Cases With a Twist: Excrement Happens

Editor’s note: Cases are obfuscated and amalgamated to protect patient privacy and provider anonymity. While staying as true as possible to the actual event, creative license is used to better explain the lesson(s) in the case.

Imagine showing up to work one day only to be pulled into your supervisor’s office and questioned, reprimanded, berated and disciplined for not following protocol. Your supervisor, after getting a notice from the quality assurance officer, refers to a trauma protocol violation you committed. He is writing you up for not providing oxygen on the scene of a major trauma case.  

In this case the patient’s legs were trapped in an auger at a rural chicken processing plant. This auger is a large machine used to grind chicken excrement. The machine accidentally restarted as the patient was inside trying to clear a jam. The auger pulled the patient’s legs down and into the machinery.

Rescue crews chose to use an acetylene torch to free the patient. The torch works by superheating and cutting the metal. The difficulty was that the excrement also would be superheated and create a highly volatile methane gas. As a result, adding oxygen to the proximity of a torch and methane gas in a confined space would be less than ideal. The team decided to limit any oxygen in favor of safety. 

Unsure if they would succeed, the crew requested a surgeon be flown in for a possible field amputation, and a helicopter was started. The police established the landing zone (as fire was tied up on the extrication efforts) on a side of the chicken coop with wire mesh and no windows. As the aircraft approached, chicken excrement became airborne, flying around the coop, spraying the crews and equipment and splattering in every direction. 

To exacerbate the scenario, when the helicopter crew got out, they didn’t have the requested surgeon because they thought they would “assess the scene before wasting the surgeon’s time.” The ground crew perceived this as arrogance, and the flight crew chose not to fly the surgeon because they didn’t trust the ground crew’s assessment skills. Upon seeing the entrapment, the helicopter crew requested a second helicopter to transport the surgeon, saying they would be unable to lift off due to safety concerns.

Knowing that waiting for a surgeon would now result in additional delays and danger, the rescue crew modified their approach. They cut much closer to the patient, freeing him but causing additional burns from the torch and heated metal. Once he was freed, the ambulance crew refused to turn the now relatively stable patient over to the helicopter crew, telling them, “You must have more important cases to attend to.” 

Put yourself in the shoes of this ambulance crew, trying to explain this scene to your supervisor as he hands you a protocol violation disciplinary form. You’re on the defensive, with a surge of fear for your job and frustration at your inability to explain before being sentenced. “Why didn’t you apply oxygen after the torch was shut down?” the supervisor asks. Your adrenaline pumps straight to your brain cells, clouding your ability to even think. You might try to answer, “The oxygen saturations maintained well, and the patient was not complaining of any difficulty breathing, just pain,” but that sounds like an excuse. “The air crew took over,” you might try to add. 

Discussion

This case has multiple twists that are worthy of discussion. If you have read previous columns, you will not be surprised to hear a reiteration of the importance of critical thinking in a world where “excrement happens.” Our protocols have traditionally been considered standing orders, mandatory actions from our medical directors. Many times they’re thought of as directives that require compliance instead of guidelines for best-case scenarios that may need modification. In this context, “deviation” is “violation.” But it is critical we learn to think of these cases in a more commonsense way, with a calm, patient-centered approach. Sometimes our care is really about thinking critically and determining a reasonable course of action within the principles and guidelines of good healthcare. 

In 1997 Dr. Lucian Leape, a Harvard professor and member of the Committee on Quality of Health Care in America, testified that only 2%–3% of major errors were reported because people hide their mistakes. Leape went on to say, “A punitive approach shuts off the information that is needed to identify faulty systems and create safer ones.” 

These concepts are at the core of establishing a no-blame “just culture.” At its core just culture describes three duties: the duty to act, to follow procedural rules and to avoid causing unjustifiable risk. In this case the crew was forced to modify their initial care approach to avoid risk—an action that should be rewarded, not punished.

It is true the crew could have placed oxygen on the patient during transport. This was a human error—an oversight, not a choice. In this case just culture would guide us to console the crew for having such a challenging case in which it would be natural to forget something; reward them for thinking critically during a crisis; then obtain more information to identify a root cause for the error and refine processes to mitigate future mistakes. 

