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Turned loose on the street…

This week we started our stage 1 ambulance rides (100 hours with the goal of “observing”) Learning how the system works, where things are in the ambulance, how to manage scenes, hand off reports etc – observe how the paramedics we will be riding with do things.

Before we talk about how the rides have gone thus far and what I’ve learned specifically about myself. Let me explain a few things… The service we are riding with is my DREAM job – I want to work there so badly I can taste it. My program is “sponsored” by that particular organization and is considered a year long job interview – impress and perform and you are in… Fall flat, have a crappy attitude, demonstrate you are not up to their high standards and you’re toast.

Knowing all that creates A LOT of self imposed pressure. I want to impress, I want to show confidence, I want to sit in the FRONT seat of that ambulance.

As someone who generally performs better under pressure – I was ready for my moment in the sun so to speak.

Classes to this point have focused mostly on skills – so for all intents and purposes I am a Basic EMT who knows how to do advanced skills: I know how to intubate, perform a cricothyrotomy, administer medications, calculate doses, apply CPAP and capnography, start IV’s , apply the monitor and name the dog in the rhythm strip, hell I even know how to dart a chest… The trouble is I don’t know WHEN to do any of these things – OK granted some of them are obvious – but formulating a treatment plan at this stage of class is still limited to basic knowledge and basic skills.

Ok enough background… Let’s get to the clinicals shall we ?

I went in to my first ride thinking the plan was to basically observe and practice the skills I had learned and SEE when they are used in the field. I met my preceptor and he agreed – Any procedure we need to do I want you to perform; help me at my direction through the shift. Hell I can do that… I mean in reality that’s what I do now everyday when I go to work right ? I knew how to prepare for all the procedures and set them up for my paramedic partner – the difference this time would be, instead of handing the syringe and vial (so he can check medication and that I drew the correct amount up) I drew up to the medic and him handing me back the vial to toss, he’s going to hand me the syringe so I can administer the medication… Cool.

The first 10 hour shift passed with no real acuity to any of our patients, but I helped as I could.

My preceptor evaluated me as a basic and as he expected a paramedic student 2 months into classes on his first ride should be evaluated, giving me very high marks on my evaluation and told me I would be a good medic. These words were music to my ears… I had impressed him and he let me know it – NICE. I was disappointed in his evaluation though… Why?

When all you tell me is great job, you offer no room for improvement, no suggestions for how to get better, no suggestions on expanding my scope or things that I will need to do better or different as a medic. That doesn’t help me, it doesn’t challenge me, it doesn’t force me to grow.

The next day I showed up for my second shift it went a little different.

OK that’s an understatement it was ALOT different….How?

That’s Friday’s post.

 

 

Posted by on November 23, 2011 in EMS, EMT, Paramedic School, Uncategorized

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Do you realize ?

That we have been granted a unique privilege by society, to enter into individuals most private lives (to share their most intimate thoughts, feelings, emotions and sorrows) it is a rare privilege which we think so little of and teach so little about in our medical schools, yet it is central to everything we do”

– Fisher “Back To Happiness” 1987

Those words resonate with me at the level of my very being. It is something we so often take for granted. I wonder how many of us stop to actually think about it…

Think about what it is like for someone to call 911 – to know that regardless of who shows up, the police officer, the fire fighter, the paramedic – regardless of who it is – they are opening up their entire life; to you… their home, the most sacred aspects of their lives – mostly without limitation because the situation is out of control for them and they need help…

That is what we do everyday, when we go on 911 calls.

There is an awful lot of gravity to that – what an incredibly special a privilege that is.

Speaking only for myself – I am not a very trusting person, I do not welcome strangers into my home – in fact I am VERY thankful the state I live in has a “Make My Day Law” – I feel strongly about that personally…. But when I need help; I’m calling 911 and no matter who shows up it’ll be “by all means, come on in.” All of a sudden everything flips, because I feel out of control in the situation and I ask for help.

It is all of us that are put in the position to help those people – I hope we always remember what a truly special opportunity that is…

It is a delicate line we walk each and every time we put on our uniform. That fine line between EMT or paramedic/patient relationship and public safety.

Where do lines of confidentiality begin, and end… where are we willing to blur them a bit? ARE we willing to blur them at all?

Due to HIPPA laws we are not allowed to tell the police officer how many drinks our “drunk driver” patient admitted to… but in the interest of public safety do we allow the officer to stand at the back door of the rig and listen to the responses our patient gives to our assessment questions? Do we ask the officer to ride along for “our safety” so he can get the information he needs for his investigation and we don’t breach HIPPA laws? Or do we steadfastly protect the privacy of that patient and close the doors of the bus behind us when we get in and tell the officer he can meet us at the hospital and do his investigation there?

