Posts Tagged ‘tips

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. *******

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?

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

22
Jun
10

Believe Me

By Jeramedic 2 Comments
Categories: Rants
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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
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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 “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

02
May
10

Looking For Trouble: Part 1

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

What do you think one of the most important skills a EMT or Paramedic can have? is it good IV skills? Maybe good airway management? Or how about a friendly bed side manor? theses are all without argument very important skills to have, but what about assessment skills?

It is the first treatment every one of  our patients receive, and one that should be continued until care is transferred. It is the one skill that no matter what the chief complaint, is always preformed… or is it?

Do you really, fully and properly assess and examine every patient? Do you take into consideration every thing the patient and the scene is telling you before making a treatment or transport decision? Unfortunately no, and I’ll the first to admit I’ve cut corners from time to time. The sad truth is we all get lazy, and can fall into bad habits of sorts. But why?

I see over confidence being a major cause of inconsistent assessments. It’s easy to roll up and say “oh it’s just another fill in the blank , their fine, lets ship it.” I have seen it too many times, and having it result in “less then appropriate care.” Perhaps another problem is the way we as individuals approach assessments. In school when it come to assessments we stress the points of being consistent and thorough. Then during field training, the advice changes, and we are told to get our assessments down to a system. And the mantra of  “don’t treat the monitor (any diagnostic equipment) treat the patient” is drilled.  Sound advice, but is it being understood?

Based on my experience of observing others assessment “habits”, I believe there may be a misinterpretation of what is being taught. ” Be consistent and thorough”  could be interpreted as “memorize an algorithm and hit every mark.”  So with that, are you using and understanding the information that your assessment is presenting? Or are you too worried about forgetting to palpate “that”, and ask “this” question?

“Don’t treat the monitor, treat the patient” could be (and I have seen)  practiced as “treat at face value, if they look ok, meh… they are probably ok.”  Now that’s having a great index of suspicion.

I’m going to ask you to shift the way you approach your assessments, and to show up looking for trouble. This is my philosophy, and I think it makes a lot of sense. Let my explain. If you (the patient) or a by stander felt it necessary to dial 911, for whatever reason, this implies that there “is” or “was”  some sort of problem needing attention. If I arrive and find you (the patient) to be in  no apparent distress, I become suspicious.

The way I see it, by the very act of using 911 you have now bought yourself an assessment. And in essence must prove me wrong to your need of my service. Now I don’t mean to be rude about it, but I would rather look for a problem and find nothing, then to just take a BP and call it good.

Beyond the normal set of vitals and an appropriate physical exam, I like to take the time to learn about the patient and the their reason for calling. Its very important to be clear on the circumstances surrounding the summon for EMS. Listen to the patient. Let them describe the event, and how they felt or are feeling in their own words. Listen without filling in the blanks or leading their answers.

Asking about a patients past medical history is something we all do instinctively. But how much are you really pursuing it? When you ask “do you have any medical problems” and they answer “no”, do you follow that with “do you see a doctor for anything?”   Nearly 4 out of 10 Americans has at least one chronic medical condition, and if it is being well managed, and has been for some time, some patients my not consider their chronic illness as a “Problem” because to them its not. Lets suppose they report that they do not see a doctor for any reason. Now do you ask when was the last time they were seen by a doctor? If someone has not seen a doctor in 10-15-20 years, could it be possible that they may have high cholesterol, un managed hypertension, the plague… Yes, and all the more reason to do a full and thorough assessment.

In part 2, I will explain how to do a rather detailed assessment with out using any equipment. But for now, think of how you assess your patients, and if they deserve a little more. After all, you cant treat  something unless you know its there.

15
Apr
10

Care Free

By Jeramedic 4 Comments
Categories: Good Medicine
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The state of emergency medical services, or  any medical service for that matter, is no care free business. But yet much of what we provide ends up being free. Hospitals around the country lose  tens of thousands of dollars a month, often through the emergency department. EMS services routinely treat and transport “non paying patients”, and the already huge cost of health care rises because of it.

Do I think its right? No. Do I think uninsured patients should be refused treatment? Of course not. I take pride in my ability to provide care to anyone, paying or not. I am also aware that as this trend continues, it becomes more difficult to maintain a functional system of care delivery. What am I saying… Its already broken.

Now this country’s recent health care reform has been met with some very, shall I say “mixed” reviews. This post is not about that. Perhaps I’ll say something on it later, but not now. I will report this however. A friend recently told me that because of the now, even lower reimbursement rate from medicare and medicaid, that his company is cutting back on ambulance coverage in the poorer communities. This to me, does not sound like a viable solution.

In a perfect world, medical care would be free. Even in this “economic climate” (meh… I feel like CNN saying that) I actually advocate more free care. I have always said that providing free monthly health screenings, and community CPR classes is a great way to bring back the “public” in public health/safety. Another practice I advocate, is to keep copies of community resources in your clip board or in the ambulance.  As we all know, many patients use 911 and the ER because they have no other choice. By educating them of alternative, and in many cases more appropriate and affordable means of care, the financial burden is lessened for both the patient, and the system.

On that note, I would like to introduce you to the National Association of Free Clinics. The National Association of Free Clinics (NAFC) is the only nonprofit organization whose mission is solely focused on the issues and needs of the more than 1,200 free clinics and the people they serve in the United States .
Founded in 2001 and headquartered in Washington , D.C. , the NAFC is an effective advocate for the issues and concerns of free clinics, their volunteer workforce of doctors, dentists, nurses, therapists, pharmacists, nurse practitioners, technicians and other health care professionals, and the patients served by free clinics in communities throughout the nation.

The NAFC provides  guidance and training for new and existing Free Clinics. As the national voice for Free Clinics, the NAFC has an active role in helping to shape national health care policy and legislation that affect Free Clinics and the people they serve. With the help of the NAFC, In 2007 alone, over $40 million dollars in donated major pharmaceuticals were distributed to free clinics.

On their website they can help you find free clinics in you area,this information can then be passed on to your patients. While you there, you can become a member of the NAFC, and of course make a donation. Seeing as it’s tax season, who would argue with worthwhile right off?

Care free my friends.


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