You are probably excited and apprehensive about starting your preceptorship. I know I was many years ago when it was my turn. I wondered whether I would make it - whether I was cut out for this job, whether I had spent so much time and effort studying only to fail, to have to hang my head and admit I wasn't cut out for the job.
Do not worry. I know you. You are smart and enthusiastic. I like that. You will pass. Precepting with me will not be a rigid test where you are constantly at risk of having a trap door open beneath you, sending you spiraling out of the profession you have studied so hard to join. If you fall down, I will pick you up. If you forget something during a call, we'll talk about it later. If you miss an IV or a tube, no big deal, you'll get more chances. My only expectations are that you care about being a good paramedic, and that you'll do your best, which if you do, will be good enough.
Here's what I want to see:
I want you to always introduce yourself to your patient by name.
If there are first responders on the scene, I want you to look them in the eye and hear their report, and then thank them. This goes for nurses and bystanders as well.
I don't want to you to cop an attitude with anyone.
I want you to see that the patient is comfortable as can be, and reassured that you are there to help them.
I want you to explain to them what you are doing and why.
I want you to ask questions after the call, anything you didn't understand or were curious about.
Here's what I'll do for you:
I will never badmouth you. If anyone asks how you are doing, I will say great.
I will be honest with you and if I don't know the answer, I will look it up or seek someone who knows.
If I am tired or in a bad mood, if I ever take it out on you, I will apologize to you.
I will do my best to make it a fun, learning experience for you.
Precepting should be a buffer period between class and the real world, a chance for you to learn and grow and gain some measure of comfort before having to deal with the job on your own.
I am looking forward to precepting you. Precepting is a privilege not only for you, but for me, the preceptor. When I have a preceptee I can look again at this job I love with fresh eyes. I may learn things that I have forgotten as well as lessons I may have missed along the way.
Let's have a good time and do some good.
Saturday, March 31, 2007
Thursday, March 29, 2007
My Week
Sorry for no posts this week. I worked four days straight. Did zero calls on Sunday, and then was flat out for three days. The highlight of the week was was a lights and sirens response to a nursing home for a stroke, only to be told the patient was outside having a cigarette and would be back in a few minutes. I did do one interesting call to the trauma room but can't write about it yet because it was in the papers.
I'm trying to be extra careful on calls that could potentially be identified. If its in the news or involves anyone who might read this blog, it will appear at some date later in time with enough details to obscure it.
Baby Medic had a A Problem lately that he seems to have weathered. The rumor was he had used a patient's first name in a post (now removed from his blog) about encountering a patient who on first impression seemed to be a drug addict. Someone told a family member about the post and the family member was very upset. Well, it turns out he did not use the patient's name. And the story was not derogatory to the patient. It was a well-written lesson story, full of humility, about how we shouldn't judge our patients. Still, the controversy just goes to show as bloggers we have a responsibility not just to tell the essential truths about our experiences as care-givers, we have to go the extra yard to protect patient's privacy. I'd like to be able to write about a call exactly as it happened, but sometimes I have to change the patient's sex, age, setting or other characteristics to protect them, while still staying true to the experience of the story.
***
I finished my latest rewrite of 10 Things Every Paramedic Should Know About Capnography.
***
I'm in charge of getting the articles for the April Journal Club, so I have been working on that. I'm looking at a couple articles:
1. Withholding resuscitation: a new approach to prehospital end-of-life decisions.
2. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study.
I haven't decided on a third one yet.
Area Paramedics and EMTs are welcome to attend. It's Wednesday April 18 7:00 P.M at the big hospital on the north side of the city. Flyers will be posted next week. You should RSVP a day or two ahead of time to get the articles to read. Dinner is provided free, and you get either 2 or 3 hours of CME. Stop by the hospital or see me for more details. We usually get 7-8 people.
***
My new preceptee starts on Sunday. She is part-time so it won't be an everyday deal. I am working on a "Letter to a New Preceptee" post, which I hope to have done on Saturday.
I'll be working a lot this month so hopefully I'll have some interesting calls to write about.
Until then, stay safe everyone.
I'm trying to be extra careful on calls that could potentially be identified. If its in the news or involves anyone who might read this blog, it will appear at some date later in time with enough details to obscure it.
Baby Medic had a A Problem lately that he seems to have weathered. The rumor was he had used a patient's first name in a post (now removed from his blog) about encountering a patient who on first impression seemed to be a drug addict. Someone told a family member about the post and the family member was very upset. Well, it turns out he did not use the patient's name. And the story was not derogatory to the patient. It was a well-written lesson story, full of humility, about how we shouldn't judge our patients. Still, the controversy just goes to show as bloggers we have a responsibility not just to tell the essential truths about our experiences as care-givers, we have to go the extra yard to protect patient's privacy. I'd like to be able to write about a call exactly as it happened, but sometimes I have to change the patient's sex, age, setting or other characteristics to protect them, while still staying true to the experience of the story.
***
I finished my latest rewrite of 10 Things Every Paramedic Should Know About Capnography.
***
I'm in charge of getting the articles for the April Journal Club, so I have been working on that. I'm looking at a couple articles:
1. Withholding resuscitation: a new approach to prehospital end-of-life decisions.
2. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study.
I haven't decided on a third one yet.
Area Paramedics and EMTs are welcome to attend. It's Wednesday April 18 7:00 P.M at the big hospital on the north side of the city. Flyers will be posted next week. You should RSVP a day or two ahead of time to get the articles to read. Dinner is provided free, and you get either 2 or 3 hours of CME. Stop by the hospital or see me for more details. We usually get 7-8 people.
***
My new preceptee starts on Sunday. She is part-time so it won't be an everyday deal. I am working on a "Letter to a New Preceptee" post, which I hope to have done on Saturday.
I'll be working a lot this month so hopefully I'll have some interesting calls to write about.
Until then, stay safe everyone.
Saturday, March 24, 2007
EMS Haiku
Eric from the EMS Haiku site has just posted his trip report from the JEMS EMS Today conference. Like his blog, it is a good read. His post gives a good feel for what the conference is like, complete with educational session recaps and photos of interesting products. Add his site to your bookmarks.
Friday, March 23, 2007
New Boots
A couple weeks ago I noticed the soles were starting to peel away from my boots. I tried to ignore it at first. I was in denial. I didn't want to admit that the end was near. I spend some time surfing the internet looking at new boots, thinking I should have some on hand when the time comes, but I just can’t commit. I love my boots. They are comfortable, sturdy. We’ve walked a lot of miles together.
Many years ago our old company gave us a clothing allowance. $250 a year. The last year I bought two pairs of boots. So when I ran out of the pair I was wearing, I had an identical pair ready to go. That pair lasted about four years, and when the treads fell off it, I had another pair in my closet. But now my closet is empty -- no identical twin ready to step into battle.
Now my boots are so worn, I don’t even know what kind they are – just big comfortable black boots. All the tags and marking are worn off. Then I step in a snow puddle and my socks and feet get wet. I can peel the soles away so my boots look like of one of those cartoon character talking boots. I have to get a new pair.
Yesterday I go out looking. The place I’d bought the other boots at years ago is out of business. I can’t go there. So the first stop I make is to the shoe repair place in hopes I can salvage them with a glue job, but the cobler tells me I have to leave the boots there, which isn’t going to work because I have to work in a couple of hours and I have nothing else to put on. Then I go to Bob’s, where I have a 25% off coupon that has come in the mail. They have only one pair in my size – 13/14 and they just donn’t feel right. I go to another store and then another. Nothing. My last stop has quite a number of uniform boots, including Rockies which I am thinking about getting, but the first couple I ask to see they don’t have in my size and then the models they do, just don’t feel right.
The price range is from $99 to $179. Then I see these Danner Fort Lewis boots $249. Gortex, waterproof, insulated. Top of the line. I try them on. Nice. Walking in them it's like each foot is wrapped in velvet cushions and I am being lifted up by lush Princesses out of the Arabian nights. Good support too.
$269 with tax.
I figure I am going to be wearing them 60 hours a week every week on the calendar and every calendar year as long as my own soul doesn't break away. You’ve got to take care of your feet and your ankles.
So last night me and my new boots are on the job trudging through snow banks and puddles, carrying people down flights of stairs, answering calls. No blood or vomit on them yet. But already we feel like old friends.
Many years ago our old company gave us a clothing allowance. $250 a year. The last year I bought two pairs of boots. So when I ran out of the pair I was wearing, I had an identical pair ready to go. That pair lasted about four years, and when the treads fell off it, I had another pair in my closet. But now my closet is empty -- no identical twin ready to step into battle.
Now my boots are so worn, I don’t even know what kind they are – just big comfortable black boots. All the tags and marking are worn off. Then I step in a snow puddle and my socks and feet get wet. I can peel the soles away so my boots look like of one of those cartoon character talking boots. I have to get a new pair.
Yesterday I go out looking. The place I’d bought the other boots at years ago is out of business. I can’t go there. So the first stop I make is to the shoe repair place in hopes I can salvage them with a glue job, but the cobler tells me I have to leave the boots there, which isn’t going to work because I have to work in a couple of hours and I have nothing else to put on. Then I go to Bob’s, where I have a 25% off coupon that has come in the mail. They have only one pair in my size – 13/14 and they just donn’t feel right. I go to another store and then another. Nothing. My last stop has quite a number of uniform boots, including Rockies which I am thinking about getting, but the first couple I ask to see they don’t have in my size and then the models they do, just don’t feel right.
The price range is from $99 to $179. Then I see these Danner Fort Lewis boots $249. Gortex, waterproof, insulated. Top of the line. I try them on. Nice. Walking in them it's like each foot is wrapped in velvet cushions and I am being lifted up by lush Princesses out of the Arabian nights. Good support too.
$269 with tax.
I figure I am going to be wearing them 60 hours a week every week on the calendar and every calendar year as long as my own soul doesn't break away. You’ve got to take care of your feet and your ankles.
So last night me and my new boots are on the job trudging through snow banks and puddles, carrying people down flights of stairs, answering calls. No blood or vomit on them yet. But already we feel like old friends.
Monday, March 19, 2007
The Other Side
I had just left the locker room at the fitness center and was standing at the information desk when a man ran out of the men's room and said, "Somebody call 911, he's having a heart attack!"
Now I hate these situations. I am in "plainclothes." I am anonymous, yet I carry a card that says I am a licensed paramedic. I have a certain duty to act, yet at the same time, I have a duty to not get in the way because legally even though I am a paramedic, unless I am working, I am not a part of the 911 system, so I am not even a first responder, I am just a bystander. Consequently, I rarely stop at auto accidents, or even announce my presence at medical scenes I happen upon -- unless it looks like someone is in dire straights. Most of the time I can eyeball it and see that it is really not a big deal.
When I had just become an EMT I stopped at a crash on the highway, and found a woman who's face had hit the windshield. While she was conscious, she was quite shaken up and badly bruised. I stayed with her until the police arrived. I told the state trooper I was an EMT, he said, "Big fucking deal! So am I," and pushed right past me.
