Posts Tagged ‘ems

24
Feb
12

Four o’clock in the morning.

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

Four 0′clock in the morning. Four ayh emm. 4am… Often passed during sleep, that time that doesn’t exist for most people. But it does exist, I mean we agree to have it on the clock. It’s there,  but what happens at 4am? It’s far too late to be considered night, and even though “morning” is in four o’clock in the morning, it’s much to early to be thought of, really as morning. Here, I will share with you some the events surrounding that most surreal of hours: 4 o’clock in the morning. This elusive hour, both very late and very early, appears often in art and literature as a way to describe the most extreme states of affairs.

Paul Simon references it. Epic 80′s band, Night Ranger wrote a song about it. Children’s author, Judy Miller even has book about making a grilled cheese sandwich at 4am… who knew?

I was first introduced to 4am as a child. I was eight or nine, and due to insomnia, or perhaps nonsense  rebellion toward rest, I often found myself awake. The time was announced by the thud of the newspaper hitting the driveway, followed by the high pitched whine of the delivery truck’s revers gear. That was then, but even now I am quite familiar with that purgatory of time.

As of late (hehe, get it? “late”. Okay, bad pun) I wake up at 4am to go to work. And while at work, at least when twenty four hours of service is on the bill, I will likely be woken again at 4am to tend to needs of the city. Having my Circadian rhythm dropped to asystole , I fuss about with strangers bodies, and with the flash and style of an open mic stand up comic I place an action on their afflictions. Or perhaps more accurately, as is often the case at 4am, lack of afflictions.

This is not to down play the very real fact that emergencies still do happen at 4am. Cardiac arrests happen at 4am. Diabetics become hypoglycemic at 4am. fights and assaults happen at 4am. The flu happens at 4am. Really the flu happened two or three days prior, it’s only at 4am do become involved. And Traffic collisions. Either due to bad weather, alcohol, poor choice of  doing The Fast and the Furious reenactments, or any combination of the three, Some of the most spectacular, violent, J J Abrams traffic collisions I’ve ever been on have happened around 4am.

Seizures happen at 4am too. Which I find a bit odd. Not the seizure, but rather the fact that I find out about the seizure that happens at 4am. You see, it’s quite unlikely that the person having the seizure called 911 during the event, or indeed even called out to someone else to do it for them. And of course after the supposed seizure there is a postictal period that greatly limits the person from calling for help there after for some time.  This then means that a second person must be present with the first, and must either witness or become aware of the seizure as it happens,  and then they must call for help. Which then presents the question, what were they doing up at 4am in the first place?

Other, less tragic things happen at 4am. Stores that are open 24hrs get as near to being closed, without actually closing at 4am. Fog happen at 4am too. Even in the middle of summer, strange, thick, spooky fog can roll in. The paper is delivered, we learned that earlier. Oh, and ghost hunting television shows do their “investigations” at 4am as well.

Its funny that I write this on the second of four days off. One of the few times that I don’t need to be up at four o’clock in the morning, but perhaps I still should try. You know, to keep up momentum and habit. Regardless, realize that there is a world of events that happen in that hour between three and five, weather you are there for it or not.

but until then, get some sleep.

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

09
Feb
11

Pill Popping On The Job. (How to reclaim the 24hr shift.)

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

We work hard for our money. At least that’s what it feels like the morning after a nasty 24hr shift. We have all been there. Going home and sleeping till 3pm, 0r getting of at 7am and trying to go about your day like a cranky zombie. Some of us have become so accustomed to it (myself being one)  that we plan our days off to include recovery sleep.

Now there are some exceptions to the the 24hr shift hangover: You are either at a station that runs less the three calls a shift, or you work during the daytime for only 8-12 hrs. But even that does not immune you from feeling fatigued at work.

Sleep deprivation and long shift hours is a big deal in health and safety, especially in the EMS world. And even though research shows us time after time that sleep deprivation significantly decreases mental focus and performance (something we need when taking care of critically ill patients, and operating heavy equipment like vehicles and rescue tools) whilst increasing ones risk for heart disease and other illnesses,  there is still a split opinion about 24hr shifts. Case in point: While one agency is taking safety and shift work very seriously, another is disciplining a Firefighter for refusing to work 72hrs straight.

