So you’ve gotten the 911 call right? You’ve taken care of the patient on scene, done all those fancy skills that you learned in the schoolhouse, and now for the next step…. where do we go?

Well, we have so many choices to choose from. In scenario 1, we have a patient who has a Cincinnati positive stroke assessment with a LAMS score of 1-1-2 (3) We have that local, tertiary hospital that’s only 10 minutes away. We’ve got a thrombectomy capable neuro center that’s 24 minutes away and a an intermediate hospital capable, primary stroke center that’s 16 minutes away. Which do you choose?

In another scenario, we have a patient who presents with what you believe is septic shock, the local hospital you know from running all day has no available ICU beds but is only 7 minutes away, the next closest hospital is 30 minutes away, but you are ALS capable and can handle keeping the patient stable for the duration of transport, which facility do you transport to?

What I am trying to address here is critical decision making when on 911 calls. Not every call should just be “load and go to the closest facility” in fact, many protocols state closest appropriate facility. In my own state, there is an agreement signed between the state EMS agency and the hospitals to allow the hospitals to go on “color” statuses (some other states identify this as “diversion” and “reroutes”) For simplicity sake, we’re going to stick with the 2 primary colors we deal with… Yellow and Red. Yellow generally implies that the Emergency Room is overloaded with patients. This includes EMS units already there and en route (yes, they track that too!) and their waiting room from walk-ins. Red status implies that there are NO cardiac monitored beds available throughout the entire hospital. This doesn’t mean just the ER…. It’s the entire facility. (Note, it’s not just physical beds, they may lack the proper staff to care for patients in those beds too)

Why do I bring those up? Because those absolutely should be brought into your decision making processes. So you have a stable patient, who potentially will be admitted, but you know that the closest hospital is on “colors” (or your state/local’s equivalent) so there will be a significant delay. The patient will likely sit in the ER for hours, and I do mean HOURS waiting for either a bed “upstairs” to open or for a bed elsewhere to open up and then they have to wait for an interfacility transport (IFT to come get them. From my time prior to career 911, and my time as a patient before, that wait for IFT can be 3-6 hours or more…. Sure, you may have gotten back to your recliner sooner, or cleared for that next stubbed toe faster, but did you really serve the patient?

Think about the patient the next time when you’re delivering care. Think about the needs beyond the call. Think about the outcomes. A friend of mine once suggested, and I concur that every medic student would do well to have a shift shadowing a hospitalist to see outcomes and how the “backend” of our EMS calls are handled. Too often I see EMS crews only worried about the immediate needs, which yes, they are important, but we should be thinking about the end goals of the patients as well. This is what will separate us as technicians into clinicians. It is often difficult to recognize these situations, and when a patient would best benefit from these decisions. Often times we can only learn when best to apply this through advanced knowledge and experience gained through time and education.

Separate note: This can be protocol and state/locale specific. You may not be able to just make that call on your own. You as a clinician may have to consult online medical direction and request the ability to bypass a local ER for your patient. If you have to make that call, be prepared to answer the hard question of WHY do you believe that the patient would be better served at a different facility. Be ready to use sound medical reasoning, not just your “feelings” on a radio report. I always recommend erring on the side of your patient, so do so with your best medical knowledge and with consult accordingly.

/End Rant

-The Hazmat Medic

The post Making the Right Patient Destination Decision…thinking ahead first appeared on The Hazmat Medic.

Recently, I saw a series of videos, vblogs or whatever the younger crowd is calling them these days about DNRs, and end of life care being discussed, and the resulting commentary was frankly disturbing. This lead to a discussion with some trusted colleagues (fellow medics) as well as a family member of my own who is a BSN and RN. One of the scariest things I’ve found, in general, is that many many people treat DNRs as “do not treats” regardless of the “level” of DNRs. An example in my state, is there are DNR B (Palliative only) vs DNR A/DNIs, which is “do everything except intubate” and they still don’t try as hard. Without delving deep into the multitude of studies, they do exist showing that even in facilities, staffs don’t try as hard regardless of “types” of DNRs when they exist. I bring all this up as a preamble to the core of these underserved patient populations.