Now whenever I happen to get involved in something, I give a quick report to the first responder, and then excuse myself, unless they need me. I also, whenever I respond, make certain to acknowledge and thank anyone -- EMT, doctor, nurse or layperson -- who is with the patient and has something to tell me.
No one stepped forward and seeing the panic in the eyes of the female staff person on duty who was fumbling to dial 911, I walked back in to the locker room to check it out. I saw a man in the shower now sitting on a chair, surrounded by several people. He looked okay. He was young, healthy-looking. I remembered him from the sauna. He'd been in there before I'd gotten in and was still there when I'd left. I guessed he'd probably overheated himself.
"Keep back, keep back, give him space, give him space," one naked man in the shower, assuming the role of general, announced to those looking on.
The man, although pale, looked in no serious distress so I went back out and told the female staff person he appeared all right, he wasn't dying just then, but to keep 911 coming so they could check him out. "Yes, he's concious," she said to the operator.
Just then another man came out of the locker room and shouted, "Hey, where's that ambulance? He's bad, he's really bad!"
I told the staff person I'd go in and sit with him, which I did. He said he was okay now. He'd just gotten dizzy. I tried to ask who had seen him pass out and whether he hit his head. One man -- who I heard later from the medic was a doctor -- said "I don't know. He passed out three times. He has to go to the hospital. Don't let him get up."
I sat there and wrote out a little info sheet to give to the crew when they got there -- name, DOB, meds, allergies, address.
Then in came the cops -- the first responders. I introduced myself and gave a quick report. The officer nodded, looked at the man and asked "Are you a diabetic?"
"No meds, no history," I said again. "He had a syncopal episode. He'd been in the sauna. He's probably dehydrated." The cop nodded and then asked the man "What happened?"
A few minutes later the fire department came in -- also first responders. I handed them my notes, gave a quick report, and then excused myself while they started taking vitals.
Out in the lobby, everything was back to normal, people checking in at the membership desk, buying drinks from the juice bar, reading the announcements on the bulletin board. I saw the ambulance crew coming in on my way out of the place. I knew the crew and gave them a quick report.
It was interesting seeing the incident from the other side. The bystanders reactions, the panic, and then the progressive waves of responders, and a gradual sense of calm. My first EMT instructor used to say the emergency ends when you arrive. I can see that. The public doesn't know if someone is dying or not. They call 911 and wait anxiously. 911 arrives and life goes back to normal.
Now I hate these situations. I am in "plainclothes." I am anonymous, yet I carry a card that says I am a licensed paramedic. I have a certain duty to act, yet at the same time, I have a duty to not get in the way because legally even though I am a paramedic, unless I am working, I am not a part of the 911 system, so I am not even a first responder, I am just a bystander. Consequently, I rarely stop at auto accidents, or even announce my presence at medical scenes I happen upon -- unless it looks like someone is in dire straights. Most of the time I can eyeball it and see that it is really not a big deal.
When I had just become an EMT I stopped at a crash on the highway, and found a woman who's face had hit the windshield. While she was conscious, she was quite shaken up and badly bruised. I stayed with her until the police arrived. I told the state trooper I was an EMT, he said, "Big fucking deal! So am I," and pushed right past me.
Now whenever I happen to get involved in something, I give a quick report to the first responder, and then excuse myself, unless they need me. I also, whenever I respond, make certain to acknowledge and thank anyone -- EMT, doctor, nurse or layperson -- who is with the patient and has something to tell me.
No one stepped forward and seeing the panic in the eyes of the female staff person on duty who was fumbling to dial 911, I walked back in to the locker room to check it out. I saw a man in the shower now sitting on a chair, surrounded by several people. He looked okay. He was young, healthy-looking. I remembered him from the sauna. He'd been in there before I'd gotten in and was still there when I'd left. I guessed he'd probably overheated himself.
"Keep back, keep back, give him space, give him space," one naked man in the shower, assuming the role of general, announced to those looking on.
The man, although pale, looked in no serious distress so I went back out and told the female staff person he appeared all right, he wasn't dying just then, but to keep 911 coming so they could check him out. "Yes, he's concious," she said to the operator.
Just then another man came out of the locker room and shouted, "Hey, where's that ambulance? He's bad, he's really bad!"
I told the staff person I'd go in and sit with him, which I did. He said he was okay now. He'd just gotten dizzy. I tried to ask who had seen him pass out and whether he hit his head. One man -- who I heard later from the medic was a doctor -- said "I don't know. He passed out three times. He has to go to the hospital. Don't let him get up."
I sat there and wrote out a little info sheet to give to the crew when they got there -- name, DOB, meds, allergies, address.
Then in came the cops -- the first responders. I introduced myself and gave a quick report. The officer nodded, looked at the man and asked "Are you a diabetic?"
"No meds, no history," I said again. "He had a syncopal episode. He'd been in the sauna. He's probably dehydrated." The cop nodded and then asked the man "What happened?"
A few minutes later the fire department came in -- also first responders. I handed them my notes, gave a quick report, and then excused myself while they started taking vitals.
Out in the lobby, everything was back to normal, people checking in at the membership desk, buying drinks from the juice bar, reading the announcements on the bulletin board. I saw the ambulance crew coming in on my way out of the place. I knew the crew and gave them a quick report.
It was interesting seeing the incident from the other side. The bystanders reactions, the panic, and then the progressive waves of responders, and a gradual sense of calm. My first EMT instructor used to say the emergency ends when you arrive. I can see that. The public doesn't know if someone is dying or not. They call 911 and wait anxiously. 911 arrives and life goes back to normal.
Sunday, March 18, 2007
King Sugar
It's been my week for diabetics. Actually where I work, as I've written before, is a diabetic town. Some towns are trauma towns or heroin towns. I work the streets of a diabetic town. Lots of African-Americans and Jamaican-Americans with diabetes. I'm constantly going into dark cluttered homes or into nursing homes for the unresponsive. Today was a private home. Old woman on diaylsis, a good shunt in one arm, a defunct shunt in the other, edema in her extremities. I tried once in the house to get an IV in the arm with the defunct shunt with no success, and then told my partners the only way I was going to get it was in the ambulance. My eyes were also screwed up from going from the bright snow glare of the outside to the dark no lightbulb in the lamp inside. Her sugar was 31, and I admitted some defeat by giving her glucagon. I like to give D50 in the event they are going through a brittle period and need recusitation again the next day as sometimes happens with diabetics. After twenty minutes she was only up to 41 and still out of it. I was still searching for a vein and not seeing or feeling anything. I had tried twice based on anatomy and come up empty. I'm always looking. I hate to be defeated. I did an EJ on the diabetic earlier in the week, but she was really out of it and had aspirated to boot. I wasn't going to do an EJ on this patient today, but I still wanted a line. Then just as we approached the hospital I saw a tiny little bump in her thumb, and thought what the hell. I used a 24, and got a flash. I only advanced the catheter a slight bit for fear I would blow it. It flushed fine. I taped it carefully around the thumb and slowly pushed in D50 diluted to D25. Got an amp in and flushed it with some more saline. Her sugar came up to 160 and she was talking and giving me an ever so sweet smile.
I haven't done a shooting for the longest time and probably would fumble and stumble my way through what I was once slick at -- I am no Trauma King these days -- but working where I do, I am getting to be known as King Sugar to the diabetic ladies of my fair town.
I haven't done a shooting for the longest time and probably would fumble and stumble my way through what I was once slick at -- I am no Trauma King these days -- but working where I do, I am getting to be known as King Sugar to the diabetic ladies of my fair town.
Saturday, March 17, 2007
Compression Only CPR
Many of you may have seen the recent news story about bystander CPR without mouth to mouth.
Here's the link:
Web MD Article
NY Times(AP): Without Mouth to Mouth CPR Still Works
And here's the study abstract:
The Lancet 2007; 369:920-926
Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study
Background
Mouth-to-mouth ventilation is a barrier to bystanders doing cardiopulmonary resuscitation (CPR), but few clinical studies have investigated the efficacy of bystander resuscitation by chest compressions without mouth-to-mouth ventilation (cardiac-only resuscitation).
Methods
We did a prospective, multicentre, observational study of patients who had out-of-hospital cardiac arrest. On arrival at the scene, paramedics assessed the technique of bystander resuscitation. The primary endpoint was favourable neurological outcome 30 days after cardiac arrest.
Findings
4068 adult patients who had out-of-hospital cardiac arrest witnessed by bystanders were included; 439 (11%) received cardiac-only resuscitation from bystanders, 712 (18%) conventional CPR, and 2917 (72%) received no bystander CPR. Any resuscitation attempt was associated with a higher proportion having favourable neurological outcomes than no resuscitation (5·0% vs 2·2%, p<0·0001). Cardiac-only resuscitation resulted in a higher proportion of patients with favourable neurological outcomes than conventional CPR in patients with apnoea (6·2% vs 3·1%; p=0·0195), with shockable rhythm (19·4% vs 11·2%, p=0·041), and with resuscitation that started within 4 min of arrest (10·1% vs 5·1%, p=0·0221). However, there was no evidence for any benefit from the addition of mouth-to-mouth ventilation in any subgroup. The adjusted odds ratio for a favourable neurological outcome after cardiac-only resuscitation was 2·2 (95% CI 1·2–4·2) in patients who received any resuscitation from bystanders.
Interpretation
Cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnoea, shockable rhythm, or short periods of untreated arrest.
***
Recently I have been attaching the capnofilter to my ET tube before I intubate. The following are typical ETCO2 strips on intubation. The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.
To me this is proof that compression only CPR, provides some degree of ventilation by itself.
***
I listened to a podcast from the Lancet (3-17-07) magazine, which published the study, and the author notes that compression only CPR is meant for bystanders only and is effective only in primary cardiac arrest and not arrests due to respiratory causes. The key difference being in cardiac arrest (presumably patients in v-fib), the blood is still largely oxygenated -- at least for the first five minutes, there are ample energy stores and the body isn't yet acidic. In respiratory induced cardiac arrest, the blood is desaturated.
***
Speaking of the difference between cardiac and respiratory induced cardiac arrests, check out this study on using capnography to differentiate the causes of arrest.
Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting.
Here's the link:
Web MD Article
NY Times(AP): Without Mouth to Mouth CPR Still Works
And here's the study abstract:
The Lancet 2007; 369:920-926
Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study
Background
Mouth-to-mouth ventilation is a barrier to bystanders doing cardiopulmonary resuscitation (CPR), but few clinical studies have investigated the efficacy of bystander resuscitation by chest compressions without mouth-to-mouth ventilation (cardiac-only resuscitation).
Methods
We did a prospective, multicentre, observational study of patients who had out-of-hospital cardiac arrest. On arrival at the scene, paramedics assessed the technique of bystander resuscitation. The primary endpoint was favourable neurological outcome 30 days after cardiac arrest.