What is the right answer to that question… both options are completely legal – and neither is necessarily right or wrong.

What about the call you respond to for chest pain and see a huge pile of cocaine on the coffee table? Does that change the answer, does it influence your judgement?

I’m not talking about the “mandatory reporting” issues those are clear-cut… I’m talking about those calls that fall squarely in the middle of that grey area.

Where do your ethics draw the line between respecting that immense privilege you are granted in being allowed into someones most sacred and private places and the general safety of the public? Have you ever thought about it?

It was suggested that we think about these tough decision type of calls ahead of time, so that we can make a split second decision we can live with when we are called upon to do so.

In theory that sounds like a damn good idea, however, I wonder if that isn’t like playing “Who Wants To Be A Millionaire” on your couch… It’s easy to find the answers when there is no pressure…

When there isn’t $ 1,000,000 on the line and no lifelines left I can right off the top of my head tell you that Dr Ignaz Semmelweiss is the Hungarian obstetrician that required his students to wash their hands in an antiseptic chloride solution before examining patients, and because of that simple task, maternal death rates plunged from a high of 18 percent to a low of nearly 1 percent in 1847. (Our pharmacology instructor is a big fan of “cocktail party trivia”)

I wonder if the memory of that particular nugget of information would come quite so easily with the spotlight shining on me under all the pressure a game show contestant feels…

Is coming up with answers to these difficult ethical questions any different?   Isn’t it easy to know what the right answer for you is sitting there at your desk reading this? Isn’t it easy for me to say “well this is what I would do” hiding behind the blinking cursor of this blog?

I’m not by any means suggesting we should never think about these things… more that, I’m not sure we can answer them with any degree of certainty until it is OUR feet that are being held over the fire.

What do you think?

 

 

Posted by on October 24, 2011 in EMS, Ethics, Paramedic School

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What would you do?

Watch your thoughts, for they become words. Watch your words, for they become actions. Watch your actions, for they become habits. Watch your habits, for they become character. Watch your character, for it becomes your destiny.
— Unknown

 

It never ceases to amaze me when the classes you think you are going to get the absolute least out of, prove to be the ones that make you go home thinking. Ethics class proved to be full of  ”things that make you go hmmmm…”

I went into class fully expecting to be bored out of my gourd, which for paramedic school is not such a bad thing, easy nights are few and far between. Class opened with the instructor saying this would be one of those classes where they weren’t there to give you answers; instead they were hoping we would leave with questions, questions about our own set of values and how we exercise those values in the field.

Whatever let’s just this over with so we can go home” – none of us actually said it, but I know I wasn’t the only one thinking it.

The lecture proceeded as expected for a while, the definition of ethics, ethics vs. morals, etc.

Then an interesting “case” was presented.

A foreign “dignitary” was brought into the hospital via ambulance – the hospital was rather busy as you would expect from an urban  level 1 facility, but tonight was exceptionally busy… the dignitary was placed into one of the rooms in the old ER which is now used as the psych ER. The room was perhaps not the cleanest in the hospital, nor was it the newest, it was however fully stocked and equipped with all the necessary equipment.

The nicer rooms in the ED were all filled with “regular people”, homeless folks, the drunk that passed out in front of 7 – 11, junior who fell and broke his arm etc.

The dignitary received the top-level of care and was treated as any other person would have been.

After their release the dignitary filed a complaint about their treatment they received and about being put into the sub standard room.

Then the questions started…  Was it OK to put that dignitary into a sub optimal room instead of homeless Joe? Should that person, based on who they are or what they do receive “special treatment”? Was the complaint justified?

Of course, all of us reacted the same way you probably just did; “Damn spoiled brat politicians” Why should they have gotten a nicer room, or faster care, or any other special treatment. We were all convinced we would have done the same thing the ambulance crew in question did, and the same thing the nursing staff did when the assigned the room…

All of a sudden though what was black and white a moment ago became cloudy and grey with a single question….

What if the dignitary had instead been a police officer, a firefighter or one of your fellow paramedics who was hurt in the line of duty? What if it had been your partner? What if it had been you?

All of a sudden we all were faced with having to admit that each and every one of us (in my class) carry some level of double standard, because we all had to acknowledge that we would have expected DEMANDED better treatment if it had been one of our “brethren”

Where do we draw the line? What is the right answer? What would I have done?

