The Golden Hour
"If he looks like shit, he is shit," our instructor tells us to begin our trauma assessment lecture. "If he's shit, get out of there. I don't mean leave him there, I mean pack him up and get to the hospital."
Trauma is any kind of injury caused by an outside force, be it a bullet, baseball bat, knife, dashboard or anything else. Trauma calls make up about one half of medical call outs. In order to determine the extent of the trauma, the EMT needs to be able to perform a rapid assessment of the patient in about under two minutes.
The lecture on how to carry out this assessment is two hours long.
Theres a lot to get through. With any severe call you have what is known as the Golden Hour. In other words you have sixty minutes from when the person drops or presents to get them into the operating room. The hour begins when the person begins having their problem. Give maybe five minutes for either the patient or someone else to call 911, another five (because I'm bad at math and don't want to say two or three) for dispatch to get the nature of the call and call fire/rescue. Let's say we're at the grocery store when the call comes in so our response time is down a bit and we get to the scene in ten minutes. That's twenty minutes gone.
Once on scene we have to get all of our gear and get into the house, find the patient and make sure we don't need any additional resources. Maybe ten minutes on scene. But let's say the patient is a 435 pound behemouth and we need to call in an additional engine for man power to lift him. Theres another five minutes. Since my department is a non-transporting EMS provider (we don't have ambulances, just a Squad like Johnny and Roy on the old Emergency! show) we have to wait for AMR to scramble an amubulance, give them five minutes because they don't usually go to the market.
So forty minutes after the patient first presented symtoms we're still working.
Once AMR gets him loaded up and decides whether or not they need one of us to jump in and help out (keep in mind an ambulance needs a driver and with a crew of only two its hard to give a severe patient adequate care) another five minutes are gone.
The ride to the hospital will invariably be through traffic, and we have fifteen minutes to get from Holden to Medical City in downtown Worcester. Even with lights and sirens it's going to be close.
At the emergency room we have to get the door unlocked, get the stretcher in and deal with the doctors who have most likely forgotten about the call we placed on the radio on the way in because they are bogged down with other patients and probably dead tired from working late rounds.
Best case senario, getting a patient from the scene into the OR is going to be very close to exceeding the one hour mark. Now after that one hour, chances of survival fall, shatter the floorboards and drill down through bedrock. With prehospital medical care, speed is your friend but it can also screw things up. Make a wrong assessment or administer the wrong drug and the patient could have a reaction. Lights and sirens allow you to run a red light but there's always some asshole who sees it as his god given right not to stop for you...not to mention the jerk riding your bumper so he can skip through traffic lights too. You have to go fast but you have to pay attention.
An EMT needs to be able to get on scene, make quick, accurate decesions regarding patient assessment and care and get out with the patient fully packaged--- be it on a backboard, MAST Trousers or any devices and get to the hospital.
Just because my department doesn't transport doesn't mean I'm off the hook. The ambulance will always arrive after fire/rescue because thats protocol. Having an ambulance with two private company EMTs arrive at a car or house fire first is useless. They don't have bunker gear or fire equipment and chances are their rig will just get in the way. So fire goes first.
The plus side is that we get to the scene with all of our equipment and take charge immediately. The downside is that we need to have the patient ready to roll as soon as AMR or whoever is providing EMS arrives on scene. Since we can't transport in the Squad (there's no stretcher bay, or stretcher for that matter) we need to get the guy on a backboard or StairChair and then strap him onto the ambulance's stretcher. If the ambulance gets stuck in traffic or a snowbank, whatever....its still tick tock, tick tock.
Time, as you can plainly tell is not a luxury afforded to emergency workers. The necessity for us to be fast and do our jobs appropriately is drilled into our heads at the Academy (fire and EMS).
To get an idea of what its like to perform a Rapid Assessment in the alloted time, find a book you've never read before, preferably one you know nothing about. Take nine random pages and read them, while developing an understanding of their contents in two minutes. Then, while you are reading nine more pages, come up with an accurate and coherent summary of the first nine pages.
