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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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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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Any Surprise? Do you agree?

Recently, CareerCast published a list of the 10 worst jobs in America in 2011 and low and behold coming in at number 6 – EMT.

“On the other hand, jobs like EMT have considerably better hiring prospects, but rank among the 10 worst jobs of 2011 due to harsh working conditions, high stress and inexcusably low pay given the extremely important nature of the work.” Source

Reading through the list it seems the factors they weighed into their rankings were : Work environment, Stress, Physical demands and hiring outlook it also seems they weighed in average pay across the nation. According to this site – the 5 jobs worse then EMT : Roustabout, Iron Worker, Lumberjack, Roofer, Taxi Driver in order from 1 to 5.

I have worked a few of those jobs throughout the years, and I have known people that have worked the ones I haven’t. I agree they are all worse jobs then being an EMT, but not for the reasons the site says.

For those of you that do not know my history, I walked away from owning a successful residential remodeling company to return to EMS, taking a SUBSTANTIAL pay cut in the process. Since making that decision I haven’t looked back even a single time.

The ranking may be helpful for someone considering entering this profession, possibly alerting them to what they are getting into. I’ve seen the wide eyed wonder drain out of many noob’s eyes when they realize this job isn’t what most people think it is. For those people, I can see where a list such as this may be helpful. However, for those who have been around for more than a couple years, it’s no surprise that an outsider would rank our chosen profession so low.

The list does take into consideration the low pay, the “disrespect”, the strenuous conditions and the stress – I do not dispute any of those things – they are all a part of the job. There are a number of other factors that I can see being viewed negatively by folks both inside and outside the profession – what I don’t see factored into the ranking are the rewards.

Speaking only for myself – I didn’t come back to EMS for the money or for the “hero” image – I had done this long enough before leaving the field that both of those bubbles had been burst for me. I didn’t come back for the adrenaline rush, or the driving fast or any of the other things a lot of folks enter the field for – I came back for the intangible rewards of the job.

Not many people get the opportunity to know they make a difference is someones life – I’m not talking about the naive notion that – we save lives for a living… sure on the rare occasion it does happen – but that isn’t what we do everyday. When it does happen its more timing and luck then anything we do. What we do do (if we are any good at this job) is make what is potentially the worst day of a person’s life better.

Riding to the hospital with 95 yo nana while gently holding her hand and maybe even coaxing a smile from her – knowing that she will remember my face long after she has faded into my memory… knowing my presence alone made what was an incredibly difficult experience for her better in whatever small way – that’s a reward most people don’t get.

I’ve described this job many times as the highest highs and the lowest lows and sometimes the two are separated by one call… an emotional roller coaster some days.

When it’s all said and done and I take off my boots for the last time years from now (I hope) I will “retire” from the streets knowing without a doubt that I made a difference – a real difference in making people’s lives better. For me that makes being an EMT the best job in the world and makes every other job out there ahead of it on the worst jobs list.

What about you? Are you surprised by the rating? Do you agree with it?

 

 

Posted by on January 12, 2012 in EMS, EMT, Personal

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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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Wait a minute how did that happen…

*** This post contains images some may find graphic or disturbing – stop reading now if you are sensitive to graphic photos of surgical procedures***

Two weeks… Really???

I looked back at the date of my last post to find it had been two weeks already. It hasn’t seemed that long in the real world. There are so many things that have come up in class that I want to share… Illicit drugs, Excited delirium, Cocaethalene, Capnography, intubation… its been a busy two weeks.Which is probably why they flew by without me even realizing it.

We have the upcoming week off – although for me it is full of rotations through clinical sites – maybe I can catch up on some of the topics I am eager to write about in that time frame.

I have been outed as well… One of my classmates found the blog on FB and started reading it and was like WOW this is all of the stuff we are talking about in class, couple that with the info in the about me and stuff I’ve shared with classmates in conversations and my time in the Marines turned out to be what gave me away. While on the one hand it’s cool to get some recognition for what I write on here, it makes it a little more awkward as well… there is something to be said for writing anonymously – it takes away the pressures of having to be ultra careful about what you say and being able to express yourself without reservation. I don’t think it will affect the blog much as I only write about those topics I really believe in and express opinions that I would not be ashamed to defend.  I am conscious of it though so I suppose if there is any blow by effect it’ll reveal itself down the road.

Last night we did a cric lab where we did both a needle cricothyrotomy and surgical cricothrotomy on sheep tracheas… Pics posted below.

The service we are doing our rides with has a waiver for surgical crics, so we are expected be able to do those as well as the standard needle crics.

Here is the set up we arrived to

We each got a chuck, a 14g angio, a scapel, and a 6.5 ett, along with a syringe to start with

Add one fresh sheep trachea (still cold from the fridge)

Trying to hold the epiglottis up and open the trachea enough to give you a view of the cords and the glottic opening

The first step was to perform a needle cricothyrotomy - insert the catheter at a 45 degree angle in a caudad direction through the cricothyroid membrane

If your question is the same as mine was at this point – ok we are in the airway but how the hell do we ventilate this patient ? Attach a 3 cc syringe to the angio and the adapter from a 7.0 ETT will fit down into the syringe allowing you to hook a BVM to the catheter. Other methods were demonstrated for us as well… but that was my personal favorite.

Next we moved onto surgical cricothyrotomy

We started by cutting our tubes down to just above the tube that inflates the cuff (in reality we would have used a full size tube and cut it after getting the patinet ventilated)

Then we made a surgical opening in the cricothyroid membrane

Beginning the incision into the cricothyroid membrane

From my blurry hand and scapel you would think I was cutting at light speed... damn cell phone camera

Passing the tube through the surgical incision

Successful insertion of the ETT through the surgical opening we created. This "patient" is ready for ventilation now

It was rather interesting to actually perform these skills on something that was close to the real thing, hopefully should I ever need to use these skills this lab will have given me enough confidence in the skills to perform them without unnecessary hesitation.

 

 

Posted by on November 17, 2011 in Airway Managemnt, Paramedic School

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Do you realize ?

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

– Fisher “Back To Happiness” 1987

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you think?

 

 

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

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Target Fixation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Expect the unexpected.

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

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

 

 

 

 

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

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

 

 

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

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The Pride Defense

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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