Findings
4068 adult patients who had out-of-hospital cardiac arrest witnessed by bystanders were included; 439 (11%) received cardiac-only resuscitation from bystanders, 712 (18%) conventional CPR, and 2917 (72%) received no bystander CPR. Any resuscitation attempt was associated with a higher proportion having favourable neurological outcomes than no resuscitation (5·0% vs 2·2%, p<0·0001). Cardiac-only resuscitation resulted in a higher proportion of patients with favourable neurological outcomes than conventional CPR in patients with apnoea (6·2% vs 3·1%; p=0·0195), with shockable rhythm (19·4% vs 11·2%, p=0·041), and with resuscitation that started within 4 min of arrest (10·1% vs 5·1%, p=0·0221). However, there was no evidence for any benefit from the addition of mouth-to-mouth ventilation in any subgroup. The adjusted odds ratio for a favourable neurological outcome after cardiac-only resuscitation was 2·2 (95% CI 1·2–4·2) in patients who received any resuscitation from bystanders.
Interpretation
Cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnoea, shockable rhythm, or short periods of untreated arrest.
***
Recently I have been attaching the capnofilter to my ET tube before I intubate. The following are typical ETCO2 strips on intubation. The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.
To me this is proof that compression only CPR, provides some degree of ventilation by itself.
***
I listened to a podcast from the Lancet (3-17-07) magazine, which published the study, and the author notes that compression only CPR is meant for bystanders only and is effective only in primary cardiac arrest and not arrests due to respiratory causes. The key difference being in cardiac arrest (presumably patients in v-fib), the blood is still largely oxygenated -- at least for the first five minutes, there are ample energy stores and the body isn't yet acidic. In respiratory induced cardiac arrest, the blood is desaturated.
***
Speaking of the difference between cardiac and respiratory induced cardiac arrests, check out this study on using capnography to differentiate the causes of arrest.
Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting.
Friday, March 16, 2007
EJ
Unresponsive in the waiting room of a large medical clinic. The woman is a GCS of 3 – no response at all. The staff thought she was sleeping, and then after walking by her multiple times, they finally noticed she was awfully pale and clammy. They checked her sugar. It was ten. I notice what looks like blood running out of the side of the patient’s mouth like she has severely bitten her tongue, but then I see it is not blood at all, but a sugary gel. The doctor explains they have given the woman two tubes of insta-glucose. That explains the gurgling sound.
My partner recognizes the woman. “We had her yesterday,” she said. “Same thing. Be careful she’s had rehab issues.” She hands me a pair of gloves. I am already taking out my IV kit. “She’s a hard stick,” my partner says. “We had to give her glucagon.”
There is always a great challenge in the IV on the diabetic in front of a crowd. I usually put a patient on the stretcher and work them up in the ambulance, but with unresponsive diabetics I work them where they are. I get the IV and wake them up – I am a hero. I miss – I look like poor excuse for a paramedic. I consider myself a first rate IV tech, but I am not finding anything but track marks. I try a little twenty four in the upper bicep, but get noting. Ditto with a twenty-two in the other arm. I finally pull out the glucagon, but I am worried it won’t work because she got the glucagon yesterday and the glycogen stores may be depleted. In the meantime three of the clinic doctors are standing around. The boss doctor has come out and is getting a report from the other doctors. “Do we have a pulse SAT?” he asks. “She obviously needs her insulin adjusted. I can help you get an IV if you’d like?”
I look up at him. This and the nurse the other day I described in No Problem are getting to be too much. “No, we’re all set, thank you,” I say. “I’m giving her glucagon now and then I’ll try again for an IV on the way to the hospital. I appreciate your offer though.”
“Oh, okay,” he says. He seems relieved. The last time he did an IV was probably in medical school.
There is no immediate response to the glucagon, but I am not expecting anything for awhile. We have a hard time picking the woman up because she is dead weight and so diaphoretic, she is slippery.
Down in the ambulance, the gurgling increases. She has surely aspirated some of the insta-glucose. I try an oral airway, but get a deep gag reflex. I see no veins, except for the jugular vein in the neck. What the hell. I go for it. I sink an 18(I know I should be using at least a 16, but it has been awhile since I've had to do an EJ). No immediate flash, but a little maneuvering and I get it, blood filling the chamber. I flush the lock, then attach the D50 to the saline lock, pull back on the D50 to see blood fill the line again to confirm I’m in, and then I push forward. She has a jowly neck so I am a little cautious, but each time I pull back I get blood flow, so I empty the entire amp.
We start to the hospital. I have the patient on a nonrebreather and ETCO2. I can’t get a SAT reading, but the ETCO2 is 35(so I know the ABCs are intact). RR is 40. The electrodes won’t stick because of all the sweat. We never did get a pressure(Oops). I start to wrap the cuff around her arm, but she is coming around now, and I have to block her hands as she tries to take the mask off and also pull out the line in her neck. Her eyes are open, but she is still nonverbal and she has a crazed look. She seems aware of her gurgling and starts gagging. I have an emesis basin ready. A few more times she reaches quickly for her neck, but I block her. I manage to hold her down enough to get another blood sugar – 180. She has calmed down some by the time we pull into the hospital driveway.
A doctor walks by at triage and remarks the patient doesn’t look too good. I explain it’s a diabetic who probably aspirated on oral glucose, but then I shout to the woman to open her eyes. She does. Say Hi to the doctor, I command. She waves. Okay, he says.
The SAT with the nonrebreather is 100, but there is still a lot of rhonci. The patient is alert, but very tired. They take a chest X-ray and when I walk by the room later she is on bi-pap.
**
Afterwards, my partner compliments me on the EJ. She says she has only seen a medic put an IV in the neck once before and she has been working there for eight years. I do about one a year so I am happy I got it.
“You should have done the EJ in the waiting room there," she says. "That would have impressed them.”
I think about that. Standing there in front of the worried, anxious staff, calm as can be, then suddenly wiping a 14 gauge needle out of my pocket, giving a karate jujitsu kung fu shout, and plunging the needle deep into the patient’s neck. If I done that and gotten it, I would have been an awesome hero stud. If I had missed, the appalled clinic staff would probably would have called the cops on me.
My partner recognizes the woman. “We had her yesterday,” she said. “Same thing. Be careful she’s had rehab issues.” She hands me a pair of gloves. I am already taking out my IV kit. “She’s a hard stick,” my partner says. “We had to give her glucagon.”
There is always a great challenge in the IV on the diabetic in front of a crowd. I usually put a patient on the stretcher and work them up in the ambulance, but with unresponsive diabetics I work them where they are. I get the IV and wake them up – I am a hero. I miss – I look like poor excuse for a paramedic. I consider myself a first rate IV tech, but I am not finding anything but track marks. I try a little twenty four in the upper bicep, but get noting. Ditto with a twenty-two in the other arm. I finally pull out the glucagon, but I am worried it won’t work because she got the glucagon yesterday and the glycogen stores may be depleted. In the meantime three of the clinic doctors are standing around. The boss doctor has come out and is getting a report from the other doctors. “Do we have a pulse SAT?” he asks. “She obviously needs her insulin adjusted. I can help you get an IV if you’d like?”
I look up at him. This and the nurse the other day I described in No Problem are getting to be too much. “No, we’re all set, thank you,” I say. “I’m giving her glucagon now and then I’ll try again for an IV on the way to the hospital. I appreciate your offer though.”
“Oh, okay,” he says. He seems relieved. The last time he did an IV was probably in medical school.
There is no immediate response to the glucagon, but I am not expecting anything for awhile. We have a hard time picking the woman up because she is dead weight and so diaphoretic, she is slippery.
Down in the ambulance, the gurgling increases. She has surely aspirated some of the insta-glucose. I try an oral airway, but get a deep gag reflex. I see no veins, except for the jugular vein in the neck. What the hell. I go for it. I sink an 18(I know I should be using at least a 16, but it has been awhile since I've had to do an EJ). No immediate flash, but a little maneuvering and I get it, blood filling the chamber. I flush the lock, then attach the D50 to the saline lock, pull back on the D50 to see blood fill the line again to confirm I’m in, and then I push forward. She has a jowly neck so I am a little cautious, but each time I pull back I get blood flow, so I empty the entire amp.
We start to the hospital. I have the patient on a nonrebreather and ETCO2. I can’t get a SAT reading, but the ETCO2 is 35(so I know the ABCs are intact). RR is 40. The electrodes won’t stick because of all the sweat. We never did get a pressure(Oops). I start to wrap the cuff around her arm, but she is coming around now, and I have to block her hands as she tries to take the mask off and also pull out the line in her neck. Her eyes are open, but she is still nonverbal and she has a crazed look. She seems aware of her gurgling and starts gagging. I have an emesis basin ready. A few more times she reaches quickly for her neck, but I block her. I manage to hold her down enough to get another blood sugar – 180. She has calmed down some by the time we pull into the hospital driveway.
A doctor walks by at triage and remarks the patient doesn’t look too good. I explain it’s a diabetic who probably aspirated on oral glucose, but then I shout to the woman to open her eyes. She does. Say Hi to the doctor, I command. She waves. Okay, he says.
The SAT with the nonrebreather is 100, but there is still a lot of rhonci. The patient is alert, but very tired. They take a chest X-ray and when I walk by the room later she is on bi-pap.
**
Afterwards, my partner compliments me on the EJ. She says she has only seen a medic put an IV in the neck once before and she has been working there for eight years. I do about one a year so I am happy I got it.
“You should have done the EJ in the waiting room there," she says. "That would have impressed them.”
I think about that. Standing there in front of the worried, anxious staff, calm as can be, then suddenly wiping a 14 gauge needle out of my pocket, giving a karate jujitsu kung fu shout, and plunging the needle deep into the patient’s neck. If I done that and gotten it, I would have been an awesome hero stud. If I had missed, the appalled clinic staff would probably would have called the cops on me.
Wednesday, March 14, 2007
A Nap
Got called to a nursing home for an unresponsive, found an obese woman laying across the bed, snoring respirations. Nurse says patient has been nodding off all morning, and won't respond to her at all. Plus her SAts are low. This is not like her. Deep sternal rub opens her eyes, but then she shuts them. She has a history of ETOH, drug abuse and "anti-social" personality. She also is an insulin diabetic, has HTN, CHF, asthma, and sleep apnea. I shout at her and try to get her to squeeze my hands. She gives a feeble attempt. They feel equal. I don't see any facial droop. I try to ask her some questions, but the best I get is a mumble.
We struggle to get her on the stretcher. I notice on the W10 she is on methadone. I check her pupils, but they are not pinpoint. In the ambulance I check her sugar --86. Her BP and HR are fine. I put her on the capnography and it is 64! A little high. Her sat is reading 88, but when I put her on a nonrebreather she goes right up to a hundred, so I back her down to a cannula and it holds in the 96-98 region. Her respiratory rate is between 10 and 20.
