What to do ’til the EMTs arrive (and what to expect when they do)
Monday, November 19th, 2012This is another guest post from Will Kone (BusyPoorDad), who works as a paramedic and emergency manager. I couldn’t decide whether it was part of the Preparedness Priorities series or not, so I’m running it as a standalone.
I know many people are preparing for the day when the EMTs and the ambulance won’t arrive. But until then, it may help to understand their methods and how best to either assist them or keep from hindering them.
As usual, I expect Will will be on hand to talk further about this in the comment section.
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You used your kit.
Ok, now your secretary just got hurt running with scissors. No kit is going to “fix” the problem of impaled scissors. (Or any other major problem.) You need expert help. So until the world as we know it ends, this means a hospital with doctors who have x-ray’s and other expensive gear. So you will call 911.
You called 911, now what?
Most systems have a trained dispatcher. This person will try to gather info about what happened, where it happened, what you have done so far, and give help till EMS arrives. That is a lot of information to get and often collected from people in a panic.
So be ready for the dispatcher to ask you what seems like dumb questions. In the case of the running with scissors example, you might get asked, “Is the person breathing” when they were stabbed in the leg, or “Are they in a car or truck”? There are reasons for this, often because someone was not breathing after being stabbed in the leg. Not breathing makes a big difference than just stabbed in the leg.
You may be told to stay on the phone till EMS arrives, often this is to help get better directions they can relay to the responders, or to report any changes (good or bad) for the patient. When they arrive it is best to have someone outside to direct them to the patient. How long and who arrives will depend on where you are.
A major city will often have a response of five minutes or less for a life threat (like scissors in a leg) or you might get prioritized lower compared to other calls. (A wound that has had its bleeding stopped vs. someone with crushing chest pain, for instance; dispatchers will send EMS to the chest pain first.) These responders will most likely be paid professionals with the local city government or a private company contracted with the local government. They will be your neighbors in the sense that they live in the same city as you work in/live near, but you really are not likely to see them around town.
If you’re in a rural area, response times can be over 30 minutes. The people who show up will most likely be volunteers. They received your call from a paging system at home or where they work, stopped what they were doing, drove their personal car to the station, got the ambulance and then drove to where you are. Greater distances mean longer response. They are normally not paid and get all their training on their own time and in many cases on their own dime. Ninety-eight percent of the time they are unpaid professionals. They will be your neighbors; you will go to church with them, run into them at the library, shopping store, etc.
In the city or systems with paid professional EMS responders, they are likely going on several thousand calls every year. (My section is almost to 35,000 runs for the year as of October and the department expects to reach 200,000.) The advantage is the responder has a lot of experience. With that many calls they are going to run into things more often. The down side is that they will also run into a lot of “B$” calls. Any paramedic that can get through the first two years can become jaded and uncaring. It is a defensive mechanism. Most paramedics will have a health dose of jadedness, but still be very caring. They did not become paramedics to become rich or get respect. (They don’t get either in any quantity.) They want to help others.
In the rural systems, the responding department might have as few as 500 calls in a year. This means the person responding may not have lots of hands-on experience. But don’t assume this means they are not professional or capable. The top three paramedics I would want to work on me are from the rural area. They used their free time to study, practice, and train. Because they don’t get paid, they are really dedicated to the profession. They do this because they love helping others. Also, in rural areas, the number of “B$” calls are a lot lower. (The number of “why didn’t you call sooner” are much higher).
Either way, this means that when they show up to the example scissor incident they will be very pleased that: 1) it is a “real” call. And 2) that you took action to help the person. (Even more pleased that you did the right thing because you took those first aid classes.) They will do some things right from the start that you may or may not note. They want to make sure the scene is safe; rushing in where a scissor-stabbing nut running loose is will not help anyone and just add to the number of people hurt. (Or is that chest pain from a leaking poison gas line and not just a heart problem)
You will see them take “BSI precautions” — Body Substance Isolation. This means gloves mostly, but sometimes a gown or face mask/goggles. The idea is to prevent skin-to-body-fluid contact, because the responder does not know what the patient has, and the patient does not want what the responder might have. (They are around sick people all day long, who know what they have contacted.)
Once they have determined who and how many patients they have, they will focus on the patient(s). They are not ignoring you. The best source of the information they need is the patient, and the answers the patient give tells them a lot about how the person is doing. Your help is appreciated, but may not be recognized right away.
When you see them, as they first come up, give them a very quick review. For example: “Sue was running, tripped and stabbed herself with the scissors, there was slight bleeding, I stabilized the wound with some bulky dressing and wrapped the area with a bandage to hold it in place.”
If they ask you any other questions, answer, but be ready for them to not ask anything after that till they are ready to move the patient.
They will approach the patient, introduce themselves, ask what happened. They will do this even if the person is unconscious and you told them this. Partly, this is to see if the patient’s status has changed from the last time you talked to them, partly because sometimes apparently unconsious people can still hear what is going on and it does not hurt to talk to them.
