics.

The patient was an adolescent girl with difficulty breathing and a history of asthma. The ground medic, presented with this information from dispatch, fell prey to confirmation bias as soon as he made patient contact, and promptly went down the status asthmaticus pathway with scarcely a thought as to other differential diagnoses. When the flight medic arrived and was briefed by the ground crew, he promptly fell victim to the bandwagon effect and agreed that this was indeed the worst case of asthma in the history of ever.

Tachycardia? Check.

Tachypnea? Check.

Chest tightness? Check.

Wheezes and diminished lung sounds? Check.

Anxiety and restlessness indicative of hypoxia? Check.

They were so sure of themselves that they had already given an albuterol/ipratropium nebulizer, an IV injection of methylprednisolone, and were getting ready to hang a magnesium sulfate drip and administer 0.3 mg of epinephrine.

When my colleague arrived, because he was the third-in medic and the fourth EMS crewmember in the room, he didn't do anything. He just stood there and took it all in.

… and noticed what had escaped everyone else's attention; her heart rate was 270.

Now, an asthma attack may elevate your heart rate, as will a beta-adrenergic medication like albuterol, but it isn't likely to cause a heart rate of 270.

One emergent synchronized cardioversion later, the patient was dramatically improved, and once everyone took a moment to think, they realized her "asthma attack" was not an asthma attack at all. She was in respiratory distress due to an unstable tachycardia, and two experienced paramedics were left to contemplate the dangers of tunnel vision and what might have happened in they gave their Wolff-Parkinson-White patient a dose of epinephrine.

The ground crew and the flight medic let the panicky school staff and the gravity of the patient's condition get inside their OODA Loop, and from then on, were too busy reacting to each new piece of information to see where it fit in the patient's clinical presentation. The school nurse and principal said asthma, and the patient was too distressed to talk. She had already had two doses of her inhaler without improvement, which is why they summoned EMS. Everyone in the room was screaming at them, "Don't just stand there, DO something!"

And so they did. The wrong thing.

The lesson we can learn is there are few interventions so urgent that they must be done without sufficient information; information to guide the intervention, information to determine which intervention is appropriate, information to determine if the last interventions was effective and yes, information to determine whether any intervention is needed in the first place.

Scene sense to think fast
I have often jokingly said that paramedics do not run. Paramedics mosey. We saunter, we stroll and we occasionally swagger when we can't keep our egos in check. But we do not run. The reason is twofold: we want to convey the impression that the emergency ends when we arrive, and we never want to move faster than we can think.

I think pretty fast. When the situation demands, I can move much faster than you'd think possible for a guy my size. Funny thing is, I have discovered that the faster (and better) I think, the less I encounter situations that demand I move fast. The same was true when I played volleyball in college (intramural, my school didn't have a men's NCAA team). I was never the most athletically gifted person on the floor, but I found myself in the proper position more often than not to make a play. I didn't have to be athletically gifted, because I had court sense.

There are myriad clichés devoted to this concept, like "slow is smooth, smooth is fast," or "when you find yourself ass-deep in alligators, it is hard to remember that the original objective was to drain the swamp," but sayings become clichés because they hold a grain of truth.

When you find yourself overwhelmed by events and it feels as if your thought processes are mired in molasses, slow down. That pause to reflect and dispassionately consider your next act is often all it takes to allow you to manage your scene, instead of your scene managing you.

Don't just do something, stand there.

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