A case of decreasing resistance in ER

a case decreasing resistance in er

I keep games on the 4th home screen of my cell phone. The third screen is blank. A minuscule of energy required to swipe my thumb has prevented me one too many times from mindlessly launching an RPG. Only to realize 2 hours later I had other plans for those 2 hours. An American comedian, the late Mitch Hedberg famously joked once,

Mitch Hedberg (1968-2005)
Mitch Hedberg (1968-2005)

I have always believed that the subtle truths kneaded so artfully in seemingly light, small-talk-worthy jokes are what makes a comedian a genius. How many times have you thought that you need to pick up that particular grocery or fill up that one conference form only to instead get consumed by what was easily available?

Our mind is built so that it follows the path of least resistance no matter how insignificant the resistance is. Although smudged all over the canvas of self-help, non-fiction genre, medicine somehow isn’t used frequently to exemplify the path of least resistance.

Today, I present to you a case that inspired us at Beltar, to remove one such small resistance from our workflow. The implications as you will see were no less than life-saving.

Rural Health System : Oversimplified

Before I present to you the case, a small preamble: Health care in rural Nepal is still run mostly by paramedics. No matter what spectrum you fall in terms of appreciating their work, the fact remains that they are the major workforce we have at the rural. It suffices to say that they are the portal of entry to the health system of our country for many. All emergency cases, once screened and declared complicated, the medical officer (usually a MBBS doctor) at the PHC sees the patient. Majority of cases are seen only by paramedics – considering 3 to 5 paramedics, usually and barely one medical officer in most PHCs.

A mobile game I wouldn't play

Now that the characters are in place, let’s dive right into the no less than a fairy tale land of the rural health system. Lamenting about the obvious lack of resources has been so old school that I don’t even make a typo while typing about it these days. We had one ECG machine at Beltar. The old ECG machine with its squeaky sound and myriad varieties of artifacts stood with all its mighty bulk inside a locked door of a room. The key protected from no one in particular by the office assistant who would open the door, drag the machine out, bring it to the bedside. The paramedic who decided to do the ECG would then untangle the wire glazed with what little of gel we had applied to the previous patient. He would then connect the limb leads and the pre-cordial leads with the trusty suction knobs which hopefully has some gel left from the previous use and then comes the biggest connection to be made: connecting the machine to the power grid. “Don’t you keep your machine charged!?”, you ask. We do. But the Li-ion battery probably has undergone autophagy, or whatever fancy name the process is given. That is a lot of steps and by extension, a lot of resistance. If this were a mobile game, I don’t think I would be addicted to it.

A Race Against Time

A patient with diabetes who had visited our ER a couple of times before was being monitored for chest pain at around 7 AM on a Saturday morning. I was washing my clothes on the first floor unaware that my Saturday is not going to be about laundry and daily chores. When I was called to check the patient, she was already deteriorating at a rate far greater than our PHC could ever catch up. We tried to borrow the speed of an ambulance and refer the patient to a higher center. An ST elevation in any two contiguous lead is an MI. Our paramedics knew that. To everybody’s surprise, ECG was not done! Given the fact that we did not have cardiac enzymes available at the PHC and Aspirin was all we could have prescribed before discharge anyway: we gave the patient 2 Aspirin tablets to chew and referred her as fast as we could. My paramedic colleagues have demonstrated utmost clinical competence and professionalism too many times to doubt any of that. The work environment was still error-prone and the circumstance demanded a change. Could we have changed the outcome given the same resources and clinical scenario? Maybe we need to decrease the resistance I thought. Changing how we store ECG (shown in the picture below), making it more accessible not only increased the frequency with which it was being used but also served as a reminder. A physical question hanging down the IV stand asking anyone who is attending a case, “Do you need to use me?”

ECG machine in plain sight with IV stand holding the limb and pre-cordial leads for accessibility

Workarounds: Because Solutions are Late to the Party.

