Posts Tagged ‘assessment

22
Mar
12

Lingo

By Jeramedic 1 Comment
Categories: Humor
Tags: , , , , , , , ,

10-8, on air, copy, en route, on scene.

Scene safety, BSI,  ABC, A/Ox3.

SAMPLE, OPQRST, AEIOU-TIPS.

Patch’em up. Print a strip. Check a sugar “little prick.”

Grab a BP, Positive PMSC.

Equal grips/pushes/pulls, eyes are PERL, Cut the clothes.

C-Spine, Strip and flip, palp the chest, rock the hips.

Start a line, strip a bag, hang a drip.

Dropping Sats, Absent breath, Needle T, Decompress.

Tube’em, Bag’em, V-FiB, CLEAR!!!!……

Code 3, ALS, Tier one, Done and done.

De Con, Restock, and oh, do you know where I can get a Face sheet?

03
Apr
11

No Habla Espanol

By Jeramedic 1 Comment
Categories: Book Reviews
Tags: , , , , , , , , , , , , , , ,

No habla espanol? No hay problema, at least not entirely.  Language  and the ability to communicate is something often taken for granted. It’s not until that fundamental part of human interaction, and a pillar of patient assessment is challenged or completely removed do we realize and respect its importance.

We have all had to manage patients that were unconscious or had an altered mental status due to drugs or alcohol, seizures, trauma, etc. Theses patients have limited, or are incapable of verbal communication. So we work around it the best we can, and rely on our physical assessment and findings to help guide the treatment plan.

But what if you have a patient that is completely awake and alert, is in obvious distress, and can not communicate because of a language barrier? Well, like we have all done, you probably look around at the other personnel on scene, patients family and friends, or sometimes even bystanders to find a translator. While this practice is an option, its not always practical or reliable. And in the case of bystander assistance, no longer is the patients information confidential.

A 2007 American Community Survey conducted by the United States Census Bureau, showed that Spanish is the primary language spoken at home by over 34 million people aged five or older, making the United States the world’s fifth-largest Spanish-speaking community, outnumbered only by Mexico, Spain, Colombia, and Argentina. Thus making Spanish one of, if not the most common non-English language encountered by EMS providers in this country.

If only there was a better way…

Lately I have been using, and introducing others to a little book called, EMSpanol.  And in my opinion, it is the most user friendly, and comprehensive English to Spanish (and Spanish to English) field translating system, that is not digitally based. I believe one of the big advantages to EMSpanole is that it was created by working EMS providers, and not a language teaching company. It is straightforward, and intuitive.

Jeff Dean, the co-creator, and working Paramedic and Firefighter says “Like most of  the prehospital providers I know, I basically speak no Spanish at all, but I work and volunteer in a region with a large and growing Hispanic population. I’ve struggled with other commercial products, finding them either too general, too disorganized, or created by authors with no EMS experience, so I created my own list of phrases and looked around for someone to translate them for me. More than seven years went by before I finally met FF/EMT-B Miguel Castañares, who embraced the project and took it to a whole new and exciting level.”

The book comes in two sizes: A 30 page ambulance edition which is approximately 9″x11″  and can be easily stored in the patient care area, and a smaller 37 page pocket version that fits comfortably in uniform pockets, and first-in bags. The two books are identical in content and format. It covers everything form the initial patient contact, all the way to MCIs and even refusals.

Each chief complaint is laid out in a logical sequence, so that the provider can start at the top of the page, and simply read through the call as if there was no language barrier to begin with. The questions are also written so the patient need only answer, yes or no. There is even a basic anatomical chart on the back.

In my experience with other field guides, I found them to be disorganized, and hard to understand. But honestly the only problem I have found when using EMSpanol, is that having a Spanish speaking partner is an easy excuse not to use it.  At this stage I can understand more then I can speak, But it has increased my emergency Spanish vocabulary.

I would love to see this little book be used in practice as common as the Broselow Tape. I would also recommend it as a gift to any new EMT, Paramedic, or Fire Academy graduate.

But wait, there’s more.

