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Takin it to the streets

I’ll begin by apologizing for it being so long between posts, you have certainly been neglected, but not forgotten. As it often does, life in general has gotten to be more than a little crazy the last few months. There have been more occasions than I can count that I have said “I need to blog about this” however the time to do that has been elusive. Let me catch you up a bit.

I was laid off from my part time EMS job about 2 months ago, the company I was working for lost a provider contract and they made massive cuts to the number of EMTs they employed. While for a minute or two I was upset about it, I never had any intentions of staying there after school, simply put, it wasn’t an organization that I felt was going to foster my development as a paramedic. The very same day I found out I was laid off, I got a phone call from the Clinical Coordinator of my Paramedic School – it seems the Chief of the school had been impressed with my work ethic and my initiative and was wondering if I would be interested in helping with administrative duties around the office.

It was a soft landing for me and gave me the opportunity to have some input into Paramedic School, and hopefully make the experience a little more enriching for my classmates. It caused a few ripples in class initially, but once my classmates figured out I really was trying to make class better for us all they smoothed out. The job is as many hours as I want to work, and the pay is better then what I was making working a bus, how could I turn that down?

One of the side effects of taking on such a responsibility has been a serious decrease in the amount of “free time” I have. Towards the end of didactic I was often having to choose between a couple hours of sleep and a couple hours of study time. I usually choose study time, my body however, would choose sleep and I’d awake a few hours later with a drool covered textbook page stuck to my check.

As class wound down there was a general feeling of fatigue setting in among my classmates – 9 months of classroom at least 12 often 20 hours a week and we were it would be fair to say “over it.” The final was on May 9th and for the first time in the history of my program EVERYONE who started the class finished the didactic phase.

As we all enter our Field Internship I’ve heard more than one of my classmates say – holy hell can we go back to class?

I’ve completed 50 hours into the internship post class (which puts me at 150 total) and while I have seen tremendous strides from hour 101 it is clear to me how VERY far I have to go, as well as how little I actually know.

In my first shift I was assigned a “homework” assignment – a paper written on the Pathogenesis of Hypertension in Diabetics – fascinating stuff and so extremely complex that I could spend the next three weeks reading about it with a medical dictionary sitting beside to look up the words I don’t understand in the articles and still not even scratch the surface.

Shift two gave me the opportunity to find the drug we carry on the box that has an off label use to relieve esophageal spasms – thinking through my limited understanding of pharm I came up with Nitro (wrong) Mag (wrong again) and Benadryl (due it’s anti cholinergic properties – wrong again) I finally ended up with the answer – Glucagon… but it took me many hours of searching to find it – due to the fact that no one understands exactly how Glucagon works in that way.

Shift three we ran a multiple stabbing – a tourniquet a few IV’s and lots of diesel and we got him to the hospital.

Shift four was with a new medic – she wouldn’t let me do very much, and I was rather disappointed to not be allowed to be more hands on. It was after that shift that I recognized how difficult it must be for a medic to have a paramedic student, how confident they have to be ability to let their student screw up just shy of the point of doing harm to the patient and then stepping in at the last minute to intervene before it was too late.

Shift five a chest pain call was the highlight of the night and for the first time in 150 hours in a busy system – I ran a call that I didn’t totally screw the pooch on – not that there wasn’t room for improvement – I’m a firm believer that there is always room for improvement – but after the call the conversation went something like this…

I walked out to the ambulance bay and awaited my preceptors feedback – which is often a “painful and eye opening” experience for me – and instead of the way he usually starts the feedback with “how did that call go?” he walks over and says “Where the hell has THAT paramedic student been all this time? Bring him back and run all your call like that”

It was a small victory for me – but it was the first time I ran a call and didn’t wonder “what the hell did I get myself into” It was the first time on the street I felt like wait maybe I CAN do this.

There are 40 more hours of rides this week – I’ll try to do a better job keeping you posted.

