EMS World

AUG 2016

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CASES WITH A TWIST By David Page, MS, NRP, & Will Krost, MD, MBA, NRP 16 AUGUST 2016 | EMSWORLD.com E xc r e m e n t H a p p e n s A complicated entrapment leads to a crew's reprimand I magine showing up to work one day only to be pulled into your supervisor's office and ques- tioned, 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. Case Report 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 accidently 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 extrica- tion 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 sur- geon, 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 complain- ing of any difficulty breathing, just pain," but that sounds like an excuse. "The air crew took over," you might try to add. 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 medi- cal directors. Many times they're thought of as direc- tives that require compliance instead of guidelines for best-case scenarios that may need modifica- tion. 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 C R M T i p s : J u s t C u lt u r e 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 organi- zations are unaware of the extent of their errors and injuries. 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.

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