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Machines that go bing

During a recent class I had one of my “illusions of being a paramedic” shattered it was illuminating for me and bears repeating. I’ve heard many of my partners say treat the patient not the (insert machine that goes bing here). I guess while I heard it I never really understood what they meant, until class the other night when one of our instructors said “you should never use a machine that goes bing without knowing what that machine is going to tell you.”

WHAT ?!? Wait just a minute – you mean I get to finally use all these shiny gizmos in the back of the ambulance and more than that, understand what they are telling me and I don’t really need them ? Talk about a bubble bursting…

The more I thought about what he said, the more sense it made. I have next to no experience at all deciding which tools to use when and even when I do get to make the decision now, its with a preceptor “holding my hand” to make sure I’m on the right track. What little practice I do have I’ve ALWAYS been asked to justify why I wanted to use the monitor, or the glucometer or the capnography – What did you find in your assessment that leads you to believe that it’s necessary to use that particular piece of equipment. If I could answer that question to their satisfaction (which occasionally I could not) the next question was what do you expect to see when you use it.

The first few times I was asked that question I was scratching my head thinking well isn’t that why I’m using the machine in the first place to find out what it says?

Over the years I’ve developed a pretty good sense of “sick, not yet sick, not sick” based on my assessment – it isn’t 100% for me or likely for anyone else within those first few moments – and I base my treatment decisions on those findings – however protocol says all patients complaining of chest pain get a 12 lead – whether I think they are really sick from a cardiac cause or a trapped gas bubble – so I tried that for an answer

I want to put the patient on the monitor because they have chest pain – ok go ahead – what do you expect the 12 lead to look like? uhhhhhhhhhhhhh I don’t really know but the protocol book says we have to do one for all chest pain patients – take a seat = I’ll run the rest of this call and we’ll talk about it later

Damn it – how am I supposed to know what the monitor is going to show before I even have the electrodes in place? I was frustrated and I’ll admit for a few minutes I thought it was haze the paramedic student stuff.

After the patient was dropped off at the ED my preceptor came out and explained it to me – I spent the next several hours kicking myself in the keister for not putting the pieces together. It wasn’t paramedic student hazing, it wasn’t pushing the student to figure stuff out – it was basic and something I should have already realized.

His logic was a simple as it was eloquent – The conversation went something like this:

Preceptor: When you checked the patient’s pulse – tell me what you learned

Me: They had a pulse, it was strong,  and regular their skin was warm and dry and based on the fact that he had a radial pulse his pressure was likely above 90

Excellent – now tell me what if his pulse had been irregular

I would have suspected he had a cardiac issue – most likely a-fib

Good – what about a thready pulse?

Again I would have suspected a cardiac issue – although lots of things could cause a weak thready pulse, but based on his complaint I would have thought cardiac

Good – now what if the patient’s skin had been pale, cool and diaphoretic?

With his c/o being chest pain – I would have suspected MI

You got all that info from a pulse?

Yes – that and his complaint

So – since this patient had chest pain with a strong regular pulse and pink warm dry skin was it likely he was having a cardiac issue?

We can’t really say based on just that information – we can’t even rule out an MI after a 12 lead that takes hospital tests

True – but based on his presentation and the rest of your assessment did you suspect he was having a life threatening cardiac issue ?

Honestly, no

I didn’t either – so based on that information – what did you expect to see on the monitor?

and then it clicked for me…

I didn’t expect to see any significant changes on his 12 lead in all honesty

Then that’s the answer to what do you expect to see, just like with the irregular pulse you would have expected to see an irregular rhythm or non perfusing beats, or possibly an ineffective rhythm with the thready pulse or significant ST segment changes if he had been pale cool and diaphoretic… are you following me?

Yes was my answer (although it was directed at the top of my boots) – I felt stupid that I didn’t piece all that together.

When you were an EMT everything was black and white – now that you are training to be a paramedic you have to remember everything is in varying shades of grey. Yes we have more tools to use, but your assessment as a medic is no different than your assessment was as a basic – you will still form your clinical opinion based on the patient’s presentation not what the machines say. If your patient says they have sharp 10 out of 10 substernal chest pain that is non reproducible, radiates to the left shoulder and jaw, is nauseous, vomiting , pale, cool and diaphoretic and they tell you they think they are dying and the 12 lead shows a normal sinus rhythm at 88 does that mean they aren’t having an MI? Of course not. If you have an asymptomatic young adult cyclist with a heart rate of 50 are you going to treat him for bradycardia just because the monitor says so?