 

Posted by on May 28, 2012 in Paramedic School, Personal

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Little Latin Generals (Cardiology and Politics)

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

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

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

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

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

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

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

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

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

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

On the other hand – we have usurping rhythms…

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

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

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

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

 

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

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Rites of Passage

Ask any prospective paramedic student what they worry about trying to learn and you will likely get an answer that contains at least one of these words: Cardiology or Pharmacology. For some students – myself included the answer contained them both. Adding to my level of anxiety is the fact that the program I am attending is all but legendary locally for its program – and more legendary then the program is the exam – 200 questions – 100 multiple choice and 100 short answer questions relating to 14 different rhythm strips, with roughly a four hour time limit – Highest score ever on the test was a 98.

Interesting to me was the number of practicing medics sitting in the back of the room to “refresh” their knowledge base. The program allows it’s employees to sit in on Paramedic School lectures for CE’s – typical classes have one or two medics back there – Pharmacology had 5 or 6 – Cardiology had 15 – 20 easily EVERY NIGHT for the entire section.

We were told to purchase calipers – as there was no way we could pass the exam without them… Granted most medics don’t even carry them let alone use them in the field – but they wanted to be sure we knew how to break a strip – even the most complicated strip down.

The exam lived up to its reputation – it was EASILY the most difficult test I have ever taken – memorization wouldn’t have helped – the exam required a genuine understanding – after we took the test they told us that as far as they were concerned anyone who got a 70 on that exam was an expert in the field of pre-hospital ECG interpretation – I got a 92 – but I certainly don’t FEEL like an expert…

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If only it was this easy

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Cardiology started with the warning that the instructors goal for us was if someone ever asked us where we learned cardiology we didn’t embarrass them when we gave their names. Both of the instructors are captains at the division I want to work at and one of them is instrumental in the hiring process – cause you know the standard student anxiety over cardiology wasn’t enough for me – I had to ramp it up a little.

I have heard many times so far during school we don’t use a certain book for this because a good one doesn’t exist to teach you what we want you to learn (More experienced providers that write – take notice) Cardiology was an exception – they did have a book for that – but it’s interesting the one they choose.

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Practical Guide to ECG Interpretation By: Ken Grauer MD FAAFP

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Available from Amazon here if you are interested.

What makes Dr. Grauer’s book so interesting is that it is out of print – The program actually contacted Dr Grauer (he includes his contact information in the book in case you want to contact him about the book or cardiology in general – wow) to ask his permission to copy the book for their students – all 500 pages of it.

The process they taught us for breaking down a strip was methodical but lengthy – in fact it takes me 10 to 15 minutes to go through each step and wrote the findings out –

  • Rate
  • Rhythm
    • P- Are p waves present in lead II
    • Q – is the QRS wide or narrow – (if wide examine for BBB)
    • R- Regular or irregular
    • S – Single or married – are the wave complexes married to each other or separate
  • Intervals
    • PRI
    • QRS
    • QT
  • Axis (fasicular blocks?)
  • Hypertrophy
    • Right or Left atrial abnormality
    • Left Ventricular Hypertrophy
    • Pulmonary Disease pattern
  • Infarction – any signs of infarction, strain or ischemia?
    • Q – are Q waves present in any lead? are they pathological? are they expected in that lead?
    • R – Is the R wave progression normal? where is the zone of transition?
    • S – ST segment changes – Elevation, depression, strain pattern?  Are the changes related to a vessel or global? What area of the heart is affected?
    • T – Are there T wave changes? what do they indicate?

The answers to all of these questions only give you HALF of the information you need to interpret the strip – This just gives you the descriptive analysis of the strip – you have to take the patients presentation and past medical history into account or the “clinical impression” as the book calls it.

Dr. Grauer also says that to get the most accurate information possible from a strip you should try to have a prior strip available for comparison – and our instructors took that one step further – if you can actually get a prior strip (unlikely in our setting – but stranger things have happened) was it the patients strip on admission or on discharge ?