Arguably, you’d think the job of explaining the DNR/MOLST/POLST form (depending on your state) would fall on the hospitalist and/or hospice group right? Except often times they’re all too busy to do so. Often times just what is on the DNR form isn’t actually explained to a patient. How often do you see the front page checked “palliative only” yet the back page (the one for the inpatient stuff) shows “do everything.” I had a patient once where no one explained the difference to them at what DNR A1, DNR A2 (DNI) and DNR B meant. They literally had no idea what they were signing, nothing was explained to them. On the other hand, when they are sent home on hospice care often times they just get dropped off by a private EMS transport and left… with little to know information or even planning or care in how to help arrange their homes to help prevent future calls.

Often times, family members call us because they don’t know what to do. We are their last line of defense, the solution to the “hand in the air, I’m lost.” An abbreviated example, I was called for a service call to a residence to assist a family member with her recently returned to home husband who had been placed into hospice care. The IFT crew had just brought him home and left him in his upstairs bedroom. They’d provided no guidance on helping her prepare the home for him, or how to setup the house for his end of life care. The hospice team had not gone over any of the papers with her, none of the MOLST forms, DNR forms, living wills, etc. Now being on the fire engine, we don’t carry stair chairs (she had asked us to help move him downstairs) so we had called for an ambulance to bring one to us non-emergency, while we waited I decided to go over some of this stuff with her. Spent the next 20 minutes or so helping her rearrange some furniture, plan how to setup her home, go over the MOLST form, what numbers in the folder to contact regarding the living will etc. Explaining what to call for, what we need we can help her with, what we can’t actually help her and everything else. In the end, the extra 20 minutes spent with the patient’s spouse set her mind at ease, has definitely alleviated further calls for service that many would call “useless” or “wasteful” and improved the quality of life for the patient in his end-of-life care for comfort in the end of life care.

The bottom line here, is that while less than maybe 5-10% of the calls are “guts and glory” we should be pay attention to the other 90-95% of the calls. Take the extra few minutes, even if you’re tired and don’t want to, to just speak for a few minutes to the family members. Those few minutes might save you an hour or two later. That public perception makes a big difference later.

The post The Underserved community within our community. first appeared on The Hazmat Medic.