Another case was presented… You are en route to the hospital with a patient suffering from symptomatic V -tach… You call the doc for a med order and to your surprise it’s your medical director who answers… You present your finding and tell the doc your plan; he denies your request to deliver an amiodarone drip and tells you instead to push 1 mg Atropine. Stunned by such an order you request confirmation, and he confirms 1 mg Atropine IV push.

What do you do?

I haven’t had my pharmacology classes yet, but even I know that if you follow the doctor’s order, you will likely kill this patient.

I pride myself on my integrity, my patient advocacy, and my absolute commitment to endeavor to do no harm… My answer was immediate and loud – I give the amiodarone drip to help my patient and I deal with the doc’s fury later…

It’s the RIGHT answer if you ask me, but then the student sitting next to me said ” I totally see what you are saying and I agree that that is probably what you SHOULD do… but how much will that help you when the medical direction gets you fired and your certification pulled, and you are standing in front of the supermarket holding out a can hoping for donations to feed your family”

I paused and considered what he had… Would that change my actions? Would the prospect of losing my chosen career after so much hard work force me to change my mind?

I like to think the answer is no… At least I will know I didn’t sell my soul to make a doc happy and potentially kill someone in the process… But it’s easy to answer that sitting here typing, much different than rolling down the road hot 3 minutes out from that very same doc, holding a patients life in the balance.

All of a sudden this stuff isn’t quite so boring, nor is it quite so cut and dry.

I’m not a huge country music fan, but Aaron Tippin sings a song called “You’ve Got To Stand For Something” there’s a line in the song that says ….

“… Whatever you do today, you’ll have to sleep with tonight…”

I guess it never really hit me much until after that class how true that was…

What would you do my friends?

 

Posted by on October 21, 2011 in EMS, EMT, Ethics, Paramedic School

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Target Fixation

Target fixation is defined by Webster’s dictionary as: a process by which the brain is focused so intently on an observed object that awareness of other obstacles or hazards can diminish. Also, in an avoidance scenario, the observer can become so fixated on the target that the observer will end up colliding with the object [1]

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The term seems to have originated from World War II fighter pilots, who spoke of a tendency to want to fly into targets during a strafing or bombing run, focusing so intently on their target everything else faded from consciousness.

That’s really interesting, but how in the world does that relate to EMS? Replace an observed object with patient and you’ll see where I am going with this.

We as providers are called to bad scenes, to violent crimes, to people’s home courts – not all of those people will be happy to see us. Sometimes, we get so fixated on the sick patient that we forget about everything else in the surroundings… I wrote about a time when this happened to me here

Wait a minute we are the good guys/gals why would anyone want to hurt us?

In 2005 NAEMT cited assault as the leading cause of injury to EMS providers accounting for 52% of all line of duty injuries. [2]

We all joke and make jazz hands saying BSI/Scene safe during our testing, but I seriously wonder how many of us forget that the world isn’t such a nice place sometimes, and we, fellow providers, are often on the front lines of that nastiness.

In that same study NAEMT found that only 21%of us expressed our safety as our primary concern. [2] That says a lot about the people who dedicate their lives to helping others, but it also shows how vulnerable we often are.

Let’s look at a couple less than obvious scenes, any of these sound familiar to you:

You respond to a street party for a DK (local term for intoxicated party) with a head lac – I know it’s a stretch to imagine such a call… Your “windshield survey” reveals of crowd of about 100 people in the street – many of them jumping up and down and waving their arms – you exit the vehicle and hear several people yelling in your direction “damn, it took you guys 15 minutes to get here – what the hell…” Undaunted,  you make your way to the patient – he has a baseball sized egg in the middle of his forehead complete with a 5 or so inch lac – your evaluation of the patient reveals he has an alcohol like odor on his breath, and he is not orientated to anything but self… he has to go to the hospital because you legally can’t leave him here – he adamantly refuses – and when he realizes his refusals are falling on deaf ears – he resorts to screaming – “OW YOU ARE HURTING ME ” the crowd wasn’t on your side to begin with and now they are all squarely focused on you and what you are doing to their friend… More screams “I’M NOT GOING ANYWHERE WITH YOU MOTHERF***ERS – YOU CAN’T MAKE ME GO” Somewhere in the crowd a lone voice says loud enough for you to hear it “They can’t do that – we gotta stop this”

That one might have made your spidey medic-sense tingle – how bout this one

You respond to an abdominal pain call for a 68 YO F – U/A you find a nice home, in a nice neighborhood, the house is well-lit and there is a family member standing in the open door waiting for you. You grab your gear and head for the door, as you enter, a gorgeous yellow lab nudges you wanting to be pet – you look at the family member in the doorway and the individual says “oh that’s just Ole Yeller, he doesn’t bite”, with a smile you reach down pat the pooches head and continue in to your patient. She is pale, cool diaphoretic and on her nightdress is the faintest hint of coffee ground emesis… you go to work

As you palpate the woman’s abdomen she lets out a pain induced cry – from the corner of the room Cujo Ole Yeller,  the gorgeous yellow lab you pet on your way in, hears her cry and springs into action to protect his master from the people hurting her.