Now this is not a post about being over worked. I don’t think there need to be much discussion about that. It sucks, and its dangerous. We have all at one time or another responded to a call at 3am in a mental state near postictal, only to fully wake up as you are immobilizing someone on the side of the highway. Rather, this is a post about the last months self experimentation on sustaining energy while on shift, and reducing the hungover zombie symptoms the day after.

After some research and self experimenting, I came up with the following nutritional supplement and sleep protocol for my days at work.

I work ten 24hrs shifts a month, from 7am-7am, and the protocol’s hourly breakdown looks like this:

  • 7am: One cup of coffee, and one multivitamin with breakfast.
  • At lunch, 2000 mcg of vitamin B-12, and two High Stress Adrenal tablets.
  • Somewhere from 4pm-7pm 1000 mg of vitamin C, and a 20-30min nap.

Thats it… The kicker for me was when after doing the above during a 48hr shift, with an average call load for that station during the day, and waking up three times both nights, I felt better after that 48hr shift then I did after most 24hrs I had done in the past.

7am Coffee. I usually get to the station  15-20min early so I can get my gear ready and do the equipment check out before I’m officially on at 0700. Although coffee is not a must have part of my day, I do enjoy it. And the social bonding that comes with  coffee around the kitchen table with the off going crews is equally if not more energizing.

Multivitamin. I think any brand of multivitamin is fine. The idea behind taking one is the inherently poor diets that too many EMS providers have, especially while on shift. It is also a way of getting the other B complex vitamins to complement the 2000 mcg of B-12.

2000 mcg of Vitamin B-12. Vtamin B12  is known as the “energy vitamin,” and it is essential for many critical functions in your body, including energy production, supporting your immune system, and helping to regulate the formation of red blood cells. Vitamin B12 is also a cofactor in the production of Melatonin, which will help you to fall asleep faster. It also enhances the phase-response of circadian melatonin rhythm.

High Stress Adrenal. High Stress Adrenal is a 100% Food supplement that supports optimal adrenal health.  The adrenal glands play a role in energy, stress, mood, immune support, and pain management.  This product contains many of the substances produced by, or naturally in, those glands including peptides, hormone precursors, and enzymes.  Additionally, it includes l-tyrosine, food B vitamins, food vitamin C, and herbs to support healthy adrenal function. Even if you don’t get a huge adrenalin rush every time the tones go off, that doesn’t mean your adrenal glands aren’t working overtime to keep you focused and alert on calls, and awake at 4am.

1000 mg of Vitamin C. Vitamin C functions as an antioxidant and may also be useful in lowering serum uric acid. Some sources claim that Vitamin C “supports” or is “important” for immune system function. Seeing as Vitamin C deficiency is detrimental to immune function, resulting in reduced resistance to some pathogens. You can see where some people would assume benefit.  But, routine supplementation is not indicated in the general population. For that reason I do not take it daily.

Napping. I touched on the subject of sleep in a previous post. And nothing beats good restful sleep when it comes to energy. Well, I mean nothing beats REM cycles when its comes to energy.  REM is the business when it comes to sleep. It’s so important, that when deprived of sleep, subjects will fall into REM cycles within seconds of closing their eyes. Have you ever had the experience of nodding off for 30 seconds to a minute, and having a dream that last for hours, or waking up and thinking you time traveled?  Thats REM. The problem with REM cycles, is that they come in cycles. Over a normal Monophasc night’s sleep of 8hrs, you drift in and out of REM. Which on a good night will add up to about only 2hrs of REM. Thats 2hrs of awesome regenerative brain time, and 6hrs of  being unconscious.

Enter the realm of Polyohasic sleep. Dr. Claudio Stampi says that in crises and other extreme conditions, people may not be able to achieve the recommended eight hours of sleep per day. Systematic napping may be considered necessary in such situations. Dr. Claudio Stampi, as a result of his interest in long-distance solo boat racing, has studied the systematic timing of short naps as a means of ensuring optimal performance in situations where extreme sleep deprivation is inevitable, but he does not advocate ultrashort napping as a lifestyle. Scientific American Frontiers has reported on Stampi’s 49-day experiment where a young man napped for a total of three hours per day. It purportedly shows that all stages of sleep were included. Stampi has written about his research in his book Why We Nap: Evolution, Chronobiology, and Functions of Polyphasic and Ultrashort Sleep In 1989 he published results of a field study in the journal Work & Stress, concluding that “polyphasic sleep strategies improve prolonged sustained performance” under continuous work situations. And having tried it myself, I’d say he’s right.