No his clinical presentation would tell me that’s likely normal for him.

Treat the patient not the machines, always know why you are using the machine and have an idea based on your assessment what that machine is going to say before you look at it, and remember what those readings on the machines do and don’t mean. They are, in a nutshell, extra information that helps you reach a conclusion but they are not in almost every single case what you are going to base your treatment on.

It was so simple I feel silly for not realizing it ahead of time. Yet another valuable lesson learned on the path to the disco path.

 

Posted by on January 16, 2012 in EMS, EMT, Paramedic School

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Defensive Training for EMS – Neccessary?

In a word – YES

I have written on many occasions how lucky I am to be attending the Paramedic Program I do.  As if I needed another reason to believe it was the right choice for me, from what I can tell it is one of only two paramedic schools in the entire country that offers defensive training for EMS providers as part of their paramedic students education.

I think this is an EXCELLENT idea and should be something more of us get. If not in our schools then certainly when we enter the workforce.

Before you get your 5-11s in a twist hear me out.

I am a former Marine, trained in hand to hand combat, defending myself was never really something I was worried about until I took this class. Was I schooled that I wasn’t as capable with my hands as I believed I was? No, in fact, I was schooled that the way I had been trained may very well severely injure someone unintentionally. Marine Corps hand to hand is all about aggressive tactics, how to hurt people enemies, not how to be truly defensive.

What’s the difference you might ask… ask Alan Miller a former Denver Paramedic who was sentenced to 12 years in prison  for assaulting a patient in the back of the ambulance. (http://firegeezer.com/2009/11/14/denver-paramedic-sentence-to-12-years-for-assaulting-patient/)

I’m not even going to comment on that case, or what happened there, I wasn’t in the ambulance so I don’t know what happened. I do know that whatever happened the injuries the patient received were severe enough that Miller is now doing a 12 year bid.

Having not had the DT4EMS class, that could have very well been me, or any of the 10 to 15 of my classmates who had some sort of “fight training” prior to our class.

Just today a study was released that found 2/3rd of the paramedics in the study have been assaulted on the job – read the report here 

Let’s face it folks pre hospital providers get assaulted – it happens – WAY more often then we care to admit. Regardless of what you are told by your senior partners, supervisors, forum trolls or even medics from back in the “rampart” days IT IS NOT PART OF THE JOB.

I know some of you are saying “don’t be a dick and you wont have to worry about it”

How do I know… I’ve had people tell me that. It is precisely that type of pervasive attitude that makes assaults on providers go unnoticed and under-reported. One of the main focuses of the class is customer service and how to use that aspect of the job to help diffuse a potentially violent situation.

If you are among those who think it doesn’t happen – PLEASE go to the DT4EMS site and take a look at the forums there (here’s a link) and read about the stories that don’t necessarily make the news.

 

Take a look at this video from the DT4EMS website:

 

Another thing I don’t want you to assume about this class – the purpose IS NOT to turn you into a ninja, an assassin or even Billy Bob bad ass paramedic – the purpose IS to get pre-hospital providers to know what to expect in certain situations and how to react should the “worst” occur.

For the basic level class we spent 16 hours between classroom and “the mats”  training to protect yourself in 4 areas

As defined by DT4EMS the four areas are:

  1. Preparing the mind – getting past the initial resistance to defending yourself
  2. Preparing for the street – training in real world techniques to increase your chances of survival
  3. Preparing for the media – How to defend yourself and still APPEAR to be the victim and non aggressive
  4. preparing for the courtroom – know the laws and how to represent yourself as a PROFESSIONAL

 

Yes, the bulk of the time is spent working on defensive tactics and how to be out of the way when an patient turns into an aggressor, but the class itself is so much beyond that.

Interview techniques, on scene responsibilities, survey stances, the assessment L, what a reactionary gap is and why you should try to maintain one, the six steps of DT4EMS self defense, moving in angles and circles, winning the R.A.C.E and R.A.C.E -2- R.E.A.C.T., the 6 D’s (types of potentially violent encounters), when a patient is no longer a patient, scene survey tips, global overviews, levels of response, physical fitness, the list goes on and on

It’s much much more than the perception that it’s a fight class.