It’s obvious after talking with, Jeff that he is very passionate about EMS and providing the best care that he can give his patients. He also has brought up some very thought provoking issues in regards to scope of practice in a language barrier scenario. Most will just try to ignore it, but these are discussions we as a community need to be having.

Jeff was featured as a guest on the EMS Educast podcast, where he talks about the book, and his thoughts about scope of practice in a language barrier scenario. I encourage you to listen the episode —-> HERE

For more information check out  http://www.emergencylanguage.com/ and follow on Twitter and Facebook

03
Jul
10

Shock Pt 2: Cardiogenic Shock

By Jeramedic 2 Comments
Categories: Clinical
Tags: , , , , , , , , , , , , , , , ,

In Pt 1, I reviewed anatomy, physiology, and the basic pathophysiology of shock. If you have not read that already, I recommend you do so first. With that, lets talk about a form of  shock: Cardiogenic Shock.

In a nut shell, cardiogenic shock is an inability of the heart to pump enough blood to supply the tissues with oxygen. And is defined as insufficient forward cardiac output.  Cardiogenic shock is usually the result of a significant bradycardia (heart rate that is too slow) or heart block, or a significant tachycardia (heart rate that is too fast) resulting in low cardiac output and hypoperfusion. Cardiogenic shock can also be caused by severe left ventricular failure secondary to acute myocardial infarction, congestive heart failure, chronic untreated hypertension, cardiomyopathy, or long term habitual use of stimulant drugs like cocaine.

The heart can be divided into two halves,. the left, and the right. The left side is responsible for receiving oxygenated blood from the lungs ( via the left atrium) and pumping it to the rest of the body (via the left ventricle). If the left sides ability to pump blood  is compromised, then back pressure will build up in the system. Because the left ventricle is responsible for pumping blood to the systemic circulation, SVR, or systemic vesicular resistance plays a large part in the process. If the stroke volume and cardiac out put is not enough to overcome the SVR, (as in untreated hypertension) or the ventricle is weakened (as in a myocardial infarction or cardiomyopathy) then pressure will back up into the left ventricle. The hearts pumping ability can also be diminished by a cardiac tamponade, or a tension pneumo/hemothorax.



If the heart is not pumping blood into the systemic circulation effectively, then the body becomes hypoperfused. As the pressure builds in the left ventricle, the myocardium (heart muscle) will stretch to accommodate the larger volume of blood. The muscle can stretch, but only to a point before it weakens and fails, causing even less efficient contractions. The pressure will then spread to the left atrium. The left atrial pressure rises and is subsequently transmitted to the pulmonary veins and capillaries. When pulmonary capillary pressure is too high, it forces blood plasma across the alveoli-capillary membrane and to the lungs, causing pulmonary edema (fluid in the lungs).


The hypoperfusion is compounded by the fact that most cardiogenc shock due to left ventricular failure is accompanied by pulmonary edema, which dramatically reduces the ability of oxygen and carbon dioxide to diffuse across the alveoli-capillary membrane. Also, since left ventricular failure is often caused by an AMI (acute myocardial infarction) be awhere that your patient experiencing cardiogenic shock, may also be having an AMI.

Right ventricular failure by it self, will not likely result in hypoperfusen in the same way as left ventricular failure. But, right sided failure is interestingly often caused by left ventricular failure. Right sided failure can also be caused be chronic obstructive lung diseases like COPD. As the back pressure spreads to the right side of the heart, peripheral edema in the dependent parts of the body, and JVD (Jugular vein detention) often occur. These are both key signs to look for during your assessment.


The patient in cardiogenic shock may present tachycardic or bradycardic. Will likely be short of breath with possible chest pain. Possible JVD (right side failure). Lung sounds may be clear, diminished, wheezes, crackles, rales or absent depending on the severity of pulmonary edema. White or pink frothy sputum may be present. The patient will likely have fast labored respirations. Level of consciousness may be diminished due to hypoxia. Skins may be cyanotic and or diaphoretic. Spo2 reading will be low. Blood pressure will likely be normal or hypertensive (in exacerbated congestive heart failure) or  low in decompensating shock.