My head has been spinning with all the information contained in this module – Brugada’s Syndrome, Ashman’s Phenomenon, WPW (Type A & B),  Default Vs. Usurping rhythms, differentiating between V-Tach and SVT with aberrant conduction, Fib-Flutter, the potential causes of a tall R wave in V1, the causes of QT prolongation…To the point where I have to run through the steps I listed above mentally or I end up staring at the strip with a blank look on my face.

The most reassuring message came after the exam – you don’t have to be an expert at this stuff now – nor do you have to be an expert during your rides… or even during your Field Internship when you get a job as a Medic… You DO have to be an expert when you are cleared to independent duty and are making the interpretation “solo” – That’s a relief I have probably another year of practice then.

Our instructors recommended several books and a few blogs to take our studies further – I’ll share them here in case some of you may be interested

Practical Electrocardiogr aphy by Henry J. L. Marriott (Hardcover) - Called the bible of ECG by our instructors

Pathophysiology of Heart Disease 4th (Fourth) Edition by Lilly (Paperback)

Pure Practice For 12-Lead ECGs: A Practice Workbook by Robin Purdie RN MS (Paperback)

 

The blogs they recommend – Dr. Grauer’s Blog , www.ecgpedia.org , www.ems12lead.com , Dr. Smith’s ECG Blog

Be good – get good – or give up

 

Posted by on February 15, 2012 in Cardiology, EMS, Paramedic School

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Assessment tools…

I’ve been trying to figure out how to explain this concept for the better part of a week now, and I’m still not sure I will do a great job without some sort of visual reference – but I’ll give it a go.

One of the things my preceptors have been stressing during my rides is maintaining a high index of suspicion on all calls so you don’t miss an important finding. Maintaining that level of suspicion is often difficult for me, as I said in an earlier post, I am pretty comfortable with the “sick/not sick” decision – by no means is it  flawless and by no means 100% accurate – I don’t pretend to know everything… in fact the further I proceed into school the more I realize how little I actually do know.

I had forgotten how as a student you need to verbalize things positive and negative, suspected and not in order to allow your preceptors inside your thought process. I often forget to verbalize things I don’t suspect even though they can’t be ruled out.

Two of the most classic differentials that can’t be ruled out on the ambulance and have such varied presentations they are on almost every list of complaints – MI and PE.

After failing to verbalize them for complaints where I didn’t suspect them, the preceptor explained a concept to me I thought I would pass along – its called Webbing. Named for the medic that came up with it (by him of course), but also something the finished product vaguely represents.

Mastery of this process takes considerable time, especially when you first try one, as you are looking all kinds of stuff up in the textbooks – but after doing a few you can do them in your head.

To start your “web” take a fresh sheet of paper and in the center of it write down a chief complaint – lets say Shortness of  Breath. Now think about some of the differential diagnosis you might arrive at that cause SOB and list those in a circle around the CC.  It was suggested that we try to find at least 6 – of course you could add as many differentials around that initial CC as you want. In listing those 6 differentials it is important to think of what differentials would be the most life altering for the patient, especially if they were unrecognized.

Here’s where the thinking and reference materials come in – once you have those 6 differentials listed – draw three lines off of each one – the first line is for symptoms – what do you expect your patient to complain of, how do you expect them to answer relevant questions, what kind of history or medications do you expect. If possible try to include things that can help you narrow down your list – for instance the onset of a PE and the onset of pneumonia are typically very different – the answer to your interview questions may help you narrow down your list.

The second line is for signs – what do you expect to find in a typical presentation of that differential – what type of vitals, what are your “machines that go bing” going to say – what type of physical findings are you expecting

The third line is for treatment – how do you need to treat the patient for that differential in order to improve their outcome the most.

Now that you have your foundation laid… you start using the lists to “rule things out” or perhaps the “better, more accurate” way to say that is – make things fall into the less likely to be the problem with my patient though I can’t rule it out category.

As you conduct your physical exam and interview you can mentally cross things off the list to help you find the likelihood of your differential being on the right track

Sudden onset vs gradual, clear lung sounds vs Rhonchi, tenderness and redness in a calf vs none – these things all help you narrow down what you think is wrong and base your treatment decisions on.