Neither of those is a scene you would necessarily “stage” for – maybe the first one depending on your system. For the first one I would expect PD on scene, does that mean that violence can’t happen? Are two EMS providers and a couple of officers enough to “handle” the crowd?

The second call could easily be just you and your partner.

Did you anticipate the outcomes? Did you recognize the risks? Did you prepare for them?

As responders we tend to fall into 1 of 4 categories with regards to our street medicine – I suggest we also fall into these same categories with our scene safety assessments

  1. Unconsciously incompetent – we don’t even know what we don’t know – sadly ALOT of providers fall into this category
  2. Consciously incompetent – holy crap I don’t shit, how the hell did I ever get out of school – (Step 1 to becoming an awesome provider)
  3. Consciously competent – I have a clue and if I focus really hard on what I’m doing I can pull it off – (There is a REAL danger of target fixation here)
  4. Unconsciously competent – It’s all second nature to me – it just happens and I don’t have to think about it much

How does one advance from one stage to the other – Practice and experience, time and exposure. This is the same way we can get good at recognizing hidden threats on scene.

How many of us do any or all of the following:

  1. Strategic parking on arrival
  2. A scene report from the passenger seat – fire is GREAT at this
  3. Scanning the windows of the house/vehicle as we approach
  4. Take the wheels/cot over land through the yard approaching at a diagonal instead of up the walk
  5. Identify the last shred of cover we can hide behind if we need to – from that point forward you are in no man’s land
  6. Is there a crowd, pet, “bad actor” on scene
  7. Are people running in the opposite direction you are going
  8. Do you pull up lights and sirens blaring, or are you discreet and shut down a couple blocks away – leaving only the running lights on as you arrive
  9. Do you search your patients before you get in the box with them? If so do you take their belongings or remove them from easy access?
  10. Do you ask – who else is here when you arrive at a house
  11. Do you stand in front of the door when you knock
  12. Do you identify the way out and position yourself with unobstructed access to that route
  13. Do you walk around the rig instead of between it and the car with the slumped over driver in it?
  14. Do you approach a vehicle like the one above from the passenger side?
  15. Do you stand in front of the elevator doors waiting for them to open, maybe even chatting with your partner (Bad guys often have to leave via the same route we enter)

Just a few examples of things we can and should do on calls. Some of them are controversial sure – (I would LOVE to debate some of them if you disagree) ALL of them will help you get home safely at the end of the shift.

Expect the unexpected.

For most of us when we evaluate a patient we start with the worst possible thing that could be wrong with the patient – Chest pain calls are MI’s until proven otherwise, man down calls are full arrests until proven otherwise – then we begin to rule those life threats out through our assessment and questioning until we arrive at an accurate picture of what is wrong with our patient.

Why is our scene size up any different? Shouldn’t every call start out by ruling out all the life threats – to YOU?

 

 

 

 

1 – http://www.websters-online-dictionary.org/definitions/Target+fixation

2 – http://www.ems1.com/ems-products/press-releases/16033-NAEMT-Finds-High-EMS-Injury-Rate/

 

 

Posted by on October 6, 2011 in EMS, EMT, Scene Safety, Warning bells

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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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“Well We’re Movin On Up…

…Movin on up,  to the east side, to a deluxe apartment in the skyyy…”

End cheesy “The Jefferson’s” theme song.

Seriously, there are some changes in the works behind the scenes going on right now. I am not at liberty to fully disclose them yet, but the winds of change are blowing. The blog will soon be moving to a blog network (which means someone other than my mother might read it 😉 ) If you are a subscriber I will post when the site moves, as I am not sure if your subscription will port with the rest of the site, you may need to re-subscribe after the move. Hopefully I will have a definite answer for you between now and then.

In the mean time, I have a few new stories to relay from P-school but they will have to wait until tomorrow…

 

Posted by on September 29, 2011 in EMS, Personal

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And so it begins

Look at that, I survived the first week of Paramedic school – cue rowdy crowd and applause – we’ll save the spontaneous throwing of money for graduation k?

I’ll be the first to admit, there were a few semi sleepless nights before school started. I know its school – a continued journey down the path towards career satisfaction and bettering myself; why so anxious about it right? The lead up to school was filled with every possible scenario of how that first night would play out – I ran the gamut from syllabus night to the first day of Marine Corps boot camp and every scenario in between. The reality of the first night was much closer to syllabus salad with boot camp dressing.