The responders will assess for “life threats,” — your basic airway, breathing and circulation. If the patient is not breathing well, the responders have tools and equipment to help. It is always nice when the patient is talking; that means the airway is open and they are breathing and their heart is beating. After the initial assessment, the responders will take vitals, the pulse, blood pressure, respiration and oxygenation of the blood (SpO2%).
From that point they will likely make a choice about where to take the patient or if to take them. Yes, if. Many times patients want to take themselves to the hospital because they fear getting the bill or “don’t want to bother the paramedics.” Depending on what is wrong, the responders may agree.
If they chose to transport, expect them to continue with questions, lots of questions. We have many mnemonics for this: SAMPLE, OPQRST, DCAP-BTLS, ACBDE, etc. Many times the patient will be asked the same questions over and over. Each time care is transferred, from the paramedic to the nurse, to the physician’s assistant, to the doctor, to the other doctor, etc. This is not because none of these people talk to each other. It is due to a few factors. First, people don’t always tell the truth to different levels of care providers. What they tell the paramedic is not what they tell the nurse and they tell the doctor something else. Second reason for all the questioning is to see if the patient is having a change in mental status. If you tell the paramedic that you are 44, allergic to sulfa, and got your scissors stuck in your leg while running, but tell the nurse that you think your allergic to “suffer” and your leg hurts really bad but you don’t know why, that tells something about what is going on inside.
The people who respond to calls for help are just like you. They are concerned about their neighbors and want to help them when they are in need. They are professional and highly trained. Both rural and urban paramedics have the same requirements for certification, same continuing education requirements, and operate under the same Medical Control protocols. The only difference is one is paid, the other is not. (and in a lot of cases, the volunteer in the rural area is a paid responder in the city.)
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“Who am I? Why am I here?” The immortal words of admiral Stockdale are best answered like this: I’m William V. Kone, a First Sergeant, Paramedic, Emergency Manager, and a “Busy Poor Dad.” I’m 23 years into the Army Reserves, currently the interim Company Commander of an HHC for an Engineer Battalion. I work for an Ambulance Company and have been with EMS since 1997, and with Fire Service since 1996. I have been with rural districts in upstate New York, a Suburban district in Maryland, and currently work the City of Cleveland and Cleveland Metro area. I also work with the Emergency Management Agency in the small city I live in, have a BSc in Emergency Management and Homeland Security, level 1 Continuity Of Operations Planning certification, and am working towards my CEM.
November 19th, 2012
My only experience with a 911 dispatcher recently wasn’t that good. Actually I wasn’t the one on the phone, but the dispatcher didn’t want to know about the person who needed help, and brushed off any attempts to tell her what was wrong, but instead was obsessed over the person making the call. “Who are you? What number are you calling from?” Yes, it was a non-local cell phone. Welcome to 2012. And she kept asking “How did it happen?” even after having it explained repeatedly that we didn’t see it happen, but just came upon an unconscious man who was bleeding. Sure, she may have been trying to see if the caller stuck to this story, or if it changed, but seriously couldn’t that have been worked out later? She also didn’t have a clue which park we were at and wanted to know a street address, even though she was told the name of the park, the location in the park (“near the gazebo”), and the businesses visible from that part of the park. And then, even though it was in a big (to me) city, the ambulance took 10 minutes or more to get there. Then, when the ambulance finally did arrive (and had to park a couple hundred feet away because that’s where the street was), they slowly gathered their equipment and sauntered over to us at a leisurely pace.
All in all, not a confidence building experience. Selfishly, I was glad it was no one I knew who was in need of help. I would have probably been a bit hostile at that point if I had any emotional stake in the crisis. I was still rather put off by the whole experience.
I am sure most don’t act like that, and maybe it was just a convergence of circumstances.
November 19th, 2012
I have a friend who was an emergency dispatcher for years. He was an endless source of good gossip about human idiocy. And his stories were about equally balanced between tales of comical or crazy callers and weird things his dispatch colleagues did.
Sounds awful. But he was, and is, a really nice guy with a great sense of humor. But that job definitely takes a level of steadiness, sanity, and good sense that few possess.
November 19th, 2012
I have to add: I never heard him utter one word of criticism, or one joke, about the responders.
The only responder-related problem I know of in our area involved a knife fight. A guy was killed, but the prosecution was blown because one of the responders destroyed all the fingerprints on the weapon. It was a cop who did that, though. Not a medical responder.
November 19th, 2012
I’ve never had the greatest experience with dispatchers either… they’re too busy asking questions to listen to the answers – equally true for police, fire or EMT. I’ve even identified myself in a hospital situation, and gotten the same response.
I don’t want to sound completely negative here (though I probably do), but first of all, I’m not sure this is a PRIORITY for preparedness. While it’s good info to know when having to call EMTs, it doesn’t help *us.* I read this as how to get out of their way, if we are the first responder and EMT is the second responder.
Secondly, while they may be required to have the same knowledge, all EMTs/first responders do NOT make the same assessments, are NOT equally polite, and are NOT up-to-date or always act safely in a given situation.
I do understand that the process written above is correct; I’ve seen it transpire many times. But it’s not consistently carried out – in city OR rural areas – even within the same district.