You will ultimately be left with a few causes you can’t say are ruled out and maybe one you are fairly sure of – here is where that treatment list comes in – for SOB – MI and PE are two of things you can’t “rule out”

IF those are the problem – how will your intended treatment affect those?

Wheezes… are they cardiac in nature or pulmonary – does it matter ?

Will Albuterol and Atrovent exacerbate the problem or make it better ?

It is a complex process and definitely NOT something you could do on an actual call – but perhaps those times when you are posted under the shade tree “borrowing” WIFI from the hotel across the parking lot…. you might try to work through some of these exercises and see if they help you focus your exams and maintain your level of suspicion – you never know, you might find with practice you can do it mentally and quickly and use the process on those calls when you just aren’t sure what the problem with your patient is.

I hope someone finds it helpful – it seems to be working for me so far.

 

Posted by on January 19, 2012 in EMS, EMT, Paramedic School

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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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Curse of the Krokodil

* Warning – imbedded videos are extremely graphic*

After writing this post, I seriously debated publishing it or scrapping it, it wasn’t until I was reminded that there are some very large communities of Russian immigrants out there, and those of us the serve those areas may have some type of exposure to the effects of this drug, that I decided to go ahead and  hit publish.

A couple weeks ago as an after thought one of our instructors told us about a new drug sweeping through Russia called Krokodil.

I had never even heard of the drug before our instructor mentioned it, but it has received a lot of press. In fact, back in June, Time did a story about it – “The Curse of the Crocodile: Russia’s Deadly Designer Drug  (http://www.time.com/time/world/article/0,8599,2078355,00.html#ixzz1i39LyQmu)

It was mentioned by our instructor that the emergence of the drug is at least in part due to the US military’s involvement in Afghanistan cutting off the supply of the poppy used to make heroin – I suppose at least in part that could very well be at least part the cause, I suspect though it has more to do with the fact that it is about 3 times cheaper than heroin and very easy to make from ingredients that are available over the counter.

The main ingredient of this literally flesh eating drug is Codeine which is sold over the counter in Russia.

“The active component is codeine, a widely sold over-the-counter painkiller that is not toxic on its own. But to produce krokodil, whose medical name is desomorphine, addicts mix it with ingredients including gasoline, paint thinner, hydrochloric acid, iodine and red phosphorous, which they scrape from the striking pads on matchboxes. In 2010, between a few hundred thousand and a million people, according to various official estimates, were injecting the resulting substance into their veins in Russia, so far the only country in the world to see the drug grow into an epidemic.” Link

In much the same way as dealers in the US took an over the counter medication (pseudoephedrine) and turned it into methamphetamine, dealers in Russia are using an Codeine which is sold as an over the counter medication in Russia. The Russian government is now making Codeine available by prescription only, which in theory should help curb the steady rise of abuse.

The addicts typically experience their skin turning scaly and green before it literally falls off – in some cases as seen in the videos below – rotting every bit of flesh all the way down to the bone.

WARNING : THESE ARE EXTREMELY GRAPHIC VIDEOS!

Take a look at the following videos from youtube – I apologize for not having the narration translated – but the videos speak for themselves

With Codeine being a prescription only medication here in the US it is unlikely that scenes like these will be seen on the streets here, but we should all be aware that these types of substances are out there.
 

Posted by on January 9, 2012 in Illicit drugs, Paramedic School

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Goodbye to Yesterday

I suppose it is borderline obligatory for a blogger to post a “year in review” entry. A time for us to reflect on the year we are leaving behind and look with optimism toward the year ahead. It is for me perhaps a good time to take of measure where I am and where I want to be.

2011 has been somewhat of a whirlwind for me both personally and professionally – I sometimes forget just how far I have come.

When 2011 ushered itself in I was driving a wheelchair van waiting for an EMT position to open up at the company where I work. Having 7 1/2 years of experience prior to taking that job it was “humbling” to have to reinvest myself in the dues we all have to pay when we enter the profession. By the end of the month I was doing my third rides to clear to independent duty on the bus.