𝐼𝑡𝑠 𝑒𝑎𝑟𝑙𝑦 𝑒𝑣𝑒𝑛𝑖𝑛𝑔 𝑎𝑛𝑑 𝑦𝑜𝑢 𝑎𝑛𝑑 𝑎 𝑙𝑜𝑐𝑎𝑙 𝑓𝑖𝑟𝑒 𝑐𝑜𝑚𝑝𝑎𝑛𝑦 𝑎𝑟𝑒 𝑐𝑎𝑙𝑙𝑒𝑑 𝑓𝑜𝑟 𝑎 “𝑐ℎ𝑒𝑐𝑘 𝑜𝑛 𝑡ℎ𝑒 𝑤𝑒𝑙𝑓𝑎𝑟𝑒” 𝑐𝑎𝑙𝑙 𝑓𝑜𝑟 𝑎 𝑐𝑖𝑡𝑖𝑧𝑒𝑛. 𝑇ℎ𝑒 𝑐𝑎𝑙𝑙𝑒𝑟 𝑖𝑠 𝑡ℎ𝑒 𝑐𝑖𝑡𝑖𝑧𝑒𝑛’𝑠 𝑏𝑟𝑜𝑡ℎ𝑒𝑟, 𝑤ℎ𝑜 𝑠𝑡𝑎𝑡𝑒𝑠 ℎ𝑖𝑠 𝑏𝑟𝑜𝑡ℎ𝑒𝑟 𝑖𝑠 𝑎 𝑑𝑖𝑎𝑏𝑒𝑡𝑖𝑐 𝑎𝑛𝑑 ℎ𝑒 ℎ𝑎𝑠𝑛’𝑡 𝑏𝑒𝑒𝑛 𝑎𝑏𝑙𝑒 𝑡𝑜 𝑔𝑒𝑡 𝑖𝑛 𝑡𝑜𝑢𝑐ℎ 𝑤𝑖𝑡ℎ ℎ𝑖𝑚 𝑓𝑜𝑟 𝑠𝑜𝑚𝑒 𝑡𝑖𝑚𝑒 𝑎𝑛𝑑 𝑖𝑠 𝑟𝑒𝑞𝑢𝑒𝑠𝑡𝑖𝑛𝑔 𝑓𝑖𝑟𝑒/𝑒𝑚𝑠 𝑝𝑟𝑒𝑠𝑒𝑛𝑐𝑒 𝑡𝑜 𝑒𝑣𝑎𝑙𝑢𝑎𝑡𝑒 ℎ𝑖𝑠 𝑏𝑟𝑜𝑡ℎ𝑒𝑟. 𝐼𝑡’𝑠 𝑎 𝑟𝑜𝑢𝑡𝑖𝑛𝑒 𝑐𝑎𝑙𝑙, 𝑟𝑖𝑔ℎ𝑡? 𝑆𝑜𝑚𝑒𝑡ℎ𝑖𝑛𝑔 𝑦𝑜𝑢’𝑣𝑒 𝑑𝑜𝑛𝑒 𝑡𝑖𝑚𝑒 𝑎𝑛𝑑 𝑡𝑖𝑚𝑒 𝑎𝑔𝑎𝑖𝑛, 𝑠𝑜 𝑦𝑜𝑢 𝑔𝑒𝑡 𝑖𝑛 𝑡ℎ𝑒 𝑢𝑛𝑖𝑡 𝑎𝑛𝑑 𝑟𝑒𝑠𝑝𝑜𝑛𝑑 𝑡𝑜 𝑡ℎ𝑒 𝑠𝑐𝑒𝑛𝑒. 𝑈𝑝𝑜𝑛 𝑎𝑟𝑟𝑖𝑣𝑎𝑙, 𝑦𝑜𝑢 𝑓𝑖𝑛𝑑 𝑎 𝑑𝑜𝑜𝑟 𝑙𝑜𝑐𝑘𝑒𝑑, 𝑤𝑖𝑛𝑑𝑜𝑤𝑠 𝑎𝑟𝑒 𝑐𝑙𝑜𝑠𝑒𝑑, 𝑎𝑛𝑑 𝑦𝑜𝑢 𝑐𝑖𝑟𝑐𝑙𝑒 𝑡ℎ𝑒 ℎ𝑜𝑢𝑠𝑒, 𝑒𝑥𝑐𝑙𝑎𝑖𝑚𝑖𝑛𝑔 “𝐹𝑖𝑟𝑒 𝐷𝑒𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡!” 𝑜𝑣𝑒𝑟 𝑎𝑛𝑑 𝑜𝑣𝑒𝑟, 𝑤𝑖𝑡ℎ 𝑛𝑜 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒. 