Airway & Respiratory, Columns, Patient Care, Trauma

Cognitive Dissonance

I was sitting at home on a Sunday, enjoying a caffeinated beverage while perusing a periodical when the Plectron went off (way too loud) and my volunteer department, along with the county ambulance service, was toned out. The call was for a guy who put his arm through a window. I live on the southern border of the township. The call was only a couple of minutes from the station in the middle of the township. So I knew that, being a Sunday, other first responders would get there first but I would probably beat the ambulance coming from downtown. Since it’s an eight-minute response time for me, I often think, “Why bother?” But, you never know.

When I got there, the sheriff’s department and first responders were on scene. As I ambled up, they were bringing the guy out of the trailer. He was probably in his 20s; pale as a sheet, freaked out and covered in tattoos. They had wrapped some four-by-fours with Kling around his wrist. Apparently, the guy was hanging curtains when he fell and put his arm through the window, cutting the radial artery. My first thought was that the trailer needed a lot more help than a set of curtains. The window and screen were opaque with filth anyway. My second thought was, why didn’t they have the bleeding controlled? It was coming right through the bandage. A lot.

We’ve all seen it before: the esophageally intubated patient (“I SAW it go through the cords!”); the fibrillating patient (“But I ALREADY shocked him three times!”); the allergic reaction (“Why is he getting so HARD to bag!”); the trauma patient (“Just hold on a minute, I NEED to get this IV!”); and the bleeding patient (“Just hold on a minute, I NEED to get this IV”). Sometimes tunnel vision convinces us we’ve done what we’re supposed to do, and the fact that the patient is still doing what he isn’t supposed to do doesn’t register. So we keep doing what we think we’re supposed to do despite the fact that it still isn’t working.

I think I learned direct pressure, elevation, pressure point, tourniquet in basic first aid in summer camp back in, oh, about 1968. I know we taught it to these guys in first responder training, but somehow it wasn’t happening. “How ’bout we keep pressure on it, elevate, and grab his upper arm and put some pressure on the brachial until we can get this thing stopped?”

“Oh, yeah, OK, right.”

“Amazing how that works out,” I thought to myself. I’m trying to control the sarcasm in my old age by not saying such things out loud.

The ambulance arrived, and we got him on the cot and in the back. Somebody was still holding pressure on the brachial and the wound, and the bleeding had stopped. “How ’bout we put a cuff on that arm?” I asked.

“Wouldn’t it be better to take his pressure on the other arm?” I was asked.

“No, I mean to control the bleeding,” I said.

“They didn’t teach us that one,” the EMT said. “Isn’t that like a tourniquet?”

Sure is. But it’s wide, and you just pump it up ’till the bleeding stops so it works great.” And it did.

The patient was moaning and groaning and carrying on. He wanted to know if he was going to die. “Yes, indeed. We haven’t discovered the key to eternal life yet,” I thought, but again I controlled the sarcasm here. However, he freaked out when I pulled the IV catheter out of the package that pushed me over the edge. “Buddy, you’ve got tattoos from head to toe but you freak out at a little needle?” This I did ask out loud. “You’veGOTto be kidding!” Go figure. Never underestimate the human ability for inconsistency.