There was a heaping helping of: this is who we are and here’s what we do lettuce; a few here are some of the really “cool” things about our program tomatoes, and a smattering of the crunchy inflexible these are the minimum requirements  to graduate croutons.

The boot camp dressing? That came in the power point slide that detailed the expectations of the student – there in glowing white letters on the blue backdrop – expectation number 1 – Eat, sleep, live, breath the program. Expectation number two – tell your family you will see them in a year and tell your entire network of friends good bye.

I wasn’t surprised to find either of those in our expectations… however I was stunned that they said it – out loud even.

I almost forgot the baco-bits – they told us all to expect that this would be the single most difficult undertaking any of us had ever attempted.  I had a little trouble swallowing that particular garnishment (you ever get one of those baco-bits that clings to the back of your throat a little?)

Speaking only for myself, (and granted I’ve lived twice as long as most of my classmates) I went to Marine Corps boot camp at Parris Island (no offense intended to my Hollywood Marine brethren), I chose to walk away from owning a successful construction company to come back to EMS (picking just two events off the top of my head from my 41 years of walking the Earth…), there was no way P-school would be as difficult to get thru as either of those challenges – We’ll see if I still say that a year from now.

I am very much a “don’t blow smoke up my ass” kinda guy and I appreciate the “brutal” honesty. So I was thankful for the no BS approach.

Other surprises during the first week was the revelation that the program and staff would be equally committed to us students – 24 hours a day- 7 days a week – if we need help, a shoulder to cry on, even advice on how to deal with a “significant other” at 3 am. The Chief of the program even told a story about playing marriage counselor on more than one occasion – sitting down with both the student and his wife and helping them thru a rough patch brought on by the demands of the program.  A sense of dedication? Not wanting “their numbers” messed up? It’s hard to say at this point, but I do appreciate that they conveyed the fact that we as students, and our success in the program matter to them.

Other “highlights” of the first week – 7 years in a row every single student that has taken the NR exam has passed both practical and written on their first try. The DOT minimum requirements for like tubes and med administration etc will all be totally shattered and FAR surpassed in the course of our 500 hours and hospital rotations (I haven’t heard what the actual number of hours of those are yet).

The thing that was revealed that I appreciated the most? It SOUNDS like they train their students to actually think – We were told that ANY intervention we want to perform on a patient from the seemingly innocuous administration of oxygen to a stroke patient to epi to an arrest victim – we will be asked to justify BEFORE performing it – asked why we want to do that and what the benefit to the patient will be… Wait – did they just say we have to THINK not just memorize?!? HALLELUJAH!!!

Actually having to understand how what we do affects the body, understanding the physiology behind our interventions, the mechanism of action of our treatments?  Not just becoming a “cook book” medic?!?

I doubt “Rogue Medic” reads my humble peckings here – but I follow his blog religiously and he’s a HUGE advocate of what does the patient need – not what does the protocol book say they need.

It sounds like maybe, at least at my program, they get you Rogue and they are listening.

 

Posted by on September 26, 2011 in EMS, EMT, Paramedic School

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Endings, Beginnings and the Quest for the Disco Patch

So in less than 24 hours The Quest for the Disco Patch begins… First things first for my non EMS friends who read this blog as well as my unenlightened brethren who are sitting with a puzzled look wondering what the hell a disco patch is and why in the world would anyone want to start a quest for one… This is the disco patch

And if the old saying is true that a picture is worth a thousand words, there is no need for me to explain why it is sometimes called the disco patch. (It would be more true if you could tell that the gold thread is all glittery)

I knew as I got closer and closer to the actual start day of school my anxiety level would begin to ratchet up (and I was right 😉 ) So I decided to work as much as I could the last few days before school started… this resulted in me working 78 of 96 consecutive hours – I know it sounds crazy but it served a two-fold purpose, first it is good training for the demands and lack of sleep the upcoming year is certain to be filled with and it kept my mind from running through the imaginary scenario of the first night of class over and over again. (How I’m going to feel about an average of 2.5 hours a night of sleep over the past 4 days by the end of this weeks classes remains to be seen)

SO now you are wondering why my anxiety level was ratcheting itself up so much right… (maybe when I’m too old for EMS I’ll go into mind reading) Every single person I have ever talked to has described p-school with same word “hell” – the length of time has varied, the adjectives before hell have changed (some wholly inappropriate for our little discussion here) but the word hell has been in every description I have heard. I didn’t choose any p-school either I chose one that was competitive to get into and is renowned for its difficulty. The medics that work for the service that runs the program are the US Marines of EMS providers locally. SO in my estimation that at least doubles the challenge level of school.