Even though I am now teaching classes on capnography, it is still new to me, and I am trying to puzzle why hers is so high. 64 and at times it goes up to 70 is serious hypoventiltation or hypercapnia if you prefer that term. But she doesn't need to be intubated. Her respiratory rate never gets below 8 and it is not irregular enough to be overly concerned. My guess is that she is just oversedated -- not that I can find any sedation on her chart, but that is not unusual. Maybe she got some extra pharmaceuticals. This one home is known for occasional drug buys by some of its younger residents with drug histories.
I just nudge her periodically on the way in. At triage, I tell the nurse that I don't know what is going on. I'm guessing she is just overmedicated. But periodically she does seem to jerk, so I don't know. I mention her ETCO2 is on the high side.
We get in the room and the nurse bangs the cast on the patient's foot by mistake. The woman suddenly opens up her eyes and screams, "Hey, that hurt. Watch it."
"Well, that woke her up," I say.
"Why don't you just leave me be?" the patient says.
"Do know why you're here?" the nurse asks.
"No, they should have just let me be. I was out of it."
"Out of it?" I say. "Why wouldn't you answer any of my questions?"
"I just wanted to sleep. What's wrong with you people? I have sleep apnea -- they know that. They wrote it on that form. Now, you went and disturbed my nap!"
I feel like an idiot, of course.
The nurse just shrugs. It's not the first time an unresponsive nursing home patient has just been sleeping.
"Can you turn the lights off, please," the patient says, closing her eyes and shifting in the bed to a more comfortable position. "And then leave me be."
***
I've done a little reading on sleep apnea and I guess many patients with sleep apnea suffer from hypoventilation, which explain her high readings. The jerking I saw was probably just slipping out of a stage of sleep like when you nod off and then wake up with a start, and then nodd off again.
We struggle to get her on the stretcher. I notice on the W10 she is on methadone. I check her pupils, but they are not pinpoint. In the ambulance I check her sugar --86. Her BP and HR are fine. I put her on the capnography and it is 64! A little high. Her sat is reading 88, but when I put her on a nonrebreather she goes right up to a hundred, so I back her down to a cannula and it holds in the 96-98 region. Her respiratory rate is between 10 and 20.
Even though I am now teaching classes on capnography, it is still new to me, and I am trying to puzzle why hers is so high. 64 and at times it goes up to 70 is serious hypoventiltation or hypercapnia if you prefer that term. But she doesn't need to be intubated. Her respiratory rate never gets below 8 and it is not irregular enough to be overly concerned. My guess is that she is just oversedated -- not that I can find any sedation on her chart, but that is not unusual. Maybe she got some extra pharmaceuticals. This one home is known for occasional drug buys by some of its younger residents with drug histories.
I just nudge her periodically on the way in. At triage, I tell the nurse that I don't know what is going on. I'm guessing she is just overmedicated. But periodically she does seem to jerk, so I don't know. I mention her ETCO2 is on the high side.
We get in the room and the nurse bangs the cast on the patient's foot by mistake. The woman suddenly opens up her eyes and screams, "Hey, that hurt. Watch it."
"Well, that woke her up," I say.
"Why don't you just leave me be?" the patient says.
"Do know why you're here?" the nurse asks.
"No, they should have just let me be. I was out of it."
"Out of it?" I say. "Why wouldn't you answer any of my questions?"
"I just wanted to sleep. What's wrong with you people? I have sleep apnea -- they know that. They wrote it on that form. Now, you went and disturbed my nap!"
I feel like an idiot, of course.
The nurse just shrugs. It's not the first time an unresponsive nursing home patient has just been sleeping.
"Can you turn the lights off, please," the patient says, closing her eyes and shifting in the bed to a more comfortable position. "And then leave me be."
***
I've done a little reading on sleep apnea and I guess many patients with sleep apnea suffer from hypoventilation, which explain her high readings. The jerking I saw was probably just slipping out of a stage of sleep like when you nod off and then wake up with a start, and then nodd off again.
Tuesday, March 13, 2007
Bloggers and PodCasters
The night before I left Baltimore, I met up with some bloggers and podcasters at a local sportsbar. It was great to put faces with people.
The meeting was organized by Eric Augustus of EMS Haiku and Dan White of Paramedic Blog. Dan works for alliance medical and is the man behind the AllMed AVC Helmet, which makes him one of my heros. Eric, who contributed an excellent powerpoint to my Capnography for Paramedics web site, is a long time field medic, who writes a great blog that also features some excellent EMS haikus. Check them out.
Also present was my friend Jamie Davis of the MedicCast, and two other podcasters, John Bignell of EMS Live and Rick Russotti of
The Mitigation Journal.
Listening to the three of them talk about podcasting, I felt like I was seeing the future. I am going to check out John and Eric's podcasts. I have been a long time listener of Jamie's. I just download it and listen on the computer while I work. It is an excellent way to get informed about EMS issues. I think EMS companies should take up their own podcasting or make use of these guys to provide continuing ed to crews on the road.
It was a good time and if I go back down to JEMS next year, it will be interesting to see how far podcasting as progressed, not to mention getting caught up again with everyone.
The Medic Cast is doing a live call-in show tonight at 10:00 P.M. Eastern Standard time. Go to the website for instructions on participating. I'm at work tonight, but will try to catch some of it if I can.
***
By the way Jamie posted a nice comment on my Funk post. He writes:
Don't get down. I think it's the time change coupled with a full weekend. I got the same impression of the "Blogerrhea" article and my instant impression is sour grapes. Their magazine comes out monthly, is written months ahead of time, and is already out of date on key issues when it gets into the hands of subscribers.
Blogs are vital, current, personal. They don't represent what an editor thinks the publisher and advertisers will put up with. Blogs aren't the party line. Blogs represent the real EMS, the street EMS, a return to the time of Jim Page's "Magic of 3 AM."
Also, podcasts represent a future, but a future of media alongside blogs. I podcast and blog at the MedicCast because I can't talk that much (my wife might disagree). There are too many articles and studies and comments to be made to do it in a one hour show each week.
Thanks, Jamie.
The meeting was organized by Eric Augustus of EMS Haiku and Dan White of Paramedic Blog. Dan works for alliance medical and is the man behind the AllMed AVC Helmet, which makes him one of my heros. Eric, who contributed an excellent powerpoint to my Capnography for Paramedics web site, is a long time field medic, who writes a great blog that also features some excellent EMS haikus. Check them out.
Also present was my friend Jamie Davis of the MedicCast, and two other podcasters, John Bignell of EMS Live and Rick Russotti of
The Mitigation Journal.
Listening to the three of them talk about podcasting, I felt like I was seeing the future. I am going to check out John and Eric's podcasts. I have been a long time listener of Jamie's. I just download it and listen on the computer while I work. It is an excellent way to get informed about EMS issues. I think EMS companies should take up their own podcasting or make use of these guys to provide continuing ed to crews on the road.
It was a good time and if I go back down to JEMS next year, it will be interesting to see how far podcasting as progressed, not to mention getting caught up again with everyone.
The Medic Cast is doing a live call-in show tonight at 10:00 P.M. Eastern Standard time. Go to the website for instructions on participating. I'm at work tonight, but will try to catch some of it if I can.
***
By the way Jamie posted a nice comment on my Funk post. He writes:
Don't get down. I think it's the time change coupled with a full weekend. I got the same impression of the "Blogerrhea" article and my instant impression is sour grapes. Their magazine comes out monthly, is written months ahead of time, and is already out of date on key issues when it gets into the hands of subscribers.
Blogs are vital, current, personal. They don't represent what an editor thinks the publisher and advertisers will put up with. Blogs aren't the party line. Blogs represent the real EMS, the street EMS, a return to the time of Jim Page's "Magic of 3 AM."
Also, podcasts represent a future, but a future of media alongside blogs. I podcast and blog at the MedicCast because I can't talk that much (my wife might disagree). There are too many articles and studies and comments to be made to do it in a one hour show each week.
Thanks, Jamie.
No Problem
We get called for a diabetic and arrive at the nursing home to find one nurse pouring orange juice in the woman's mouth, while another nurse checks her blood sugar. On the bed table, I see an empty glucagon vial and a syringe. "Her sugar was forty and she was vomiting," the nurse says. I gave her one glucagon fifteen minutes ago. Her sugar's fifty seven now, I'm going to give her another."
"Why don't you hold off on that," I say, "and hold off on the orange juice unless she can swallow. We'll give her some sugar in her vein."
I put a tourniquet on the woman's arm, and start looking for a vein. I'm not seeing much. I notice the nurse standing next to me, looking at the arm as well. I am tempted to say, could you please move. "There's one," she says. She runs her finger along the forearm.
I look. I don't see anything. "I don't think so," I say.
"I could get it, no problem," she says. She pats me on the head as she walks behind me and exits the room.
Yeah, okay.
I find a vein on her other arm, along her wrist and put in a 22. I see the nurse poke her head back in the room as I slowly push in the D50. The patient is alert now.
I don't see the nurse again.
"Why don't you hold off on that," I say, "and hold off on the orange juice unless she can swallow. We'll give her some sugar in her vein."
I put a tourniquet on the woman's arm, and start looking for a vein. I'm not seeing much. I notice the nurse standing next to me, looking at the arm as well. I am tempted to say, could you please move. "There's one," she says. She runs her finger along the forearm.
I look. I don't see anything. "I don't think so," I say.
"I could get it, no problem," she says. She pats me on the head as she walks behind me and exits the room.
Yeah, okay.
I find a vein on her other arm, along her wrist and put in a 22. I see the nurse poke her head back in the room as I slowly push in the D50. The patient is alert now.
I don't see the nurse again.
Monday, March 12, 2007
Seizure Notes from JEMS/EMS Today
Here are my notes from Notes from Bob Page's Whole Lotta Shaking Going On Presentation (any inaccuracies are my fault):
Seizure is a temporary malfunction of the brain, an "electrical storm in the brain."
For every 1 time someone has a seizure and calls 911, there are 20 others who don't call.
Idiopathic seizures (epilepsy) are easily controlled.
Symptomatic Seizures show an underlying injury or structural lesion. They are unpredicatable and difficult to control.
A partial seizure affects one side of the brain.
A generalized seizure affects both sides, and results in loss of conciousness or awareness.
A simple partial has no loss of conciousness. Usually lasts no more than 90 seconds, and can be characterized by sudden jerking and may have some temporary residual weakness.
A complex partial may alter conciousness. Lasts 1-2 minutes, often has an aura, patient may wander unaware, have amnesia of the event and mild confusion.
A gran mal has the tonic clonic activity. Usually 1-2 minutes. Followed by amnesia, confusion or deep sleep. may produce cyanosis. Patient does not breath during seizure. Often is incontinent and bits tongue.
A partial seizure may progress to a generalized seizure. That is called the "Jacksonian march."
Eyewitness accounts are crucial for diagnosis of seizure. Ask what happened before, during and after the seizure.