Treatment is aimed at airway and cardiac support. The patient should be placed in a position of comfort. If pulmonary edema is present, the patient well likely prefer to be sitting upright in a high fowler’s position, with their legs hanging off the gurney. Although the patient may present in a state of shock, treatment should also consist of treating the underlying cause (AMI, CHF) which if managed effectively, can relieve the hypoperfusion.

When available, a 12 lead EKG should always be obtained. Support the airway and breathing with High flow O2 via non rebreather mask, you may need to assist ventilations via BVM (bag valve mask), CPAP, or intubation. Nitroglycerin (if blood pressure is acceptable) will reduce cardiac work load and oxygen demand through vasodilatation, and relieve pulmonary hypertension and edema. Morphine may also be useful. Furosemide 40-80mg IV will relieve pulmonary edema through diuresis. IV fluid administration should be minimal so as not to exacerbate the pulmonary edema.

Cardiac support with Dopamine at 2-10mcg/kg/minute, or Dobutamine at 2-20 mcd/kg/minute will increase the force of cardiac contractions, increasing systemic perfusion and reducing pulmonary hypertension.  If the patient is bradycardic, than 0.5mg of Atropine IV, or trans-cutaneous pacing to increase the heart rate to a perfusing level is appropriate. Always be cautious of AMI in a badycardic patient, because bradycardia can be a protection response of an ischemic heart. Tachycardias (depending on the type, and severity) can be treated with 6-12mg of Adenosine, and other antiarrhythmics like Amiodarone and Lidocaine. Also Synchronized cardioversion if available, and in some systoms a Beta blocker may be indicated.

The patient may have additional cardiac compromise such as AMI which will require appropriate treatment, and transport destination.

*** Always treat your patients according to your local protocols and scope of practice. And use medical control as needed. ***

In part 3 we’ll leave medical, and deal with trauma, burns, and Hypovolemic Shock.

30
Jun
10

Shock Pt 1: Anatomy, Physiology, and Pathophysiology Review

By Jeramedic 8 Comments
Categories: Clinical
Tags: , , , , , , , , , ,

This is the first in a series of posts, that will go over the five types of shock. Covering the basics of pathophysiology, presenting signs and symptoms, and the course of treatment. Before we can understand the various types of shock, we must first have a foundation on which to build.  What follows is a review of  anatomy, physiology, and the general pathophysiology of shock.

Shock is a serious life threatening medical emergency, and can be caused by several conditions.No mater what the cause , the end result will be Hypoperfusion of the cells (Shock) and if uncorrected, death. The cells of the body require a constant supply of Oxygen and other nutrients, as well as a content removal of Carbon dioxide, and other waist products in order to functions efficiently and maintain Homeostasis. For normal perfusion to occur, three systems must be intact: The pump (the heart) The pipes (the blood vessels) and The fluid ( the blood ).

The pump is what “pushes” the oxygenated blood from the lungs, and circulates it to the cells, tissues and organs of the body, where oxygen and other nutrients are exchanged for carbon dioxide and other waist products, which are then carried back to the lungs and other organ systems (such as the liver and kidneys) to be removed. If the pump is too slow, as in Bradycardia, or pumps too fast or inefficiently as in Supra-ventricular tachycardia or other arrhythmias, or if the pump is not strong enough to circulate the blood effectively, hypoperfusion may occur.

The pipes are what carries the blood to the cells and tissues of the body. If there is a obstruction in the pipe as in a Thrombus or Embolism. Blood flow and thus perfusion beyond the point of occlusion will decrease.  If the integrity of the pipe is lost either through Trauma, a ruptured Aneurysm or increased vascular permeability resulting in a decrease of circulating volume, there will be less blood available to transport nutrients and waist. Also, excessive vasodilatation can lower blood pressure resulting in hypoperfusion.