I am a planner, I like to take a list of obstacles and plan for how I’m going through, over or around each of them to get to the destination, while I have a general idea of the obstacles (cardiology, pharmacology, pathophysiology and scene management) I have no idea at this point in what order or how long of a time frame I have to master them. For me that is VERY unsettling. Throw that onto the above mentioned stuff and maybe you will glean a shred of understanding into the ratcheting stress level.

Some good did come out of it though, I had a very interesting discussion with one of the firefighter medics in the station I worked in this weekend. She pointed out what in her opinion were some of the “weaknesses” an EMT who works in a system like mine are likely to have going into to P-school and strategies to overcome said weaknesses. This was all helpful information, the particular department my service is quartered with are among the best fire medics I have ever worked with so her advice was both appreciated and respected.

A friend pointed out to me as well today “You do realize that today is the last day you will ever be “JUST” a basic (emphasis hers not mine)” While that thought hadn’t actually crossed my mind I suppose they were right, starting tomorrow “I am Paramedic student” not that that isn’t still “just” a basic, but they were right somehow it is different (in my mind at least)

The text is sitting on the desk – the first 4 assigned chapters (due the first night of class) have been read (for those interested below is our main text and work book)

Let the quest for the Disco Patch begin…

 

Posted by on September 18, 2011 in Anxiety, EMS, Paramedic School, Personal

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SOAP – Not just for your hindquarters anymore – Conclusion

The original plan was to type out one of these sections daily until I had finished it, BUT thanks to a standby yesterday that went a whole 4 hours longer than it was scheduled for I didn’t get a chance to post yesterday. SO lucky you. You get a double dose of documentation in a single setting… Don’t you feel special 😉

The A section is the place for your assessment of the patients condition, I know over the years we have all been told we don’t diagnose in EMS and that’s true, but it’s also a misconception. You HAVE to form some kind of opinion of what is wrong with the patient, otherwise how do you decide what to do for them? You have an opinion – write it down, the diagnosis box at the hospital will be filled in by the ED doc, and I don’t care how big a rock star you are. He isn’t going to just copy what you write down. Don’t be afraid to form an opinion of what is wrong with the patient or to express that opinion; even if you never say the words your treatment tells everyone what you suspect is wrong.

In the scenario patient we’ve been documenting his injuries are obvious and I would have absolutely no qualm with writing them down as you will see, but what about nana who presents with a medical condition you can’t be quite as sure of? You still will have formed an opinion of what is wrong with her, but you can’t be sure if it’s CVA, A TIA, or is secondary to a previous CVA and she’s just presenting with a case of generalized weakness. Two little letters R/O (rule out) come in extremely handy in these situations. You can list every suspected injury, illness or condition with confidence when preceded by the letters R/O; this is a suggestion to the ED that based on your assessment you believe they should look for ______________.

Generally speaking, that should be sufficient to satisfy even the most ardent defenders of the “we don’t diagnose” argument.

You wouldn’t dream of walking into the ED and in your hand off report telling the doc: Well Doctor Smith, the patient presented with an asymmetric smile, slurred speech and arm drift that occurred suddenly about 30 minutes ago, but I have no idea what’s wrong with her…. You would say she’s suffered a stroke. If you would say it don’t be afraid to write it as well, granted we can’t tell if the patient is having a TIA, or a CVA, but at this point neither can the doc… He needs to see if the symptoms resolve and examine the scans, but if this is a concern for you then list your assessment as: R/O CVA/TIA

Enough of my SOAPbox (pun intended) grandstanding, back to the narrative.

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

During our exam we confirmed each of these injuries; I have no problem writing them exactly as I did, if it makes you feel better put an R/O in front of them.

Finally the last section P – procedures – this is the section where you document EVERYTHING you did for the patient. This is one of the sections I see A LOT of people skimp on, I was guilty of it myself until I was set straight by my paramedic partner in an ED lounge one day. He had a valid point and I adopted the things he told me and my reports have never been better because of it.

We are required to obtain consent from our patients before we ever touch them right? DO you document it?

What about how the patient got into the ambulance, or if you fastened all the straps on the cot?

Then there is always how the patient got into the ED… I think you get the drift.

DOCUMENT DOCUMENT DOCUMENT – more than any other THIS is the section lawyers have a field day with, if it isn’t here you DID NOT do it period.

