Build a Safety Net

   It was early in my EMS career that I first heard the phrase "safety net mentality" from Jim Adams, MD, one of the ED docs at Ingalls Memorial Hospital, where I got my paramedic education and training and where the service I worked for transported 99% of our patients.

   The thought process behind Doc Adams' safety net mentality was pretty straightforward: You have limited people and technology resources and are constantly working in an unstable environment. While calling Chicago's South Side an unstable environment may have been an understatement, his point was still well made. Jim felt that one way to hedge your bets in this work setting was to build a safety net so you were prepared when something happened to compromise your care plan. Let's talk about how to build that net.

Everybody Gets Oxygen

   Statistically, close to 25% of all EMS calls involve some form of respiratory emergency. Whether the complaint is "I can't catch my breath," "I can't breathe," or any other variation of same, any patient in this category needs supplemental oxygen therapy. Certainly, any patient appearing to be in the throes of a cardiac emergency will benefit from supplemental oxygen as well. These two groups are obvious beneficiaries of oxygen, but, in truth, anyone under duress benefits from oxygen therapy. Any time we can support the body's efforts to improve perfusion, we need to do just that.

   Inevitably, someone will raise the question, "What about those COPDers?" It is mostly urban myth that COPD patients are "hypoxic drivers" and will quit breathing if you give them too much oxygen. The vast majority of patients with COPD are not hypoxic drivers, and for those who are, it usually takes quite a bit of time for their respirations to decrease or stop altogether. It's only happened twice to me in my career, both involving long transports and extended periods of high-flow oxygen therapy--once close to 45 minutes, the other at just over an hour. In both cases, I intubated the patients and everything worked out fine. For this small subset of patients where extended high-flow oxygen therapy can be a problem, you just need to monitor the patient carefully.

   When it's all said and done, oxygen therapy will benefit almost everyone a little, and for some, it benefits them a lot, as supplemental oxygen may be all that keeps an irritable heart from heading into v-tach and potentially v-fib.

Establish Vascular Access

   Once again, Doc Adams had an incredibly astute thought process: "It's much easier to put a cannula in a pipe vs. a riverbed." How true. For any patient you identify as moderate to high risk, having vascular access is a real plus. For a moderate risk patient, one line is indicated; for high risk, start two lines.

   Clearly, if pharmacological intervention is indicated, having an IV line in place is paramount. When your patient's problem is trauma or cardiac in origin, one of the most catastrophic events is circulatory collapse, which immediately compromises perfusion and, if uncorrected, will shortly result in death. When in doubt, start two lines and either saline-lock or hep-lock one line, keeping the other at TKO/KVO. If the bottom unexpectedly falls out of the bucket, you are already positioned to respond immediately.

More Vital Signs Are Better Than Less

   One set of vital signs on a patient is nothing more than numbers. Getting a second set of vitals suddenly provides you with comparative data. Adding a third set allows you to map trends. Whether you are using 400 cc serial fluid boluses to raise blood pressure or oxygen therapy to improve blood saturation levels to correct hypoxia, multiple vital signs give you a numerical barometer as to just how effective your patient care efforts are.

   Let's say you give a 400 cc bolus to a patient you think is dehydrated. Once the fluid is in, you reassess and note that the pulse has dropped from 122 to 104 and blood pressure has risen from 88/54 to 102/68. In this case, the bolus is both diagnostic and therapeutic. It is diagnostic because the vitals confirm that your therapy is on the right track, and therapeutic because it reduced cardiac workload and O₂ consumption, and raised the BP to a more stable level.

Use Diagnostics Appropriately and Frequently

   Check blood sugar levels on any patient with altered mentation. All patients with abnormally slow, fast or irregular pulses need to be on a cardiac monitor, as well as any patient with a cardiac history or presenting with one today. Pulse oximetry allows you to monitor blood oxygen saturation levels. Capnography gives you invaluable data on CO₂ levels, and the waveform lets you stay on top of ventilation issues.

   Each of these tools is meant to supplement your assessment and patient care efforts. As always, don't let technology distract you from your patient.

   Just as a safety net protects aerial performers at the circus, a safety net mentality puts you and your patient in a much better position. Until next month...

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.