𝐺𝑖𝑣𝑒𝑛 𝑡ℎ𝑒 𝑐𝑖𝑟𝑐𝑢𝑚𝑠𝑡𝑎𝑛𝑐𝑒𝑠 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑏𝑟𝑜𝑡ℎ𝑒𝑟 𝑜𝑛 𝑠𝑐𝑒𝑛𝑒 𝑦𝑜𝑢 𝑚𝑎𝑘𝑒 𝑡ℎ𝑒 𝑑𝑒𝑐𝑖𝑠𝑖𝑜𝑛 𝑡𝑜 𝑜𝑝𝑒𝑛 𝑡ℎ𝑒 𝑑𝑜𝑜𝑟. 𝐴𝑠 𝑦𝑜𝑢 𝑜𝑝𝑒𝑛 𝑡ℎ𝑒 𝑑𝑜𝑜𝑟 𝑠ℎ𝑜𝑡𝑠 𝑟𝑖𝑛𝑔 𝑜𝑢𝑡, 𝑦𝑜𝑢 𝑑𝑖𝑣𝑒 𝑜𝑓𝑓 𝑡ℎ𝑒 𝑝𝑜𝑟𝑐ℎ, 𝑦𝑜𝑢𝑟 𝑝𝑎𝑟𝑡𝑛𝑒𝑟 𝑔𝑒𝑡𝑠 𝑠ℎ𝑜𝑡 𝑖𝑛 𝑡ℎ𝑒 𝑐ℎ𝑒𝑠𝑡 𝑎𝑛𝑑 𝑜𝑛𝑒 𝑜𝑓 𝑡ℎ𝑒 𝑐𝑟𝑒𝑤 𝑜𝑓𝑓 𝑡ℎ𝑒 𝑓𝑖𝑟𝑒 𝑒𝑛𝑔𝑖𝑛𝑒 𝑔𝑒𝑡𝑠 𝑠ℎ𝑜𝑡 𝑖𝑛 𝑡ℎ𝑒 𝑙𝑒𝑔𝑠, 𝑎𝑏𝑑𝑜𝑚𝑒𝑛 𝑎𝑛𝑑 𝑏𝑎𝑐𝑘. 𝑌𝑜𝑢𝑟 𝑝𝑎𝑟𝑡𝑛𝑒𝑟 𝑑𝑖𝑒𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑎𝑚𝑏𝑢𝑙𝑎𝑛𝑐𝑒 𝑒𝑛 𝑟𝑜𝑢𝑡𝑒 𝑡𝑜 𝑡ℎ𝑒 ℎ𝑜𝑠𝑝𝑖𝑡𝑎𝑙, 𝑡ℎ𝑒𝑦 𝑡𝑟𝑦 𝑡ℎ𝑒𝑖𝑟 𝑏𝑒𝑠𝑡 𝑏𝑢𝑡 𝑡ℎ𝑒𝑦 𝑐𝑎𝑛’𝑡 𝑟𝑒𝑣𝑖𝑣𝑒 ℎ𝑖𝑚. 𝑌𝑜𝑢 𝑓𝑖𝑛𝑑 𝑜𝑢𝑡 𝑙𝑎𝑡𝑒𝑟 𝑡ℎ𝑎𝑡 𝑑𝑖𝑠𝑝𝑎𝑡𝑐ℎ 𝑤𝑎𝑠 𝑖𝑛𝑓𝑜𝑟𝑚𝑒𝑑 𝑜𝑓 𝑝𝑟𝑒𝑠𝑒𝑛𝑐𝑒 𝑜𝑓 𝑓𝑖𝑟𝑒𝑎𝑟𝑚𝑠 𝑏𝑢𝑡 𝑛𝑒𝑔𝑙𝑒𝑐𝑡𝑒𝑑 𝑡𝑜 𝑖𝑛𝑓𝑜𝑟𝑚 𝑐𝑟𝑒𝑤𝑠. (𝑅𝐼𝑃 𝐿𝑡/𝑃𝑎𝑟𝑎𝑚𝑒𝑑𝑖𝑐 𝐽𝑜ℎ𝑛 “𝑆𝑘𝑖𝑙𝑙𝑒𝑡” 𝑈𝑙𝑚𝑠𝑐ℎ𝑛𝑒𝑑𝑖𝑒𝑟)