I went through two partners before being forced by my employer to go to part time status if I wanted to pursue my education.

I discovered EMS social media and the multitude of blogs out there. I read and I read and I read somemore – somewhere in the recesses of my mind I decided I wanted to give this blogging thing a shot… it started with random stuff – I read something that moved me, or about a shift whatever… after a couple months EMS Blogs.com decided to pick up the blog – which was really an honor to me – and now a lot more people read the blog then ever before.

The days when I put out what I believe is a killer post – I’m often disappointed at the numbers of people who read it – or how often it is(n’t) shared on FB or whatever – then I remember what a privilege it is that even one person takes the time to read the drivel I spout here. At those times I remind myself the reason I write is to “vent”, to process, or just to release some of the pent up “stuff” this job brings out in us all – whether anyone reads it or not – I still get that.

I wrapped up all my pre-reqs for paramedic school and stressed my way through the spring hoping I would get the nod for what is THE program for me… after a couple months of sleepless nights and constant stress I got the acceptance letter  and for the last three months paramedic school has all but been my life.

I regularly work on a 911 car now in one of several districts that our company is the provider for… It’s a rare occassion anymore when I work a flex car doing routine transfers.

I’ve learned that I know even less then I thought I did, and that anyone who says they know all they need to is full of crap.

I’ve gotten better at leaving all the “preconceived” notions about calls and patients behind, and am trying to learn to maintain a high level of suspicion on all calls.

I’ve realized that all the fancy machines that go beep and buzz and whirl – they dont really tell you anything you shouldn’t already know from a THROUGH assessment.

I am slowly making the transition I believe is the hardest part of going from being an EMT to a paramedic – being the team lead and running things.

It’s been a year of tremendous growth and rapid change, and one I’ll look back on with fond memories… see you in 2012

 

Posted by on December 31, 2011 in EMT, Paramedic School, Personal, Uncategorized

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Interesting Perspectives

This week I had the opportunity to gain a unique and interesting perspective on a call from an angle we as EMS providers don’t often get to see.

It was an “off week” from class due to Thanksgiving and I decided to use the extra time to get some of my clinical time in. Wednesday night from 2300 to 0700 I worked in the ED, and Friday morning at 0645 I was in the OR.

During my extremely busy ED shift a trauma activation came in – “gun shot wound to the head – pulseless and apenic – CPR in progress”

I knew what to expect having called in activations to this busy urban facility in the past… call in the Calvary – Trauma 1 was readied while the ambulance was en route – The docs and nurses had their stuff wired as they readied the room… who’s getting first pressure, who’s got the drug cart, who’s going to bag, who’s recording… They orchestrated the symphony before the particular piece of music arrived. The senior resident was at the head of the bed ready to conduct and all of the members of orchestra stood ready – shortly thereafter the “sheet music” arrived via gurney.

He was a large 30’s male CPR was in progress and they moved him from the gurney to the bed in no time flat. Report lasted about 10 seconds.  (I had heard about these “loud and proud” reports in the trauma room, but I’ve never seen one given, it was impressive.)

Immediately after he was placed on the ED table – compressions resumed, lines were started, orders called out. Doc asked why no tube was in place, medic replied with,  “jaw was clinched and we couldn’t get it”.

“Fair enough” he said as he inflated the cuff on the tube he had just dropped.

Two minutes – nothing.

“Let’s go one more round and call it.”

I climbed up on the stool next to the bed and began compressions – fast and deep, fast and deep over and over – while it shouldn’t be any different it felt like I was being graded by all the docs and nurses in the room and I wanted to be sure every single compression was as perfect as I could get it.

Two more minutes – and one of the docs says – “I have a pulse”, initial pressure was something like 60/30. Meds went in and a physical exam began.

Here’s where it started to get interesting, the patient did indeed have a “hole in his head” and a broken jaw, he also had a hole in his back and in his right bicep. ED Doc decided that the hole in his head was not due to a bullet (no palpable fracture or crepitus below the wound) but that the other two wounds were. A chest tube was inserted and 2300 cc of blood were drained from his chest – he began to stabilize and was sent up to trauma surgery.