The nine pages represent the areas of the body we assess immediately.
At the head we assess breathing, airway, circulation, skin color/temperature/moisture. We move on to the neck and check for vein distention, tracheal shift and C-Spine injuries.
At the chest we assess breath sounds, expansion and heartrate. The abdomen has us checking for rigidity, distention, tenderness and discoloration. We check the legs for obvious injuries and deformities.
Once we've done our intial assessment, we don't have time to write anything down so we just remember it and start taking vital signs--- pulse, blood pressure, breathing rates, pulse ox.
Over the course of ten minutes you will have to take in and remember the equivalent of reading ninety pages of something as foreign to you as the Soviety Military Handbook on Propper Table Manners. But you do it, and you do it well or the person who has trusted you to take care of them and make sure they live to see Little Hiram's Bar Mitzvah will not make it.
Deep down this job is about helping people and caring for your fellow human being. We don't like to admit it, its not macho to talk about loving your fellow man. Thats why we spend so much time beating ourselves up at the gym, thats why we love destroying things in a fire, its why we drink, fart, tell dirty jokes and act like cavemen at the station. We try to act like Steve McQueen--like we're tough guy badasses who do our job for the thrill (and they are some of those)--- but deep down we do it because we love people. Firefighters and EMTs, yeah even cops too, do what they do not to be macho but because we want to help people. We can go into a burning building and tear the place apart, joking and laughing during the clean up, yeah someone's life is ruined but if we think about it ours will be too. We may destroy a sofa or a dresser but you can be damn sure we will grab and protect any photoalbums we find. One minute we'll be swearing and sparring at the station, telling dirty jokes and the next we're holding the hand of an old lady with no family left to be there when she rides in the back of an ambulance.
So thats why we spend hours training for the worst, its not because we're disaster perverts, its because we want to be ready to help our neighbors. Don't get me wrong though, if we get to destroy stuff, use our cool toys and drive really fast, its defintly bonus.
Trauma is any kind of injury caused by an outside force, be it a bullet, baseball bat, knife, dashboard or anything else. Trauma calls make up about one half of medical call outs. In order to determine the extent of the trauma, the EMT needs to be able to perform a rapid assessment of the patient in about under two minutes.
The lecture on how to carry out this assessment is two hours long.
Theres a lot to get through. With any severe call you have what is known as the Golden Hour. In other words you have sixty minutes from when the person drops or presents to get them into the operating room. The hour begins when the person begins having their problem. Give maybe five minutes for either the patient or someone else to call 911, another five (because I'm bad at math and don't want to say two or three) for dispatch to get the nature of the call and call fire/rescue. Let's say we're at the grocery store when the call comes in so our response time is down a bit and we get to the scene in ten minutes. That's twenty minutes gone.
Once on scene we have to get all of our gear and get into the house, find the patient and make sure we don't need any additional resources. Maybe ten minutes on scene. But let's say the patient is a 435 pound behemouth and we need to call in an additional engine for man power to lift him. Theres another five minutes. Since my department is a non-transporting EMS provider (we don't have ambulances, just a Squad like Johnny and Roy on the old Emergency! show) we have to wait for AMR to scramble an amubulance, give them five minutes because they don't usually go to the market.
So forty minutes after the patient first presented symtoms we're still working.
Once AMR gets him loaded up and decides whether or not they need one of us to jump in and help out (keep in mind an ambulance needs a driver and with a crew of only two its hard to give a severe patient adequate care) another five minutes are gone.
The ride to the hospital will invariably be through traffic, and we have fifteen minutes to get from Holden to Medical City in downtown Worcester. Even with lights and sirens it's going to be close.
At the emergency room we have to get the door unlocked, get the stretcher in and deal with the doctors who have most likely forgotten about the call we placed on the radio on the way in because they are bogged down with other patients and probably dead tired from working late rounds.
