Posts Tagged ‘education

23
Oct
11

A view from the other side.

By Jeramedic Leave a Comment
Categories: Good Medicine and Rants
Tags: , , , , , , , , , ,

Lately I have been spending some time in other parts of the company other then the back of an ambulance. I must admit that I was a bit apprehensive when I started to take on some duties behind the scenes. But I found it to have been a very eye opening and educational experience in the world of EMS, especially from the prospective of a field provider.

I thought I would share a little of what I have learned with you, in the hopes that perhaps you will think a little different about your job the next time you pull into the station, or are dispatched to a call.

So here are a few things that as a field provider, you may not of necessarily known was going on while you were out running calls.

  • You are posting, or on a move up because other units are busy. its as simple as that. Its not because the dispatcher doesn’t like you, or because “those knuckleheads at station 18 can’t handle their area”. It’s because coverage is being lost left and right, and you are one of only a small number of crews left in the city.
  • Document Document Document. I know that may sound obvious, but if you knew how many calls come through every day from lawyers asking for patient care records, you would think twice about what you’re signing.
  • No one likes to run the non-emergent, “BS”, system abuser calls. It’s one of the issues being handled in EMS 2.0. But would you believe that many people, (sometime several a day) call non emergency phone numbers, asking for simple BLS transport for things like: Chest pain with shortness of breath. Altered levels of consciousnesses. Seizures. And Obstetrical problems.
  • It really takes a lot of time, money, and energy to keep “your” ambulances and equipment in working order. So please take care of them when you’ve got them.
  • Dispatch is not a cushy job. Its had work. It might just be me, but I found dispatching to be more challenging and stressful then any field work. So when the dispatcher does’t copy you back, understand that sometimes it’s loud, business phones are ringing, while emergencies are coming in, while neighboring cities are calling for mutual aid, and any number of other distractions. So please… Give them a minute.
  • And finally, and this one is important so pay attention. We all know that reputations mean everything in this industry. When you are in a position where you can watch over fifty field staff working throughout a shift, and over multiple shifts, you realize that it doesn’t require much effort to stand out from the crowd, in both positive and negative ways. And that should be your take home message. Small changes in your behavior and work ethic, really make big differences.
So there you go, just a few tidbits of insight from the other side. Do with it what you will, but do good, and be safe.
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

12
Oct
10

The Community of Paramedicine: Pt 2

By Jeramedic 5 Comments
Categories: Good Medicine, Rants and Uncategorized
Tags: , , , , , , , , , , ,

So in part one I discus the idea of an “EMS Brotherhood”, and that we are all one and the same (even if your partner or common perception tells you otherwise) But after looking at how the industry is set up, and even still how we as members of this industry interact with one another, I am starting to look at things differently.

EMS does not have a “brotherhood” (at least not in the way as defined be our colleagues in Fire and Law) because we already have something . We have a community. And just like any small or mid sized town, we all know each other, we see each other around town, we share stories and ideas, we drive similar yet personalized cars, we all live and work in different areas, and we take pride in our little town, no matter how small it may look compared to the bright lights of New York city.

But how did we all become residence of “EMSville” ? And how can we expand? Well, like often mentioned, the connections and friendships made with social networking sites combined with the face to face interactions at regional and national, and even international conferences has helped to strengthen the community tremendously. The fact that you are reading this, and even care what I have to say is proof of that.

But Why?

Well, we need more friends. Both in, and out of EMS. We make these friendships by taking a leap, and talking to strangers.  Ever since many of us were little kids, we were told to never talk to strangers. While this was done out of a concern for our safety, many of us have carried this mantra over into adulthood. But its okay now. I don’t think the EMT ride-a-long thats with the other company, or the ER Doc, or the police Sergeant is going to lore you away with a bag of skittles and lost puppy story. And if you are still stuck on the ridiculous notion that “I wear blue, they wear white, we’re not from the same tribe.” All I can say is, Evolve already.

By not talking to, and getting to know your neighbors, you (and we as a community) are losing out.  Your best friend, fellow supporter of a cause, Jedi master educator, or ever your future medical director could be standing next you, and you would never know.

I used to work in an area where my main hospital was also the regional trauma center. Three fire departments and two private ambulances would all transport there, not to mention all the non emergency transport services as well. If you ever wanted a melting pot, the wall of that ER was it. I would talk to everyone, and guess what? I made friends. Friends that had on different uniforms, and made less then me, and who made a lot more then me. And it pays off. When I needed help with a patient, they were there. When then needed help with CE’s or a new job, we were there. Its like borrowing  cup of sugar.

Expanding a small town community into a thriving city is the same for EMS as it is a real town. Strong relationships must be made, trust must be built, and Infrastructure put in place.  There must be a sharing of recourses, and so on. Whats good for you, is good for your neighbor. We are not stealing secrets, we are sharing knowledge.

