Cases With a Twist: Why We Need To Be Redundant

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.

While the house appeared simple and the call routine, the baby monitors at the door—along with a thin, nearly invisible fishing line strung ankle-high along the perimeter of the front yard—painted a more nefarious picture.

As the crew approached they nearly tripped the first booby trap. They looked at each other and began a careful retreat, retracing their steps exactly. They were a few feet into the retreat when the patient’s brother walked out the front door and asked for the crew to enter the house.

“Come quick,” he said, “my brother is off his meds. You need to help me.”

The two arriving police officers had been warned about the house being a possible methamphetamine lab. Hiding in plain sight, this suburban home with a white picket fence had drawn the attention of neighbors because of the outdoor baby monitors and strange smells. Local law enforcement didn’t have enough reason to search the dwelling until now.

The police officers quickly stepped in front of the EMS crew and were ushered inside by the brother. Seconds later the ambulance crew was summoned urgently to the basement, where they found the patient seated. “I swear he hasn’t touched the stuff [methamphetamines] for two weeks,” said his brother. “He just seems sad today and really not talking.”

The patient simply looked despondently at the crew, stood and began walking out without saying a word. One officer checked the patient’s belongings while the other moved to pat him down. The call was moving quickly—so quickly that the crew found themselves in the back of the ambulance within three minutes of entering the residence and shortly thereafter en route to the hospital.

“For your safety and ours, we will be putting on a few seat belts,” one member told the patient as he placed loose Velcro restraints. That good idea seemed like overkill until 10 minutes into the transfer, when the patient snuck his hand into his right pocket and began playing with a lighter.

It wasn’t until flames were three feet high that the attendant in the back realized the problem. As he swatted out the fire, his partner stopped the ambulance to help. Eventually the crew got the fire under control and completed the transport.

Discussion

Rapid scene times are an excellent way of minimizing danger. In this case, a meth lab is the last place you want to be. But moving quickly sometimes means that a small detail, like the lighter in this case, will elude the most thorough of patdowns.

Like so many other examples in aviation and EMS, slowing down to avoid errors is key. Slow is smooth, and smooth is actually faster. It is essential to concentrate on each key element of a call so that we don’t miss something important, especially if we detect danger or a potential life threat to us or the patient.

Redundancy is also a key to ensuring we root out errors. In this case a physical exam, including a blood sugar check and full sweep of the body, may have yielded saving the patient a burn injury and the potential lighting of the entire ambulance on fire.

The embarrassment the crew suffered when they reported the incident in the emergency department was small compared to the possible disaster the fire might have created.

Call Analysis

Given the potential for significant injury in this case, a comprehensive analysis of all variables was undertaken. The crew was commended for reporting the incident and fully assisting in the root cause analysis. As a part of the review and in addition to the operational review, the medical director was asked to weigh in on causative factors. The medical director’s review revealed that the patient, while having a significant psychiatric history, was also diabetic and, as you might suspect, arrived at the ED with a blood glucose level of 48. It is virtually impossible to know if the hypoglycemia contributed enough to the alteration in his mental status to tip the scales of his psychosis or it was simply his underlying psychiatric pathology. Either way, the glucose abnormality needed to be addressed.

In addition to missing the low blood sugar, the crew neglected to perform their own safety evaluation of the patient. It is no doubt helpful and comforting to have a patient screened by law enforcement prior to our engagement and ultimate transport, but as demonstrated in this case, it’s equally important to EMS providers to perform their own safety evaluations.

A number of incidents seen over the years in emergency departments have led to the standard practice of getting all psych and altered patients completely naked. While stripping our patients down completely in the field may be both impractical and unnecessary, it does have limited value and should not be entirely excluded.

Conclusion

This crew should be applauded for their situational awareness and honest reporting after making some understandable errors.

Instead of blaming the personnel, this ambulance service placed scrubs in the ambulances, packaged with the restraints. This made it feasible for crews to remove patients’ clothing and, if that were impractical, served as a visual cue to remind them to carefully search each patient with altered mentation.

The other innovation was to clip to the restraints a small plastic sign, made with a Sharpie and using a zip tie, that said BGL = ______. This is a cue to ensure patients with an altered mental state or exhibiting potentially combative behavior have their blood glucose checked during their care.

CRM Tips

Redundancy and confirmation are among the keys to aviation’s safety successes, especially when interdisciplinary responses require multiple agencies to work together.

In a culture of safety and conventional CRM strategy, a common principle is the “Swiss cheese model.” The idea is that we pull all processes and variables together to ensure that all holes are removed. If you look at a block of Swiss cheese, there are no visible holes. Once we slice the cheese, the holes become evident. An effective system requires many redundant layers. Ideally all layers will be solid and lack holes. Where the holes (in process) do occur, it is important to ensure that other redundant layers can compensate and the holes of multiple layers don’t align to let errors through.

E.V.E.N.T.

Help identify errors and near-miss events that affect the safety of EMS providers and patients by reporting anonymously at www.emseventreport.com. Data collected will be used to develop policies, procedures and training programs.

Bibliography

Perneger TV. The Swiss cheese model of safety incidents: Are there holes in the metaphor? BMC Health Serv Res, 2005; 5:71.

David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MD, MBA, NRP, is a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.