Saving Accounts
When was your last save?
Unless you moonlight as a relief pitcher or a hockey goalie, you were probably thinking about cardiac arrests just now. I don't remember ever hearing "save" applied to a call that didn't require resuscitation. Consider this case from 2003:
A 15-year-old female was found pulseless, hanging by her neck from the top of a tall tree in her backyard. Firefighters cut the noose, lowered the girl a few feet to the gently sloped roof of her house, started CPR and got "no shock indicated" from their AED. EMS confirmed a nonshockable rhythm, intubated the still-unconscious teen, then administered epinephrine. Almost immediately she regained a pulse and a systolic blood pressure in the low 100s. A high-angle rescue team transferred her via Stokes basket to a waiting ambulance for transport.
Was that a save? Anyone who was there would say yes--although the patient died a few hours later without regaining consciousness--because the case met two unofficial but traditional "save" criteria: return of spontaneous circulation (ROSC) and drama. Not duration or quality of life. That bothers me.
Why should we limit saves to a small subset of cardiac arrest patients, only a tiny fraction of whom ever leave the hospital? And do we really want to emphasize drama as an objective, rather than a distraction? I think the TV networks are already doing a pretty good job of that. Perhaps by broadening the use of "save," we can focus attention more on quality of care and less on collateral imagery.
What's "save" supposed to mean, anyway? My dictionary isn't much help; all entries for that noun are sports-related. Should we simply paraphrase former Supreme Court Justice Potter Stewart's remarks about pornography, and conclude that we know a save when we see one?
Let's concede "save" is one of those EMS colloquialisms--like "good call," "cluster" or "train wreck"--that help us categorize calls and, by doing so, achieve some measure of closure. By using such ambiguous expressions, though, we unintentionally ascribe quirky, even paradoxical characteristics to some cases: "train wrecks" can become "clusters," especially when the "train wreck" is really a train wreck; "good calls" aren't always good for our patients; and although all saves are good calls, not all "good calls" are saves. Maybe some of our slang is a little too quirky.
I'm thinking about old alarms that were probably considered good calls by partners, bosses and, yes, by me, too. I'm embarrassed to admit that almost all of those cases had bad outcomes for my patients--e.g., intubations that extended clinical life only an hour or two, victims of violence who never took another breath, and megacodes that left patients no more responsive than manikins. These shouldn't be saves--what did we save those people from?
To earn a save, I think we need to do more than postpone death. Whether the reprieve lasts an hour, a month, a year or longer, let's call it a save if the postcare levels of comfort and consciousness permit the patient and family to savor that favorable outcome. To summarize my working definition:
A save occurs when deliberate action by a caregiver directly prevents or delays significant deterioration in quality of life.
Scientific? Hardly. But think about cases you've had that fit those criteria. Suddenly we're not limited to cardiac arrests or near-exsanguinations. That mottled anaphylactic who learned to live without peanuts after your shot of epi? Save. That chest pain patient whom you transported to the STEMI center in time for a cath, a stent and a burger? Save. That hypoxic CHFer, alert and saturating well after you put her on CPAP? Save. Well done. Enjoy the moment. Now I have one more case for you:
The frantic father of a seizing 2-year-old handed his febrile, cyanotic son to Brad, a paramedic at one of our entertainment venues. Brad called for an ambulance, then addressed his little patient's apparent hypoxia by using a modified jaw-thrust to maintain the airway during the seizure. Brad wanted to do much more: Start oxygen, establish an IV, push Valium--all that stuff they teach in medic school. With two mandibles to control and a maximum of one per hand, Brad's options were limited. He delegated blow-by O2 to dad, quickly checked blood glucose to rule out hypoglycemia, and delivered a postictal but pink baby boy to the transport team.
Another save? I want to say yes, but I'm not sure. I don't know what happened at the hospital. If it were a cardiac arrest--even one without ROSC--I'd have all the details.
Our industry has become very good at tracking people without pulses. I used to do that for a living. We learned a lot about which resuscitative measures were worthwhile (CPR and defibrillation) and which weren't (everything else). Why not provide that same level of feedback to caregivers for all our calls? Before you decide HIPAA won't allow it, read the law: HIPAA permits the disclosure of protected health information to EMS agencies for "oversight activities." QA/QI is a big part of oversight. Think how much we could improve our care by knowing what worked. And when the outcome is a save, we could give ourselves permission to feel good about our contributions and appreciate the closure.
It would be nice to have more saves than clusters.
Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.