𝐴𝑛𝑜𝑡ℎ𝑒𝑟 𝑐𝑎𝑙𝑙, 𝑦𝑜𝑢 𝑎𝑛𝑑 𝑦𝑜𝑢𝑟 𝑝𝑎𝑟𝑡𝑛𝑒𝑟 𝑎𝑟𝑒 𝑐𝑎𝑙𝑙𝑒𝑑 𝑓𝑜𝑟 𝑎𝑛 𝑎𝑙𝑡𝑒𝑟𝑒𝑑 𝑚𝑒𝑛𝑡𝑎𝑙 𝑠𝑡𝑎𝑡𝑢𝑠. 𝑈𝑝𝑜𝑛 𝑎𝑟𝑟𝑖𝑣𝑎𝑙 𝑦𝑜𝑢 𝑛𝑜𝑡𝑖𝑐𝑒 𝑡ℎ𝑒 𝑐𝑎𝑙𝑙𝑒𝑟 𝑖𝑠 𝑤𝑒𝑎𝑟𝑖𝑛𝑔 𝑎 𝑓𝑖𝑟𝑒𝑎𝑟𝑚 𝑜𝑛 ℎ𝑖𝑠 ℎ𝑖𝑝. 𝐵𝑒𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑡𝑎𝑡𝑒 𝑦𝑜𝑢’𝑟𝑒 𝑖𝑛 𝑎𝑡 𝑡ℎ𝑒 𝑡𝑖𝑚𝑒, 𝑖𝑡’𝑠 𝑙𝑒𝑔𝑎𝑙, 𝑦𝑜𝑢 𝑗𝑢𝑠𝑡 𝑛𝑜𝑡𝑎𝑡𝑒 𝑖𝑡. 𝑊ℎ𝑒𝑛 𝑦𝑜𝑢 𝑒𝑛𝑡𝑒𝑟 𝑡ℎ𝑒 𝑟𝑜𝑜𝑚 𝑦𝑜𝑢 𝑒𝑛𝑐𝑜𝑢𝑛𝑡𝑒𝑟 𝑎𝑛 𝑎𝑔𝑖𝑡𝑎𝑡𝑒𝑑 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑤ℎ𝑜 𝑖𝑠 𝑝𝑎𝑐𝑖𝑛𝑔 𝑏𝑎𝑐𝑘 𝑎𝑛𝑑 𝑓𝑜𝑟𝑡ℎ. 𝑌𝑜𝑢 𝑛𝑜𝑡𝑖𝑐𝑒 𝑎𝑛 𝑢𝑛𝑠𝑒𝑐𝑢𝑟𝑒𝑑 𝑓𝑖𝑟𝑒𝑎𝑟𝑚 𝑜𝑛 𝑡ℎ𝑒 𝑏𝑒𝑑 𝑛𝑒𝑥𝑡 𝑡𝑜 𝑡ℎ𝑒 𝑝𝑎𝑡𝑖𝑒𝑛𝑡. 𝑌𝑜𝑢 𝑚𝑜𝑡𝑖𝑜𝑛 𝑡𝑜 𝑦𝑜𝑢𝑟 𝑝𝑎𝑟𝑡𝑛𝑒𝑟 𝑤ℎ𝑜 ℎ𝑒𝑙𝑝𝑠 𝑚𝑜𝑣𝑒 𝑡ℎ𝑒 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑎𝑤𝑎𝑦 𝑓𝑟𝑜𝑚 𝑡ℎ𝑒 𝑓𝑖𝑟𝑒𝑎𝑟𝑚 𝑠𝑜 𝑦𝑜𝑢 𝑐𝑎𝑛 𝑚𝑜𝑣𝑒 𝑖𝑡 𝑤ℎ𝑖𝑙𝑒 𝑦𝑜𝑢 𝑐𝑎𝑙𝑙 𝑓𝑜𝑟 𝑝𝑜𝑙𝑖𝑐𝑒 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒.

