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Little Latin Generals (Cardiology and Politics)

I suppose most paramedic students experience some sort of frustration when they are going through Cardiology and trying to integrate what they are learning to recognize on the strip into the ACLS algorhythm and at the same time figure out how to implement their newly found knowledge into ever increasing treatments and interventions they have only read about thus far.

I struggled a little with the concept of recognizing when a dysrhythmia is a good thing that needs to be coddled and supported and when it needs to be escorted from the building in an expeditious fashion so to speak.

The concept became clear for me with a political metaphor of all things.

Before we get the political unrest – Let’s look at a much simplified explanation of how the “government” of the heart is supposed to work…

In normal conduction the electrical activity of the heart is “governed” by the intrinsic rate of the Sinoatrial node (SA) – due to differences in the slope of diastolic depolarization the specialized myocytes of the SA node reach their action potential stage faster then the other specialized conduction cells. Each of these specialized cells has an intrinsic rate that is governed by a leak of ions through the cell membrane leading them towards to their action potential, and they all want to be the “guy in charge” but the “influence” of the SA node is so powerful that they never get the chance to act out due to the SA nodes impulse reaching them before they can act out on their own.

When things start to go awry and the protestors march or occupy or whatever type of political unrest makes it easier for you to comprehend things can change a little.

Let’s start with default rhythms and how I think about them – If the SA node is “in charge” of this political process let’s call it the president – the president of the heart belongs to the sinus party and when he is running the show – we see a sinus rhythm on the strip.

What happens when the “president” for whatever reason can’t do its job – Much like the democratic process we have here in the USA the heart has a backup plan in place – a “Vice President” if you will – the AV node the AV node tends to look like he belongs to the sinus party as well, but subtle difference tell us he really belongs to the junctional party – which shows up as a junctional rhythm on the 12 lead. It runs a little slower then the president does, but can be quite effective at running things.

So what if the President and the Vice president are incapacitated – in our form of Government the Speaker of House would be next in line – in the heart it would be the ventricles – The ventricles belong to a totally different party then either the president or the vice president and they don’t try to hide it either – they appear as a ventricular rhythm on the 12 lead looking very different (in most cases) then either the sinus or junction. The ventricles are slower still and (for default purposes we’ll say they) run things marginally usually just enough to get by.

The heart and our Government are set up to allow lower level sites to take over or pick up the slack for a failed or ineffective “leader” when this happens it’s a default rhythm and we should do everything we can to nurture and support it – drastic interventions into this type of rhythm can lead to “anarchy” completely knocking out the system of government and leading to chaos.

On the other hand – we have usurping rhythms…

These rhythms are the “little Latin generals” staging a coup. For whatever reason an ectopic site (little Latin general) goes off the reservation and decides it can do better job running things and tries to take over. If the “little general” manages to fire faster then “el presidente” he can totally usurp the normal leader’s authority and due to those same conduction fibers make the higher ups bend to his will. Little Latin Generals usually work really fast as evidenced by their tachycardic rate.

Generally speaking the heart (and the Government) is in total chaos at this point and maybe minimal stuff gets done – but all of the Government is in total disarray and the “citizens” (tissues in need of perfusion”) suffer –

These are the instances when as a medic we need to call in “the Marines” and provide some sort of intervention to restore order and the normal balance – whether that means a surgical strike with a specific medication to try and interrupt the ectopic sites overactive ambition or a carpet bombing with the defibrillator where we force em to “ride the lightening” and hopefully reset the normal balance depends on both the rhythm strip and the patients general presentation.

The metaphor and concept seems to work for me and makes it easy to remember – Does it make sense to you? What kind of ways do you use to understand complex processes and how they relate to your treatment plan?

 

Posted by on February 17, 2012 in Cardiology, EMS 2.0, EMT, Paramedic School

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Hindsight is always 20/20 or If had known then…

It’s only been a short while since paramedic school started, but I am already looking back to the prerequisite courses with regret. Just like most programs, my school required an A & P pre-req, as of this year they changed the minimum from needing 8 credits worth to 4; instead of the year-long course they are now accepting a one semester intro to A & P (I have my own thoughts on that, but I’ll save them for another day). I opted for the 8 credit 32 weeks of Anatomy and Physiology knowing that the knowledge gained there would provide a strong foundation to build upon during paramedic school. That was a wise choice and I have no regrets about that at all… here’s what I do regret –

Listening to all the paramedics who told me I’d never need to know most of what I was learning. The Krebs cycle (now called the Citric Acid cycle) Action potentials, Ph… the list I’m sure by the end of school will be extensive.