The fluid is what holds and transports the nutrients and waist products. The blood contains erythrocytes (Red blood cells) which have a protein called Hemoglobin. Oxygen molecules attach them selfs to the hemoglobin so that they may be carried throughout the body. In the lungs deoxygenated blood travels through the capillaries surrounding the alveoli. Through the proses of diffusion, oxygen which is at a higher concentration in the alveoli, crosses the alveoli-capillary membrane into the blood where there is a lesser concentration of oxygen. At the same time, carbon dioxide which is at a higher concentration in the blood, crosses the capillary-alveoli membrane into the alveoli, where it is removed during exhalation. The oxygen molecules bind to the hemoglobin and is transported throughout the body. The blood enters capillaries within the tissue where again through diffusion oxygen is exchanged from the blood to the tissue, and carbon dioxide form the tissue to the blood. The blood, now deoxygnated returns the the lungs where the process repeats it self.

If there is a decrease in circulating volume as with blood loss and or dehydration, there will be less blood to transport nutrients and waist products. Also conditions effecting the red blood cell and its hemoglobin such as anemia and carbon monoxide poisoning can decrease the amount of oxygen that can be transported to the tissues, resulting in hypoperfusion. As you can see, a malfunction in any one of the systems can result in shock.

During hypoferfusion the cells become ischemic and switch from a Aerobic metabolism ( with oxygen ) to a Anaerobic metabolism ( without oxygen ). The primary energy source for the cell is glucose. In a Aerobic metabolism glucose is broken down ( Glycolysis ) which produces pyruvic acid which is further broken down into carbon dioxide, water, and energy (ATP). However during hypoperfusion the cell switches to an Anaerobic metabolism (without oxygen) where only the first stage of glycolysis is possible. This produces very little energy and with out oxygen pyruvic acid can not be broken down, and instead is converted into lactic acid which accumulates in the cell, lowering the cellular pH. The acidosis reduces the ability of hemoglobin to transport oxygen which compounds the problem. The lower intracellular pH causes the membranes of the lysosomes and other organelles to rupture releasing enzymes that damage the Sodium-Potassium pump which causes an influx of sodium and fluid, which causes cellular edema, which causes the cell to rupture releasing the lysosomal enzymes, lactic acid, hydrogen and other cellular contents into the interstitial and intravenous space causing further acidosis.

The body has various ways of compensating during shock. However if the cause of the shock is not corrected the compensatory mechanisms will become overwhelmed and fail, causing death. A decrease in blood pressure is detected by the Baroreceptors which activates systems to reestablish normal blood pressure. The sympathetic nervous system stimulates the adrenal glands to secrete epinephrine and nor-epinephrine which causes an increase in heart rate and contractile strength, as well as  vasoconstiction all of which increase blood pressure.

In the kidneys, the detection of low blood pressure stimulates the Renin-Angiotensin-Aldosterone system. The enzyme renin is released by the kidneys. Renin acts on a plasma protein called angiotensin, which is converted into angiotensin I. Angiotensin I is converted into angiotensin II in the lungs by angiotensin converting enzyme (ACE). Angiotensin II is a potent vasoconstrictor which increases peripheral vascular resistants which increases blood pressure. Angiotensin II also stimulates the sympathetic response, and stimulates the pituitary glands  secretion of antidiuretic hormone (ADH) which causes the kidneys to retain electrolytes and fluid. The hormone Aldosterone which is secreted by the adrenal cortex also stimulates the kidneys to reabsorb sodium potassium and water, increases the intravascular volume. As the blood pressure slowly decreases, so does the intravascular osmotic pressure, which causes fluid to shift from the interstitial space and the intracellular space, into the intravascular space to increase the circulating volume.

Respirations increase both in rate and depth. This increases the amount of oxygen available, and attempts to eliminate the build up of toxins from the anaerobic metabolism. If there is blood loss due to hemorrhage, the damaged blood vessels constrict slowing the amount of blood flow and the clotting and coagulation cascade begins. If the conditions causing shock are too serious, or progress too rapidly, the body will be unable to keep up with the demands and move into a state of decompensation.