𝑇ℎ𝑒 𝑙𝑎𝑠𝑡 𝑒𝑥𝑎𝑚𝑝𝑙𝑒; 𝑦𝑜𝑢’𝑟𝑒 𝑐𝑎𝑙𝑙𝑒𝑑 𝑡𝑜 𝑎 𝑟𝑒𝑠𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑎 3 𝑠𝑡𝑜𝑟𝑦 𝑔𝑎𝑟𝑑𝑒𝑛-𝑠𝑡𝑦𝑙𝑒 𝑎𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡 𝑓𝑜𝑟 𝑎𝑛 𝑢𝑛𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑖𝑣𝑒 𝑝𝑎𝑡𝑖𝑒𝑛𝑡. 𝑌𝑜𝑢 𝑎𝑟𝑟𝑖𝑣𝑒 𝑎𝑛𝑑 𝑠𝑒𝑒 𝑎 𝑦𝑜𝑢𝑛𝑔 (𝑒𝑎𝑟𝑙𝑦 20𝑠) 𝑚𝑎𝑙𝑒 𝑝𝑎𝑠𝑠𝑒𝑑 𝑜𝑢𝑡 𝑜𝑛 𝑡ℎ𝑒 𝑏𝑒𝑑. 𝐴𝑙𝑐𝑜ℎ𝑜𝑙 𝑐𝑜𝑛𝑡𝑎𝑖𝑛𝑒𝑟𝑠 𝑙𝑖𝑡𝑡𝑒𝑟𝑒𝑑 𝑡ℎ𝑟𝑜𝑢𝑔ℎ𝑜𝑢𝑡 𝑡ℎ𝑒 𝑎𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡, 𝑡ℎ𝑒 𝑜𝑡ℎ𝑒𝑟 2 𝑚𝑒𝑛 𝑖𝑛 𝑡ℎ𝑒 𝑎𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡 𝑎𝑑𝑚𝑖𝑡 𝑡ℎ𝑎𝑡 𝑡ℎ𝑒𝑦’𝑣𝑒 𝑎𝑙𝑙 𝑏𝑒𝑒𝑛 𝑢𝑝 𝑝𝑎𝑟𝑡𝑦𝑖𝑛𝑔. 𝑊ℎ𝑖𝑙𝑒 𝑜𝑛𝑒 𝑜𝑓 𝑦𝑜𝑢𝑟 𝑐𝑟𝑒𝑤 𝑚𝑒𝑚𝑏𝑒𝑟𝑠 𝑠𝑡𝑎𝑟𝑡𝑠 𝑒𝑣𝑎𝑙𝑢𝑎𝑡𝑖𝑛𝑔 𝑡ℎ𝑒 𝑝𝑎𝑡𝑖𝑒𝑛𝑡, 𝑎𝑛𝑜𝑡ℎ𝑒𝑟 𝑔𝑒𝑡𝑠 𝑎𝑔𝑖𝑡𝑎𝑡𝑒𝑑 𝑡ℎ𝑎𝑡 𝑦𝑜𝑢’𝑟𝑒 “𝑛𝑜𝑡 𝑤𝑜𝑟𝑘𝑖𝑛𝑔 𝑓𝑎𝑠𝑡 𝑒𝑛𝑜𝑢𝑔ℎ” 𝑎𝑛𝑑 “𝑤ℎ𝑦 𝑑𝑜𝑛’𝑡 𝑦𝑜𝑢 𝑑𝑜 𝑠𝑜𝑚𝑒𝑡ℎ𝑖𝑛𝑔!” 𝐺𝑖𝑣𝑒𝑛 𝑡ℎ𝑒 𝑑𝑒𝑠𝑖𝑔𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑎𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡 𝑡ℎ𝑒𝑟𝑒 𝑖𝑠 𝑜𝑛𝑙𝑦 𝑜𝑛𝑒 𝑤𝑎𝑦 𝑖𝑛 𝑎𝑛𝑑 𝑜𝑢𝑡, 𝑠𝑜 𝑦𝑜𝑢 𝑠𝑡𝑎𝑟𝑡 𝑡𝑜 𝑚𝑜𝑣𝑒 𝑡𝑜𝑤𝑎𝑟𝑑𝑠 𝑡ℎ𝑒 𝑑𝑜𝑜𝑟 𝑤ℎ𝑖𝑙𝑒 𝑎𝑐𝑡𝑖𝑣𝑎𝑡𝑖𝑛𝑔 𝑡ℎ𝑒 𝐸𝐼 (𝑒𝑚𝑒𝑟𝑔𝑒𝑛𝑐𝑦 𝑖𝑑𝑒𝑛𝑡𝑖𝑓𝑖𝑒𝑟) 𝑜𝑛 𝑦𝑜𝑢𝑟 𝑟𝑎𝑑𝑖𝑜. 𝑌𝑜𝑢’𝑣𝑒 𝑡𝑢𝑟𝑛𝑒𝑑 𝑡ℎ𝑒 𝑟𝑎𝑑𝑖𝑜 𝑑𝑜𝑤𝑛 𝑠𝑜 𝑦𝑜𝑢 𝑑𝑜𝑛’𝑡 ℎ𝑒𝑎𝑟 𝑑𝑖𝑠𝑝𝑎𝑡𝑐ℎ 𝑠𝑎𝑦 “𝑀𝑒𝑑𝑖𝑐 1, 𝑣𝑒𝑟𝑖𝑓𝑦 𝐸𝐼 𝑠𝑡𝑎𝑡𝑢𝑠” 𝑎𝑛𝑑 𝑝𝑟𝑎𝑦 ℎ𝑒𝑙𝑝 𝑖𝑠 𝑐𝑜𝑚𝑖𝑛𝑔. 𝑂𝑛𝑒 𝑜𝑓 𝑡ℎ𝑒 𝑚𝑒𝑛 𝑖𝑛 𝑡ℎ𝑒 𝑎𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡 ℎ𝑎𝑠 𝑝𝑎𝑟𝑡𝑖𝑎𝑙𝑙𝑦 𝑠𝑡𝑒𝑝𝑝𝑒𝑑 𝑖𝑛𝑡𝑜 𝑎𝑛𝑜𝑡ℎ𝑒𝑟 𝑟𝑜𝑜𝑚, ℎ𝑖𝑠 ℎ𝑎𝑛𝑑 𝑟𝑒𝑎𝑐ℎ𝑖𝑛𝑔 𝑢𝑝 𝑓𝑜𝑟 𝑠𝑜𝑚𝑒𝑡ℎ𝑖𝑛𝑔. 𝑌𝑜𝑢 𝑚𝑎𝑛𝑎𝑔𝑒 𝑡𝑜 𝑔𝑒𝑡 𝑡ℎ𝑒 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑢𝑝 𝑎𝑛𝑑 𝑜𝑢𝑡 𝑎𝑠 𝑝𝑜𝑙𝑖𝑐𝑒 𝑎𝑟𝑒 𝑎𝑟𝑟𝑖𝑣𝑖𝑛𝑔. 𝐶𝑜𝑚𝑒 𝑡𝑜 𝑓𝑖𝑛𝑑 𝑜𝑢𝑡 𝑡ℎ𝑒 𝑜𝑡ℎ𝑒𝑟 𝑝𝑒𝑟𝑠𝑜𝑛 𝑤𝑎𝑠 𝑟𝑒𝑎𝑐ℎ𝑖𝑛𝑔 𝑓𝑜𝑟 𝑎 𝑙𝑜𝑎𝑑𝑒𝑑 ℎ𝑎𝑛𝑑𝑔𝑢𝑛. 𝐼𝑡 𝑤𝑎𝑠 𝑎𝑛𝑜𝑡ℎ𝑒𝑟 𝑛𝑒𝑎𝑟 𝑚𝑖𝑠𝑠.

