I knew I was in trouble when I heard the patient praying for ME.
I’m back in school again, studying for my MSN and FNP. I have been working hard to learn as much as I can. And now I find myself remembering how, in the past, I always seemed to learn lessons the hard way. I found my most brutal professor was dean of the School of Hard Knocks. As a returning student at Hawai’i Pacific University
, I am thankful my professors are pushing me to expand my horizons. And as I think back to the beginning of my career 20 years ago, I am even more motivated to ensure nothing is missed in my education. As a family nurse practitioner, a knowledge deficit may have deadly results.
I did not start my career as a nurse; I started as a paramedic. As a rookie, I graduated with the minimal knowledge needed to operate safely. But the job is inherently dangerous, and mistakes can lead to injury or death—of the patient or the EMS crew. I learned this hard lesson on the side of Interstate 5 in central California where I responded to a call about a car that had rolled over multiple times, trapping the driver inside.
I arrived to find the car on its right side with the driver, an extremely obese woman, pinned between the steering wheel and driver’s seat. As the paramedic, I was in charge. I immediately crawled under the car, where I was able to slide through a broken window and position myself under the patient. She was injured, but hemodynamically stable. The volunteer fire department arrived shortly after and started working to extricate the woman with the Jaws of Life and other cutting tools. Just before they started cutting, they threw a blanket over the patient and me to protect us from glass and began their task.
From Jaws of Life to jaws of death
Their work proceeded well, and soon the patient was no longer trapped. Unfortunately, as a result of her release, the overweight woman slid down to the passenger side of the vehicle and came down on my head, pushing my chin to my chest and blocking my airway. Amidst the noise of the heavy rescue, my muffled calls for help went unheeded. As I began losing consciousness, I could hear the patient praying for me, “Dear God,” she pleaded, “please don’t let me kill the medic!”
This personally embarrassing story is a classic example of a medical professional acting rapidly without having a plan. Like so many of us who find ourselves in a crisis, I had tunnel vision and took action based solely upon what was in my immediate field of view. I did not make a plan with my partner. I did not wait for the fire department—the extrication experts—to arrive. I did not assess the patient from outside the car to determine if she was hemodynamically stable or required rapid extrication. Upon arriving at the scene, I had observed through the windshield of the ambulance a small hole beneath the car where I would be able to enter, and I moved directly from one place to the other without further thought. This line-of-sight action nearly suffocated me.
As stated, I, the paramedic, was in charge of the scene. My partner and the firefighters went along with my actions assuming I knew what I was doing. While I may have been in charge, I was certainly not leading the team of EMS professionals responsible for the safety of the patient effectively. Fortunately, I have learned my lesson.
Actually, I thought I had learned this lesson earlier, while studying to be a pilot, but as a paramedic, working in a different environment, I hadn’t recognized how the lesson I learned as a pilot related to emergency medical service.
Lesson on contingency planning, Take 1
During flight training, my instructor was aggravated that every time I landed, it was more like a controlled crash, and the plane always hit hard. Finally, he noticed that, just as the plane was about to touch down, my eyes were focused on the pavement, just a few feet in front of the aircraft.
“What are you thinking?” he yelled, as he grabbed the controls of the Cessna. The plane bounced five feet off the ground and he had to quickly add power. “Your eyes need to be looking at the end of the runway! Nothing near the propeller matters right now. If a deer runs onto the runway 10 feet from the nose, you can’t do a thing about it, because we are traveling too fast. If it crosses the runway 100 yards down, you can avoid it. Stop looking at the nose, and keep your eyes looking out! Try it again.”
It doesn’t matter whether we are flying an airplane, driving a car, or caring for a critically ill patient—we are either reacting to the environment or interacting with it. If I’m too close to a car and its driver slams on the brakes, I have to react and do the same. I have no control over what happens in the next few seconds. So when I drive, I maintain a proper distance and, if possible, try to avoid having another car directly beside me. Now if the driver in front of me stops immediately, I have more time to brake or swerve. These same concepts hold true in health care.
A, B, and C
As I have matured, contingency planning has become part of my everyday life. My career has taken me into high-risk scenarios with aircraft, boats, explosives, and rebel forces. Without planning, people die! When I am involved in critical operations, I have Plans A, B, and C. Having contingency plans is a way to look ahead, into the future, as a pilot does while landing. As Plan A is failing—and it frequently does—I am implementing Plan B and developing Plan C.
In my career as a critical-care transport nurse, such contingency planning was often part of my duties. With patients who might decompensate during transport, I would determine which hospitals could serve as sites for transport diversion and make certain my EMT driver was familiar with the hospital I chose and that, even before the transport started, he or she was consulting a map to know the best route.
If a patient had potential for becoming hypotensive, I calculated the drip rate well before the patient became hypotensive. If my concern increased, I would even spike the bag, connect the drip, and program the pump. Then, in those few moments when the patient actually did become hypotensive, instead of reacting to the event by calculating drug doses under stress, I did little more than turn the pump on and start working on the next plan.
As nurses, contingency planning is part of our regular activities, and we may not even recognize it. When a patient arrives in the ED with shortness of breath, one nurse may believe the etiology is secondary to acute hyperventilation syndrome, but a quality nurse will also consider multiple differential diagnoses, such as pulmonary embolus, and be prepared to take more serious action if needed. We must always recognize the current patient presentation, but also be concerned about the worst-case scenario. When we do this, we are no longer reacting to the patient, but interacting with events as they unfold.
Share the plan
We need to do more than instinctively make silent plans in our heads and consider differentials. As nurse leaders, we need to be vocal. We need to verbalize our plan to the rest of the team so they can move away from reacting to a problem and begin interacting with a solution. Your Plan A may be terribly flawed because of a problem known only to another member of your team. If you verbalize your plan, that problem can be addressed and the plan revised. Then, as the condition of the patient changes, you can easily dance left and right as if the event was choreographed, and your team members will think you’re amazing!
But, as I said, I learned the hard way. I did not look amazing to anyone that day on Interstate 5. I did, however, look cyanotic. Had I made a plan, verbalized it, and had alternate plans available, the result would have been dramatically different, and there would be no story to tell.
Fire department responders would have suggested I wait for the vehicle to be secured before entering the car. Someone would have been smart enough to think about where the woman’s body would fall when she was no longer pinned in the seat. We would have established team communications, and someone would have realized I was unable to breathe.
But, on that day, I was not a leader. I did not do contingency planning. I was a rookie, working with only one game plan and betting my life it would work. As I said, I learn the hard way!
Rene Steinhauer, RN, EMT-P, a nurse and paramedic who has worked in all corners of the world, is now working toward his MSN degree at Hawai’i Pacific University. An expert in disaster management, he is author of the book
Saving Jimani; Life and Death in the Haiti Earthquake. Steinhauer can be contacted via his webpage, www.renesteinhauer.com.