The rest of the shift was pretty uneventful and at 0700 I called it a day.

Friday morning rolled around and I headed up to the OR, I was more than a little nervous about intubating my first actual patients. It was a slow day in surgery with only 3 cases scheduled day (a typical day sees between 20 and 30 scheduled surgeries in the 13 different OR suites). The first case however intrigued me, it was the gunshot victim I had worked in the ED.

He had been taken into trauma surgery from the ED and had the bleeding in his chest and right arm controlled, a second chest tube inserted and then was sent to SICU to stabilize before further surgery. Since he was already intubated there wasn’t much I could do, but I was allowed to observe from bedside.

They reopened his chest and after removing several handfuls of clotted blood they began to examine his lung. When the surgeon found out I was a paramedic student and that I had worked this guy in the ED he invited me to “scrub in”.  What an amazing opportunity – how many of us get to not only observe but actually scrub in on a patient.

After the obligatory hand washing to your elbows, the whole dressed by the nurse twirl to get the gown on and sterile gloves I was ready. The surgeon invited me to watch over his shoulder as he showed me the damage the bullet had done to the lung tissue, he explained what he was looking for and at. It was amazing to see the lung in his hands as it inflated, if I looked at just the right angle I see the pulsating aorta as it exited through the diaphragm – this beat cadaver lab hands down.

Satisfied that he had adequately repaired the lung the doc said he was going to attempt to find and remove the bullet – “do me a favor – hold this” he said as he gestured at the retractor sticking out of the guys chest. I looked around through the safety glasses I was wearing, not seeing anyone else he would have been talking to, I pointed at myself (careful not to touch the gown) and said “me?”

I swear I could see the surgeon smile through his mask while he reassured me that I could in fact hold his retractor.

I took a firm hold and was careful to follow his instructions to the letter… he found the bullet and repaired some more damage, it was fascinating to watch. My amazed wonderment overcame any lactic acid build up in my shoulder and arm and I didn’t miss a beat. The surgeon explained to me what he was doing and why as he did it.

Once he was finished and getting ready to close I asked where the bullet had entered and what it had damaged. He invited me around to the other side of the bed and explained that the bullet had just missed the spinal cord and the aorta, and he slid his hand way into the patients chest – he lifted his hand lifted the lungs in the process and said – Here slide your hand against mine – be careful not to rip your glove there are some broken ribs back there.

Could this experience get any better? I slid my hand into the patients chest and could in fact feel the shattered ribs, the vertebral column and the pulsations of the aorta – I’m pretty sure I had that same look a kid who sees Cinderella’s castle for the first time has – It was a truly amazing experience, one I will probably never get again.

Interestingly enough even after surgery the docs weren’t sure if the hole in the patients head was due to a bullet or something else. I suppose it doesn’t really matter, and is a further illustration of how inexact our practice can be sometimes.

It also gave me perspective that most EMS providers never get – while I didn’t actually pick this guy up on the street, I did get to “follow” him from his arrival in the ED to his discharge to ICU. What an amazing experience and how fascinating to watch the treatment plan be implemented and carried out.

 

Posted by on November 28, 2011 in EMS, EMT, Paramedic School

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Consciously Incompetent

Back during our scene safety lectures the instructor said that EMS providers could be broken down into 4 categories and that each marked a different level of progression in our evolution as professionals.

The Four levels of progression as defined by our instructor:

  • Unconsciously incompetent – At this stage of development the provider doesn’t know how much they don’t know – I suggest most beginning paramedic students fall into this category.
  • Consciously incompetent – At this stage the provider begins to understand how woefully inadequate their knowledge base and skill set really are. – This is where I am finding myself these days.
  • Consciously competent – When they reach this stage if they really focus on what they are doing and concentrate fully on the task at hand they can perform their duties and provide adequate patient care.
  • Unconsciously competent – this is where the rockstar medic lives – they go about every call looking like they knew what was wrong with the patient before they even got there and make everything from handling an MCI to holding 95 YO nanna’s hand look like something were born to do. Executing flawless appropriate patient care without even thinking about it.