From Day 1 (ok maybe day 2 or 3) of EMT school, the phrase “Scene Safety, BSI” is a mantra drilled into students’ heads. But what is scene safety really? Scene safety encompasses a myriad of things, and this post isn’t designed to rehash it all, but focuses on what I feel is one of the most important parts of scene safety and that’s situational awareness.

So what is situational awareness? I polled a small group of like-minded medical professionals and came up with a few answers, some of which I am detailing below.

One of the main points is no scene is ever really secure, “scene safe” is a misnomer that we should refocus into refined situational awareness. A friend of mine said “Every situation is dynamic with multiple variables, which is what makes situational awareness so critical.” I 100% whole heartedly agree with her. Two other points that I also agree with, that you must learn to trust your gut instinct or “spidey sense” and that we as a profession woefully undertrain our folk for what we do on a daily basis.
I still fall back on training I received in the Marines regarding situational awareness. While it has to be adapted to civilian work, it’s easy to, as they say, “Improvise, adapt and overcome.”

The first thing I want to focus on is what we call the “OODA Loop.” This well-known concept originally by military strategist John Boyd for continual risk assessment is taught in various capacities. It’s in my opinion that it should be included in very basic core instruction for EMS and other medical fields.

So what IS the OODA Loop? Well it’s simple and complicated at the same time. Simply put, OODA is an acronym that stands for “Observe, Orient, Decide and Act.” Sounds simple right? But let’s break each one down a bit.

Observe: This is your scene size-up, they teach that fairly well over on the fire and hazmat sides, but in EMS it seems like it’s just glossed over. So what are some things to look for?

– What do you notice as you arrive? Is the area in disarray? House/location unkempt? Damage to the building? Does it appear run-down?
– Is the area known for crimes and / or drugs?
– Are there any indications for animals? Such as chains or dog houses? Growling dogs? Warning signs saying “Beware of dog?”
– Opening the door, what do you see? (We look for a lot of the same visual cues we mentioned above)
– What is the appearance of the patient?
– General impression of the family?
– Are they armed?
– Are there weapons about?
– What are your escape routes?
– Locations of furniture?
– Hazards?

Orient: So we take in lots of information, and I mean a lot, and we’re expected to process it in milliseconds. Not a lot of time to do this and it takes practice. The military and law enforcement spend months training on this from the get go and then years honing it. In a disservice to our folks in the medical field, we might get what 2-3 hours of training on this topic tops? What about practical applications? Orienting and observing happen almost simultaneously. Another caveat I would pressure you, is constantly think “where am I?” Even driving to a call, don’t rely on the “GPS” signal to track you. You should always know at least the general area of where you are. This also applies on the micro scale when you’re on scene. Always look for 2 ways out of every room. One of the “weird” things I do is I always pop the deadbolt behind me, if I can’t do that, I’ll drop one of the “spare” bags at the door or even chock it, it’s part of my thought process of avoiding being trapped. Also be prepared to move in the event that area is blocked off or becomes hazardous.

Decide: Again, this is a split-second decision; what is it I am going to do? Is this area (relatively) safe? Can I approach the patient? Is there something I need to do to ensure egress? This might be the hardest part of the topic to explain, but it’s the decision you choose to make.
Finally, we get to

 Act: This is the final phase in the OODA loop. Once you’ve taken in what the scene is, figured out where you are in the scene and what your next step is, you do it. It takes infinitely longer to describe the OODA Loop than it is to do it. In fact, many of you already do this without understanding what you are doing. The OODA Loop can pertain to literally everything you do in life, from cooking a box of pasta, driving on the interstate or running a complex active shooter call with multiple victims.
Last take-away on OODA Loops, is that they never end. As soon as you have acted you immediately start to reassess the scene, asking yourself if you action (or inaction) changed anything. You then process the entire loop over and over again.

