How to write a PCR properly

Be matter-of-fact. Be detailed. Record your surroundings. No subjective opinions. Use direct quotes.

And look it up or ask someone if you don’t know how to spell something. How unbelievably embarrassing when your mistake is projected onto a 8-foot screen in court.

For example:

This was a 25-year-old male who was found on the couch of a rather tidy residence with his head up his ass. He otherwise appeared to be in no apparent distress, had a strong odor resembling ETOH on his breath, and c/o that his “pussy hurt.”

He was polite and cooperative, but was a poor historian and did not provide much useful detail regarding his complaint despite crew’s multiple attempts to elicit such information. He denied any vaginal trauma/bleeding/spotting/discharge or dysuria. He denied any other pain/complaint or history of similar events.

He admitted to ingesting ETOH and using “a lot of meth” over the past 24 hours.

No obvious abnormalities noted in his genital area. Physical exam otherwise unremarkable.

Pt was instructed, sternly, to pull his head out of his ass and “quit being a little bitch.” He was then instructed to walk to the ambulance, which he did with a steady gait and no apparent difficulty.

Pt was transported without incident, and he rested quietly and comfortably on the gurney.

Pt care was transferred to ED staff without incident.

Fairly straightforward, no? About 8 out of 10 PCRs you’ll write will sound like this. The other 2 will mostly be neck pain s/p fender bender.

Sometimes I get writer’s block.

It’s the damage, stupid

Frequently at wrecks, I come across crews who place way too much emphasis on the answer to the question, “How fast were you going?”

First of all, most drivers have great incentive to lie about their speed. The liars aside, many are simply unaware of how fast they really were traveling. Besides, in the majority of cases, drivers slam on their brakes, or spin out, or skid down the road on their roofs, and because they’re much more likely to be looking at what they’re about to hit and not the speedometer, they’re not going to be able to tell you with any accuracy what their actual reduced speed was at the moment of impact, if there even is an impact, which is really the only speed that matters.

Normally, I wouldn’t really care much about this stuff, but when other personnel interrupt me to ask patients, “How fast were you going?” as if they’re on to something earth-shattering, it really pisses me off.

“Why, how stupid of me. Good thing you interrupted me to ask that question. He’s a fucking child. Now go the fuck away.”

Instead, I prefer opening my fucking eyes and looking at damage, and I prefer categorizing it into minor, moderate and severe, bearing in mind that modern cars are designed to crumple and collapse around the more rigid passenger space to absorb the energy and protect the occupants, making the cars look a lot worse than the wreck really is.

Just like the degree of damage, I prefer to categorize the likely speed at the moment of impact, based on the visible damage, into low, moderate and high. Anything more, it is just handwaving. That is combined with occupant position(s), subjective complaint(s) and experience to form decisions on treatment and transport. If you’re not Sir Isaac Newton or a classical mechanics professor, it’s probably best to avoid nailing down speed to the nearest mph and writing it on your PCR.

Hey, but you do what you want. I’m just another moron driving an ambulance.

Management 101

There are all sorts of training materials devoted to the secrets behind being a successful supervisor. Is it integrity? Is it competence? Is it fairness? Is it trustworthiness? Or is it understanding?

I think that this is all a little too specific. In fact, so specific that whenever this topic is addressed in some classroom setting, the instructors inevitably provide in one way or another a huge list of 50 or 100 adjectives that describe different desirable attributes that people may want in a supervisor. Many of these words have similar and overlapping meanings as other words. Worse, students are then asked to choose several as a demonstration that different employees prefer different types of supervisors.

I submit to you that instead of thinking of specific attributes, we should be thinking of general attributes that make someone a good supervisor. I have only 2 general attributes, and in them you can see many, many of the aforementioned specific attributes:

  • Help employees by making it easier do their work properly. (Loose translation: Cut the bullshit.)
  • Protect good employees from bad employees. (Loose translation: It drives people nuts if you don’t give those bad employees the heaping amounts of shit they deserve.)

That’s all I ask.

