All-Hazards EMS & Patient Access

One of the places I feel like that pre-hospital care needs to shine above every other discipline in the medical field is the ability to access and take care of our patients in just about any environment we can find them in. While we consistently find patients on the floor or somehow trapped between the toilet and the bathtub, I want to take this a step further. I want you to ask yourself are you doing everything you can to prepare yourself at work to take care of patients in an all-hazards approach and every possible environment that you encounter patients in when you go to start your shift?

This is an intersectional issue; it involves all the prep work like training, being fit for duty, and experience and/or being coachable to learn to be a good provider. I also think it involves other processes like understanding risks, holistic approaches to patient care in the pre-hospital environment, to just have the right footwear on for the job. I realize the following is kind of a rambling message of lets do a lot of things to make things better, but the more I thought about it, the more I was ok with this being kind of a tanget: lots of the calls we run are tangets, with lots of intesections, I feel like that’s not the worst way to approach operations in pre-hospital care.

Risk Assessment

Risk is a loaded word. I think there are a lot of interpretations out and plenty of viewpoints on it. I think we all shrug off a lot of inherent risks and maybe don’t think about the way we should. I also think that’s the bravado we sometimes need in our work line, but if it’s in some form of bounded awareness and groupthink, we know how that turns out in places like HEMS-many times poorly.

There are, however, simple things I think every agency, crew, and individual can do to help mitigate day to day risk. My agency is lucky to have a Chief who came from a National Parks background and believes greatly in pre-planning and understanding risk. For every IFT we do, every 911 call or rescue we may go on, we’re expected to some sort of risk assessment. It may be very formal; we have a book with a ‘Green-Amber-Red’ (GAR) matrix for our IFTs. It may be less formal, with a purposeful pause on how we’re going to park our ambulance on many of the very narrow mountainside self-roads we run calls on, and it is probably more in-depth if we are going to use the ambulance as an anchor point for something over the edge. We carry harnesses and rope for this on our trucks; we have patients we have to access, which leads me to talking about gear.

Figure 1 IFT Matrix

This isn’t a gear post

I promise. Mostly. I like gear, and I will very openly admit I am critical of providers and services that I think skimp on personal protective equipment, medical equipment, and those types of things. We all work on feet, invest in them. There isn’t a one boot fits all solution, but taking the time get good boots that hold up, keep your feet dry, and protect them honestly is a no brainer. I see a lot of entry-level folks on both the ground and flights skimp on this; good boots have a heft price tag. Save up, cut out that extra coffee, or take out meal; your feet are worth it. Making it personal and picking on the HEMS folks, I so often see teams that are second or third due to my area, who work mostly urban show up in the winter in boots, or even shoes that have no business in the snow and cold.

Having footwear that keeps you protected and comfortable is a must-have for me. When I was a young volunteer EMT, I was struck by a vehicle, which broke my leg and caused many other injuries. My ankles somehow got out intact, and I honestly think my boots (remember those old zippered Warrington Pros?) are hugely to thank for that.

Figure 3 source: Its Gore-Tex! https://process.fs.grailed.com/AJdAgnqCST4iPtnUxiGtTz/cache=expiry:max/rotate=deg:exif/resize=width:2400,fit:crop/output=quality:70/compress/https://process.fs.grailed.com/K0DrxLRKTyOdjCaXg0vU

It’s beyond footwear, though. It’s easy to be warm in a bulky coat.  It’s not easy to do patient care in one. I feel like too many agencies skimp on functional gear for their providers; I get it expensive. I also see this as a mark of going from mediocre, to good, to great for an agency: if we have solid gear that works, that’s ergonomic, people will wear it.

Think about your agency and certain risks you face that you may or may not have the appropriate gear for. For those working in rural and backcountry areas, that list can get extensive. We all carry backcountry bags, and each unit has a tent, sleeping bags, MREs, etc. Why? We can push out on calls that may go overnight, foul weather, and access our patients and be prepared to do so without being more of a liability. We can also access these patients because we have things like OHV helmets, PFDs, and other PPE. I see too many EMS agencies who don’t train on all-hazards patient access or don’t have the equipment for their persons to do so. EMS has to move past waiting for someone to bring them the patient; access point of care injury makes a difference.

