It was a tranquil, rainy night a few years back when I got the call for a “sick person.” On arrival, it was easy to understand that I was looking at a trainwreck, and I’m not talking about Amtrak, etc. I’m talking about an elderly, morbidly obese, non-English-speaking diabetic, who had bilateral knee amputations and was on dialysis and who was in and out of consciousness with severe respiratory distress. Without a doubt, she needed emergent dialysis.
Our local hospital was approximately one mile from the scene of the call, but the closest hospital that had emergent dialysis was approximately 27 miles away. When I called the hospital that had dialysis capabilities, I was told that it wouldn’t take the patient. I called my local hospital, which stated that I needed to take my patient to the dialysis hospital.
I was one block away from our local hospital when I was diverted and told that I needed to transport my patient to the next-closest dialysis-capable hospital, 45 minutes away in priority response.
I did what I was told, but I was quite certain that bad complications for the patient were on their way.
Approximately 12 minutes after I was diverted, my patient crashed and went into respiratory arrest. We worked her, and with the help of additional members of my department, we regained return of spontaneous circulation (ROSC). However, we ran into a ventilatory dilemma. I was unable to intubate the patient and to effectively ventilate her.
We now were at Plan D. My partner and I decided that it was time to cut, meaning cricothyrotomy, the emergent airway intervention by which the cricothyroid membrane that’s around the Adam’s apple is cut with a scalpel and an endotracheal tube or similar device is inserted to secure the airway.
In medic school, my paramedic instructor, the legendary Mike Smith, told us that a cricothyrotomy was a seven-minute procedure. All of us looked baffled. It didn’t make sense to us that it would take seven minutes to cut someone’s throat and stick a tube in it. Then he clarified: “It’s one minute to perform the cric, but six minutes to grow the balls to cut their throat.” Boy, he wasn’t wrong.
Decision to act
I bring this up in this column because this decision-making lag doesn’t apply only to cric when you’re a new EMT. It applies to every intervention, from minimally invasive, to critically invasive.
In all facets, we must deal with a decision to act. So, what makes you pull that trigger? I firmly believe that if I feel that I need to do something and, particularly, if I must do it right now, I probably should.
I felt this way with all of the interventions that I have done, in particular the first time—like when I needle-decompressed a patient’s chest on my third rotation as a new medic.
Usually, one’s gut feeling is pretty darn right—you know, that feeling that you get when you believe that you should be doing something, but you aren’t wanting to jump over that ledge. However, once you take that substantial step, you already are 80 percent done. The rest of what’s involved is following up to make sure that you accomplish the task that you have practiced for months or years.
Do it
We all can go back to those calls where we wish that we made a different treatment-path decision. However, you shouldn’t let those bring you down. Use those scenarios in the form of growth, to see things early in a patient’s presentation, so you can mitigate the situation as soon as possible.
I really appreciate how Nike put it back in the late 1980s: “Just do it.” If you feel as though you should pull the trigger in regard to your decision, you probably should “just do it.”
Take the step. Save the life. Do what you know.