If we look at it this way, it’s apparent that what people want in supervisors is not that varied after all.

Dear new people/probies

Perhaps it’s a generational thing, and maybe it’s not, but folks new to this line of work who actually know their places are quickly becoming extinct. These days, new people’s sense of entitlement is mind-boggling.

So, for the new person or probationary employee or “probie,” here’s a simple refresher:

  • Eyes and ears wide open
  • Mouth shut
  • Less talking and more doing
  • Earn your place
  • Build your reputation
  • Reinforce people’s faith in you

And:

  • You either want to do your work properly or you don’t. If you need to be talked to, then that means you don’t want to do it properly.
  • Bad reputations are not erased overnight. We won’t buy your I’m-a-changed-person act unless it lasts longer than what got you the bad reputation in the first place.

Come to think of it, this pretty much applies to any workplace and life in general.

Thank God we have IV access 15 seconds sooner

Sometimes I really wonder what people are really thinking. Wait – I take that back – I already have a reasonable idea of what most of our patients are (not) thinking. Sometimes I really wonder what my fellow co-workers are thinking based on what I see them doing (or not doing).

I came to work the other day and this is what I found in the ambulance:

What exactly was this last crew expecting to happen?

That is one spiked IV bag and, not one, but two flooded saline locks. Clearly the last crew to use this ambulance opened all the packages some 12-24 hours earlier to prepare these devices so that they’re “ready to go.” I’m not sure where, because none of it was used. It was “ready to go” to the trash, as far as I’m concerned.

Let’s set aside for a moment issues of sterility, aseptic techniques, general cleanliness of the patient compartment, infections and other unimportant topics. Everywhere I go, I see crews doing this. (OK, maybe not to this extent.) That’s a lot of opened but unused IV bags thrown out. Isn’t this perhaps a bit wasteful?

More importantly, what provider actually thinks s/he absolutely needs to start an IV right now at this very moment and not a second later that s/he feels it necessary to have these things pre-spiked? How long does it take to spike a bag? I don’t believe I’ve ever seen or heard of any patient who was wrested from the grips of death by an IV start that came just in the nick of time.

Seriously.

This is why you LOOK

Visualize the complaint. UNDERNEATH the clothing.

Recognize this movie scene?

You probably won't find this, but you still have to look. And touch.

Basics #2

So, let’s take a look at a hypothetical situation, even though you know it’s really not all that hypothetical, but whatever.

A certain provider has been observed, over a period of months, to take blood pressures that always ended in zeros and were almost without fail in the same range, i.e. 140/90, 130/80, etc. Well, that’s if he even bothered to take an auscultated blood pressure, and not a lazy palpated one. He also is apparently never able to measure anything under 110 – “I can’t hear it…” – while the next person who handles it never has any trouble getting 82/54 or 66/44.

Kind of a problem, especially if there’s hypotension involved, isn’t it?

No one really says anything, because there is a concern that he’ll just end up making stuff up if anyone points out that his blood pressures are crap, since there really is no real-time way to confirm his measurements. Instead, fellow providers just make sure, on actual legitimate patients, that they don’t waste time letting him take any blood pressures.

At some point, perhaps because someone has spoken to him, he begins to be observed to report blood pressures that are intricately accurate-soundin… uh, I mean, what normal providers obtain, i.e. 124/66, 158/92, etc. It’s also observed that he takes 4 times longer than before to get these numbers.

Seems suspicious.

So now, several possibilities are evident:

Previously Now
  • He was getting shitty blood pressures because he’s a lazy fuck
  • He was making up blood pressures because he’s a lazy fuck
  • He didn’t know how to take blood pressures
  • He is earnestly trying to do better
  • He is taking 4 times longer to make sure he does a good job obtaining blood pressures
  • He is simply making up the new blood pressures now that he’s been called on it
  • He still doesn’t know how to take blood pressures

The logical person would simply conclude that nothing he says is to be believed. Ever.

It’s difficult to see the good in people.

Once you’ve shown that you can’t be trusted, it’s over. And that extends to everything else you do.