The heart rate and respirations will increase dramatically. The skin will be very pale cool and diaphoretic. Peripheral pulses will be weak or absent. Urine out put will low or almost none. Level of conciseness will decease from agitated to unresponsive, and the body moves into irreversible shock. At this point the blood pressure is so low the heart and brain become hypoperfused. The hypoxic heart will tire quickly, possibly becoming arrhythmical before failing. The Vasomotor, cardiac, and respiratory centers of the brain will become ischemic and die causing the cessation of compensatory efforts. The blood will begin to pool and coagulate in the capillaries. Because of the loss of vasomotor control from the brain and the low blood pH, capillaries become permeable and the pre and post capillary sphincters relax causing wash out sending microemboli and toxins into the tissues and systemic circulation, and the body dies. Once the body moves into the late stages of decompensation and irreversible shock, resuscitation and survivability are extremely low.

Now that we have all that taken care of, we can move in to the various types of shock, and what to do about them. Remember that for a patient experiencing shock, the best treatment is always safe and efficient transport to an appropriate facility.

In part two, the basic pathophysiology, signs and symptoms, and treatment of  Cardiogenic Shock. <—- Read Here

01
Jun
10

Looking For Trouble: Part 2

By Jeramedic 2 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , , ,

In part one I talked about the importance of being thorough in your patient assessment, and to resist falling into bad habits. So in that same vein, Lets talk about an assessment style that is both quick and easy for you, and will lead to a better  assessment and more appropriate patient management.

Lets start off by making sure we have all of the right diagnostic equipment, and enough time to use it all. Equipment: Eyes, ears, hands, and brain. “check.” Time needed: 5 minutes or less. “wait wait, no gear and 5 min?… now who is being lazy” let me explain. I am in no way down playing the enormous benefit of having sophisticated diagnostic equipment in the field, or am I saying that 5 minutes is enough time to know exactly whats wrong and what to do about it. What I am saying is that by just paying attention for a few minutes, and using your  “own” tools, you can actually learn quite a lot about your patient.

The reason I am suggesting you hold off on the “go go gadget Lifepak” for just a moment is two fold: First, I have seen many a practitioner both fresh and seasoned become entranced in the ritual of test that, analyze this, attach the purple thing,  chart that reading that they become blind to the picture that all this data collecting is painting.  Second, is that these assessment techniques can be used by any level of responder, and  there may be a time when the high tech equipment may be malfunctioning  or is unavailable.

So lets start with the first bit of info you receive about the patient: The dispatch. Now it doesn’t take you long to realize that dispatch info can at times be a hit or miss when it come to accuracy. But that doesn’t mean you shouldn’t  start preparing for what you may find while en rout. Consider the Chief Complaint and scene info, from that you can already start to think of a differential diagnosis, and  possible issues like safety and the need for additional resources. Also ask yourself if you know this Patient? Could this illness or injury be similar to one that you have treated them for in the past? If so, what did you learn from the past contacts that could be applied to this one?

Now you’re on scene, and after observing the environment for possible dangers as well as clues the NOI (nature of illness) or MOI (mechanism of injury), you make contact with the patient. This is where the real assessment begins.

The Initial assessment.

This is where you form you general impression. Put simply, how do they look from across the room? Would you know this person was sick if you had not been told? Or did they need a hospital three days ago?  Observe the position they are in. They could be lying on the ground, which should alert you to possible head or neck traumas.

Mental status, Airway, Breathing, and Circulation.

As you approach the patient and introduce yourself, do they respond appropriately? Or at all for that matter? If their response is abnormal or absent, the info you have gathered form you the dispatch, and the last 30ish seconds on scene, should be able to point you in the direction of trauma or medical. Act, and assess accordingly, based on their level of consciousness.

But lets suppose they do respond, and are quite verbal and appear to be  oriented to their surroundings and the situation. Without any obvious respiratory distress, as assessed by observing there posture, speech pattern, effort needed to breath, and the absence of abnormal breath sounds (at least at this stage) you know that for the moment at least. their airway is open, they are breathing adequately, and they have a pulse.

As you ask the patient about why they called  today, bring your self down to their level, and listen. Listen to what your patient tells you. If you don’t pay attention now, they wont feel that inclined to tell you again later .  Ask if you may hold their wrist to check their pulse while they talk. What you are looking for is the rate, rhythm and strength of the pulse. Is it too fast, or too slow? is it regular or irregular? Is it strong or weak? This is a good time to note their skin for color, temperature, moisture, and condition. If you listen,  pulse and skin can tell you a lot about the cardiac status of your patient. As basics, one of my partners and I had a joke that we carried a “LifePak II”.  The II, to represent the two fingers used when palpating a pulse.