Sadly, the pictures taken during the classes don’t show those parts because they don’t make for great action shots… but they are equally important aspects of the training.

Before I get to the pictures of our class – I URGE you to go take a look at the DT4EMS website and get a more in depth look into the program and what it’s founder Kip Teitsort had in mind when he developed the program.

The web site is here DT4EMS

Here are some of the pictures from our class – yes they all emphasize the physical techniques (because they make good pictures) but again the class is much much more than just this stuff.

 

Even without the F.I.S.T. suit, do you have any trouble figuring out which one of these two is the aggressor and which one is the "victim" - How much better does this look then the firefighter who was kicking a patient in the video?

 

After a double tap parry a simple shove is often all that is needed to create separation and allow you to escape.

 

Probably the smallest girl in class - with the instructor as the attacker - will the techniques taught work for her too?

After a double tap parry - a "distracting blow" is quite effective in taking down the attacker - any question whether she can now escape or not?

Using a double tap parry to deflect the attackers blow...

Following the double tap parry with a distracting blow to the ear - notice the open hands

The elbow control takedown drill...

Elbow control takedown step 2

Even experienced people can have trouble - I should not have ended up on top of him after the take down

Escaping from a choke hold - step 2 .The first step is to bury your "meathooks" between the attackers arm and your throat before dropping to your knee

The last step of escaping from a choke... bending forward and twisting your body to pull the attacker down

For the very last part of class we got to “go against” the instructors while they were wearing a F.I.S.T. suit, this part of the class was entirely optional, but it gave us the opportunity to put the skills we just learned in practice.

Here are some pics from my “encounter”

 

Assuming a defensive posture and anticipating the right hook that is about to come my way... A double tap parry followed by a shove will give me some space, but he still has about 50 seconds of the minute long attack to go.

The attacker retreating after a distracting knee to his thigh... that pissed him off and we ended up on the ground lol

It took him about 15 seconds to get through the basic ground defense in the suit, but after escaping the mount - I ended up in this position as the whistle blew ending my minute long session. This is perhaps the only picture that doesn't have a purely defensive feel to it.

I know there was a picture of the smart ass pose I took with my arms flexed sitting on his back… but mysteriously it wasn’t on the camera when I uploaded the pics… Damn, I wanted to put it on the graduation plaque for him 😉

At one point it was one of the instructors (Jeff) vs one of the bigger guys in class - he was a former deputy sheriff and is a big boy... the F.I.S.T. suit wasn't enough to save Jeff from stepping into a distracting blow that laid him out. I only include it to bust Jeff's chops - it is neither a focus of the class nor an intended outcome of a distracting blow... but Brad didn't have any trouble getting away from this attacker, and that after all is the goal.

My last and final point about this excellent class – while you may never ever need any of the physical techniques taught – chances are you wont have to actually do one of those surgical crics they taught you in paramedic school either, but if you do need it – it sure is nice to know isn’t it?

If this class only ever saves ONE provider from harm – I can say for certain that all the effort Kip put into organizing this class will have been worth for him.

DT4EMS – I HIGHLY recommend it – it was an absolute blast of a class and just may save someones life on the streets one day.

 

 

 

Posted by on December 30, 2011 in Defensive Training, EMS, Paramedic School, Scene Safety

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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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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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Drinking from a fire hose

I’ll begin my apologies for a week between posts. I haven’t been away from the blog, I just haven’t put out a post… What I did put out is a tutorial for medic math. Right now it’s only available on the blog, although I am working on making a downloadable .pdf out of it.

I know I looked and looked for resources to help me learn some of the things from P-school ahead of time, and had no real success- hence the tutorial. As we progress through pharmacology I will try to add a drug reference and list of the drugs they have given us to learn for future students to get a head start.

The first couple of weeks of classes were fairly mellow, rehashing old information and a very quick walk through of new procedures. We got a tour of the ambulance garage we’ll be working out of.

looking in from the outside... We'll be VERY familiar with this place by the time class is over

We stuck each other with sharp objects…

The first EJ of class...

