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EMSWORLD.com | MAY 2016 13 The Facts The patient's van was not on fire. The accelerator was stuck, and the tires were spinning loudly and burning rubber. The police officers were trying to turn the car off while warding off "zombies" with expired fire extinguishers from the trunks of their squad cars. The white powder covering the "walking dead" was harm- less: The building was an unmarked (ille - gal) bakery. Imagine the surprise when our patient crashed into an employee appre- ciation party, smashing her van into a stor- age room full of large sacks of bleached flour and powdered sugar. After canceling the hazardous-mate- rials teams and extra police, the crew turned their attention to the patient: a 59-year-old female complaining of chest pain. She was conscious and begging for pain relief; the responders believed she might have been intoxicated. A three- pack-a-day smoker, she sported a diabet- ic alert bracelet. Her son reported she had a severe headache and arm numbness after taking depakote earlier in the eve- ning. The police also reported a starred windshield and bent steering column. The woman's initial vitals were BP 80/50, pulse 120 and respiratory rate 24. The paramedic student thought to ask, "Should we go to a Level 1 trauma center?" But once again the scene unfolded quickly, and before he could realize it, the back doors to the ambulance were closed and the driver was pulling into the ER across the street. There was only time for the student to begin establishing an IV and his precep- tor to put ECG patches on for a 12-lead that was still being acquired when the ambulance reached the ER garage. The ER crew, having watched the event from across the street, was ready. They rapidly interpreted 1 mm of elevation in V2 as a STEMI, starting heparin and sending the patient to the cath lab. It was the cardiology team that, upon finding no coronary blood flow obstruc- tions, finally slowed down long enough to assess the patient properly. That team discovered and fixed a pericardial tamponade, but more astutely sent the still-hypotensive patient to surgery after interrogating the aorta. The patient was really having a dissecting aortic aneurysm. Case Discussion While it might be tempting to say the scene was not safe and the crew should not have entered, the reality is that we take calculated risks every day. At first glance, with other responders on scene, this scene appeared (and eventually was proved to be) safe. We can't get out of ambulances in full hazmat suits on every call. This case evolved so quickly that responders could not keep up with changing conditions. If this happens to you, it may be time to slow down, take a step back and think. Regaining situ- ational awareness is key to ensuring safe operations. Experts suggest using three Rs: react, regain, reconstruct. A good rule to live by is "Slow is smooth, and smooth is fast." In many aviation crashes investigators discovered that someone on scene knew things were going badly but was afraid to speak up. In this case the paramedic student may have had valuable input that could have prevented hours of wait time and dangerous anticoagulation therapy in a patient having a surgical emergency. Using a flat hierarchy and promoting the use of appreciative inquiry by this para- medic student may have helped mitigate potential errors. Removing one's ego may be the hardest thing to do. In EMS we tend to place a lot of emphasis on seniority and street experience. This encourages the assumption that senior members must know what they're doing and does not empower junior members to speak up. The case also had a wide set of differ- ential diagnoses—from uncomplicated angina to chest trauma, head injury, stroke and seizure. This is the detective work of EMS, making the job more inter- esting and challenging. The hypotensive presentation with possible hemorrhage or circulatory compromise made the patient critical. Rapid transport was indicated, and the community hospital across the street may have been the right choice, but always consider that destination hospi- tal's capabilities—they can really change the outcome. In this case there was a bit of tunnel vision, which can occur when we initiate a prehospital procedure such as a 12-lead and fail to take a wider look at our assess- ment. While it is unlikely the ambulance crew would have detected a dissect- ing aortic aneurism, it would have been reasonable to suspect chest and head trauma and potential bleeding. Last but not least, during our criti- cal handoff reports, ED staff should be encouraged to stop and listen. Many trauma centers that are attuned to the culture of safety have adopted a "moment of silence." And of course, once we have the floor, we need to ensure we start with our leading differentials. If we begin with the classic "We were called for…" and cite a dispatch reason that is of little conse- quence to the condition we ultimately found, we are simply wasting precious time and diverting attention in a way that may confuse the next care provider. 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. ABOUT THE AUTHORS 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, 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. 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.