Hitting The Undo Button In The Ambulance
Every intervention that we introduce on emergency calls is intended to make a difference. Improve the situation in one way or another. Some will work and cause an effect that makes things better. Others will not, and may result in making things much worse.
Knowing how, why and when, or not, to go ahead is one thing, but knowing how to manage when something goes wrong, has to be our most sound safeguard in aiming for the safest of paramedic practice.
An "undo" button might exist in some of the moves we make, so we have to understand where we can find it when we need it, fast. If there is none, it becomes our duty to deal with any cascade of effects that could come tumbling down around us. The “Uncovering The Undo Button” chapter in The Good, The Bad & The Ugly Paramedic Student Handbook, has a few suggestions.
Get Familiar With Gut Feeling
The emergency nature of prehospital care creates a natural sense of urgency, but any urge to rush involves untold risk. Sometimes, our gut instincts are like a “get out of jail free” card. On those occasions that it causes us to falter, it is generally not something to ignore.
A screaming patient or family member may be persuasive enough to drown out our thoughts. Peer pressure may be priming us to carry on with an air of confidence. Fear of looking foolish may force us to forge ahead. But despite any external distraction, a nagging sensation that niggles in the back of the mind may be trying to do us a friendly favour.
Current training and education standards generally demand in-depth study and intense training over several years. During that time, we learn a lot about the intricacies of prehospital care. Although not everything can remain available for ready recall, deep down in our memory banks, we have a wealth of knowledge just waiting to break out. Sometimes, a distant snippet of information will arouse suspicion. It wants us to wait until it has worked its way back to the surface. Ready to remind us of the very thing that we really need to know in the heat of the moment.
Ignoring it is a gamble in the high stakes of patient care. So, preventing any unnecessary need to hit undo in the first place is the ultimate goal. Not to mention avoidance of the frustration involved in mentally kicking ourselves after the fact.
Weigh Up The Pros & Cons
Before we intervene, weighing up the likelihood of benefit against the possibility of harm helps us get to grips with any potential risk. Just because a protocol, procedure or guideline prescribes a particular course of action, it does not dictate that we go ahead regardless. We are educated health professionals who are entrusted with the autonomy to make educated decisions.
Seeking input from others can challenge some paramedics, those with concerns of appearing less confident, less competent or less in control. But, we cannot presume that our peers will put their hands up and say something unless we ask for their opinion. They may be comfortable commenting in the aftermath, but it holds no value whatsoever when it's too late to retract actions taken.
We might decide to go ahead and do the deed anyway. But being aware of the positives and negatives in advance prepares us to deal with any issues as they arise.
Find It In Advance
By paying heed to gut instinct and weighing up the pros and cons, we begin to build a clearer picture in the mind around methods to help us manage, or undo, the unwanted effects of interventions. Some start to sink in right from the early days of education. An accidental opioid overdose and its nemesis, naloxone. Laryngeal spasm and an influx of oxygen. Standing a hypotensive patient before quickly placing them supine.
Over time, knowledge of reversal agents and actions increases. Most of them simple and seemingly obvious, but not until we learn them from experience, education or others. Seeking them out is a vital ingredient in the recipe for success, but until we know what any intervention's undo button looks like, we have to assume that none exists. Being prepared to watch and wait in case adverse effects arise.
Stay One Step Ahead
From the point of intervention onwards, we can expect one of two outcomes, improvement or deterioration. It may be that nothing noticeable happens, but we cannot see what's happening internally. Some changes will be hidden from sight.
Steady or sudden decline is something that we react to rapidly, ready or not. Dragging items out of bags, cupboards and drawers to deal with the situation as it evolves. Any proactive preparation for the more predictable poor reactions to interventions is helpful when it’s prioritised as part of the intervention itself.
If we know that we are administering a medication likely to elicit a common reaction, our responsibility is to be ready to deal with it. When we change an unconscious patient's position, we need to be prepared to manage their airway. Should we decide to ventilate with a bag-valve-mask, we must be willing to work with the issues caused by accidental gastric insufflation.
On the other hand, it might feel exciting to see things changing. The patient's status improves, it's working, we did it! But, this is no time to sit back and bask in the glory. This could be the point at which the biggest surprises of all are sprung. Just when we think that we've done the work, our intent to improve matters means that new issues arise.
