Knowing Normal

For a single-vehicle crash, the mechanics of the event were impressive. A Jeep driven by a young man who looked to be in his early 20s had left the road and cleared an 8-foot-wide, 4-foot-deep culvert before slamming into a massive oak tree. As is almost guaranteed when the story is motor vehicle vs. large tree, the tree emerged mostly unscathed, minus a couple of chunks of bark. The oak would live to see another day.

For the Jeep and its occupant, the story was different. The front of the Jeep bore the half-moon damage pattern of a near-perfect hit. There was close to 2 feet of intrusion into the engine compartment, with significant deformity to the firewall as a result of the engine being torn loose from the motor mounts and shoved backward. The unbelted driver had gone up and over, wrapping initially around the steering wheel, resulting in a massive contusion to the chest wall, and then continuing up into the windshield. His face was flushed and engorged with blood. The bulging eyes and tongue confirmed traumatic asphyxia. He was clearly DOA.

My partner had done the primary survey and called me over to the vehicle and said, “Check out this guy’s chest.” I put my hand on his chest, noticing immediately that the sternum was free-floating and just kind of wobbling around. All the cartilage where the ribs attached to the sternum had been torn loose, and it appeared the skin was all that was holding the sternum in place. Though this was my first exposure to a flail sternum, I knew for certain I would not have to see it twice to recognize it the next time.

In a perfect world, our training and education should expose us to examples of all the major trauma events in EMS: tension pneumothorax, devastating head trauma, flail chest, open-book pelvic fracture, bilateral tib/fib fractures, dislocated shoulder/knee, Colles fracture of the wrist, etc. We would also see examples of the major medical events we encounter: myocardial infarction, stable and unstable angina, pulmonary embolism, hyperventilation syndrome, diabetic coma, insulin reaction, narcotics overdose, alcohol intoxication, etc. Of course, these are not inclusive lists for either category, and not one of us gets to “see it all” during our training and education and ultimate field practice.

Consider for a moment the countless volunteers who serve across our country with agencies that run between 100–250 calls a year. How does this work out for them? In truth, a flail sternum is so unique that even in a low-volume environment, one exposure is enough. That being said, with maybe two or three dozen volunteers on the department, only a couple might ever have this experience, even over an 8- or 10-year time frame. What about the rest of the folks who missed the call and thus miss the experience? In fact, a better question might be, “What about all of us?” What can we do to address this deficit in learning relative to gaining exposure to an adequate variety of pathophysiology that results in us being knowledgeable field practitioners?

First and foremost the answer is to seek out any and every opportunity to learn about the abnormal. A brief discussion with an ED doc or nurse about a particularly challenging aspect of a case contributes to your fund of knowledge. Base station meetings and continuing education classes often use case-based formats, allowing exposure to even more pathophysiology. Clearly, running more calls helps, and that would be beneficial to our brothers and sisters in the volunteer ranks, but the mathematical fact remains that the high-acuity calls will be spread among all the members of the squad, often over a lengthy period of time, in some cases many years.

One of the alternative solutions is to pursue development of an almost hypersensitive awareness and understanding of the “normals.” If you listen to enough normal breath sounds, at some point you develop an awareness and sensitivity when you hear something that is clearly different—i.e., “something just isn’t right with this guy’s breath sounds.” In time this awareness evolves to an appreciation, and if you diligently study, you eventually develop an increased understanding.

The same learning moment occurs every time you check and evaluate a pulse, as you develop muscle memory. Over time those locations become easier and easier to find. Once again, your ability to readily identify a strong, regular pulse increases the likelihood that a red flag arises when you find a pulse that’s barely palpable, fast, thready or grossly irregular.

When the abnormals aren’t readily available, the normals are still there for you, and though this path is arguably circular and more time consuming than the direct path of simply seeing aberrancies, learning is still occurring, and in the end that still contributes to an improvement of your craft.

Take the time to know the normals. 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 the EMS World editorial advisory board.