But How?

First off,  introduce yourself.  Say where you’re are from and what department or company you work with. Don’t think that just because you are in uniform that your patches and badges will speak for themselves.

Take a genuine interest in the other person. Hard to admit, but we all like to talk about ourselves. So Let them talk. Who are they? What are they doing in their career? Where do they want to go? Afterward, remember somethings about that person and the conversation. Next time you see them in the ER, or elsewhere, you’ll have something to talk about.  ”Hey Jen, how’s that fire science class going?” “Mike, I did not see you last week, did you take that vacation you were talking about?”

People like it when you remember their names, and something about them. You may have only just met lest week, but it creates a bond. Before you know it, you’ll have a study buddy, or a great reference for an application. And they will benefit too.

Also, and I must stress this. No egos allowed. When making friends, leave the deck of certs in your pocket. No one uping stories, no Medic vs EMT  rubbish. When speaking to someone with less experience and education then you, remember where you came from. When speaking to someone with more experience and education then you, still remember where you came from. Just be human.

And these gestures of peace are not just for personal gain. These are the people that are going to have your back on a major incident. building a strong relationship with not only your fellow EMS workers, but also Fire, Police, and Hospital staff  is something the strengthens the communities you serve. These were the driving principles behind the TAK Response conference I attended in September. And the San Bruno gas explosion the week before was a great example of expanding their our community aided in the response, fire fight, and patient care.

The community is growing, and with the help of friends like you, it is getting bigger and brighter every day.

06
Oct
10

The Community of Paramedicine: Pt 1

By Jeramedic 4 Comments
Categories: Events, Good Medicine and Rants
Tags: , , , , , , , , , , , , , ,

Last week I spent my time in Dallas at this years EMS Expo. It was a wonderful experience of both personal and professional growth, and something a recommend everyone attend at least once. But this post is not about the event, or the speakers, or the podcasts, blogger meetups, or even the “shhhh, super secret high-viz, bluetooth  enabled airway adjunct/C-Spine translator backpack gurney, that is going revolutionize the way we…”

This is more of an observational post about what happens at events like EMS Expo, and in the online communities. Something that I am seeing more of, but not as much as I’d like. Our friends in Fire Suppression and Law Enforcement have had a “brotherhood” for nearly a century. That unspoken bond that removes the illusion of rank and department and simply says “we are.”

Granted, Fire and Law have had about a century’s head start. And when it comes to the method and delivery of Fire protection and Law enforcement, a  near uniformity exists from one department or city to the next. But when it comes to EMS, there can be near poller opposite within the same county. Private, Public, Volunteer, Hospital based, Progressive protocols, and antiquated equipment, BLS, ILS, ALS, all sharing boarders. And any combination of the above could respond in teams from one on up to six plus. They could be in a car, ambulance, fire engine, or a private vehicle.

No wonder we struggle to find an identity, let alone a brotherhood. In many ways we are our own oppressors. Thanks to the “popularity” of privatized/for profit ambulances, we are treated like numbers, and view other providers from other services as competitors rather than colleagues. This is a an unfortunate and foolish mistake. We are all EMTs and Paramedics. We went through the same testing, we have same card(s) in wallets, we take care of the same people. So can we just be done with this whole tribal nonsense already?

The funny thing about all this, is that it only happens in the field. What is it about driving around in different colored ambulances that makes many of us act this way? You see, I don’t believe that this is our true nature. I don’t act this way, and I know many other who don’t either. But for some reason only at EMS conferences and on social sites like twitter and facebook do these  walls come down on a large scale.

There, out of uniform,  we stand as equals. Its in this space, in person and online where a student from Ohio can be mentored from Louisiana. Where providers from opposite coasts can feel like old friends, when in fact they just met. And where Medics from around the world can come together and create something bigger then themselves, and give back to the community that helped create it.

This community is what strengthens us as a profession, and as individuals. Its this community that wanted EMS 2.0 when its was just called “I wish things were better.” And its this community thats going to gets its wish. We all agree that it take a special kind of person to do this work. Well, what kind of person is it who will take time off of work, and spend money to go be surrounded by work? This is EMS Expo, and this is the community of paramedicine.

This kind of community is what we need when the boots hit the ground. I wear a blue shirt, you a white shirt, and others red and green, But we are all on the same team, and until we start playing like a team, none of us will win.

More to  in part 2.

03
Jul
10

Shock Pt 2: Cardiogenic Shock

By Jeramedic 1 Comment
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 6 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

29
Jun
10

GenMed Show, and FIRESTOME Premiere

By Jeramedic Leave a Comment
Categories: Events and PodCasts
Tags: , , , , , , , , , , , , , , ,

Natalie and and myself welcome special guest Sam Bradley to the show, and talk about our experience in San Francisco at the FIRESTORM Movie premiere.