I have said many times that I am not now nor have I ever been interested in being a cookbook medic… give this drug for this then give that drug for that – regardless of the patients presentation… In my mind all chest pain does not necessarily equate to Oxygen, Aspirin, Nitro and Morphine – that’s not to say this isn’t effective treatment for chest pain – just that I don’t believe just because the patient says they have chest pain we HAVE to follow that particular algorithm every single time…. I want to be allowed  encouraged expected to actually THINK.

Here’s the thing that no one bothered to tell me – to understand a drug… ANY drug – you have to understand the physiological actions of the body process the drug effects FIRST in order to then understand how the drug alters that physiological action.

Do you need to understand those specifics to pass the NR exam? probably not… but again I am not interested in just memorizing a list of drugs and what they are used for… I have always wanted to know the hows and whys behind the pharmacology.

We had three lectures (the first three pharm classes) that were all about action potentials – what ions move where when, how that effects the cell and what happens when we alter the normal phases with chemistry. Two of those lectures focused strictly on Vaughan Williams antidysrhytmics  4 (5) classes of drugs that are classified by which ions movement they effect (and beta blockers).

Why did no one tell me this sooner, why did no one say… hey bud- make sure you remember that stuff cause its going to come back big time in p-school? Does it go to the educational standards of other paramedic schools where as long as you can remember the drug info on the NR sheet they don’t care if you understand what you are doing? Is it more the medics I spoke to are by definition “cookbook” and I just didn’t know it until now? Sadly, I don’t have the answers to those questions.

As a basic I wanted a good solid foundation to build on, but I only had people who had been through paramedic school already to guide me as to what was important to learn and what wasn’t. So if you follow this blog and are preparing for paramedic school – I’m telling you now

LEARN about cellular physiology – study action potentials, which ions move during which phases and what that means both to you as a provider and to your patient. Study the ways that the body maintains homeostasis, learn µ, α,and β receptors – where they are located and what they do. THIS simple thing will make your pharmacology classes SO much easier.

I am wasting valuable study time re-learning stuff I should have had down before school started – Don’t make that mistake.

Don't neglect the cellular physiology when you prepare for P school - so figures like this one don't cause you panic

 This stuff IS important and yes my friend you DO need to know it if you want to progress beyond being a cook book medic.

You can’t say I didn’t warn you…

As a reminder its Movember, and I’ve donated my face to raising awareness and funds for Men’s specific cancer… please make a small donation to help raise awareness and funding for research… You can make a tax-deductible donation here

 

Posted by on November 2, 2011 in EMS 2.0, Paramedic School

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The Pride Defense

Now that I’ve had ampule opportunity to digest my heaping portion of syllabus salad with boot camp dressing (And So It Begins…), it’s high time we take the swan dive off the high board and find out just what it is I have gotten myself into. With blind enthusiasm, I lept; landing with a thud and a huge splash in medical legal issues class.

Medico-Legal class – what else can I say. Yes, it is dull, it is boring, and it is necessary. It turns out I had prejudged the class though… this one was about to get interesting

My twisted sense of humor grew fond of the instructor (a lawyer-paramedic) telling us “unless you want your policy and procedure manual and that big ole binder with our protocols in it reconstituted in suppository form by some slimy lawyer, you will…” It would be remained funny if he hadn’t said it so often. I had a similar fascination with recto-cranial impaction for awhile so I get the draw.

After the standard misfeasance, malfeasance, abandonment, HIPPA, Good Samaritan laws, etc. Something came over him and he changed from the boring legal guy into a genuine caring paramedic.

“Look I know this stuff sucks, but it is important” Now that we have talked about the required DOT stuff let me give you MY medico-legal class. The stodgy lawyer guy was gone, as were the bad jokes and the lawyer “smell” that permeates the room sometimes when you there is an ambulance chaser attorney in the room.

There before us was a medic who genuinely cared about us as students, about his patients and EMS in general. “I’ve been doing this a long time ladies and gents, and it all comes down to three things. Three little rules that will ALWAYS have you on the right side of any encounter or treatment you render. 3 little rules that will ensure you are delivering the highest quality patient care that you each are individually capable of, and yes for those of you that worry about such things, 3 little rules that will cover your ass.