So there you go, Folks.  an alternative to SVT in a can. Everyone is different,  and maybe my strategy is not for you.  Either way, I hope you find rest on your next shift. The point is that with a little planing, you can be more alert and focused on shift, and feel better when you clock out.

Already have some tactic in use? Please feel free to share.

***** Disclaimer. I am not a doctor, nor do I play one on TV. These are the results of my own trials on myself. I am not prescribing or recommending anything to anyone,and I do not  claim to be an expert or authority on what you should to with your body. Talk to your doctor before taking any dietary supplement, or starting a diet, exercise, or lifestyle routine. *******

29
Jan
11

Milestone Month.

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

Its nearly the end of January, and I haven’t posted for a while. I know busy is a lame excuse, but its true. Anyways, January has  some significant meaning to me. And I thought It might be nice to share with you why this month is so meaningful.

First is my birthday. The 14th of this month marked the day that I have been on this earth for a quarter century. Kinda a big deal I think. If for nothing else, I can rent a car now.

There is another birthday this month: The Blog. On the 10th this blog had its one year anniversary. I can tell you it doesn’t feel like its been a year. This little blog has lead to many great friendships and adventures. I would like to thank you guys for sticking with me during the last year. The fact that you take the time to read my little stories, rants, and ideas means a lot to me. So to you who have been here from the beginning, thank you. And to those who are new, welcome.

And finally the 12th of this month marked my fifth year in EMS. It doesn’t feel like it’s been that long. But when I look back on all of things I’ve done, the places I’ve been, and all I have learned… I can see where the time has gone. Also seeing the badge numbers of some my coworkers is a friendly reminder.

I know five years isn’t much compared to some of my twenty plus year colleagues. But it’s nice to be at a place where people often “burn out”, and actually be more motivated and passionate then ever. You, the readers and online EMS community deserve some credit for that passion and motivation. Having the support of fellow EMS providers from around the world who feel just as strongly about this profession as I do, it can’t be said enough how valuable that is.

So in the month of birthdays, in life, blogging, and medicine. All I can say is it’s been a fantastic journey. And one that I plan to be on for quite a long time.

16
Dec
10

Finding Zen In A Career of Chaos

By Jeramedic 1 Comment
Categories: Good Medicine and Uncategorized
Tags: , , , , , , , , , ,

The Zen tradition holds that in meditation practice, notions of doctrine and teachings necessitate the creation of various notions and appearances that obscure the transcendent wisdom of each being’s Buddha-nature.

Another way to think about is: A total state of focus that incorporates a total togetherness of body and mind. Zen is a way of being. It also is a state of mind. Zen involves dropping illusion and seeing things without distortion created by your own thoughts.

I think of Zen as a Physical, Mental, and Emotional homeostasis. A personal “set” point where you are at your best, In mood, health, and effectiveness.

My personal interpretation and practice can be summed up in;

  • Chilling out .
  • Refueling.
  • De-stressing.
  • And getting ready.

I will break these down with the goal of helping you find a little Zen of your own.

Chilling out: Resting is a huge part of returning to, and maintaining your center point. We, humans have a limited amount of physical, mental and emotional energy at our disposal. And despite our best (or addictive) attempts, no safe amount of coffee, V-Tac in a can, or 5hr B12 Vitamin shot  can compete with the natural energy and focus that is created from rest. Now I’ll admit I do enjoy the effects of a caffeinated beverage or two, but with in reason.

I know that in this field, rest is often hard to come across. But I find that if you are  proactive in your quest for rest, you’ll be surprised at how many opportunities there actually are. It starts at home, if you can get a good nights sleep before your shift, you will be miles ahead of most of your coworkers. Think of yourself like a cell phone: If you are not going to have access to a charger for the next 24hrs,  it would be best to start with a full battery.

