Oatmeal Cookies

My grandmother's name was Edna A Ball. For as long as I can remember she lived with us in our house in a small addition off of the back porch. She was a fixture in my life and provided me with many great memories.

In a family of Republicans she was a staunch FDR Democrat. She didn't argue politics with us, she simply told us we were wrong and that was that. As a strapping 18-year-old full of myself, one of the few people I truly feared was Gram. I knew she could whip my butt if she really wanted to. But she left the discipline to my parents and concentrated on her cooking and baking. She liked to help my mom with the Sunday meals. I still remember the Sunday noon meal waiting for us when we got home from church: Pot roast with brown potatoes, gravy, corn and rolls. Desert was usually pie of the chocolate or lemon variety.

But what she really did best was oatmeal chocolate chip cookies. She always had some stashed somewhere and they were awesome. I remember helping make them. Flour, sugar, water, eggs, shortening and cinnamon were all mixed with the chips and baked to perfection. It was a kid's dream come true. I used to think no one could bake her cookies like her. That is until I did. Yes, it's true. I bake oatmeal cookies just like Grams. The secret is the recipe off of the back of the Quaker oatmeal carton. Disappointing but true; Gram's recipe was available in every store in America. What I thought was magic as a 4-year-old was freedom as an 18-year-old. Now I could have her cookies anytime I wanted without pestering her all the time.

So why the long dissertation about cookies and Grandma's recipes? The point is this: anyone can do the same thing I did. Nestle does it all the time and makes a fortune at it. If all else fails, follow the recipe.

A recipe is no different than a protocol. A recipe is a list of ingredients and instructions that when followed result in good food. A protocol is a list of actions and instructions that when followed result in a good outcome. Now I know and you know there are no guarantees in life. Things can still get messed up even with a recipe or a protocol to follow. But we certainly stack the odds in our favor when we know what we are going to do, how to do it and when we are going to do it. We should view a protocol as a tool to simplify our job. It gives us freedom to act as well as a safety net for protection.

As I see it, protocols provide three distinct advantages:

First, a protocol defines our duty. In the most common or severe circumstances a protocol tells us what we are responsible for and gives us permission to act.

Second, a protocol decides our actions. It gives us clear steps to take to resolve certain situations. We can take these actions without fear of reprisal.

Third, a protocol defends our decisions. The framework provided by a protocol was built by our medical control doctors. They have empowered us to act in their names. As long as we neither exceed nor neglect the protocols we can defend ourselves and our actions based on the authority given to us by medical control.

A fourth and more subtle benefit is that a protocol allows us to emphasize or prioritize our assessment and skills. The hard part of EMS is figuring what is going on with our patients. Once we have an idea of what is going on we can initiate the correct protocol, and suddenly the whole team is on the same page. Our actions as a unit suddenly fall into place. The EMTs can carry out their assigned tasks knowing they are providing the appropriate initial care and paving the way for advanced care to proceed unhindered. The EMT-Is and medics are now free to concentrate on advanced skills and scene management. The whole process becomes more organized. In addition, when we are with an unfamiliar crew due to a normal crew member being ill or on vacation, the protocol gives us the framework to coordinate with each other even in new surroundings.

This discussion brings up the topic of "Cook Book Medicine," that much dreaded concept of treating without thinking. This leads to the idea that we must treat every call as a complete and separate incident from every other, thinking every call through from beginning to end. I would like to spend some time on this by asking some questions and sharing some thoughts with you.

The first question I have is: Where do we really spend most of our mental energy during an incident? I believe the answer is in the assessment phase of the incident. It is during the assessment phase that we discover the needs of the patient and the priorities for treatment.

In regard to patient assessment I believe that every incident is a complete and separate event from every other.

Even incidents of a similar nature will vary in many ways because no two patients are alike. Each patient will have their own physiological and anatomical idiosyncrasies. They will present differently and communicate differently. To take anything for granted during the assessment phase is asking for trouble. Hence, in the assessment phase there really is no time during which we cannot make informed, intelligent decisions based on our ongoing thinking process. In the assessment phase of patient treatment the "cookbook" only applies to standard questions that get you started. From there on out your questions can be varied and unlimited based on the answers your patient gives.

The second question is: How many treatment modalities are really available to us as prehospital providers? I believe there are really only two general modalities and only a few more sub-modalities. The two general modalities as I see them are the trauma patient and the medical patient. The trauma patient needs rapid triage and transport to an operating room. The only skills done on the scene are basic stabilization in preparation for transport. The medical patient may or may not benefit from certain on scene interventions and then they also ultimately need transport to a definitive care facility.

When I refer to sub-modalities I refer to the options available to us for intervention on a patient's behalf. Even here the prehospital provider's options are very limited. They typically consist of the following:

Trauma Patients

• ABC's (this would include advanced airway/ventilation interventions)
• Spinal immobilization
• Bleeding control
• Oxygen
• Rapid Transport
• IV fluids en route to the hospital

Medical patients

• ABC's
• Oxygen
• IV therapy
• Monitoring (cardiac, blood glucose, SpO2)
• Possibly drug or electrical therapy

With the exception of drug or electrical therapy, my experience tells me that most of what I do for all trauma and medical patients falls under the two lists above. (I call this "sameness.") Why then should I have to re-think, every time, my initial treatment actions? Our choices really are defined for us by our limited scope of practice and the equipment we carry.

The gist of what I am saying is this: we must think our way entirely through our assessment to come up with a plan of action and to stay abreast of our patient's condition. However, the skills involved in accomplishing our action plans almost always involve the same and require very little thinking. They are essentially rote and automatic. In their most basic sense they are a recipe for either the trauma or medical patient. In addition to this, with the exception of drug and electrical therapy, the skills listed above are generally "no harm no foul" interventions. By this I mean by taking these actions you gain significant benefits without taking significant risks. (I call this "safeness.")

Hence, once I identify the medical patient in need of definitive care I can interrupt my assessment long enough to have my team initiate the standard care package of skills in preparation for the rest of the incident. Having done this I can return to my assessment knowing the foundations for further interventions are being laid. The same applies to the trauma patient.

The practical application is this: We can make our scenes most effective by emphasizing our patient assessment skills. A good assessment = a good plan. We can make our scenes more efficient by acknowledging the "sameness" of most of our scenes and "safeness" of most of our intervention options and initiating these intervention options earlier. Said another way: "We do not need to know everything that is wrong with our patient before we do something for them."

The analogy of cookbook medicine is the obvious choice. It is up to us to use the concept of cookbook medicine appropriately. To sum things up I would say this:

• Every assessment is a unique event requiring maximum care and attentiveness
• Most interventions (with the exceptions of drug and electrical) are a recipe (protocol) and can be done prior to knowing everything about our patient.

I hope these thoughts challenge you to think about how you do your job. Thanks for your time. Be Safe.

Jim

Jim Baird is the Fire Chief for the City of Brunswick Fire Department in Ohio. He is a Certified EMS instructor and also serves as a Certified Fire Instructor for Cuyahoga Community College Fire Training Academy. He is retired from the Mesa Fire Department in Arizona where he served as Firefighter Paramedic/Captain Paramedic for 20 years. He has 29 years of experience in the emergency services. You can contact him via E-mail at JBaird@brunswick.oh.us or Bairds2468@sbcglobal.net.