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

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

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

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

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

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

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

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

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

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

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

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

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

You can’t say I didn’t warn you…

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

 

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

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And so it begins

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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Endings, Beginnings and the Quest for the Disco Patch

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

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

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

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

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

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

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

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

Let the quest for the Disco Patch begin…

 

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

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SOAP – Not just for your hindquarters anymore – Conclusion

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

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

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

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

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

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

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

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

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

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

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

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

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

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

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

John Q. Rockstar NREMT-P, Ambulance Company

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

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

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

 

NARRATIVE

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

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

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

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

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

Back: no complaints

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

Pelvis: no complaints

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

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

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

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

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

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

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

LOC: confused and abusive, won’t follow commands

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

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

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

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

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

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

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

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

Sensory and motor function: normal

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

Airway: patent

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

Circulation: no major bleeding noted

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

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

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

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

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

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

ONGOING EXAM: Performed after secondary interventions

BGL: 80

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

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

A:

Tension Pneumothorax

Intra-abdominal bleeding

Hypoglycemia

Fx Left Femur

Scalp Lac 

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

John Q. Rockstar NREMT-P, Ambulance Company

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

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

Til next time…..

 

 

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

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SOAP – Not just for your hindquarters anymore Part 2

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

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

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

NARRATIVE (Continued)

O: Findings on initial examination

Airway: Open and patent

Breathing: Rapid w/ poor movement

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

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

LOC: confused and abusive, won’t follow commands

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

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

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

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

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

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

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

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

Cardiac Monitor – 3 lead – Sinus Tach

Sensory and motor function: normal

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

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

Airway: patent

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

Circulation: no major bleeding noted

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

Vitals: 100/60, pulse 110, respirations 30

Cardiac Monitor – 12 lead – Sinus Tach

LOC: unchanged

GCS: unchanged

BGL: 40

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

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

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

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

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

ONGOING EXAM: Performed after secondary interventions

BGL: 80

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

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Cardiac Monitor:  unchanged

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

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

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

NARRATIVE

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

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

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

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

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

Back: no complaints

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

Pelvis: no complaints

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

Upper extremities: no complaints

Allergy to PCN

Medications: insulin

PMHx: DM 2

Patient does not remember the last time he ate.

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

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

O:

INITIAL EXAM

Airway: Open and patent

Breathing: Rapid w/ poor movement

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

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

LOC: confused and abusive, won’t follow commands

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

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

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

Abdomen: slightly distended, tender to palpation

Pelvis: No DCAP/BTLS – intact and stable

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

Lower legs and arms: no injuries noted

Posterior: No DCAP/BTLS

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

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

Sensory and motor function: normal

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

Airway: patent

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

Circulation: no major bleeding noted

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

Vitals: 100/60, pulse 110, respirations 30

LOC: unchanged

GCS: unchanged

BGL: 40

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

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

Chest: unchanged

Abdomen: distension and tenderness are both increased from prior exam

Pelvis: unchanged

Upper extremities: NO DCAP/BTLS, Good CMS function

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

ONGOING EXAM: Performed after secondary interventions

BGL: 80

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

GCS: 15

Breathing: movement of air continues to improve

Vitals: 110/70, pulse 110, respirations 30

Skin: unchanged

Neck: trachea remains midline and JVD remains absent

Chest: breath sounds still diminished on the left

Abdomen: distension/tenderness continues to worsen

Distal CMS on Left leg still intact and adequate

 

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

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

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

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

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

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

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

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

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

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

Stay tuned

 

 

 

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

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