Absense seizure, formally known as petite mal last from 2-15 seconds, may have eye lid fluttering, amnesia of event, but no confusion, patient picks up right where they left off.
Status epliepticus. 5% of epileptics may suffer from this. Has a 10-20% mortality rate due to anoxia and acidosis caused by not being able to breathe (get air in and out) during seizure. Greater than 30 minutes of continuous seizure or greater than two sequential seizures without full recovery of conciousness. Interceed if seizure has gone on for five minutes.
Psuedo seizures are intermitent behavioral changes that resemble a seizure. No organic cause. No EEG changes suggestive of epilepsy. usually due to a psychological conflict. Almost exclusively female. frequently have history of childhood physical or sexual abuse. It can take 3-10 years to diagnose. Treat it as if they are having a real seizure, err on the side of the patient.
Alcholoic withdrawl seizures need sugar, fluid, vitamins and lots of ativan.
People may stop seizing when their arms get tired, the seizure may still be seen in their hands, fingers.
tegretol is the drug of choice for partial seizures
Ethosuximide (Zarontin) is the drug of choice for absense seizures.
Dilantin is the I don't know what else to give them seizure drug
***
I had more notes, but couldn't make sense of them or my handwriting.
Again, Bob Page is a great presenter, and by all means try to take a class from him someday.
Here's his download page. He has his entire presentation there available for download. You need Quicktime and some other type of software to see the videos, but it is worth a run through.
Bob Page's Download Page
Seizure is a temporary malfunction of the brain, an "electrical storm in the brain."
For every 1 time someone has a seizure and calls 911, there are 20 others who don't call.
Idiopathic seizures (epilepsy) are easily controlled.
Symptomatic Seizures show an underlying injury or structural lesion. They are unpredicatable and difficult to control.
A partial seizure affects one side of the brain.
A generalized seizure affects both sides, and results in loss of conciousness or awareness.
A simple partial has no loss of conciousness. Usually lasts no more than 90 seconds, and can be characterized by sudden jerking and may have some temporary residual weakness.
A complex partial may alter conciousness. Lasts 1-2 minutes, often has an aura, patient may wander unaware, have amnesia of the event and mild confusion.
A gran mal has the tonic clonic activity. Usually 1-2 minutes. Followed by amnesia, confusion or deep sleep. may produce cyanosis. Patient does not breath during seizure. Often is incontinent and bits tongue.
A partial seizure may progress to a generalized seizure. That is called the "Jacksonian march."
Eyewitness accounts are crucial for diagnosis of seizure. Ask what happened before, during and after the seizure.
Absense seizure, formally known as petite mal last from 2-15 seconds, may have eye lid fluttering, amnesia of event, but no confusion, patient picks up right where they left off.
Status epliepticus. 5% of epileptics may suffer from this. Has a 10-20% mortality rate due to anoxia and acidosis caused by not being able to breathe (get air in and out) during seizure. Greater than 30 minutes of continuous seizure or greater than two sequential seizures without full recovery of conciousness. Interceed if seizure has gone on for five minutes.
Psuedo seizures are intermitent behavioral changes that resemble a seizure. No organic cause. No EEG changes suggestive of epilepsy. usually due to a psychological conflict. Almost exclusively female. frequently have history of childhood physical or sexual abuse. It can take 3-10 years to diagnose. Treat it as if they are having a real seizure, err on the side of the patient.
Alcholoic withdrawl seizures need sugar, fluid, vitamins and lots of ativan.
People may stop seizing when their arms get tired, the seizure may still be seen in their hands, fingers.
tegretol is the drug of choice for partial seizures
Ethosuximide (Zarontin) is the drug of choice for absense seizures.
Dilantin is the I don't know what else to give them seizure drug
***
I had more notes, but couldn't make sense of them or my handwriting.
Again, Bob Page is a great presenter, and by all means try to take a class from him someday.
Here's his download page. He has his entire presentation there available for download. You need Quicktime and some other type of software to see the videos, but it is worth a run through.
Bob Page's Download Page
Sunday, March 11, 2007
Funk
Back at work. I've been trying to put together my conference notes, but for some reason I just feel all EMSed out. It's odd because usually when I come back from a conference, I'm all psyched up and rearing to go. Today, its been like "What hospital do you want to go to? Okay. We're going to get the stretcher ready." And then at the hospital, my report has been, "Here's my patient, he's...ah, ...he's sick." That's been about it.
I don't know why I'm in this funk. I'll take a stab at it though.
The last seminar I went to was on ambulance safety by Nadine Levick. Here's her website:
Objective Safety
There are lots of handouts and slides you can see that will hit her main points.
She is famous for showing her videos of crash test dummies in the back of ambulances, and it is not a pretty sight. The bottom line is while we spend billions on biohazard prevention, we (EMS people) are being slaughtered in ambulances. We are sent lights and sirens to BS calls in vehicles no safer than than laundry trucks. While other countries have state of the art ambulances with roll bars, automotive safety seats, brackets to hold down equipment, helmets for personnel to wear, we are just waiting for the reaper to call our numbers.
I'm guilty. I don't wear an seat belt in the back -- I can't do patient care and wear a seatbelt. I don't fasten down any of the equipment. My oxygen tank is laying there often on the bench next to the monitor. I don't always put the harness restraint on the patient. I drive with people who I wouldn't consider the safeest drivers.
It is making me reconsider the way I practice. I hardly ever go lights and sirens, but I also hardly ever wait on scene. I usually do everything en route to the hospital in a nonemergency mode. I may seriously start doing everything on scene and then belt myself, my patient, and my equipment in, including buying a helmet.
For years I have seen medics wear bullet proof vests. But that's not what is going to save their lives. Start with seat belts, include gloves, and throw on top the helmet. You're way more likely to get killed in an accident than shot on the job.
But what will my patients think, if I put on a helmet, but don't have one for them? Should I offer mine to them? Maybe I can buy one, get one half off. Then I would have to decontaminate the patient helmet after every call. Not a pretty thought.
What else has me down besides worrying about getting killed on the job?
I think the EMS EXPO depressed me. By EXPO I mean the vendor area, not the educational sessions. On the one hand, I should be "Wow look at all this cool stuff to help my patients," but on the other hand, it was like, "Everyone is out to make a buck and how much of this stuff is even neccessary or does what it claims to -- save lives!" (Aside from the helmets, which I would have seriously looked at but I hadn't yet been to Levick's ambulance safety seminar).
Along with the money line, I am bothered by the research dilemna. Much of the research being done is on potential money-making products. Research costs money so industry sees to it their products get researched by their experts. You don't see too much research on the cheap stuff.
The EMS conference/expo (while great from an educational perspective) brought it home just how much of a big business EMS has become.
On the educational part, I always end up coming back with new knowledge that says something to the effect that you know the way I have been practicing, well, that's all wrong. Instead of doing it that way, I need to do it this way. I'm all for change and evidenced-based medicine, but I get depressed when I learn the way I have been doing something is wrong and it makes me wonder what else is going to change. Last year it was the CPR (and I am a huge advocate of the new CPR -- it just sort of depresses you that all those compresions over the years weren't being done right). This year it is smaller. I learned that psuedoseizures are an actual problem, not just someone being a psych. I learned that there are many grades to a seizure, not just the tonic clonic, bite your tongue, pee your pants kind. I mean, I knew that already, but having it explained in such detail brought to light that I have had some patients who I probably judged to be full of it when In fact they really did have a seizure problem.
The Epilepsy Foundation sells a video cassette called How to recognize and Classify Seizures that you can get for $40. Bob Page showed excerpts from it during his session "A Whole Lotta Shaking Going On." I should probably buy a copy and show it in educational sessions around here as penance for the times, I thought my patients were just faking it.
What else is bothering me? I came home to find a new Emergency Medical Services magazine in my mailbox. In it there was an article called "Preventing Bloggerrhea". It was a needed article advising EMS managers to make certain they have a policy on blogs and that every employee knows what it is, but I resented the implication and title -- Blogerrhea. Sure, there are some bloggers who have stepped over the line, but still to compare blogs with diarrhea, that's pompous and ignorant. The only article I've ever read about blogs in the magazine and it compares them to watery crap. There are a lot of bloggers out there who are doing good work. I am going to try to make a better effort to highlight other bloggers -- important voices from the field who should be heard.
Maybe I'm going through a midlife paramedic crisis. Instead of feeling fresh, I feel stale.
I met with the bloggers/podcasters and as much as I like blogging, I am feeling that podcasting is where its at as far as the future. Its like books and movies. But I was meant to write, so it shouldn't matter. I need to just keep doing what I do.
I check my hit counters too much. I get around 220 a day. I've been as high as 400 lately, as low as 150. I check it way too often. Why should I care? I worry sometimes the quality of my writing suffers when I try to crank out some quantity, some new content. I'm from the tedious rewrite school, but I have sort of gotten out of that style. I need to think about the best way to do this blog, to keep it fresh. Sometimes I think I have had my say, it is time to let other voices take the stage.
I'm a little depressed I was going to be precepting Baby Medic, but there were union/administrative issues that seem to have interfered. We have a precepting list that needs to be followed in proper order, I guess. I thought it would be interesting to read two blogs about the same calls, one from the perspective of the new preceptee, the other the tired preceptor. Baby Medic was down at the JEMS conference too, and reading his account of the conference, I envy his enthusiasm, his future. I guess one way or the other I will be getting someone to precept, and that usually is good for me. Most of the new preceptees coming out this year are top of the line.
Still, I'm in a funk. Maybe it's because they turned the clock up an hour last night and I didn't find out until 12:15 when I thought I was going to bed at 11:15 -- even that too late, and had to get up at 5:00 to come to work, so I'm a little sleep deprived, a little trip tired.
Yeah, and I got a hair cut just before I went on the trip. Even I thought I was looking a little unkempt -- my hair was about to land again on my shoulders like it did when I was 17. Now I am clean cut again, and everyone is complementing me, but I feel like a sellout in some way. When I was young I had long hair, and with long hair again recently, I felt young again -- and with that I felt like my own man, like the world was whatever I wanted it to be. The problem was while one person told me I looked like a wistful old hippie, another told me I looked like an ax murderer freak.
Every so often in your life, you need to just stop and figure out what is important to you. What battles do you want to fight? What flags do you want to wave? Who do you want to love? What mark do you want to leave? What kind of person do you want to be?
I need to think about this all.
I don't want to be stale, not as person, not as a paramedic, not as a writer/blogger.
I don't know why I'm in this funk. I'll take a stab at it though.
The last seminar I went to was on ambulance safety by Nadine Levick. Here's her website:
Objective Safety
There are lots of handouts and slides you can see that will hit her main points.
She is famous for showing her videos of crash test dummies in the back of ambulances, and it is not a pretty sight. The bottom line is while we spend billions on biohazard prevention, we (EMS people) are being slaughtered in ambulances. We are sent lights and sirens to BS calls in vehicles no safer than than laundry trucks. While other countries have state of the art ambulances with roll bars, automotive safety seats, brackets to hold down equipment, helmets for personnel to wear, we are just waiting for the reaper to call our numbers.
