Posts Tagged ‘habbits

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.
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. *******

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 2 Comments
Categories: Clinical
Tags: , , , , , , , , , , , , , , , ,

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

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

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



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


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

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


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

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

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

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

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

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

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

23
Jun
10

I Little Privacy Please

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

So I think this all started with a post by a blogger named Lissa. Now the theme of this post is not very EMS, but we’ll go with it. Lissa posted about finding odd reading material  in her bathroom while she was cleaning up for some weekend house guests. She then passed on the Blog chain to the blog “To old to work, to young to retire“.

The tail of bathroom reading was told, and then passed to “Rescuing Providence“, who tagged “The Happy Medic“, who tagged “Ms Paramedic“, who then tagged me. So here we go.

Really there is not much in the way of paper reading in my bathroom. There have been times when I’ll bring in a copy of JEMS or something, but that’s not often. You see thanks to the magic of 3G, I, like most of you reading this, carry the internet around in my pocket. So, I’ll read a Blog, check emails, creep around twitter (which I guess makes me a shweeter) and will even watch some YouTube.

Now here is the kinda weird part, (if shweeting wasn’t weird enough) if I don’t have my phone, I like to read the packaging of products. So, shampoo and conditioner for instance: I think its interesting to read the claims these products make. I like to see what the ingredients are. I even think it kinda funny to read the instructions and see what “they” believe is the best way I should  wash my hair.

This is not just limited to hair care, no sir. I’ll read about toothpaste, shaving cream, lotion, cleaning agents, even the toilet paper packaging.

Hmmmm, you know after putting it all out there, it does sound a bit odd. Hopefully you all haven’t judged me too hard, and we can all go about our “business” so to speak. But now I must pass the confessions on.

So,

Insomniac Medic

Medic Madness

EMS in the New Decade

Consider yourselves tagged.

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
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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

24
May
10

GenMed Show “Deal Or No Deal”

By Jeramedic Leave a Comment
Categories: PodCasts
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In this episode we talk about workplace stress, how people cope, and what happens when coping doesn’t work.

An interesting topic with good discussion.  To listen to the show, click here

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