As a basic, I considered myself among the top two – certainly competent whether it was consciously or unconsciously depended on the call.

Now that I am a paramedic student, at the very beginning of my rides – I am more than aware what I don’t know, how much work “my game” needs and where I fall flat on my face.

When my preceptor for my second ambulance shift got in the bus he opened every sealed cabinet so I would know exactly what was in every box, gave me the narcotics code (hell I don’t even have the narc code where I work), and told me it was MY show to run that day… scene management, assessments, treatment plans, procedures ALL of it. “I will let you totally run the show, until you show me that you can’t, and then I’m going to take the call from you. I won’t let you kill you anyone and I will approve or squash your treatment plan before you implement it – you good with that?”

Seriously? You are going to take the proverbial leash off and let me run the call? HELL YES I’m good with that.

I am totally convinced that somewhere someone has etched “HELL YES I’m good with that”  down as famous last words…

Our first call was for a woman with stomach pain. I jumped out of the bus, grabbed the kit and was off. Ma’am I’m Jeff, I’m with the paramedics can you tell me the problem today? Was about as long as I lasted. She said her stomach hurt and curled up face down on the couch. I looked up at the preceptor probably with that deer in the headlight  look on my face, like now what? That was all the prompting he needed. He got her to sit up, asked his questions and got a response faster than I could even think what I should be asking next. I blew two IV attempts en route to the hospital and felt like a heel… Talk about screwing the pooch. Since I came back to EMS  I haven’t had to deal with someone who wanted our help but was uncooperative… I’ve watched my partner do it, but its never been up to me and my brain just wasn’t going to move that fast.

The second call was a guy who was punched in the face after trying to stop a shoplifter… my assessment was ok (there was really nothing to assess) but being unfamiliar with how refusals work I had to left him take the call from there so it was done properly.

Third call chest pain… I’ve been on a thousand chest pain calls… I had this one down cold – My assessment was good, my line of questioning solid and appropriate, I had come to the conclusion the lady was having a panic attack and so had he… she refused transport and I handled it – we’ll call it a double in baseball terms, good but not great.

Two more refusals and 5 hours of being posted at the airport later the shift ended. That 5 hours without patients was the best part of shift, not because I’m lazy and don’t want to run calls, but because it gave my preceptor time to TEACH me how to do the things I need to work on better. My biggest regret was that I didn’t get to show him how I could implement the suggestions he offered to me into my assessments. I learned a lot about myself in that shift and a lot about how to get better. The scores on this eval weren’t nearly as high as the first ones… but he evaluated me as a paramedic student not as a basic. He challenged me to get better, he pushed me to learn, he asked questions I didn’t know the answers to and then told me how to find them.

When my third shift came around I asked if I could work on the scene management and the assessments because I had identified weaknesses in those area on shift two. My preceptor was happy to oblige and add that he also wanted me to do the hand off reports at the hospital.

Awesome another challenge – now we’re talking.

My assessments were better and I was able to implement a lot of things I had been told the day before, still not great but a whole lot better then when I started. Hand off reports were a little sloppy, but again not something I get to practice often. I tried to implement all the suggestions and make things smoother and more orderly. I felt like I was getting into the rhythm – then we got a call for a sexual assault… It was a teenage girl – tops she was twenty. She had been severely beaten, most likely raped and left for dead naked in a heap on a snow bank.

That rhythm I had been developing was gone… I guess I just stood there unsure what to do because my preceptor jumped in and ran things right out of the bus. Evidence, the suspect, the tragedy this young woman had just endured, injuries My head was spinning and I had no clue which should come first.

My preceptor was a pro – he handled it all professionally, preserving/gathering evidence, assessing and treating all at once – it was impressive.

It was also the point when I realized just how incompetent I am.

 

 

Posted by on November 25, 2011 in EMS, EMT, Paramedic School

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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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