1 / 85

Don’t Ask, Don’t Tell? Not Safe in Any Environment

Don’t Ask, Don’t Tell? Not Safe in Any Environment. J Brent Myers, MD MPH Director Wake County Dept of EMS. Never put off until tomorrow What you can put off Until day after tomorrow -Mark Twain. Take Calculated Risks. That is Quite Different From Being Rash. -George Patton.

arlo
Download Presentation

Don’t Ask, Don’t Tell? Not Safe in Any Environment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Don’t Ask, Don’t Tell?Not Safe in Any Environment J Brent Myers, MD MPH Director Wake County Dept of EMS

  2. Never put off until tomorrow What you can put off Until day after tomorrow -Mark Twain

  3. Take Calculated Risks. That is Quite Different From Being Rash. -George Patton

  4. Culture of Safety • We should be ashamed of ourselves • We have sat idly by while: • Response time has become our measure of success • The main purpose of medical direction was to catch people when they make a mistake • The patient and our providers have been lost in our anti-safety culture

  5. Areas of Focus • Clinical Decision Making • Medication errors and adverse events • Vehicle incidents • Endotracheal intubation

  6. Clinical Decision Making • Transport vs no transport • ALS vs BLS • Alternative destination

  7. Evidence • Without additional training, paramedics may have some difficulties in determining who needs transport • With additional training, paramedics may be able to do this well

  8. Medication Errors and Adverse Events • Use of drug dosing cards and clinical checklists can help reduce errors • One example from the literature: • Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care 2008;12:486-94.

  9. Results • With and without drug dosing cards: • Accuracy 65% vs 94% • Severe errors 20% vs 5% • Ten fold error rate 6.8% vs 0.8% • Correct size ETT 23% vs 98%

  10. A Distinction No Longer? Pilots Surgeons

  11. The Truth About Our MVCs • 36 deaths per year in ambulance related crashes per year • More likely to have fatalities than police or fire crashes • Occur in good weather at intersections and on straight highways • Unrestrained passengers in the back most likely to have injury/death

  12. We Should Wear These

  13. It Is Time to Stop the Madness • EMS providers are much more likely to be injured in a crash than our other public safety colleagues • There are ultra-time critical emergencies but we can tailor our response to these • We need to develop evidence-based responses and stop allowing the public to think that fast = good

  14. If All You Have is a Hammer . . .

  15. The Take Home Message • As a profession, we should: • Create an environment where near-misses and true misadventures can be shared – the so-called “just culture” • Follow the lead of the airline industry – there is no place for math in medicine but there is every place for a checklist • Never tolerate an injury to our providers or the public

  16. Do Ask, Do Tell

  17. Now That’s A Cool Idea – Hypothermia in Non-Traditional Cases J Brent Myers, MD MPH Director Wake County Dept of EMS

  18. Case #1

  19. Case #1 • 60 year old male collapses in a parking lot • Bystander notices patient on the ground with blood from back of head • Bystander compression initiated • 9-1-1 is activated

  20. Case #1 • EMS arrives to find the patient in ventricular fibrillation • Compressions are continued • Patient is a “one shock” save with only one epinephrine and one vasopressin administered • Cold IV saline is used both during and after the resuscitation

  21. Case #1 • En rte to emergency department, patient has spontaneous respirations assisted with BVM • Patient has no purposeful movement but does have some non-purposeful flailing of the arms/legs

  22. Case #1 • Is this patient a candidate for continued hypothermia treatment? • ROSC post v. fib with spontaneous movement • Laceration to the head with fall onto a parking lot • What helps with the decision?

  23. Case #1 – Post ROSC 12-lead

  24. Case #1 • Cold IV saline is continued while en route • Versed IV 5 mg required to keep patient on the stretcher • Patient continues with flailing but will not follow commands • Secondary survey reveals extensive third degree burns on the back/posterior legs

  25. Case #1 – Emergency Dept Arrival • 60 year old male arrives with the following conditions: • S/P V-fib arrest • Induced hypothermia in progress • STEMI • Head trauma • Severe burns

  26. Panel of “Experts” Assembles

  27. From theory to practice • Immediate life threat • Known – STEMI • Potential – head trauma • Critical clinical issues • Known – burns • Potential – ischemic brain injury • Now ain’t this a mess. . .

  28. So What Happened? • RSI due to patient being too restless to go for cardiac cath, but we lost our neuro exam • CT scans deferred until after cardiac cath, but who was going to the OR with an active STEMI anyway? • IV cold saline was continued, if he lives, don’t we want to maximize outcomes?

  29. The Case for the Heart • Measureable decline in survival for every 30 minutes of delay to the cardiac cath lab • Can’t argue that no other interventions will be done until the vessel is open

  30. The Case for the Brain – s/p Ventricular Fibrillation Arrest • Class I evidence from AHA • Clear recommendation of AHA and ILCOR • “Strongly recommend” from many national and international groups

More Related