𝐌𝐞𝐧𝐭𝐚𝐥 𝐚𝐰𝐚𝐫𝐞𝐧𝐞𝐬𝐬 𝐂𝐨𝐥𝐨𝐫 𝐂𝐨𝐝𝐞
Another key factor in situational awareness comes from Colonel Jeff Cooper, USMC (Ret.) Col Cooper developed the “Combat mindset and the Cooper Color Code.” This particular code has been revamped and adopted so many times it’s hard to track them all. While it mostly focuses on armed response in a combat zone, I’m going to put my EMS mind think spin on it. So the codes start out at the bottom level, which is “white” and elevates to yellow, orange, red and then black. Each color as it pertains to situational awareness is explained below:

– White

o White is typically compared to being asleep or aloof, completely unprepared and unready to act. One can also be in condition white when engrossed in things like their mobile phones etc. We see this kind of mindset when providers are fatigued or burned out; or just have lost their “give a damn.”

– Yellow

o This state is defined as prepared and alert, but relaxed. This should be your everyday general mental status. When you show up to work you should do a self-check, how are you feeling that day? Did you get enough rest? Do you have a lot on your mind? What can you do to help focus? Are you doing the proper checks of your gear and learning something about your area each shift? These are all concepts of preparedness that prep you for the next phase.

– Orange

o Here is the state you should be in on calls. It’s a heightened state of awareness. A state of preparedness. Remember all those things I was talking about in the OODA loop above? Knowing exits? Knowing surroundings? That’s condition orange.

– Red

o Red is a dangerous condition. When we are in red, we are engaged. This is often referred to the “fight or flight” mode. This is when a scene has actively gotten out of control and you are in danger. Unless cornered, the best option is almost always to retreat and call for police assistance.

– Black

o THE MOST DANGEROUS OF ALL CONDITIONS. In this state people typically freeze completely in fear and/or shock. This could literally be the difference between life and death in a violent situation.

These brief synopses of the OODA Loop and Color Threat Chart aren’t meant as an end all, but a start point. You can literally make a week long (or longer!) course out of these topics.

Some other pearls I have found from other instructors and my own experiences.
– Always scan for exits/egress
– Position yourself between the patient and the egress point whenever possible
– Try not to get tunnel vision
– Place one of your EMS bags between you and the patient, at the patient’s feet, make it appear like you’re doing it just for ease of access, when really you’re creating a tripping hazard.
– Flip open deadbolts whenever you enter a residence/apartment to prevent the door from locking automatically, and also make it easy for backup to enter if needed.
– Assess the scene, don’t be afraid to call for additional help and/or police as needed.
– Keep your head on a swivel, ears open.
– Never stand directly in front of a door you’re knocking on or opening
– ALWAYS identify yourself, with proper uniforms and announcing when you make entry (Fire Dept! or “XYZ Ambulance” etc)
– Avoid “tacticool” uniforms and gear as it may provide an appearance that you’re a cop… and thus make you a target (especially in today’s climate)
– Always ensure your radio is charged and on…and not in the rig when you enter a scene. Consider it part of your PPE (You know “scene safe, BSI”)
– Be safe out there and look after your partner, sometimes that’s all you got in the streets.

References
ADTA Member Wu Chin. (2012). The Color Code of Awareness. Retrieved 06 08, 2020, from Armed Defense Training Association: https://armeddefense.org/color-code
Barishansky, S. K. (2015, 12 23). The Art of Awareness for Emergency Medical Calls. Retrieved 06 08, 2020, from Domestic Prepardness- Healthcare: https://www.domesticpreparedness.com/…/the-art-of…/
Lamberson, E. (2018, 11 01). Mindset: The Cooper Color Codes. Retrieved 06 08, 2020, from MultiBriefs: Exclusive: https://exclusive.multibriefs.com/…/law-enforcement…
NIOSH Line of Duty Death Report. (2018, 10 18). Career Firefighter killed and volunteer fire fighter seriously wounded when shot during a civilian welfare check – Maryland. Retrieved 06 11, 2020, from NIOSH LODD: https://www.cdc.gov/niosh/fire/pdfs/face201606.pdf

The post 𝐒𝐜𝐞𝐧𝐞 𝐒𝐚𝐟𝐞𝐭𝐲 𝐚𝐧𝐝 𝐒𝐢𝐭𝐮𝐚𝐭𝐢𝐨𝐧𝐚𝐥 𝐀𝐰𝐚𝐫𝐞𝐧𝐞𝐬𝐬. first appeared on The Hazmat Medic.