“Get out your pens and something to write with – THIS is important. In this line of work it isn’t a question of if you get sued, it’s a question of when, and in addition to making you a better medic, these 3 rules will make you as bulletproof as a medic can be. Ready…”

1 – Do what is in the best interest of your patient (this of course should be our guiding principle always)

2 – Do what your medical director would want you to do (sometimes harder to know than what is in your patient’s best interest – depending on your particular medical director and service – this one could be a sticky wicket for some of you out there.)

3- Do what you would be proud to defend. (WOW… I have never heard it put so simply and so brilliantly before.)

“Do those three things and your patients will get the treatment they need, your service will get the medic they deserve and YOU ladies and gentleman will be able to sleep at night and hold your head high when you tell people you are a Paramedic. Have a good night.”

The moment was lost on some, as they eagerly picked up their books and bolted, or began to discuss what bar they were going to meet at for beers after class. For a few of us though, we just sat there in stunned silence – jaws agape.

I felt like I had just been given the meaning of life…

Let’s be honest, if all of us could just do number three ALL the time, how much simpler would our lives as EMS providers be. Would we even need rule number 1 or 2 if we could always do 3?

Call me an idealist (you’d be right), but think about all the negative news stories you have ever heard about EMS, EMTs, Paramedics, ambulance services – public and private – How many of those stories would simply dissolve into nothingness if the individuals involved had followed rule number 3?

Do what you would be proud to defend – it’s so simple yet so eloquent.

It should be easy to remember, not most of the time, not for 98% of the calls – but for EVERY single call we run – including the “drunk” at 3 am that swears that telephone pole jumped into the road, 95 YO nana who fell down and just wants help back up when all you want to do is sleep, AND the emergent response to 7-11 – you know the one the “man down” call that proves to be a convenience store attendant is tired of looking at the homeless guy sleeping outside so he calls 911 and says “man down”.

I can’t speak for anybody but me, but I know I would not be proud to have to defend every single action I have ever taken on a call. How about you? Can you look at yourself in the mirror and say that you have honestly given every patient you have ever encountered your best?

If you can say that, then either you are deluding yourself, or your best might need a little work. For those who will say I have given every single patient, every single time nothing but the absolute best I had to offer and are neither delusional nor incompetent – where do I put in my application, I would be honored to work with such an legend partner  EMS God.

For the rest of us human EMS providers, I learned something when I was in the Corps that has stuck with me to this very day “If it feels good to do or to say – you probably shouldn’t” Following this mantra has extracted me from more than one situation that could have turned out much worse then it did. I have used it in both personal and professional life; it wasn’t until sitting in a classroom full of bored paramedic students that it hit me. My mantra was indeed sound, but it didn’t go quite far enough, particularly when dealing with someone who very well may be having the worst day of their lives.

Pride is defined as “feeling pleasure or satisfaction over something regarded as highly honorable or creditable to oneself” (1)

As I continue the journey toward the glittery disco patch, the first standard of care that I intend to change from my days as a basic is to try to remember to always ask myself  “Would I be proud to defend what I am about to do ?”

Now that is a gold standard to try and live up to.

(1)    http://dictionary.reference.com/browse/proud

 

Posted by on October 1, 2011 in compassion, EMS, EMS 2.0, EMT, legal, Paramedic School, Personal

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We’ve come a long way – with OH SO FAR to go… Part 2

I said it yesterday, and I’ll repeat it today, all of the changes and evolutions that EMS has seen over the past 20 years haven’t been as beneficial to the profession or more importantly to our patients as the ones I pointed out earlier.

I am no “rockstar” EMT who thinks he knows everything, far from it. Over 8 years I have learned a lot, sure; but there is a mountain of knowledge out there I haven’t even looked at the map for; let alone begun to climb. That being said I can also tell when the garbage stinks for lack of a better metaphor.

Newer EMT’s most 1/2 my age will view me as the idealistic dinosaur who lives in a galaxy far, far away in a time long, long ago for some of this and I suppose to some extent they’re right, but that’s a whole different post on a much wider topic .