Medicine, like aviation, has made significant progress in establishing a just culture. Unfortunately many EMS agencies continue to focus on holding individuals accountable for errors instead of improving systems that protect patients from the mistakes we know humans commit. We know we are not perfect—to err is human, after all—so why not build redundancies that ensure errors won’t hurt patients? This will require a major shift in our culture, one that requires EMS to learn and adopt a culture of safety. (To learn more about this, see www.emscultureofsafety.org.)

A second element that caused harm to the crew and patient in this case was a breakdown in teamwork: The police landing a helicopter without thinking of the consequences of rotor wash, a flight crew thinking they knew more than a ground crew, and ultimately a ground crew that chose to retaliate against the air crew and put the patient at further risk.

We included this element of the story because it illustrates the need for collaborative and trusting relationships among all arms of public safety, EMS and healthcare. All components of the team have important roles, none greater than the other. A flight nurse/medic has more training than a street medic, and medics more than EMTs and first responders, but that does not mean they’re more important. Each member of the team plays a vital but different role in the patient care continuum. 

Understand the Physiology of Hemoglobin Saturation

Understanding the physiology of hemoglobin saturation helps us think critically about the potential benefits and dangers of monitoring and using oxygen. 

This patient’s SpO₂ maintained well. However, a well-maintained saturation in the presence of hemorrhage can be somewhat misleading. While the percent of saturation will likely be accurate, the amount of hemoglobin that remains within the vasculature cannot be appreciated. 

Consider this rudimentary example: If an uninjured patient has 100 hemoglobin molecules and an SpO₂ of 100%, then it can be assumed that all 100 hemoglobin molecules are completely saturated. Now consider the patient with acute hemorrhage. They may have 75 hemoglobin molecules (25 lost through the injury) with an SpO₂ of 100%; then it can be assumed that all 75 hemoglobin molecules are completely saturated. If 100 molecules is the normal value in this scenario and 25 molecules are lost to hemorrhage, we can deduce that the patient has lost 25% of their entire blood volume, and while all molecules are saturated, the oxygen demands of the body are not met. One study actually found that in severely anemic patients, SaO₂ was frequently overestimated when the hemoglobin ranged from 2.3–8.7 g/dL (normal is about 12 g/dL).

While it was reasonable to delay oxygen therapy in this patient during the extrication for the reasons noted, oxygen should have been applied as soon as the patient was removed from the scene. The crew simply became distracted with other tasks. In a previous column we discussed employing checklists to prevent errors (see www.emsworld.com/12158110). Using the cross-check methodology with your partner will help ensure critical steps like O₂ therapy are not neglected.

CRM Tips: Just Culture

Just culture encourages reporting: As a result of a punitive work environment, and because healthcare workers and the lay public often believe healthcare-related errors are caused by personal carelessness, most healthcare organizations are unaware of the extent of their errors and injuries.

E.V.E.N.T.

Help identify errors and near-miss events that affect the safety of EMS providers and patients by reporting anonymously at www.emseventreport.com. Data collected will be used to develop policies, procedures and training programs.

Bibliography

Brewer K. How a “Just Culture” Can Improve Safety in Health Care, www.medscape.com/viewarticle/746089. 

Helmreich RL. On error management: lessons from aviation. BMJ, 2000 Mar 18; 320(7,237): 781–5.

Jay GD, Hughes L, Renzi FP. Pulse Oximetry Is Accurate in Acute Anemia From Hemorrhage. Ann Emerg Med, 1994 Jul; 24(1): 32–5.

Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manage Rev, 2009; 34(4): 312–22.

Lazarus I. On the road to find out…transparency and just culture offer significant return on investment. J Healthc Manag, 2011; 56(4): 223–7.

Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med, 2002 Oct; 77(10): 1,001–6. 

Leape LL. Testimony, United States Congress, House Committee on Veterans’ Affairs, Oct. 12, 1997. The Joint Commission. Sentinel Event Alert, Aug. 27, 2009, www.jointcommission.org/assets/1/18/SEA_43.PDF.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area. 

Will Krost, MD, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.