Keep Assessing.

As you move on to your SAMPLE and OPQRST questions, make a quick mental note of what you have  observed about you patient so far. As you ask, and they answer, look in their eyes for color, pupil size, shape, and clarity. This is also a good time to look for any facial droop. Also observe their rate and effort of breathing a bit closer. You my also consider doing a quick visual, or semi physical head to toe exam. looking for things like Bruising or discolorations, Scars,  Jugular vein distention, Dependent edema, and so on.

Putting it all together.

So lets recap. In less then five minutes, we established a chief complaint, obtained a baseline mental status, assessed Airway/Breathing/Circulation, did a brief preliminary physical exam, gathered pertinent information as to the chief  complaint/related signs and symptom/medical history/medications, and hopefully established a patient rapport.

so, what did you learn from this assessment? Do your findings correlate with the chief complaint? If they don’t, why not?   Does this patient need immediate interventions and transport? Do you have a working diagnosis?

Plan and act.

By now you should have a pretty good idea of what is going on. If you haven’t done so already, now would be the time get a blood pressure, auscultate lung sounds,  and to start a treatment and transport plan. Now when it comes to the use of the more advanced equipment, ask yourself why you are preforming the test? well the easy answer is that its standard practice, and is part of the protocol for “X” complaint. What I mean is why do You want the test? is it to conform something you suspect? Or is to gather more data to help lead you in a direction?

This is about finding a problem, and doing something about. Always do your best to correct any life threatening conditions as they present. Remember that the low tech assessment is not a replacement for the advanced and detailed assessment. What it does, is it serves as guide to where further assessments and treatment should go. And as a solid foundation on which to build on.

Remember that no matter how much advanced equipment and treatments we can bring to the patients side, the most valuable is parked right outside. The Ambulance it self. Weather the hospital is 10 minutes, or 2 hours away, early, safe and efficient transport is one of, if not the best therapies we have. Also consider that the ambulance is the closest you’ll get to a controlled environment.

Have faith in your abilities, and have faith in yourself.

20
Mar
10

Don’t Just Do Something, Stand There!

By Jeramedic 4 Comments
Categories: Good Medicine
Tags: , , , , , , , , , , , , , , , ,

Being a passionate provider, as I’m sure many of you are as well. We are drawn to this line of work because of a sometimes overpowering drive to do the best and the most we can for others. There are however times when doing the best for our patients means doing nothing.

This can be a difficult time for anyone put in this situation. We want to do all that we can, no matter what.  Sometimes we find ourselves in scenarios where we are unable to provide care do to safety issues, or at other times having reached the limit of what can be done in the field. Either way, in any situation the EMT or Paramedic is sometimes left feeling helpless, frustrated, and angry at themselves or at others involved. There is a lot of talk and research on the other, more commonly thought of job stresses. Things like, sleep loss, post traumatic stress, the time spent away from home and its impact on families and so on. But I see this occurrence as an equally significant, and yet less mentioned stress.

Some of us take patient outcomes very seriously, and we all like to be in control.  When put in a situation were things are out of our control, or there is nothing else that can be done, feelings of stress can soon follow. When feelings get out of hand, I see basically two behaviors. One having thoughts and feelings directed towards  our self, such as feelings of failure or inadequacies. The other being directed outward, such as blaming others for what happened.

Like other forms of stress, over time these feeling and behaviors will negatively effect your professional and personal life. Proper management and care must be taken in order to have a long and healthy career. I say this because I have experienced these feeling myself. I can remember arriving to shootings before the police, and having to wait a block or two down the street until the scene was secured. I could see the incident, I could tell that I was needed, and yet I couldn’t help. There were times when someone would run down the street to the ambulance pleading for us to help. Often they would not understand why we had to wait, and I would find myself feeling helpless and frustrated.