A successful intubation attempt, followed by adequate oxygenation and a range of supportive measures, may cause an unconscious patient to regain awareness, then claw at the airway adjunct. Administration of intravenous fluids in a hypotensive polytrauma case can reinitiate vascular flow into open wounds. Causing previously unnoticed severed vessels to leak without warning. Resuscitation attempts in cardiac arrest are geared toward positive outcomes. Still, the return of spontaneous circulation means that we have to switch up our stance and start from scratch with a new list of items to work through.
If every intervention is designed to make a difference, it stands to reason that we have every intention of being prepared to deal with the difference it makes. Positive or negative, something may need to be addressed in response. Staying one step ahead can help us to evade the unwanted and enhance the desired effects of our efforts.
Be Ready For The Rest
Not only do patient interventions require full attention and a proactive approach, but we can also manage numerous elements of our own safety and wellbeing in the same way.
With every step into a scene, the undo button exists in knowing the exits before we need to use them. For every long-distance transport we undertake, we need to know where to refuel before the tank ends up empty. When we lift a heavy load, we ideally have a plan in place for when and where to put that load down and rest.
In any rush to respond to situations or react to events, we can benefit from preparing ourselves for what is most likely to happen next. We’ll always be subject to uncontrollable elements. But, taking the reins of the things within our control might help to keep us calm, increase confidence, and enhance competence in providing professional, safe and effective care.
Set Up Safety Nets
Of course, it’s not always be necessary to undo, act, or deal with drastic changes in every situation, thankfully. Especially if, before we even get to that point, we set up safety nets as a matter of habit. Things that we do without thinking. Avoidance of issues arising in the first place makes for more pleasant interactions with patients, a more relaxed way of working through long shifts and a much-appreciated absence of investigations, interviews and incident reports.
Our stretcher may be one of the best and most frequently utilised options. For some, it might never become a preference. But many prioritise it over everything else in an emergency. If instinct suggests that a patient is likely to collapse, it could be worth assuming that collapse is imminent. The sooner we get them on the stretcher, the sooner we have them in a position of safety and on wheels so that we can get moving whenever we choose. No unnecessary falls trauma, less kneeling and bending to treat them, and no dangerous lift required from the floor.
With experience, plenty of ambulance personnel develop a habit of drafting an extrication plan while walking into every situation, depending on the level of chaos that greets us. If we do have an idea in mind, it frees us up to work with colleagues on critical treatment, already knowing which resources we need to call upon for help.
An ongoing approach to maintaining continuity of care while waiting in a hospital corridor helps others to ensure more predictable outcomes more often. If something works well until the point of arrival, they avoid the situation quickly changing by not stopping what they started.
Every deliberate step that we take to form preventative habits may protect us and our patients, while relieving some of the pressure involved in an emergency role. For every proactive measure that we put into place, we are actively attempting to avert adverse events. The odds instantly improve. Less time dealing with drama and more time making the most of the moments that make our jobs worthwhile.
Know What To Do When It All Goes Wrong
Something will go wrong at some point. It is an unavoidable, inevitable and expected aspect of every industry. The role of a paramedic increases the likelihood, in its constant balance, between stepping in and stepping out with educated risk. We are taught to assess a scene and decide whether to exit the vehicle before entering a situation. Gain information and vitals from a patient to determine whether or not we intervene. Drive through traffic under priority conditions, constantly reassessing risk as we go. The most stringent approaches to safety cannot predict or prevent all issues in prehospital care among unpredictable humans in the most unpredictable situations.
Accepting this fact relieves some of the pressure. Leaving us free to prepare ourselves for dealing with any dilemma. Seeking information from employers and organisations regarding systems already in place is a liberating approach to adopt.
An understanding of what is in store allows us to act appropriately in the aftermath of any accident or incident. Knowing who to call in moments of mayhem and how to handle our mishaps and mistakes is pivotal in avoiding blind panic. Admitting to errors can feel much more comfortable when we remove our fear of the unknown.
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Looking for a means of undoing mistakes is stressful no matter what is at stake. But when patient care and paramedic safety are on the line, the desire to push a range of undo buttons is undeniable. If we build our knowledge collection to know where and when they exist, they can provide us with an option as a last resort. But planning, preparing and pre-empting issues saves us some stress in the first place. Developing habits and routines that set us up to be one step ahead helps us feel satisfied and safe, rather than rushed and reactive. It may involve a little more time, but the personal and professional rewards to be gained make it worthy of all effort.
Do you have any handy undo buttons that you rely on in your everyday practice?
Thanks for reading.
Tammie
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Content
Adapted from Chapter 19 “Uncovering The Undo Button” from Book #1 in the GBU Paramedic series.