In their defense, they are in the same position as a public health nurse going into a home – they’re forced to deal with the situation/environment as it stands, and work around it to achieve the best outcome for the patient, as quickly as possible.
November 19th, 2012
“I’m not sure this is a PRIORITY for preparedness. While it’s good info to know when having to call EMTs, it doesn’t help *us.*”
That’s why I didn’t post it as part of the preparedness series.
If he continues writing guest posts (and that’s up to him), Will may write other things that aim at explaining emergency responders and emergency managers to us skeptics. In fact, this entire idea of guest posts came up because Will and I had some fairly adamant disagreements about the value and competency of professional (or at least government-sponsored) emergency management and I invited him to give his point of view.
November 19th, 2012
I live in Rural Northerwestern AZ. I have been an EMT-B for 13 years now. I have decided to remain an EMT-B rather than upgrading my certification to paramedic due to the financial and time commitment to become a medic. My service runs 1500 calls a year, we have a 60 minute ground transport time to the nearest hospital. If we think the level of the call warrants it we will call for an airship before leaving on the call and then cancel the bird if it is not needed after we arrive onscene. On thing I wish more people would do is have a typed up current medication list, a list of all current medical conditions, and GPS coordinates for their home. This would help the dispather greatly in relaying the information to the first responders.
November 20th, 2012
Not long ago an elderly neighbor called 911 for an ambulance. Because we are in a very rural area they came to our house instead of his by mistake. The ambulance backed up our long driveway and into a tree. My wife went out to see what was going on, told them they were at the wrong place and pointed out to the driver that he had backed into a tree. His response? There’s no tree back there and I didn’t hit anything! They departed with a dent in the bumper and eventually made it to the correct house.
Years ago when enhanced 911 was making its way into our area the county government sent around questionnaires asking a lot of intrusive questions about what you had on your property and in your house (guns, flammables, chemicals, etc.) A lot of people simply threw the forms away. Others were thrilled that the government was so concerned about their safety. Even out here people are becoming less suspicious of and more dependent on authority. Sad.
November 20th, 2012
Every situation will be different. Many dispatch centers started taking 911 calls and there were no standards or guidelines. The rural area I started out in use to have two phone numbers to call for an emergency: the station – in case someone was there at the time; and the near by sheriff’s office in the next town – they had the home phone numbers of the Chief and Assist. Chief’s.
When the 911 system took hold, the radio dispatchers for the police were handed the fire and EMS calls with only a $0.25 an hour raise. (for tripling their work load) Over time, best practices’ have started taking hold. More and more systems require training of dispatchers and continued education.
But, like paramedics, they get to filter out a lot of “B$” calls. (just hit youtube for calls to 911 about fast food stores not having a menu item.) This does not excuse bad behavior, they are human and will behave like humans. Sadly we don’t have a “Worthing” set of angles (Orson Scott Card wrote of a group of humans who would protect everyone from pain and harm with their mental powers, short stories collected in “The Worthing Saga”)
The dirty little secret about paid EMS is the burn out. When EMS get together, unlike the Fire Service, they don’t tell stories about exciting things they did but rather try to out do each other with the worst calls ever. (the Patient was 500 pounds, on the third floor with narrow stairs, too weak to stand up, we were in a van-ambulance with a ferrno narrow cot and back up was 30 min out. – Paramedic 1. “That sucks, but we had a 600 pound on the 12th floor with the elevator out, were bike paramedics…-Paramedic 2) I feel this feeds into the burn out as it conditions people to look at the bad side of everything.
The more you look at the bad, the more you see it. because you see the worst of humanity in the worst situations, while looking for all the bad things, you can stop caring. Maybe you stop hurrying, “after all, all bleeding stops eventually”. Maybe you stop caring about how they feel, “don’t worry, this will hurt but I won’t feel it”. Maybe you stop feeling the urgency everyone else is feeling in an emergency, “unconscious in a park? they are dunk.” (i’ve even found myself saying these things to myself even though i’m trying not to.)
it is hard. the 8th call of the night for “shortness of breath” that you arrive and find them laying on the couch smoking a cigarette, for gout of the foot. (they called short of breath or chest pain so you would show up sooner.) can do that.
The 911 system in my city has handled over 1 million 911 calls (police, fire, ems, “good intent”, and informational) I will bet some were not handled at the professional level they should have been.
November 20th, 2012
I could tell you some bad 911 stories from California… but I won’t.
Just remember to be very careful what you tell the 911 operator. More and more such calls result in police kicking down doors, coming in with guns drawn, shooting the family pets and threatening everyone with little or no attention paid to the real reason for the call – quite often leaving the EMTs out in the cold instead of taking care of the patients.
The good news is that rural areas like mine are pretty much exempt from that nonsense. Our sheriff and the various volunteer responders ARE our neighbors and incredibly good people. The house next to me burned last year, and I was astounded at how fast the firemen got here…
And, sadly, the drunk who lived there died because of that fire. I watched the young EMTs pull him out. They were obviously upset, but very professional… loaded him into the van, and then stood around comforting each other after it pulled out. Theirs is one annual fund drive I happily contribute to.