When I got my first EMT certificate it meant something… not just to me, but to every other person who busted their butt trying to learn what being an EMT meant. No, I’m not talking about newbie enthusiasm, we had that too, this was bigger than that. There was a sense of pride in what we did and we showed it. We showed it by continuing our education beyond the bare minimums required by our state. We showed it by showing up to work with a professional appearance (read – ironed uniform, clean shaven, polished boots). We demonstrated our pride by meticulously cleaning our rig EVERY day inside AND out.We cared enough to take part in the communities we served in and were thanked by the citizens who depended on us. In short  – WE CARED about everything EMS and about being the absolute best pre-hospital care provider we could be. I’m not saying none of this happens now, but it is nothing like the way it was.

Do I blame all of this on the people becoming EMTs now? NO – I blame those of us who came before them. It was our job to pass the torch, to teach the lessons to guide the “noobs” – to make them better then we ever were. We failed miserably, we failed to pass on the pride, we failed to pass on that in its purest form this job MEANS something.

Can our failure be linked to our not caring?  In some cases maybe, even then we had mediocre providers who were content with being mediocre, the difference is that in the systems I worked with back then, they didn’t last long and they damn sure didn’t train new employees.

More often than not, The problem is that we do care, we care enough that it hurt us when we are unappreciated or treated like just another name on the schedule, both the norm nowadays rather then the exception. We care enough to be pissed off when the system is abused, not just because the “bullshit” call woke us up at zero dark thirty, but because while we were tending to the person with a cold who called 911 because she couldn’t afford a taxi – but more because  somewhere out there there could be a “real” emergency and we were unavailable. We care enough to be frustrated with the brand new partner we just got that refuses to learn anything beyond what they taught them in school, because “we don’t need to know that,” or “its outside our scope” We care enough to be mad as hell when the rig we use on a daily basis goes out with someone else and gets trashed, not just because it looks bad, but because our rhythm is now messed up with things missing or not where there are supposed to be.

WE DO CARE – so why are we content to sit complacently by while the pool of providers out there gets dumbed down so much? Why are we content with the status quo, when the status quo is what got us in this mess in the first place ? Why do we accept programs who teach their students to pass a test as opposed to treat a patient?

Increasingly, we’re not, more and more of us are coming to the realization that WE need to be the change we want to see, we hope desperately that the example  we provide to our co-workers will stick, that all the bitch sessions we have with management will finally sink in. I read on @Msparamedic’s blog that we are beginning to understand that the changes we want to see in EMS DON’T belong to the future waves of providers, and I agree wholeheartedly, they begin with each and every one of us who DO care.

There are huge obsticles lying in our path, and sadly none of them will be easily overcome, but like they say if you can’t go over it, or around it… go through it. EMS systems are notoriously stubborn to change, and that is the one thing we can count on staying the same. The system is never going to change until we first change the attitudes from the ground up.

We need to define ourselves – are we health care providers, or public safety personnel? We need to STOP defining ourselves by what the patch on our sleeves says we can do. We need to stop prepping people soley for the NREMT exam and teach them actual patient care. We need to stop demanding to do more – Paramedics want to insert chest tubes, EMT’s want to drop ET tubes and push more meds… Can we all finally come to the realization that our education is woefully inadequate and that we NEED to LEARN more not DO more. Skills are so much more diluted now then they should be already, why should we be allowed to be mediocore at even more invasive procedures ?!?

Can we find/form a national organization that actually DOES something to improve EMS? Perhaps it’s already there looking for it’s scope to expand, I don’t know. I do know that until a lot of companies/educational institutions are forced to change they won’t… and until they do we will continue to be the red headed step children sitting at the kiddie table during thanksgiving dinner.

Sounds daunting doesn’t it? maybe it is… but there is something YOU can do to help:

Push yourself beyond where you are, learn something from every call you go on – even the “bullshit” three AM ones. Realize that EVERY interaction you have with a health care provider from the clueless CNA at a SNF to the cocky trauma surgeon in the ED helps form that persons opinion of EMS providers in general, when we present ourselves in a professional manner, show we know what the hell we are talking about and have given our patients they treatment they deserve maybe we will be looked at as more then just ambulance drivers. Until then stop giving your co-workers shit and calling them names for wanting to improve their skills, and maybe gently prod that newbie into learning something they didn’t learn in school and try to do so in a way that makes them learn it because they want to rather then beating them over the head with have to.

