A 9-1-1 call comes in for a suspected overdose, and the closest available BLS unit arrives first on scene. The patient has a Glasgow coma score of 6, respiratory rate of 12, and pulse of 128. A non-rebreather is placed, and the patient is moved to the ambulance when ALS backup arrives.
The medic looks for the cords and scans the monitor for rhythm, rate and QRS, oxygen saturation, blood pressure, and end-tidal carbon dioxide (EtCO2) waveform and height. An induction agent (ketamine) is pushed, there’s a failed intubation attempt before the tube is placed and the EtCO2 detector gets clogged and has to be replaced twice. The situation soon spirals out of control: The patient subsequently arrests en route to the hospital.
The QA Review
Like many bad cases in EMS, this one might never trigger a sentinel event notification or quality assurance review. And if it did, the tools to analyze what really happened (continuous EtCO2 waveform capnography) might not even be available.
Review of the patient care report, cardiac monitor upload and EtCO2 tracings shows that assisted ventilations were initiated only once inside the ambulance, where the first recorded oxygen saturation was 76%. The EtCO2 waveform remained flatline even though the detector was changed out twice. The oxygen saturation dropped, the QRS complex progressively widened, and the patient continued to brady down. Eventually the rhythm degraded to asystole, and resuscitative efforts were unsuccessful.
Into the Woods
Most patients don’t have time-sensitive emergencies, but for others the 9-1-1 call comes just as they’re teetering on the edge of life and death. Yet we still often rush to package and get them into the ambulance, burning precious minutes that might be used to fully stabilize them on scene. The reasoning may be that the ambulance is a controlled environment, and that all the necessary tools are close at hand. There are no screaming family members or barking dogs, and no one is breathing down your neck to get the patient off scene.
But a powerful emotional response may also click in–the ambulance feels familiar and safe, even though all of your training and education, experience and tools are screaming at you, “The patient is about to die!” And the same thing happens when you take a big gulp of diesel and race to the hospital before the patient has been fully stabilized.
If you’ve ever been lost going down a mountain, that same visceral response may prevent you from climbing back up to where you first went off route. Instead you feel the pull to go down, no matter how you get there. Even as you run into insurmountable cliffs and get hopelessly lost, you become increasingly committed to the new route, unable to find your way back.
You may think the way back is just over the next ridge (and then the next), often ignoring all the clues that say otherwise. You effectively create, and then follow, an internal picture of your environment that, unfortunately, doesn’t accurately reflect the one that’s actually out there.
And so the medic believes the EtCO2 detector is clogged, but that the tube is still in the right place. The declining oxygen saturation, the slowing heat rate and the progressively widening QRS are all tuned out. He doesn’t remember that dashed line indicates a clogged detector and that a flatline tracing means there’s no expired CO2.
A Different Approach
We think of our education, training, experience and tools are what make the difference in moments of life or death decision-making. Taken together, these provide a framework on which to structure our clinical judgment. But what if, in the heat of the moment, other forces kick in and drive behaviors and thinking that may set the stage for disaster?
Our hearts and brains aren’t just the anatomy and physiology that we learn about in the classroom. How they work under stress, in the woods, down a mountain, or on the street, may require a deeper sense of awareness and an entirely different approach.
Whether through training in the simulation lab or ride time in the field, our focus shouldn’t just be on sharpening the mechanical or even cognitive skill sets for the job. We also need to recognize and manage the instincts and emotions that drive us, thereby better adapting to rapidly changing conditions and cues that might otherwise be missed. Once we find our path in EMS, both we and our patients may do better, as we straddle together the critical boundary of life and death.