If you have been following my writings, you’d have noticed this as another small tweak, a workaround, a nudge to the existing system so to speak that isn’t the substitute for the actual sustainable solution. Robust training that helps hard-working paramedics conceptualize and understand the protocols related to the use of basic yet life-saving diagnostics like ECG can be a start. We tried printing and pasting some protocols on the walls; another workaround we hope would help make patient care better until it actually sustainably improves. Another workaround that a friend suggested was: everyone who aches above the waist, gets an ECG. Such simplification works well to decrease the resistance in learning complex protocols. I am sure there are plenty of workarounds used worldwide, a necessity, after all, is the mother of invention. I leave you with a thought: What effect do you think will a systematic sharing of such workarounds among the rural healthcare workers will produce?

Guides to ECG electrode placement and protocols
Cite this article as: Carmina Shrestha, Nepal, "A case of decreasing resistance in ER," in International Emergency Medicine Education Project, February 21, 2020, https://iem-student.org/2020/02/21/a-case-of-decreasing-resistance-in-er/, date accessed: November 28, 2020

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So What About Those Ambulance Crews?

A few years ago, a staff pediatrician at my hospital asked me who ranked higher - a paramedic or an Emergency Medical Technician (EMT)? I remember thinking two things: first was the obvious "duh!", but the second was "hmm...maybe some things are not so obvious to non-Emergency Medicine (EM) physicians."

If you are already doing an EM rotation at an Emergency Department (ED), then chances are that EM is already established or is being established at that locale. Chances are, your ED is receiving ambulance traffic and of course you know the answer to the above question.

So why even talk about pre-hospital emergency medical services (EMS) at all? What does that have to do with your EM/ED rotation, or even with your future EM practice?

Image by F. Muhammad from Pixabay

Receive your information about a patient directly from the ambulance personnel.

For one thing, it’s simply prudent and efficient. What was happening at the scene? Who called? Who else is coming? What did the EMS medics do or not do? What is the patient’s primary concern, and does that match or not match the ambulance crew’s primary concern?  Much information can be lost or misconstrued if we solely rely on the nurses, even worse – on paper, to tell us the full story.

Watch the patient on the EMS gurney carefully

Often their facial mimics, gestures and the way they are looking around the ED will tell you a lot. Can they transfer to the ED bed themselves? What’s their body mechanics while doing that?  There is much to learn here in just a few seconds –  trust me.  The patient may not end up being yours, but in a little bit of time, an hour or two, look them up on the ED board and see if your own initial impression was right: sick or not sick? Serious or so-so? Admitted or discharged?  This is a critical skill to hone for any EM provider.

Anticipate EMS patient needs even before they are roomed.

While it is true that most of our ED patients are walk-ins, multiple analyses have shown in multiple locations around the world that the EMS patient population tend to be sicker. So this population is where some of those cool and awesome procedures that you want to see, learn or perform are often found.  Healthy 18-year-old man, tall, suddenly short of breath while playing basketball with his friends – there is your chest tube arriving, see?

Your main task is to learn to comprehend the entire emergency care system. EM providers in EDs do not function in isolation. We are part of the emergency care continuum and should thus be those most proficient is seeing and knowing the big picture. EMS is the beginning of that picture.

EM physicians all around the world participate in pre-hospital work via multiple avenues:  supporting public and sporting events, serving as cruise physicians, staffing ICU-ambulances and EMS support vehicles, flying on medical helicopters, writing EMS protocols, training paramedics and providing real-time phone, radio or teleconsultations. Chances are, you will too!

So while you are rotating at an ED, especially a foreign ED or one away from your home base, take a small effort to learn about the local EMS. Talk to the medics, talk to ED personnel taking EMS radio calls and look pertinent things up on the internet on your own (like local EMS protocols). Talk to the attending EM physicians in your ED –  chances are, one of them is the local EMS guru!

Some simple things you may wish to focus on to gauge any EMS system anywhere

Finally, many an interesting medical student or resident research project began out of some EMS-related consideration or observation, so keep your eyes and ears open for those research ideas!  Good luck!.

Cite this article as: Anthony Rodigin, USA, "So What About Those Ambulance Crews?," in International Emergency Medicine Education Project, May 31, 2019, https://iem-student.org/2019/05/31/so-what-about-those-ambulance-crews/, date accessed: November 28, 2020