I'm guilty. I don't wear an seat belt in the back -- I can't do patient care and wear a seatbelt. I don't fasten down any of the equipment. My oxygen tank is laying there often on the bench next to the monitor. I don't always put the harness restraint on the patient. I drive with people who I wouldn't consider the safeest drivers.
It is making me reconsider the way I practice. I hardly ever go lights and sirens, but I also hardly ever wait on scene. I usually do everything en route to the hospital in a nonemergency mode. I may seriously start doing everything on scene and then belt myself, my patient, and my equipment in, including buying a helmet.
For years I have seen medics wear bullet proof vests. But that's not what is going to save their lives. Start with seat belts, include gloves, and throw on top the helmet. You're way more likely to get killed in an accident than shot on the job.
But what will my patients think, if I put on a helmet, but don't have one for them? Should I offer mine to them? Maybe I can buy one, get one half off. Then I would have to decontaminate the patient helmet after every call. Not a pretty thought.
What else has me down besides worrying about getting killed on the job?
I think the EMS EXPO depressed me. By EXPO I mean the vendor area, not the educational sessions. On the one hand, I should be "Wow look at all this cool stuff to help my patients," but on the other hand, it was like, "Everyone is out to make a buck and how much of this stuff is even neccessary or does what it claims to -- save lives!" (Aside from the helmets, which I would have seriously looked at but I hadn't yet been to Levick's ambulance safety seminar).
Along with the money line, I am bothered by the research dilemna. Much of the research being done is on potential money-making products. Research costs money so industry sees to it their products get researched by their experts. You don't see too much research on the cheap stuff.
The EMS conference/expo (while great from an educational perspective) brought it home just how much of a big business EMS has become.
On the educational part, I always end up coming back with new knowledge that says something to the effect that you know the way I have been practicing, well, that's all wrong. Instead of doing it that way, I need to do it this way. I'm all for change and evidenced-based medicine, but I get depressed when I learn the way I have been doing something is wrong and it makes me wonder what else is going to change. Last year it was the CPR (and I am a huge advocate of the new CPR -- it just sort of depresses you that all those compresions over the years weren't being done right). This year it is smaller. I learned that psuedoseizures are an actual problem, not just someone being a psych. I learned that there are many grades to a seizure, not just the tonic clonic, bite your tongue, pee your pants kind. I mean, I knew that already, but having it explained in such detail brought to light that I have had some patients who I probably judged to be full of it when In fact they really did have a seizure problem.
The Epilepsy Foundation sells a video cassette called How to recognize and Classify Seizures that you can get for $40. Bob Page showed excerpts from it during his session "A Whole Lotta Shaking Going On." I should probably buy a copy and show it in educational sessions around here as penance for the times, I thought my patients were just faking it.
What else is bothering me? I came home to find a new Emergency Medical Services magazine in my mailbox. In it there was an article called "Preventing Bloggerrhea". It was a needed article advising EMS managers to make certain they have a policy on blogs and that every employee knows what it is, but I resented the implication and title -- Blogerrhea. Sure, there are some bloggers who have stepped over the line, but still to compare blogs with diarrhea, that's pompous and ignorant. The only article I've ever read about blogs in the magazine and it compares them to watery crap. There are a lot of bloggers out there who are doing good work. I am going to try to make a better effort to highlight other bloggers -- important voices from the field who should be heard.
Maybe I'm going through a midlife paramedic crisis. Instead of feeling fresh, I feel stale.
I met with the bloggers/podcasters and as much as I like blogging, I am feeling that podcasting is where its at as far as the future. Its like books and movies. But I was meant to write, so it shouldn't matter. I need to just keep doing what I do.
I check my hit counters too much. I get around 220 a day. I've been as high as 400 lately, as low as 150. I check it way too often. Why should I care? I worry sometimes the quality of my writing suffers when I try to crank out some quantity, some new content. I'm from the tedious rewrite school, but I have sort of gotten out of that style. I need to think about the best way to do this blog, to keep it fresh. Sometimes I think I have had my say, it is time to let other voices take the stage.
I'm a little depressed I was going to be precepting Baby Medic, but there were union/administrative issues that seem to have interfered. We have a precepting list that needs to be followed in proper order, I guess. I thought it would be interesting to read two blogs about the same calls, one from the perspective of the new preceptee, the other the tired preceptor. Baby Medic was down at the JEMS conference too, and reading his account of the conference, I envy his enthusiasm, his future. I guess one way or the other I will be getting someone to precept, and that usually is good for me. Most of the new preceptees coming out this year are top of the line.
Still, I'm in a funk. Maybe it's because they turned the clock up an hour last night and I didn't find out until 12:15 when I thought I was going to bed at 11:15 -- even that too late, and had to get up at 5:00 to come to work, so I'm a little sleep deprived, a little trip tired.
Yeah, and I got a hair cut just before I went on the trip. Even I thought I was looking a little unkempt -- my hair was about to land again on my shoulders like it did when I was 17. Now I am clean cut again, and everyone is complementing me, but I feel like a sellout in some way. When I was young I had long hair, and with long hair again recently, I felt young again -- and with that I felt like my own man, like the world was whatever I wanted it to be. The problem was while one person told me I looked like a wistful old hippie, another told me I looked like an ax murderer freak.
Every so often in your life, you need to just stop and figure out what is important to you. What battles do you want to fight? What flags do you want to wave? Who do you want to love? What mark do you want to leave? What kind of person do you want to be?
I need to think about this all.
I don't want to be stale, not as person, not as a paramedic, not as a writer/blogger.
Saturday, March 10, 2007
Back
I'm safely back from the conference today in time to work tomorrow. It will take me a couple days to write up all my impressions, they'll include:
Notes on Seizures session with Bob Page
Great, but chilling, session on ambulance safety with Nadine Levick.
Report on beer with bloggers/podcasters.
General impressions.
Notes on Seizures session with Bob Page
Great, but chilling, session on ambulance safety with Nadine Levick.
Report on beer with bloggers/podcasters.
General impressions.
Friday, March 09, 2007
JEMS/EMS Today Report #2
First session of the day was on mechanical adjuncts to CPR. Most of the session was about the physiology of CPR, which I am pretty comfortable with. The man teaching the class was a scientfic advisor to the Autopulse (but had no financial interest), and had done the Autopulse study in Richmond, Virginia, which was the one positive Autopulse study. He tried to poke holes in the big multi-center study that was so negative toward the Autopulse that they had to shut the study down because human CPR was proving to be so much better. He said he'd heard that medics in that study used the Autopulse on patients they would have just called dead because they wanted to play with what he said they called “The Geezer Squeezer.” He said a new randomized study on the Autopulse is on the way. He didn’t have much to say on the ResQPOD other than there is the big multi-center trail going on.
The EMS Expo has just opened up. I’m waiting for the crowds to clear some before I venture in. I have my digital camera with me so I will be taking pictures of the interesting things I see and will hope to post them when I get back.
I’ll go to two more afternoon sessions, and then tonight I’m having beers with the bloggers. I’ll head home tomorrow.
The EMS Expo has just opened up. I’m waiting for the crowds to clear some before I venture in. I have my digital camera with me so I will be taking pictures of the interesting things I see and will hope to post them when I get back.
I’ll go to two more afternoon sessions, and then tonight I’m having beers with the bloggers. I’ll head home tomorrow.
Thursday, March 08, 2007
Report from JEMS/EMS TODAY #1
Drove down with a fellow medic, and on the way discussed ways to get other medics more interested in education. I believe medics are not opposed to getting more education, its just that the economics of the job make it difficult to take the time off, not just to get to a nightly session, but more particularly to take a few days off and spend the money to get down to a place like Baltimore, pay for a hotel, meals, conference fees, and other costs.
Still, going to a conference is great way to improve yourself and your patient care. Last night I attended Bob Page’s “Slap the Cap” capnography class.
Last year in Las Vegas I saw the half hour condensed version. I envy anyone who has been able to attend his half day course. He is a phenomenal educator/entertainer.
People filtered into the classroom before show time to see Queen and then Billy Joel performing on the big screens set up in the front of the room. When Bob Page appeared to start the class, he humbly thanked his opening acts...Queen and Billy Joel.
Page calls capnography an “upgrade,” and to illustrate this he describes his first airline upgrade to first class and how he found out the drinks were unlimited, you could be served before the plane took off, you got peanuts, cashews and pistachios in a bowl rather than a tiny bag of salted peanuts and you also got warm moist lemon scented towels. Like first class on an airplane, capnography gives you stuff that you can’t get in coach.
Before getting into what that stuff is, he does a great demonstration of a blood cell carrying carbon dioxide in which he plays the blood cell running through the body. He simulates what happens to him during cardiac arrest, during a PE, and during a hemorrhage how he is thrown out of the body, and describes the effect of that all on the end tidal C02.
I’m not going to go through his entire class, but I will point out the key points from his presentation that I found personnaly found valuable or helped clarify my own thinking on the issue.
1. While most people use the definition of hyperventilation and hypoventilation to describe low and high ETCO2 numbers, he uses the terms hypocapnia and hypercapnia, which may be a more accurate was of describing it.
2. He does a killer job of trashing colorimetric capnography devices and the turkey baster/bulb syringe by reading their instructions and then applying them to real situations. For instance, the colorimetric says you must give six breaths to determine the reading to make certain all of the carbon dioxide is out of the stomach. Well six bags into the stomach is going to visually tell you there is a problem before the device does.
3. He takes about the wave form you will get from an intubated patient who is coming out of sedation before they start bucking the tube, so you can get out more sedation before they actually buck the tube. It is another example of how capnography makes you proactive as opposed to reactive.
4. He talks about asthma and makes the point you can’t fake a broncospasm/shark fin wave form. Anyone who says they are having an asthma attack and is trying to make a wheezing sound deliberately will have a straight up wave form unless they are actually having an asthma attack.
5. He calls wave form capnography a “one stop tube confirmation stop.” Technically, it is a two stop shop, because you still have to listen to lung sounds to make certain you don’t have a right mainstem intubation, which won’t show up on capnography. Still a desciptive phrase, meaning you don't have to go through all the step you might otherwise have to use if you didn't hve capnography.
6. He suggests hitting record on your intubated patients right before you move them to the ED’s stretcher and then immediately after you have moved them over to time stamp your intubation in case the ED says your tube is no good.
7. On the issue of ventilation rate, while the new AHA guidelines specify the rate as 8-10 for a patient in arrest and 10-12 for an intubated patient, you should instead use the capnography as your guide. If their ETCO2 is 70, you might want to increase your ventilation rate to blow some of that CO2 off.
8. Finally, before I could ask, he addressed the COPD/CHF question and his take is if the wave form is upright, there is no obstruction, so the wheezing is caused by the CHF, not the COPD, so you might want to withhold the neb treatment.