Even those working in urban environments need to have a solid sit down and think about this: do you carry an extra set of glasses or contacts at work? Is there water on the rig for you to drink, or are you hoping to stop at a gas station? Will this work if you get stuck on post or standby for hours or in the middle of civil unrest? What about medications you may need if you don’t go home on time.

What about medical care?

I think the concept of taking care of patients from a more holistic approach is greatly missed in many EMS agencies. We get to the scene, we decide if there is anything life-threatening to treat, we hopefully manage pain, and if we are in an agency that has made that move from good to great, we’re doing everything we can that makes sense to do, preparing that patient for the next echelon of care they are going to maybe its labs for the ED, those extra lines and taking their pants off if you’re going from the field to the Cath Lab or a foley for a long-distance IFT for that patient with a pelvic fracture.

It isn’t super new, but the concept of providing higher-level care for prolonged times is something the military has embraced. Prolonged Field Care (PFC) is a fantastic concept, and system of approaches and is generally designed around the concept that a single provider may be with a patient for 24 plus hours. It teaches the use of making a care plan, identifying gaps in capabilities, and even doing only basic nursing care. You can read more about it right here:

https://prolongedfieldcare.org/2018/05/11/welcome-to-somsa-2017/

I bet you’re saying to yourself, “But Nick, we just work in an urban environment, or we have short flights, or we don’t do backcountry rescues or operational-type EMS.”

I’m still going to tell you there are some absolute take-homes here for use on day-to-day calls to when bad things happen: trucks break, we get stuck in traffic, crew members get sick, helicopters crash, snowstorms happen… I’m not telling you to run out and have a prolonged field care set up in your bag. Still, I think some of the concepts that this mental model looks at in terms of patient care can significantly help us when we have to access patients in irregular environments or be better prepared for all-hazards.

If you work with me, when we’re loading the patient into the back, you’ll often hear me verbalize what I’m thinking: ‘When we get to the truck, let’s get another set of vitals, do a secondary, get a line going, and work on some pain meds.’ That’s the start of my care plan, and I think we should do this on every call. We’ve gotten in the habit on our critical care IFTs to work through some scenarios with the team at the hospital and the sending ED doctor before we hit the road. Having a care plan gets everyone on the same page, can identify gaps in the plan or hazards that may occur: Do you have enough pain meds to make it? What about nursing care needs, like a foley, pressure points, or even just nutritional needs? To me, this is a feedback loop and can change as needed: How does your care plan change when your truck breaks down, and you’re now sitting there for two hours with no heater or AC?

I know this seems like a gimme, but I’ll put money on it that many of us don’t think that systematically. The folks who came up with the concept of PFC have a great 12 and 24-hour nursing care plan. I urge you to check it out: https://prolongedfieldcare.org/wp-content/uploads/2018/05/PFC-Nursing-Care-Plan_.pdf. Those of us doing IFTs may very well be taking patients that need timely things done, like being rotated, fed, oral care… we can often do those en route, and if our patient needs them. We can safely do them to improve comfort, care, and improve the transition to the next level of care; why shouldn’t we be doing these things?  SHEEP VOMIT is an acronym covered here: https://prolongedfieldcare.org/wp-content/uploads/2018/09/pfc-nursing-mnemonic-sheep-vomit.pdf It’s a great resource. Give it a read and ask where do some of these actions and concepts fit into my pre-hospital care, even for short transports, and how can these be implemented on longer IFTs, or long rescues, or if you get stranded somewhere? Something like just adding a temperature probe to your monitoring capability can significantly change how you take care of your patients.

Figure 5 Photo Credit C. Dressel is there better gear beyond turnouts?

Being able to be safe, perform to our highest level, and provide total patient care is our job as pre-hospital providers. Accessing these patients, the safest and quickest way, while providing the best patient care we possibly can, is also our jobs. I hope some of the concepts I covered spark some thoughts: Am I doing everything I can to take care of my patients not just during the average operational day but also when everything goes wrong? What improvements in care can I do: before taking my patient out in the cold, under rotor wash, who is intubated? Making sure we aren’t putting a patient on a wet, cold cot, we get them out of a vehicle or their home.

Being prepared to be out in the elements taking care of patients protects our cognitive abilities versus being distracted by the environment; I truly believe this is part of our craft and is what can take anyone’s care, regardless of its on the ground, or in the air, to the next level.

 

 

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