Rest can be found even at work. If you post a lot, there’s nothing wrong with taking some of that time that you would have spent playing on your phone, walking through shops, or complaining about unimportant administrative matters with your partner, and directing towards some rest. It doesn’t have to be a nap. Just sitting still, and quieting your mind for a few minutes can really help. Kinda sounds like meditating, doesn’t it?

If you spend your time at a station between calls and assignments, thats even better. Some departments and companies have policies about sleeping during the day. But, like i said, it doesn’t have to be a nap. Just chill out for a bit.

Refueling: What you put into your body, will directly effect what kind of performance you can get out of it.   Since your shift is predictably unpredictable, like rest, its start at home. Insuring that you are appropriately fueled up before your shift, or packing healthy food with  you to have at the station during your shift, Will keep your mind and body capable of handling the challenges ahead. While in contrast, too much fast food wreaks havoc on your body. And being dehydrated, and mildly hypoglycemic is a major Zen killer.

Depending on the length of your shift, and call volume of your area, you could compare it to a work out, or marathon of sorts. I work 24hrs and sometimes 48hrs in a busy area. Lately I have experimented with “Carbo-loading” the day before, or between 4pm-7pm during my shift. I have found that it has increased my stamina during the day, and helped with my performance on 3am calls. This isn’t just for work, because  having a healthy diet off shift, will make it easier to maintain one while you’re on shift.

De-stressing. Being able to manage stress healthily and effectively could be the most important strategy for keeping your Zen.

We in emergency services are a unique animal. There is something about the inherent danger, chaos, drama, and unpredictably that pulls at us like moths to flame. Most of  us would claim the we are “immune, desensitized, strong, or can just deal with it.”

That may be true to some degree, but underneath that macho and or calm facade, a million plus years of evolution is responding to the danger,chaos, drama, and unpredictability, and in not so positive ways. Kinda interesting when you think that the stress stimulus that gives some of us an “adrenalin high”, can send others into an anxiety attack.

Leave work, at work.

Easier said then done for a lot of us, myself  included. Anyone can tell you I love my career, in fact I’m kinda a geek about it. If I’m not on shift, I’m usually thinking about, or doing something work related. Which isn’t a bad thing necessarily, but it does blur the lines between EMS life, and “normal” life. The negative side of that, is that many in this field are at risk for developing  Post-traumatic stress disorder. Go ahead and kid yourself, but its rough out there.

Having a good system for stress management both on, and off duty is key. Everyone will have there own practices that work best for them. It will take some experimenting to  find out what fits you personally, but here are some things that I currently do, or have tried and seen good results from.

On duty:

Paperwork, Cleaning and Organizing .

Everyone says they hate doing paperwork and station duties. But I, as well as some station mate  have found that the act of filling out a PCR (patient care report) checking boxes, and recounting the events of the last call through your narrative to be therapeutic at times.  It causes you to focus, and can symbolically bring closure once its  finished and filed away.

Cleaning and organizing gives you a simple and repetitive task, that has a noticeable and positive result. In emergency services we are very result driven: I don’t care how I get there, but i wont the result to be “X”. Reversing brochospasms, Getting a perfusing rhythm, Extricating a patient safely and quickly…. Results. As trivial as it may seem, organizing equipment, or having a clean day room, trips the same result driven reward centers in your brain.

Escaping.

Doing activities between runs that allows you to escape. Things like reading a book, watching a movie, getting lost on the interwebs machine, phoning or Skyping with friends or family, anything that brings you enjoyment. You know the tones are going to go off at some point, why sit around and tap your feet waiting for it?

Stop complaining.

Stop complaining about dispatch, management, the other guy on the other shift, blah blah blah. It only breeds negative feelings. If you really don’t like something, try directing that energy towards changing it for the better.

Off Duty:

Recharge yourself.

Go out and have fun on your days off, live it, use it, its your time. Take a day trip somewhere, go on a date, spend time with your family, just do something good for yourself. If your life can be described as go to work, go home, repeat. Then you need to find some excitement. It doesn’t have to be expensive, or some big deal, just something that is meaningful and enjoyable to you.