There is obviously much more to the class than this. As I have said before, if you ever get a chance to attend one of his courses, do it, he is great.
Afterwards I had a couple beers with some friends, and then got to bed early. I’m in a nicer hotel this year than last. This morning, though I was disappointed by the fitness center that had only four cardio machines and no weights. I rode a bike for fifteen minutes until a treadmill opened up and I could run.
I made it to the opening ceremonies on time, but it turned out they didn’t start for another half hour, so I could have eaten my Dunk'n Doughts bagel a little slower rather than scarfing it down on the way.
Paul Pepe was the opening speaker, and he spoke about the future of disaster management although much of his speech was a recap of Hurricane Katrina. The Hurricane has been the big topic at all the conferences and the bottom line is always the same – it was a mess, but we worked through it, and something like will happen again and we need to be prepared, etc. He said many people are worried about the avian flu pandemic.
Here are the three educational classes I attended today.
Primary Care -- An interesting history of attempts to expand paramedics into primary care, nearly all of which failed. I walked out convinced it was not going to happen soon. There are too many competing interests and roadblocks, not to mention lack of a financial mechanism. Probably the best chance and the biggest need would be to train us for primary care during disasters – we could tetanus shots like we did during Katrina or hydrate people in their homes.
Seizures – Couldn’t decide which class to take so I went with the best instructor and I’m glad I took the class. Page went through all the differenct types of seizures as well as showing video of them. Boy do I feel bad now, I can’t tell you how many people I have pooh-poohed their seizures, only now to discover now they may have actually had seizures.
I took about eight pages of notes. He covered partial seizures, partial complex seizures, generalized seizures, and broke them all down. I learned about myclonic seizures, more bout febrile seizures than I knew, absense seizures, atonic drop seizures and psuedo-seizures. In a few days I will transcribe my notes to share all the excellent information I received. It was very instructive and I will be much more understanding of people who have had nontraditional seizures.
Pain Management - A good class. The instructor made a big pitch for fentanyl as the perfect pain med. I think I am going to spend the year gathering information and studies on fentanyl with the goal of trying to get it in next year’s new protocols.
They are having a 25th anniversary party for JEMS at the Baltimore Aquarium tonight, but they sold out before I could get a ticket so instead I went to California Pizza Kitchen, ate one pizza, had two beers and bought another pizza, some for later and the rest for breakfast, then returned to my hotel to watch American Idol before getting to bed early.
Still, going to a conference is great way to improve yourself and your patient care. Last night I attended Bob Page’s “Slap the Cap” capnography class.
Last year in Las Vegas I saw the half hour condensed version. I envy anyone who has been able to attend his half day course. He is a phenomenal educator/entertainer.
People filtered into the classroom before show time to see Queen and then Billy Joel performing on the big screens set up in the front of the room. When Bob Page appeared to start the class, he humbly thanked his opening acts...Queen and Billy Joel.
Page calls capnography an “upgrade,” and to illustrate this he describes his first airline upgrade to first class and how he found out the drinks were unlimited, you could be served before the plane took off, you got peanuts, cashews and pistachios in a bowl rather than a tiny bag of salted peanuts and you also got warm moist lemon scented towels. Like first class on an airplane, capnography gives you stuff that you can’t get in coach.
Before getting into what that stuff is, he does a great demonstration of a blood cell carrying carbon dioxide in which he plays the blood cell running through the body. He simulates what happens to him during cardiac arrest, during a PE, and during a hemorrhage how he is thrown out of the body, and describes the effect of that all on the end tidal C02.
I’m not going to go through his entire class, but I will point out the key points from his presentation that I found personnaly found valuable or helped clarify my own thinking on the issue.
1. While most people use the definition of hyperventilation and hypoventilation to describe low and high ETCO2 numbers, he uses the terms hypocapnia and hypercapnia, which may be a more accurate was of describing it.
2. He does a killer job of trashing colorimetric capnography devices and the turkey baster/bulb syringe by reading their instructions and then applying them to real situations. For instance, the colorimetric says you must give six breaths to determine the reading to make certain all of the carbon dioxide is out of the stomach. Well six bags into the stomach is going to visually tell you there is a problem before the device does.
3. He takes about the wave form you will get from an intubated patient who is coming out of sedation before they start bucking the tube, so you can get out more sedation before they actually buck the tube. It is another example of how capnography makes you proactive as opposed to reactive.
4. He talks about asthma and makes the point you can’t fake a broncospasm/shark fin wave form. Anyone who says they are having an asthma attack and is trying to make a wheezing sound deliberately will have a straight up wave form unless they are actually having an asthma attack.
5. He calls wave form capnography a “one stop tube confirmation stop.” Technically, it is a two stop shop, because you still have to listen to lung sounds to make certain you don’t have a right mainstem intubation, which won’t show up on capnography. Still a desciptive phrase, meaning you don't have to go through all the step you might otherwise have to use if you didn't hve capnography.
6. He suggests hitting record on your intubated patients right before you move them to the ED’s stretcher and then immediately after you have moved them over to time stamp your intubation in case the ED says your tube is no good.
7. On the issue of ventilation rate, while the new AHA guidelines specify the rate as 8-10 for a patient in arrest and 10-12 for an intubated patient, you should instead use the capnography as your guide. If their ETCO2 is 70, you might want to increase your ventilation rate to blow some of that CO2 off.
8. Finally, before I could ask, he addressed the COPD/CHF question and his take is if the wave form is upright, there is no obstruction, so the wheezing is caused by the CHF, not the COPD, so you might want to withhold the neb treatment.
There is obviously much more to the class than this. As I have said before, if you ever get a chance to attend one of his courses, do it, he is great.
Afterwards I had a couple beers with some friends, and then got to bed early. I’m in a nicer hotel this year than last. This morning, though I was disappointed by the fitness center that had only four cardio machines and no weights. I rode a bike for fifteen minutes until a treadmill opened up and I could run.
I made it to the opening ceremonies on time, but it turned out they didn’t start for another half hour, so I could have eaten my Dunk'n Doughts bagel a little slower rather than scarfing it down on the way.
Paul Pepe was the opening speaker, and he spoke about the future of disaster management although much of his speech was a recap of Hurricane Katrina. The Hurricane has been the big topic at all the conferences and the bottom line is always the same – it was a mess, but we worked through it, and something like will happen again and we need to be prepared, etc. He said many people are worried about the avian flu pandemic.
Here are the three educational classes I attended today.
Primary Care -- An interesting history of attempts to expand paramedics into primary care, nearly all of which failed. I walked out convinced it was not going to happen soon. There are too many competing interests and roadblocks, not to mention lack of a financial mechanism. Probably the best chance and the biggest need would be to train us for primary care during disasters – we could tetanus shots like we did during Katrina or hydrate people in their homes.
Seizures – Couldn’t decide which class to take so I went with the best instructor and I’m glad I took the class. Page went through all the differenct types of seizures as well as showing video of them. Boy do I feel bad now, I can’t tell you how many people I have pooh-poohed their seizures, only now to discover now they may have actually had seizures.
I took about eight pages of notes. He covered partial seizures, partial complex seizures, generalized seizures, and broke them all down. I learned about myclonic seizures, more bout febrile seizures than I knew, absense seizures, atonic drop seizures and psuedo-seizures. In a few days I will transcribe my notes to share all the excellent information I received. It was very instructive and I will be much more understanding of people who have had nontraditional seizures.
Pain Management - A good class. The instructor made a big pitch for fentanyl as the perfect pain med. I think I am going to spend the year gathering information and studies on fentanyl with the goal of trying to get it in next year’s new protocols.
They are having a 25th anniversary party for JEMS at the Baltimore Aquarium tonight, but they sold out before I could get a ticket so instead I went to California Pizza Kitchen, ate one pizza, had two beers and bought another pizza, some for later and the rest for breakfast, then returned to my hotel to watch American Idol before getting to bed early.
Wednesday, March 07, 2007
Off to JEMS/EMS TODAY
Bitterly cold here today. The tones go off and we get a call and you feel like saying "Do we have to?" or "No, I'm not going, it's too cold!"
I guess it is all what you are used to and dressing warmly enough.
I'm hoping it will be warmer in Baltimore. Last year I had a nasty chest cold when I went. I had booked a hotel a mile away from the convention center thinking the $60 a night was a great deal, but it was a mile nearly straight uphill from the convention center and I would wonder as I staggered home against the night wind if I would ever make it, and then the elevator wouldn't work and I'd have to climb five flights of stairs, and then I'd sit in my room that looked out on the elevator shaft and watch the half black and white/half two-toned color TV, and cough like a dying man. I have another cold this year, but it doesn't seem to bad and this time I will only be a block away.
I'm driving down tomorrow with another medic and then will probably take the train back on Saturday, so I can be home in time to work Sunday morning.
Here's the sessions I'm looking to attend:
Wednesday evening:
Slap the Cap! Real Uses for Capnography taught by Bob Page. I caught a half hour abridgement of his class in Las Vegas and am looking forward to the whole class. he is a great teacher, and I'm hoping to expand my capnography knowledge and may get some thoughts on the capnography questions I have thought about, in particular, can you use capnography to distinguish between COPD wheezing and cardiac asthma wheezing of CHF in a patient with a history of both CHF and COPD.
Thursday
Morning:
Primary Care in the Streets -- a class about using medics for primary care
Early Afternoon
Cardiac Care and cardiac Arrest resuscitation: State of the Art
or
A Whole Lot of Shaking Going On! Understanding Seizures (also taught by Bob Page)
or
What Does the Future Hold for EMS?
Late Afternoon:
Pain Management: Analgesia and Sedation in the Field
Friday
Morning:
Mechanical Adjuncts for CPR
or
Selected Medical Emergencies
or
EMS New Technolgy Coming to Your EMS System: Is it Worth Having?
Early Afternoon:
Critical Issues in Ventilation
Late Afternoon:
Lightning Round- Report from the Eagles, which is ask a panel of docs your questions on any EMS issue
or
Spinal Immobilization: What We Thought We Knew!
or
Congestive Heart Failure vs. COPD
Friday Night:
Beer with the Bloggers
Last year when I went to JEMS they gave us a CD with the powerpoints and handouts from many of the speakers. I will probably look through this to gage whether I should go to a session or not. Sometimes the handout answers the questions so I don't need to go or it may make me want to go.
I'll report when I get back. If possible I will try to report from down there if I can get internet access.
Looking forward to seeing some of you down there!
I guess it is all what you are used to and dressing warmly enough.
I'm hoping it will be warmer in Baltimore. Last year I had a nasty chest cold when I went. I had booked a hotel a mile away from the convention center thinking the $60 a night was a great deal, but it was a mile nearly straight uphill from the convention center and I would wonder as I staggered home against the night wind if I would ever make it, and then the elevator wouldn't work and I'd have to climb five flights of stairs, and then I'd sit in my room that looked out on the elevator shaft and watch the half black and white/half two-toned color TV, and cough like a dying man. I have another cold this year, but it doesn't seem to bad and this time I will only be a block away.
