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CASES WITH A TWIST W h e n E x h a u s t i o n E q u a l s E r r o r s A crew is too tired to go, but too scared to say "no" 12 APRIL 2016 | EMSWORLD.com S ooner or later even the most "normally quiet" shift turns into a nonstop, back-to-back, cra- zy-busy nightmare of a day. In this month's case, our crews start their rural-based 24-hour shift expecting to get their usual morning nap, a sit-down lunch and dinner, and be tucked in by 10 p.m. watching the evening news. In fact, they are so sure this will be a "typical" slow shift in "the boonies," they both stayed up late the night before, one working a second job, the other nursing a sick child. However this Tuesday in December offers an entirely new experience for both crew members. The ambient temperature is below zero and for call after call, the crew drags the stretcher through slowly accumulating snow and slush. As they eat ED cookies and gas station sandwiches when they can, things finally seem to slow down at 1 a.m. Both crew members want to believe their day is finally done. They drift off into a deep sleep in the cab of the ambulance, parked in the bay, not even bothering going to their beds. Unfortunately, just one hour later, the tones go off again. This time they are dispatched to a "stat" transfer from the local community hospital to the level 1 trauma center, a two-hour drive away. Dis- patch information indicates the head-injured patient is intubated and on a vent with three IVs on pumps. "Is air available?" the crew asks over the radio. But before the dispatcher answers with the expected "Negative…bad weather" response, their cell phones start vibrating. Text messages from their peers taunt them: Trying to get out of the transfer again? What's the matter, don't remember the vent training in your academy? Need your beauty sleep? and, from their union steward, They better give you critical care pay for this one. As they start on the call, the paramedic, with six months on the job, begins looking up protocols for ventilator settings, as his EMT partner tries to call their dispatcher. "You know we aren't a critical care crew, right?" he asks. "Yes," the dispatcher answers, annoyed, "just go to your call! They asked for the closest rig ASAP." This patient has a documented head bleed and GCS on scene of 5. The patient was intubated at the referring facility and a mannitol drip initiated per the orders of the receiving neurosurgeon. The crew is reassured by the ER staff: "We can't send anyone, C R M T i p s : I d e n t i f y P r o b a b i l i t y f o r E r r o r The air medical world has a "no-go" rule. This rule has been established as a non-punitive way for a crew member to voice concern over safety and abort (or refuse to accept) a mission. In EMS this could be invaluable. How many times have you felt so exhausted that you were praying for a mindless run? If you've found yourself in that scenario, consider a no-go if the option is available. In the flight service, no-gos are not typically abused and highly effective. See the checklist available from Mayo Medical Transport and published in the new NAEMT safety course textbook available at www. emsreference.com/checklists. 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.