And then it happened basic pharmacology… so much information in so little time. It lasted a week but each night of class yielded an average of 20 pages of handwritten notes… and in reality we didn’t really cover anything other than the drug math.

After a week of that we shifted gears to basic cardiology. Mostly “naming the dog” in lead II.

The reasoning behind the shift and what we are covering now is preparation for ACLS class etc. They want us to have at least a bare bones understanding of strips and drug dosages before then. Additionally, we will be able to start our phase one rotations soon, and we will be expected to know how to start and IV, administer a medication, put on ekg leads and have a clue of what kind of rhythm we are dealing with. There has been a mountain of information in the last 24 hours of classroom time, and all of it is new, and because it is a glancing blow over things we will be going way in depth to later, its been hashed over quickly. It has begun to feel like drinking from a fire hose.

 

I don’t mean the nice easy fire hose stream either

Drinking from the fire hose

I don't mean THIS fire hose...

Image credit

I mean this stream…

Fire hose

I mean THIS fire hose

If you’ve seen the movie “Backdraft” – there is that scene in the burning warehouse where the line is lost and its spraying and flying around all over the place… that’s the kind of hose I’m talking about.

I fully expected it, and no I’m not complaining, but there are moments when I say to myself… Damn, what did we get ourselves into it. I imagine that is something every student out there goes through, I just wonder of it happens to everyone so early.

1 week from today is our first exam… So I may be a little quiet this week…

 

 

Posted by on October 12, 2011 in Paramedic School, Personal

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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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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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Endings, beginnings and limbo

A couple of days ago I found out that I was in fact accepted into the paramedic program I have been working so hard to get into.  5 days later, after considering where I had been, where I wanted to go and where I am right now, I realized with that single phone call I reached an end, a new beginning and found myself in a sort of limbo.

It isn’t often that a single event can bring about all those paradigm shifts, life tends to reserve such a substantial change in perspective for equally substantial events. I can hear some of you saying it’s just paramedic school man, get over it; and yes, on the most basic of levels, you are right it is “just” paramedic school. Of course when you take into consideration that I have wanted to be a medic for over 20 years now, that I was away from EMS for over 15 years, and that I walked away from owning a successful construction company to return to the field I love, it takes on more meaning, If you factor in that I took a SUBSTANTIAL cut in salary to return to EMS, and that every decision I have made in my professional career over the last two years had led up to that phone call, well you might then begin to understand how important that phone call was to me.

Now I found myself wondering whats next – it’s no longer I want to go to p school this fall, it’s I am going to paramedic school this fall. It’s no longer have to do x,y,z to impress the selection committee, it’s I have to do x,y,z because it’ll make me a better paramedic student and ultimately a better paramedic. The pre-requisite classes are now all officially over and it feels as if this stage is coming to a close. I didn’t get to this stage by myself, it took a lot of support from people who care, it took a gentle kick in the kiester (or two) and someone to believe in me and tell me I could do it.

Now that p-school is no longer something that I am working towards, it is something I will be in. I find that all the anxiety about not getting in has now shifted to “oh my God, I got in… now I have to do more than just talk about it.” The whole new set of challenges, the new base of knowledge, even the physical demands of paramedic school all bring a renewed set of challenges, new obstacles to overcome. A new beginning to an old dream, needless to say, I am more than a little excited about it. So excited I find myself having to stifle the urge to start right this very minute… to not to dive into pharmacology, cardiology and patho phys. Not to say that I won’t prepare and try to get a head start, but I have some time for that still. Hell, I haven’t even received the new student packet yet.

That brings me to now and the “limbo” – school doesn’t start until September – and I can’t say what day in September yet – (see new student packet above) I’ve been so focused on getting in that now that I am in and until it starts I feel sort of lost, like I don’t know what I should be working on. The fun-loving side of my brain says take some time for yourself now – plan a trip up to the mountains and try to get as much “fun” in outside of work as you can because once school starts opportunities for that kind of recreation will be very few and very far between. The practical, professional, driven side of me says start studying now, because I can’t seem to suppress that drive to be the best (frankly, I don’t really want to either).

For the moment I think I will dwell in the satisfaction of a job well done, I will plan a trip to mountains before school starts and I will take a moment (or two) to breathe, before I start the early studying.

Til next time…

 

Posted by on August 2, 2011 in 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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