There have also been times when I’ve had to take care of someone who was very sick, and yet had nothing for them. Again, more feeling of helplessness and frustration. I found this to be a common scenario when I was an EMT Basic while waiting for ALS to arrive. Even still, as an ALS provider there are times when you cant fix the problem. And what you do have to treat the patient, may actually do more harm then good.

It’s important to be rational about these situations. And to come to terms with your limitations, and to work with them the best you can. Remember that on calls of a hazardous nature like violent crimes, and HazMat, that the safety of yourself and your partner or crew is vital. I know you have heard it before, but I can not stress it enough. You can not help anyone if become a patient yourself. As hard as it may be sometimes, just stop. Stop and wait for the scene to be safe. Your grand kids will thank you for it.

Also, be honest with yourself about your limitations. Now prehospital care has made huge advances in a relatively short period of time. But as much as we can diagnose and treat in the field, very little of that is definitive care. And very often just getting the patient to the hospital is still the best treatment we have. I know that statement may go against what many progressive system are working towards. Like alternative transport and treat and release protocols, but its true. Despite what your ego may tell you, you are not a superhero. And being a good clinician not only means knowing what to do, but also knowing what not to do.

There are of course other situations when no treatment is the best treatment. Like when honoring a Do Not Resuscitate order, or having to triage a Mass Casualty Indicant. The decision to stop or withhold treatment can be a difficult one, even when you know it’s the right one.

Remember why you do this, and that you do make a difference.

Be well my friends, I promise you  it’s all worth it.

An episode of the GenMed show was inspired by this post, and recorded soon after. To listen to the show click here

03
Feb
10

Frequent Flyer Benefits

By Jeramedic 8 Comments
Categories: Good Medicine
Tags: , , , , , , , , , ,

Is there such a thing as Frequent Flyer Benefits? Yes there is, and I’m not just talking about flying across the country on the cheap either.

In this business, “Frequent Flyer” is a semi derogatory term given to those patients to whom we see often. They are the homeless alcoholics, the poorly managed type II diabetics, and the lonely widow. Anyone who has been in the field for a few months can tell you who their preferred customers are, and they know their address and chief complaint by heart.

These patient are not just the habitual 911 callers, but are also the weekly scheduled transfers like dialysis and chemo patients. I recently had a discussion about this with a good friend of mine. He is an administrator at a mid sized ambulance company specializing in inter facility transfers, and he has been dealing with a rather problematic trend amongst the field providers. He told me that  many of his personal were not doing assessments on frequently transported patients.

When he would ask why they weren’t doing full assessments, he was met with poor excuses like “Mr Johnson has CHF, he’s always tired” or “Ms Conner is post CVA, she’s always altered.”

This is a very dangerous  practice. I know at times it is tempting to think of our frequents as static characters that we give rides to. But that is  just  not the case . And it should be reiterated that for the time on scene and during transport, regardless of your level. You are the person that is most responsible  for that patient. And not doing a full assessment is frankly irresponsible and could cause harm.

So you ask where’s the benefit’s? , why should I be happy to be transporting this patient for the third time this week? well because you are at a huge advantage to provide really good care. You’re even at a greater advantage then the patients primary physician.

If you transport Mr Fillips to and from dialysis three time a week, that means you do six assessments a week on the same patient. That’s twenty four assessments a month, and one hundred and forty four assessments  every six months!  Do you think his primary physician, let alone anyone assesses this man health twenty four time a month? Probably not. And if anything was out of the ordinary, who do you think would notice first? You would. That is of course if you did an assessment.

When treating a frequently seen patient, we should pretend that it is the first time we have seen them. Sure you know their name and medical history but that’s where the familiarity stops. Afterward ask yourself  how what you found compares to what you know? Whats different or new about the patients presentation?

EMS, despite what it might claim is not an emergency service. At least not exclusively. Our place in medicine is quickly expanding in many ways.  If we can lose the “trauma junky ” hero mentality, and embrace our true role as Health Care Professionals. Then we will not only benefit ourselves as providers and our industry, but also provide our patients with better care.

So the next time Mrs Miller starts singing “ca’mon ta my my house, ca’mon ta my house” Be true to your role. Be kind to your patients. And give them the respect and attention they deserve.

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