APR
10

"Set Me Up": On Partner Duties

I want to preface this by saying that I work in a double-paramedic system, which helps make this possible, though there is no hard reason why this does not work in a high-functioning Medic/Basic system with well trained EMTs. I also recognize that this is not appropriate for all patients, there are plenty of sick  patients who benefit from initial stabilization and treatment on-scene; this is for the rest of the cases. 

In my system, we have a set, codified division of labor between the “attending paramedic”, who handles direct patient care, and the “driving paramedic”, who does big-picture scene management, interviews bystanders, and family members, and generally helps facilitate the attending medic’s ability to perform high-quality medicine. The new-hire paramedic’s ability to do these partner functions well is taught and tested on in our field training program. 

One of the more unique things that falls under “partner duties” is “setting up” the attending. What this entails is as soon as the attending determines it’s “time to go”, the driving medic high-tails it to the back of the ambulance with the goal of having everything the attending will need for the rest of the call setup and ready. 

The attending asking their partner to “set me up” can happen at any point in a call. It can happen from down the block as you’re pulling up on a nasty shooting or it can be after being on-scene for 15 minutes resuscitating a patient. If you have a really dialed partner (most of mine are) by the time you look over your shoulder to ask them to set you up, you can just make their silhouette in the doorway. 

As a driving medic,  you develop your “doorway” general impression. Based off of sometimes only seeing a patient for a second or two, how they are interacting with providers on-scene, their skin signs, their work of breathing, etc., you now have to form a general impression, have a sense of how this call is going to develop over the next 10-20 minutes and prepare your partner for that. This is harder than it looks, but is low stakes. Don’t think about something your partner ends up needing? Not a big deal, be better next time. Over-prepare your partner? Pull out an airway roll for a patient who’s awake and talking by the time the wheels click in? No big deal at all. This general impression “practice” absolutely pays dividends for anticipating where a call will be going the next time you’re attending. This in turn helps improve delegation skills, which are after all, a reflection of your ability to be  minutes ahead in your head of where the call is now.

So what does this actually look like? I’ll talk through a scenario. 

The first will be the run-of-the-mill STEMI alert. You and your partner get on-scene, rapidly recognize the need for an EKG, and identify as STEMI. As soon as you and your partner agree, you as the driving medic would head toward the ambulance, leaving your partner with the fire department to work on extrication.

Once there, you will make sure all the lights are on in the back, turn on AC or heat depending on what’s needed, make sure the electric oxygen button is pressed. You then spike two lines (or whatever your setup for bilateral lines is), have a nasal cannula hanging from the christmas tree should their SpO2 be <92-94%. You’ll also pull out the fentanyl with a few syringes to draw it up. If the patient looked like they were hurting and you have time you might even draw up the fentanyl and label the syringe.

You’ll also have the nitro out. As soon as the wheels click in, you’ll go to work ensuring electrodes survived the transport, shoot another EKG, ensure defib pads are in place if not already. While your partner is making a phone-call and depending on distance to the ED you might even rope off an arm and start an IV for your partner. Then it’s time to get up front and drive. 

Having everything set-up and ready to go makes the call feel that it “flows” a lot better. Indeed, having things laid out, ready, and setup makes it easier to get into and stay in a “flow state” which is the point of peak cognitive performance and a place we should strive to be in with sick patients. 

How can you apply this to your system? Because of how much reliance it takes on a partner, when we are training paramedic students we insist that they specify what they want: “Hey can you set me up with two lines and airway stuff?” This is totally something that could work with an EMT or even a paramedic partner. Test your own general impression and tell your partner what you want set up as soon as you recognize that the patient is sick. I think you’ll find it’s a great exercise to improve your “doorway impression”, helps to make the stress of a sick patient feel more manageable, as well as reduce your scene times for the few patients that need a trauma surgeon RIGHT NOW. 


I think the patients for whom this is most useful for in most systems is sick trauma patients. My system has an expectation that trauma which is an emergent return will have a scene time of <9 minutes in blunt trauma and <6 minutes in penetrating trauma. These times are easy to make, but a large part of being able to do this well is having your partner set you up. In the sickest penetrating trauma scenes i’ve run, my partner doesn’t even see the patient, they set me up as I make patient contact, roll the wheels to a firefighter. We get the patient on the bed and by the time the wheels click the ambulance is in gear rumbling to the trauma center with everything I’ll need for the short transport setup. 

I hope this has been helpful, and has some pieces that you can incorporate into your practice to help make your scenes run more smoothly, with more control, and you get to spend more time in the flow state giving high quality clinical care to the sickest of sick patients!

 

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APR
01

The Art of Taking It Off...

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I would have never imagined that I would be writing about taking off personal protective equipment (PPE) and certinely didn't think I would be learning about a fella referred to as the 'tiger king',  but here we are in 2020 and I am writing about taking off PPE. I was going to do this as a vlog but really didn’t want to waste the PPE.

This is going to be a quick overview of doffing PPE with the use of illustrations, because I am a visual leaner and I wanted to get this out quickly (I draw faster than I write). Hopefully we are pretty good with putting on the PPE, but honestly how much time was spent on taking it off, PPE that is.

As the PPE requirements change at a rapid rate, this is not going to be an all-inclusive review, just the basics of doffing gloves, goggles, mask and gowns. 

Special thanks to Courtney Graham for allowing me to use the amazing drawing of Sam. 

 

The sequence for putting on donning PPE should be: 

 Gloves > Gown > Mask > Eye Protection or Face Shield > Gloves 

1️⃣: ???????????? or ???? ???????? 

2️⃣: ????

3️⃣: ????

4️⃣????

5️⃣????

6️⃣:????

Notice that you will be double gloving. Your second pair of gloves should be pulled over the wrist area of your gown. 

 

Now we will move on to taking it off…… 

Doffing PPE is much more difficult than it seems, as the risk of inadvertent personnel contamination is high. While doffing PPE it is important to be slow and methodical. Many instituations have facilitated the use of check lists as well as observers to ensure inadevertent contamination does not occur.  

For taking off or doffing PPE the sequence will be: 

Gloves > Gown > Gloves > Eye Protection or Face Shield > Mask  

1️⃣: ????

2️⃣: ????

3️⃣: ????

4️⃣: ????

5️⃣: ????

6️⃣:???????????? 

This is Sam. Sam will show you the propper way of doffing your PPE. 

Gloves: 

As you remove your first pair of gloves, remember they are contaminated. 

Remove your first glove by grabbing your palm area and begin to pull them off. After they are removed, remove the opposite side by sliding your fingers under the glove and between the gown and peel them off. 

Gown: 

Remove your gown by grabbing the front of the gown and pull it away from your body. As you are pulling the gown forward, turning it inside out into a bundle. 

Gloves: 
Remove your second pair of gloves as described above. 

Eye Protection or Face Shield: 

Remove goggles or face shield by grabbing the back of the strap. If you are using eye protection, do not grab the front of the glasses, grab the sides. 

Mask: 

When removing your mask, do not touch the front of the mask, untie the ties or pull the rear band to remove your mask. 

When this is completed, wash your hands! 

Be safe out there and remember there are no emergenices in a pandemic! 

 

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