Disclaimer first – the treatments below are based on our local protocols, and any ALS interventions were suggested by one of our paramedics whom I greatly respect… I am a basic so if I botch the dosage or something it’s because I didn’t know any better – (that’s why I’m going to paramedic school next month after all)

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

While some of the treatments the patient got may be open for discussion, there is NO question about what was and what was not done for this patient.

So let’s take a look at the narrative from top to bottom start to finish.

 

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

P: Consent, assumed control of patient’s C-spine from bystander, primary survey, survey interrupted to perform needle decompression (10g, 2nd intercostal space, midclavicular line, with flutter valve), ventilatory assistance via BVM with reservoir and 15 LPM O2, initial survey resumed, Trauma activation called into St. Injury Trauma Hospital, interview, CMS check, C-collar sized and applied, Pt log rolled onto long spine board and secured with spider straps (back exam performed during log roll), head blocks applied and patients head and blocks secured to board with 2″ tape, CMS check, Patient loaded onto cot using long board by crew, foot of long board raised aprox 6 inches by placing med box under it (Trendelenburg), all 5 straps fastened and side rails raised, patient loaded into back of ambulance by crew, Patient transported emergent to St. Injury Trauma Center, vascular access (bilateral A/C, 14g angio, blood pump), BGL, fluid challenge 20ml/kg started (1600 ml total), vitals, 3 lead cardiac monitor, head to toe survey, 50ml (25 gm)D50 administered via established IV – Right arm, CMS check of Left leg, traction splint applied (to help relieve pain), CMS check of left leg, 12 lead cardiac monitor, vitals, repeat BGL, monitor decompression site for patency, call in consult to S.I.T.H Dr. Bones to administer 2 mcg/kg fentanyl, order received from Dr. Bones 1 mcg/kg fentanyl IV. 80 mg fentanyl IV via established IV in left arm, vitals, CMS check, patient unloaded from ambulance by crew on cot and wheeled into ED – red 1, patient transferred from cot to bed on long board by crew with assistance of SITH staff, hand off report given to trauma team RN, Patient and care transferred to SITH ED staff without incident.

John Q. Rockstar NREMT-P, Ambulance Company

————————————END OF NARRATIVE—————————————

After reading through it top to bottom, do you have any question as to why this guy is in the ambulance, what is wrong with him, or how you intervened to try to help? Can you say the same thing about the last narrative you wrote?

Til next time…..

 

 

Posted by on August 1, 2011 in documetation, EMS, legal, Paramedic School

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SOAP – Not just for your hindquarters anymore Part 2

Yesterday we dove into the S – Subjective potion of the SOAP narrative, today we’ll move on to the O – Objective. This is the section of the narrative where you both document your examination of the patient AND what you found. For our young trauma patient we will have our rapid trauma survey, initial assessment from head to toe, secondary assessment as well as any changes we discover on subsequent exams. An important point to note here – in the first post of this series we talked about the fact that if it isn’t written down it wasn’t done, this is especially important in this section. Often many of us will fail to put the areas where we didn’t find anything pertinent into our objective section. We know that we checked the areas that aren’t listed there BUT someone picking up our PCR later that wasn’t on scene with us has no idea why it isn’t there. So list the results of your head to toe assessment – even if they offer no clue as to why your patient called 911.

I like to separate my initial findings from my secondary exam/response to treatment findings, but to the best of my knowledge there is no hard and fast rule about how this should be documented, form isn’t necessarily the most important aspect here – documenting what you did and what you found is.  A lot of providers out I have worked with will type their sections as one long paragraph – while this is acceptable (provided everything is in there) let’s pretend you are the ED doc who is going to look at the report – do you want to have to scan through the entire paragraph when all you need is three words buried in the middle, or would it be easier and more efficient for you to be able to look for findings related to your patients chest and pick them out instantly? No brainer right? We all bitch that our reports aren’t read and use that as an excuse to do a sloppy and incomplete job – it doesn’t have to be that way. If you want your reports read/used write them in a way that they are ACTUALLY readable/useable.

Just like yesterday, actual narrative is bold – comments are in normal font. At the end of today’s entry, I’ve included yesterday’s S section along with today’s O so we can begin to see the whole narrative in one place

NARRATIVE (Continued)

O: Findings on initial examination

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Cardiac Monitor – 3 lead – Sinus Tach

Sensory and motor function: normal

At this point we have completed our “rapid trauma survey” and would make the decision that this is a “load and go” patient. There are some interventions that would have occurred during this portion of the survey: (needle decompression, ventilatory assistance, spinal motion restriction, etc) – however this section is about our findings not what we did – you will see the effects of those interventions on further exam but we won’t spell out in detail what we did until we get to the P section.