Yes my friends the system itself needs overhaul, there is no question we are all over worked, underpaid, and rarely appreciated – there is no question that that needs to change, but for many of us those changes are things we can bring about slowly and are subject to our influence, but ultimately they are out of our control; BUT If we don’t see the things we ourselves need to do – the things we CAN change right this very second, we are missing the bigger picture.

Dust off that iron, shine those boots, throw the chip off your shoulder and BE the change you want to see… who knows someone may actually be paying attention, and if not, so what… what did it cost you?

Til next time…

 

Posted by on July 24, 2011 in EMS, EMS 2.0

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We’ve come a long way – with OH SO FAR to go… Part 1

I suppose I should preface this post with a few things before diving into the meat of it. As someone who was away from EMS for almost 20 years the changes in focus and scope of practice have been glaringly obvious. I suppose you could compare my perspective to that of  the grandmother who only sees your kids once a year. She raves about how they’ve grown since she last saw them, while you silently wonder if it’s time to take granny to the “wrinkle ranch” as she has surely lost her ability to reason; the kids look exactly the same to you as they always have. Sadly, much like that grandmother also sees how values aren’t what they once were, I too wonder if we haven’t “evolved” in our role so much that we forgot what it means to be an EMS provider.

Because I try to always find the bright side in everything, I’ll start with how much EMS has grown. I work in Colorado which is a pretty progressive state in terms of EMS, from my understanding the scope for a basic here far exceeds what is allowed in other states, I point that out because my scope may be different then that of a basic working somewhere else. Having gone through EMT school twice (damn I never should have let that cert expire) it became clear to me that the “focus” of a basic’s education has shifted from trauma to medical which is a great thing… trauma is easy, medical requires some investigation. The days of “stay and play” at least to the extent they used to be emphasized are long gone – replaced with the correct assumption that the most important thing we can do as pre-hospital providers is deliver our patients to definitive care – preferably with a pulse.

AED’s were bursting onto the scene when I got my first cert, and required a separate 24 hour-long class, AND a separate cert. after successful completion you were an EMT-D. The difference between professional rescuer CPR and lay person was the professional was also taught two person and pediatric/infant CPR. MAST pants are no longer a required skills basics are tested on, replaced by a tool that is more useful to us a glucometer. On my first go round, basics could give O2, ipecac, activated charcoal and oral glucose – period.  Ipecac has been removed (as has activated charcoal from our system though still taught). Basic’s can now give aspirin, assist with Nitro, assist with MDI’s, and epi-pens. In Colorado with an IV cert basic’s can also administer D-50 and naloxone, our protocols even allow basic’s to administer albuterol nebs (as a call in). In Colorado basic’s can also take an EKG class, and become certified in EKG, (a useless skill for us other than knowing how to place leads for our paramedic partners (but that’s another story as well) Oxygen delivery has been simplified – we had the nasal cannula, simple mask, partial rebreather and non rebreather to remember flow rates for as well as oxygen percentage delivered by each, these days it’s the nasal cannula, and non rebreather, and if you can remember hi flow O’s for everybody you can pass the test (pointing out how it is not how it should be…. so don’t shoot the messenger)

Oxygen tanks were steel, and the stretcher had to be lowered all the way to ground before you and you partner lifted it from the ground to the back of the rig.

Speaking of partners when I took my very first EMT job doing IFT’s in NY – my partner was a driver, no not a pointed stab at the first responder, he was literally a driver, he didn’t even have a CPR card. In fact, I remember coming up on a MVC and sending him back to the bus for 4X4’s and he asked what those were. :O. While I could be mistaken, I don’t think this occurs anymore, I know here in Colorado it is prohibited by Rule 500.

Getting that first job required no more than a valid certificate, a CPR card and a pulse. Once I got that job, it was there’s your shirt, there’s your driver and your bus, go to work. These days testing – both written and skill – are conducted prior to hiring, then there’s the interview process, followed by an academy, and then a field internship where you are again tested on your specific knowledge of the system you are working in.

For a profession in its infancy I’d say that’s pretty significant change over 20 years… Most of those things can be viewed in a positive light by most providers, although there are folks out there who will dispute basic’s administering fluids, starting IV’s and “interpreting” strips, and some of their arguments are more than just medics being pissed we are playing with their toys.

Sadly, all of the changes haven’t been quite so positive… that’s tomorrow’s post.

Stay tuned

 

 

 

Posted by on July 23, 2011 in EMS, EMS 2.0

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