Every minute in the United States, an ambulance gets turned away from an emergency room because hospitals are simply too full. In Los Angeles, where the wait time in some ERs is as long as 48 hours, the entire 911 system is being challenged in ways that are alarming.

It was a really great experience going back to San Francisco for this event. I was able to spend some time with some friends from the Chronicles Of EMS event. Something very special about this trip, was being able to share it with my mom and sister. The week before we were visiting family in beautiful Lake County California, about 2 1/2 hours north of San Francisco.  After the visit, we all drove down to the city. Before the premiere, we had breakfast with Chief Seb Wong of the SFFD. After breakfast, we were given a tour of the SFFD EMS station 49. Then it was off to a late lunch with Sam Bradley, and then the to the premiere and meet up. After the premiere, the very hospitably Seb gave us all  a private tour of China Town. Truly priceless.

You can Listen to the show —–> HERE

Also, My Good friend Scott Kier Wrote a great review of the film on his blog

22
Jun
10

Believe Me

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

In this day of computer aided dispatch (CAD) systems, GPS locators, and EMD (Emergency medical dispatch) algorithms, one could argue that the process of getting the closest and most appropriate resources to the scene of an emergency, has been greatly stream lined. There is however two things these technologies are lacking: Eyes, and judgment.

You see no matter how much tech we load into a response vehicle and or dispatch center, there are still humans that need to operate the system, update the information, and make treatment and transport decisions. Field providers, dispatchers, and hospital staff need to be able to communicate effectively with each other, and most of all, believe each other.

What follows are two examples of a break in the communication trust.

Example 1:

30min before the end of my shift, and I am en route back to the station. My partner and I notice a large cloud of black smoke rising up a few blocks away. It was 12:30am, and radio chatter was lite. We did not hear anything relating to a fire go out, and so we thought we would go investigate. What we found was a two story house, fully involved in flames, and no one was around. No crowd of neighbors, no police, and no fire engines. Me: “Base, 1116”. Dispatch: “go ahead 1116”. Me: “1116, who do you have responding to the structure fire on 132nd street?”. Dispatch: “ummmm, no response. There is no fire on 132nd street”. Me: “yes there is, I’m looking at it” Dispatch : “umm, ok? Well we don’t show any fire calls in your area. Where are you?” Me: “At 123 132nd street, and there is a house that is VERY much on fire”. Dispatch: “……. Oh! There it is… ok, well show you on scene”. Me: “Thank you”

Example 2:

At a red light, a car pulls up behind the ambulance, and two men exit the car. “this is when we get robed” I jokingly said to my partner, Bobby. The two men begin pounding on the window, they did not speak english, but it was obvious that they were asking for help, and not for our wallets and cell phones. I flipped on the amber secondaries as Bobby followed the men back to their car. As I stepped out of the ambulance I saw Bobby’s eyes get wide. “Its a GSW” (Gun Shot Wound) he shouted. I met him with the gurney at the back of a blood soaked SUV. The patient was quickly loaded into the ambulance, and I was on the radio. Me: “802, were at the corner of Any street and Somewhere Blvd, With a still alarm GSW, we need PD!”. Dispatch: “can you repeat?”. I repeated. While I waited for a reply, I helped Bobby assess and and start treatments. The patient was a male in his late teens. He was pale and moist with labored respirations and diminished lung sounds on the left. He had a a 2cm entrance wound to his left upper chest, mid clavicle. And a 3-4cm exit wound just below his left scapula. Dispatch: “whats the gender of the patent?” Me: “Male! Is PD en route?” I handed Bobby an occlusive dressing and asked if he was ready to go, “yeah, lets get moving” he said. I got into the drivers seat just as a county sheriff pulled up. I gave him a 10 sec report and left. Me: “dispatch 802, we are transporting code 3 to Saint F’s “. Dispatch: “do you need fire to respond”. Me: “No thank you”.

I understand that dispatching is not always the easiest job, and that there are protocols and procedures that must be followed. But when I ask for help, believe me. I promise I don’t make things up just to complicate things.

We are a team. And if we cant communicate and trust one anothers information, we loose points on the field. I am not ragging on dispatchers, I’m just promoting better professional trust. I encourage you to get to know your colleagues in the little dark room, offer a ride along, and play nice.

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.

24
May
10

GenMed Show “The Hills Have (i)’s”

By Jeramedic Leave a Comment
Categories: PodCasts
Tags: , , , , , , , , , , , , ,

In this episode Natalie, Myself and special guest Scott Kier (@medicsbk) discuss our recent trip to NAEMT’s inaugural event: EMS on the Hill in Washington DC. They talk about the policies being pushed by EMS leaders and field medics alike and why they are relevant to all in the healthcare industry. —–>Listen Now

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