A lot of people compare a critical care scene to spaghetti . There are IV lines everywhere, the BP cuff hose and pulse ox are tangled in the mess, and the ventilator is never on the same side of the bed as everything else... Sending facilities don't pay much attention to this kind of stuff because when the patient is theirs, they don't really move much. However, when we come in, we have to unravel two weeks worth of wound up mess. To me, this is my least favorite part of the call. It was easy for the nurse to hook up those seven infusions with a piggy back on each one, but transferring them to my own tubing can be a real task! So, I've come up with a system for fighting through the mess that works well for me and my crew. Maybe you will find these tips useful too!
I've made up and actually printed the cards you see below, but I have yet to deploy them on real calls. Right now, I am just telling people their roles prior to arriving on scene. I have, however, used these cards in simulation, and they worked very well. The idea is that the provider wears the card during the call, or keeps it in their pocket so that they can check things off their 'to-do' list as the call progresses. Hopefully soon we will actually deploy these for real calls. Here is a little about how they work:
The Assist!
There are three assigned roles that I give to providers (including myself) before we arrive on scene. Here is the first one, which I call the "assist."
The assist should be setting up the vent on the way to the hospital, if it isn't already done (in our ambulance, it is already set up). This leaves patient transfer and basic v/s monitoring equipment left up to this provider. Here how I might approach this provider prior to arrival on scene:
'Alright guys, I want you (physically point at the assist person) to organize the transfer of the patient. When we get in the room, take everything off of the patient except for the infusions and the vent. Then, get our bed right next to theirs, get the beds at the right height, unhook the ends of the bed sheets, and let me know when we can move the patient. After we move the patient, hook up everything you ripped off before, except obviously with our equipment.'
I like the assist person because this can be a brand new, super inexperienced person, and they will likely still feel comfortable performing this task on the the CC scene.
The Secondary!
The other roll I will assign is called the 'secondary.'
'Alright, when we get in there, we will all help -the assist-(you should probably use their actual name) with the patient transfer, and then you (actually point at them) can focus on the IV lines. We have labels in the bag, and we have all the IV tubing and pumps we need.'
The Secondary is a life saver. They start on the infusions and get as far as they can, or maybe even finish the job if they are proficient with the IV pump and tubing. This gives you time to attend to whatever else you need to do and then check back later.
The Lead CC Medic
This leaves you. The lead CC medic in charge of the call.
Let's catch up. The patient is already on our bed, the v/s monitoring equipment is being hooked up, and your secondary is working on the infusions. Next, there is something I've been doing for a while now that I absolutely think makes everything a lot easier. I will move the patient's hospital bed completely out of the room, or totally out of the way (or have the staff do it). This gives us a lot of room to work with, and we now can have 360 degree access to the patient. After I do this, I will attend to the duties listed above. If the patient needs titration or administration of medications, I will do that. If I am ready to transfer vents, I will recalculate their settings and put them on my own settings. If they have an art line, i'll quickly switch that over. What about the report?
The report is absolutely the LAST thing I try to do when on a scene (unless there seems to be something I need to know immediately). In fact, if someone tries to stop me while I'm on my way to the patient's room, I'll politely tell them that I am going to establish patient care and get the patient moved over before I take their report, and that I'll be right back. The staff is usually relieved when I saw this, since they want to get their unstable patient out of their hospital as fast as possible. If the patient is very unstable and there is an ongoing resuscitation going on, the staff is in the room anyway, and I can receive report while we are doing everything I mentioned above. Whenever I recommend this to people, this are always a little skeptical. Consider the following interaction (this is the average report I usually get):
'We've had them for a few hours. She's a 60 year old female. They were altered, now intubated. Possible sepsis. I'll page respiratory for the vent and tube stuff. They have IV access. PICC line on the left arm, peripheral on the right. They have propofol going, we had to put them on levophed too. I put the labs in the packet, I know their white count was like 13. Some kind of infection, unknown source. Possibly pneumonia. Their last vitals were ------------. ECG was sinus. They are going to the medical ICU at the receiving hospital.'
This would usually end with me asking follow up questions, which causes the provider to have to check the computer, which takes forever. Let's consider a different scenario next. In this scenario, I've not received report first, and have gone into the room, established patient care, and assessed the patient and their interventions before talking to the sending staff.
Lead CC Medic: "Okay we have the patient moved over to our bed and my team is currently evaluating them and switching some equipment over. I saw their wristband, 60 year old female, your pump is infusing according to 70kg. I'll tell you what I already know so I don't waste any of your time. I saw that they have a size 8 ETT at 23 at the teeth, and I already have some vent settings figured out for her based on her height. PICC in the left which we are switching onto now, 20 gauge peripheral in the right. Levophed and propofol infusion. We are switching them to ketamine right now, and did have to increase the levophed to 10 mcg/min. We took a set of vitals just now, they were --------------. MAP is coming up with the levophed increase. Can you fill me in on the story?'
At this point they will give me the stuff I don't know, or tell me where I can find it. Most of the things we receive in a report we can quickly find out by just walking into the room and assessing the situation and the patient. This gives us the opportunity to ask more relevant questions when I do decide to get report.
3 quick tips for making your scene a little easier to manage.
1. Don't butt your bed up against the hospitals bed with the IV pole closest to their bed. This makes the whole transfer more complicated. And, make transfer of the patient to your cot your first priority!
2. Remove the patient's hospital bed from the room after you move them over (you can have the staff do this).
3. Always make the roles clear!