On the flip side, you might just need to stay home and do nothing. If you fall more on the Introvert side of the personality spectrum, realize that being on shift, also means being put into one social encounter after another for 12 or 24hrs. Giving yourself the time to be alone, read a book, veg out in front of the T.V, or whatever it is that you need, is very important.

Get Moving.

Physical activity is a great stress reducer. It oxygenates your body, helps to flush out toxins, and it fills your brain with endorphins (happy chemicals) and it keeps you fit.  And as long as we are doing things that give us enjoyment on our off time, why not include a sport that you love. Join a local league or club, or organize a weekly game with your friends. Being in the gym, cycling, swimming, running, its up to you, just move.

I would not recommended exercising on shift though. Unless your department or company has a daily PT program, the fact that we only have so much energy to put to use, and the risk of injury makes working out at work a low priority for me.

Gratitude.

Taking a few minutes to be grateful that you have the skills and knowledge to help people. That you have a job to go to, a home to return to, and a family and friends who love you. And that after all the tragedies you witness, be grateful that none were your emergency.

Getting Ready.

Not being ready for whatever you are expected to do, is a major cause of stress for many people. Misplacing something important, being late for work, feeling lost, these are awful and avoidable.

Many aspects of our job are unpredictable and out of our control. But take control of what you can, and set yourself up for success. Lay out your uniform and pack your car the night before. Give your self plenty of time to get to station at least 15min before you shift starts, and know where you are going. When you get there, make sure all your equipment is working and in its proper place. Also have your personal gear ready, and on the vehicle you are assigned to.

I will continue to experiment and fine tune these practices in my own pursuit of Zen, and I hope this will help you find some Zen of your own.

What ways have you found to keep your Zen?

15
Nov
10

The Return.

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

Its been a while since I last posted, and understandably so. My time and energy have been stretched pretty thin, and there is alway more to do. Its been almost a month since I returned to Los Angels after being in Louisiana for three plus months. My Chapter of the Mutual Aid project has closed, but the lessons learned both professionally and personally are ones i’m not sure could have been learned any other way. It truly was an eye opening experience. Everything from the food, to the culture, weather, politics, landscape, etcetera… It was completely different from what I had known. Because of that, I gained a huge appreciation for my home, and really felt what it was like to be “home sick.”

With an area of 4,752 sq mi, containing 8,000ft mountains, miles of coastline, lush forests, deserts, dense urban areas, and rural farms and ranches. All inhabited by nearly ten million  people speaking over 90 different languages, L.A County is an amazing place to work and live.

Interestingly, after working in a different EMS system, I have a greater understanding of how and why the EMS/Fire system in California and Los Angeles is the way that it is. If you ever have the opportunity to experience how Paramedics and EMTs in other states or even countries operate, go for it. You will learn a lot, i”m sure.

But now I’m back. I returned to a new house, because my family moved while i was away. I am now living in the north west end of the city, and am quite happy with my surroundings.

On the career side of things, I was happy to see that all three of my jobs (Yes, three. Ambulance, AHA Instructor, and special event Ninja… Uh, I mean medic for hire)  had all been awaiting my return. Its been great teaching, its something i really enjoy and am finding very rewarding.  It has also been nice to button up my county blues and reconnect with old partners and crew mates. Many who i’m happy to say have either promoted, gone to paramedic school, or in some way advanced in their career.

Family and friends were missed, and I am slowly making my way around with visits and nights out.  Whether its time spent and a friends house, meeting for lunch, or even just coffee when I’m in the neighborhood, there are many stories to tell and a lot to catch each other up on. Just last night, The GF and I celebrated the belated baby shower of my dear friend and old partner, Tyler’s first child. I’m very proud of him and his new family, the really have been though a lot, and deserve the best.

As for all the Twitter/Blog/CoEMS/EMS2.0/Web series/EMS___(fill in the blank)___  I am, and will continue to participate, advocate, educate, and celebrate (insert Jesse Jackson impression) all of the above and more. As time and allows of course.

People say I seem better then ever. And whether or not that’s true, its still nice and motivating to hear it.

Dorothy was right. “There’s no place like home.”

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.

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

« Previous Entries

Twitter Updates

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 44 other followers

Follow

Get every new post delivered to your Inbox.

Join 44 other followers