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

Cardiac Monitor – 12 lead – Sinus Tach

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

We have now completed our detailed head to toe survey, we have an idea that the interventions we initially provided for our patient are helping, and we identified another area that requires our attention, from this point forward we have identified all obvious injuries/concerns with this patient that we will be able to find in an EMS setting, subsequent exams/documentation need to focus on continued exam of problem areas and any improved/worsening conditions we find.

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Cardiac Monitor:  unchanged

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

Unless you have an ungodly long transport time (in which case I hope you considered a chopper for this guy) if you get this much exam done you are doing fantastic – but this should give you an idea of how to document initial, secondary and focused findings on a patient who has several critical injuries. Now I’ve removed the comments and put the whole objective section after the Subjective section – if you put the two of them together you should be able to figure out what will appear in the A and P section as these are all based on the sections we have already completed, if at this point you can’t figure out what’s wrong with this patient either I didn’t document it properly or you need to review trauma 😉

Notice how easy it is to find what you are looking for when everything is separated into its own line and listed in the order of examination.

NARRATIVE

Ambulance 123 and engine 456 dispatched emergent to go fast speedway at 123 any street for an auto-ped MVC

U/A found approx 20 YO M pt lying next to the race track in a semi prone position. Patient’s c-spine is being held by track employee and two other track employees are talking to the patient. Patient’s pants have a large tear in them in the left upper leg region and the left leg is bent at an awkward angle. Blood is visible in the patient’s hair and the patient appears very pale.

S: Pt is a 23 YO M. Patient states he “Can’t breathe” and his “chest and leg hurt”. Patient speaks in one to two word sentences and is confused and disoriented. Patient states that “a car drove right over me!” Patient states he isn’t sure how long ago this occurred.

HEENT: no complaints – pt states he “thinks he feels blood running down his face, but it could be sweat”

Chest: pt C/O pain to left chest – Pt denies having this pain before the collision, breathing/moving makes it hurt worse, pain is described as being sharp and squeezing at the same time, patient denies any radiation, pt rates the pain a 10

Back: no complaints

Abdomen: Pt C/O pain on palpation, patient denies any pain before accident, “you pushing on it” makes it worse, pain is described as dull all over his abdomen with no specific site, patient denies any radiation, patient rates the pain a 6

Pelvis: no complaints

Lower extremities: Pain to Left upper leg, patient denies having any pain before the accident, trying to move it makes it worse, pain is described as sharp and pulsating, patient denies any radiation, and rates the pain as a “12″

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

Patient also states he has a headache and some dizziness. Patient denies N/V/D as well as any LOC, but says he isn’t sure about that.

Bystanders give verbal report as follows: patient was walking from the pit area when he was struck by a vehicle traveling at a high rate of speed. Bystanders say that car did in fact drive over the patient saying he collapsed on impact and went under the car. Bystanders add that the patient was unconscious until just prior to our arrival. Bystanders also report that patient has not been moved and that track personnel were to him almost immediately keeping him still and “holding his head”.

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

Circulation: rapid radial pulse, minor bleeding from scalp lac, no major bleeding found

Skin: Pale, Cool, diaphoretic, cyanosis noted around lips

LOC: confused and abusive, won’t follow commands

Head: Blood in hair, no active bleeding, no other wounds noted, PERRL

Neck: No DCAP/BTLS noted, possible tracheal deviation to the right, positive JVD

Chest: Contusions noted to left chest, no paradoxical movement, crepitus and tenderness on palpation, breath sounds absent on left

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

Upper legs: Swelling, tenderness, deformity of left upper leg, normal CMS

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

Initial vitals: 90/50, pulse 150, respirations 36

GCS: 13 (eyes – 4, verbal -4, motor -5)

Sensory and motor function: normal

SECONDARY SURVEY: performed after initial interventions – en route to hospital

Airway: patent

Breathing: improved movement of air, less work to breathe, breath sounds now present on the left although diminished

Circulation: no major bleeding noted

Skin: pale, cool, diaphoretic, cyanosis around lips is improved

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

Head: blood in hair from approx 4″ long scalp lac, no active bleeding, no battle sign or raccoon eyes, no drainage from ears or nose, face is atraumatic, PERRL

Neck: trachea appears more mid-line, JVD is no longer present – No DCAP/BTLS

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

Lower extremities: Left leg in traction splint – CMS present, right leg no injuries noted

ONGOING EXAM: Performed after secondary interventions

BGL: 80

LOC: Patient is awake and alert, less combative and able to follow commands

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

 

Posted by on July 30, 2011 in documetation, EMS, legal, Paramedic School

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