Best case senario, getting a patient from the scene into the OR is going to be very close to exceeding the one hour mark. Now after that one hour, chances of survival fall, shatter the floorboards and drill down through bedrock. With prehospital medical care, speed is your friend but it can also screw things up. Make a wrong assessment or administer the wrong drug and the patient could have a reaction. Lights and sirens allow you to run a red light but there's always some asshole who sees it as his god given right not to stop for you...not to mention the jerk riding your bumper so he can skip through traffic lights too. You have to go fast but you have to pay attention.
An EMT needs to be able to get on scene, make quick, accurate decesions regarding patient assessment and care and get out with the patient fully packaged--- be it on a backboard, MAST Trousers or any devices and get to the hospital.
Just because my department doesn't transport doesn't mean I'm off the hook. The ambulance will always arrive after fire/rescue because thats protocol. Having an ambulance with two private company EMTs arrive at a car or house fire first is useless. They don't have bunker gear or fire equipment and chances are their rig will just get in the way. So fire goes first.
The plus side is that we get to the scene with all of our equipment and take charge immediately. The downside is that we need to have the patient ready to roll as soon as AMR or whoever is providing EMS arrives on scene. Since we can't transport in the Squad (there's no stretcher bay, or stretcher for that matter) we need to get the guy on a backboard or StairChair and then strap him onto the ambulance's stretcher. If the ambulance gets stuck in traffic or a snowbank, whatever....its still tick tock, tick tock.
Time, as you can plainly tell is not a luxury afforded to emergency workers. The necessity for us to be fast and do our jobs appropriately is drilled into our heads at the Academy (fire and EMS).
To get an idea of what its like to perform a Rapid Assessment in the alloted time, find a book you've never read before, preferably one you know nothing about. Take nine random pages and read them, while developing an understanding of their contents in two minutes. Then, while you are reading nine more pages, come up with an accurate and coherent summary of the first nine pages.
The nine pages represent the areas of the body we assess immediately.
At the head we assess breathing, airway, circulation, skin color/temperature/moisture. We move on to the neck and check for vein distention, tracheal shift and C-Spine injuries.
At the chest we assess breath sounds, expansion and heartrate. The abdomen has us checking for rigidity, distention, tenderness and discoloration. We check the legs for obvious injuries and deformities.
Once we've done our intial assessment, we don't have time to write anything down so we just remember it and start taking vital signs--- pulse, blood pressure, breathing rates, pulse ox.
Over the course of ten minutes you will have to take in and remember the equivalent of reading ninety pages of something as foreign to you as the Soviety Military Handbook on Propper Table Manners. But you do it, and you do it well or the person who has trusted you to take care of them and make sure they live to see Little Hiram's Bar Mitzvah will not make it.
Deep down this job is about helping people and caring for your fellow human being. We don't like to admit it, its not macho to talk about loving your fellow man. Thats why we spend so much time beating ourselves up at the gym, thats why we love destroying things in a fire, its why we drink, fart, tell dirty jokes and act like cavemen at the station. We try to act like Steve McQueen--like we're tough guy badasses who do our job for the thrill (and they are some of those)--- but deep down we do it because we love people. Firefighters and EMTs, yeah even cops too, do what they do not to be macho but because we want to help people. We can go into a burning building and tear the place apart, joking and laughing during the clean up, yeah someone's life is ruined but if we think about it ours will be too. We may destroy a sofa or a dresser but you can be damn sure we will grab and protect any photoalbums we find. One minute we'll be swearing and sparring at the station, telling dirty jokes and the next we're holding the hand of an old lady with no family left to be there when she rides in the back of an ambulance.
So thats why we spend hours training for the worst, its not because we're disaster perverts, its because we want to be ready to help our neighbors. Don't get me wrong though, if we get to destroy stuff, use our cool toys and drive really fast, its defintly bonus.
posted by Nick Stabile at 12:09 PM
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