I'm driving down tomorrow with another medic and then will probably take the train back on Saturday, so I can be home in time to work Sunday morning.
Here's the sessions I'm looking to attend:
Wednesday evening:
Slap the Cap! Real Uses for Capnography taught by Bob Page. I caught a half hour abridgement of his class in Las Vegas and am looking forward to the whole class. he is a great teacher, and I'm hoping to expand my capnography knowledge and may get some thoughts on the capnography questions I have thought about, in particular, can you use capnography to distinguish between COPD wheezing and cardiac asthma wheezing of CHF in a patient with a history of both CHF and COPD.
Thursday
Morning:
Primary Care in the Streets -- a class about using medics for primary care
Early Afternoon
Cardiac Care and cardiac Arrest resuscitation: State of the Art
or
A Whole Lot of Shaking Going On! Understanding Seizures (also taught by Bob Page)
or
What Does the Future Hold for EMS?
Late Afternoon:
Pain Management: Analgesia and Sedation in the Field
Friday
Morning:
Mechanical Adjuncts for CPR
or
Selected Medical Emergencies
or
EMS New Technolgy Coming to Your EMS System: Is it Worth Having?
Early Afternoon:
Critical Issues in Ventilation
Late Afternoon:
Lightning Round- Report from the Eagles, which is ask a panel of docs your questions on any EMS issue
or
Spinal Immobilization: What We Thought We Knew!
or
Congestive Heart Failure vs. COPD
Friday Night:
Beer with the Bloggers
Last year when I went to JEMS they gave us a CD with the powerpoints and handouts from many of the speakers. I will probably look through this to gage whether I should go to a session or not. Sometimes the handout answers the questions so I don't need to go or it may make me want to go.
I'll report when I get back. If possible I will try to report from down there if I can get internet access.
Looking forward to seeing some of you down there!
Tuesday, March 06, 2007
Hot Dogs
Been slow this week and most of the calls have been for young people with the flu. Yesterday I had a seventeen-year old with fever and diarrhea. He spoke in a death bed whisper. I wanted to say you are not on TV or trying out for a movie role -- there is nothing wrong with your voice. Me, I have a sinus infection again -- runny nose, cough. This winter has been the worst for me. The bird flu ever hits, I am going to be the canary in the coal mine. It seems I have had every thing this winter.
Another young person call I had the day before was a lethargic twenty-eight year old who had taken too many ambien. The doctor had told her to take one before bedtime. Well everytime she went to bed, she was taking an ambien. She'd take a nap, she'd take an ambien. She'd get up to use the bathroom, go back to bed and take another ambien. The phone would ring, she'd answer it, talk to her girlfriend for awhile, and then get back in bed and take another ambien. "The doctor ought to have explained that better," she said.
***
I'm still waiting to get a preceptee. It's looking like when I get back from Baltimore I'll start training someone.
***
Yesterday the boss asked us if we wanted hot dogs. Our base is designed to also function as a shelter. There is a special locked room room with a big kitchen, meat freezer, big grille, etc. The last general meeting we had there were a lot of extra hot dogs so we put them in the big freezer to supplement the other frozen stuff they had in there for emergencies. The next thing I knew the boss was running out of the room. About a minute later the smell hit me, and I was dry heaving too. Somehow the power had gotten cut off to freezer and when he opened the door, the rotten meat smell hit him. It smelled just like a several day old dead body. "I'm not even putting the leads on," I said. "Time of death -- 12:45. I'm out of here."
We had to wheel the freezer outside and hose it down, and then clean it out with bleach.
Nasty.
No hot dogs for my lunch.
***
We got a letter from one of the hospitals that they will no longer be taking our blood tubes. Ten years ago all the hospitals took them. We drew blood on all the patients. Then one of the bigger hospitals stopped taking them, claiming their lab couldn't process them or something. Now the other big hospital won't take them due to some new system where you need to be assigned lab numbers, and since we don't work for the hospital we can't get lab numbers. Some people say the hospitals have stopped taking bloods so they can charge big bucks when they draw the blood. Others say it is another issue. Who knows? I will miss taking the bloods out of my pocket and handing them to the nurses and saying, "Oh, and I got bloods for you." And they always smiled and said, "Thank you! You're the best!"
In the words of F. Scott Fitzgerald: "That thing is gone. That thing is gone. That thing will come back no more."
On the other hand, drawing blood could be a pain. I usually figure out how far I am from the hospital, figure out everything I need to do and how long it will take me, and then use that to either have my partner help me in the back or else have him start driving while I do everything, all timed so it is done by our arrival at the hospital. While most of the time the blood draws were real quick, sometimes the blood draws would take the whole trip. You have the IV in, you want to get the blood out, but it is coming really slow and after awhile you become an expert at positioning and repositioning to keep the blood filling the tubes. Now it will just be, boom! slam the line in, flush it, tape it down, and on to the next task.
Another young person call I had the day before was a lethargic twenty-eight year old who had taken too many ambien. The doctor had told her to take one before bedtime. Well everytime she went to bed, she was taking an ambien. She'd take a nap, she'd take an ambien. She'd get up to use the bathroom, go back to bed and take another ambien. The phone would ring, she'd answer it, talk to her girlfriend for awhile, and then get back in bed and take another ambien. "The doctor ought to have explained that better," she said.
***
I'm still waiting to get a preceptee. It's looking like when I get back from Baltimore I'll start training someone.
***
Yesterday the boss asked us if we wanted hot dogs. Our base is designed to also function as a shelter. There is a special locked room room with a big kitchen, meat freezer, big grille, etc. The last general meeting we had there were a lot of extra hot dogs so we put them in the big freezer to supplement the other frozen stuff they had in there for emergencies. The next thing I knew the boss was running out of the room. About a minute later the smell hit me, and I was dry heaving too. Somehow the power had gotten cut off to freezer and when he opened the door, the rotten meat smell hit him. It smelled just like a several day old dead body. "I'm not even putting the leads on," I said. "Time of death -- 12:45. I'm out of here."
We had to wheel the freezer outside and hose it down, and then clean it out with bleach.
Nasty.
No hot dogs for my lunch.
***
We got a letter from one of the hospitals that they will no longer be taking our blood tubes. Ten years ago all the hospitals took them. We drew blood on all the patients. Then one of the bigger hospitals stopped taking them, claiming their lab couldn't process them or something. Now the other big hospital won't take them due to some new system where you need to be assigned lab numbers, and since we don't work for the hospital we can't get lab numbers. Some people say the hospitals have stopped taking bloods so they can charge big bucks when they draw the blood. Others say it is another issue. Who knows? I will miss taking the bloods out of my pocket and handing them to the nurses and saying, "Oh, and I got bloods for you." And they always smiled and said, "Thank you! You're the best!"
In the words of F. Scott Fitzgerald: "That thing is gone. That thing is gone. That thing will come back no more."
On the other hand, drawing blood could be a pain. I usually figure out how far I am from the hospital, figure out everything I need to do and how long it will take me, and then use that to either have my partner help me in the back or else have him start driving while I do everything, all timed so it is done by our arrival at the hospital. While most of the time the blood draws were real quick, sometimes the blood draws would take the whole trip. You have the IV in, you want to get the blood out, but it is coming really slow and after awhile you become an expert at positioning and repositioning to keep the blood filling the tubes. Now it will just be, boom! slam the line in, flush it, tape it down, and on to the next task.
Sunday, March 04, 2007
JEMS - Bloggers
I understand some EMS bloggers are going to try to get together down at JEMS on Friday night. I am going to try to meet up with them.
Blogger Meeting
From what I gather, the group could include:
EMS Haiku
Paramedic Blog
Mad Dog Medic
and possibly more. I know Baby Medic will be down there as well.
I'm also hoping at some point to meet Jamie Davis, the Pod Medic, who lives down that way.
The MedicCast
I'm going to be there from Wednesday evening until Saturday morning. I'll post more about which sessions I am planning on attending. Any one else, bloggers or nonbloggers, going? Please leave a comment if you are so I can look out for you or say hi down there if you see me.
Blogger Meeting
From what I gather, the group could include:
EMS Haiku
Paramedic Blog
Mad Dog Medic
and possibly more. I know Baby Medic will be down there as well.
I'm also hoping at some point to meet Jamie Davis, the Pod Medic, who lives down that way.
The MedicCast
I'm going to be there from Wednesday evening until Saturday morning. I'll post more about which sessions I am planning on attending. Any one else, bloggers or nonbloggers, going? Please leave a comment if you are so I can look out for you or say hi down there if you see me.
Saturday, March 03, 2007
Blogging about EMS
It seems that with increasing frequency I am reading or hearing about someone involved in EMS getting in trouble, and occasionally losing their job over what they have written in their blog or posted on the internet.
The link below is the latest story:
Warning Issued to Kentucky Paramedic After Web Site Posting
When I first considered starting a blog, I consulted with "the MacMedic,"* (a paramedic who at the time was working in my state) who was a forerunner of EMS bloggers. He gave me some advice as well as directing me to a blog post written by Tom Reynolds, an English EMT, and author of the blog, Random Acts of Reality. (Probably the most famous (as well as prolific) EMS blogger, Reynolds turned excerpts from his blog into a book, Blood, Sweat & Tea: Real-Life Adventures in an Inner-City Ambulance
, that has done very well. Reynolds incidently mentions the MacMedic in his book.
Here is Reynolds' post on blogging:
How To Blog And Not Lose Your Job
I followed Reynolds's advice, as well as advice given to me by the Macmedic, and made certain my employers knew I was writing a blog. I emphasized to them I valued my job and was open to any changes or suggestions to prevent any problems. My policy is not to rank on anyone or the company, or at least not in a hateful way. (I occasionally rail against the system, but not against any individuals. Generic subjects can be fair targets, identifiable ones are not.) While in my books I used the real names of my partners and coworkers believing they deserved credit for the fine work they do, I have chosen for the most part not to follow that course on the internet. Consequently sometimes my posts appear as if I am the only responder there or if I have a partner, they are largely faceless, unless the story is centered around their involvement on the call.
I have also taken great strides to protect patient confidentiality. In addition to changing identifying details, I often use a randomized method of selecting sex and age to further obscure any case that might be known to the public. In only a few cases have I not written about a call for fear that I would reveal personal details that could be readily identified. In other cases, I have written about a call months out of sequence. It is easier for me to write about calls when I am working in the city and can respond to any of a number of towns beside the city, than when I am working in the one suburban town to which I am assigned.
I think it would be very difficult to write a blog in a small town with a low call volume and still protect confidentiality. The greater the population you serve, the easier it is to safely write about a call. I have heard many stories of small town bloggers offending fellow crew members or even town residents. I would advise anyone writing about a small service to be extremely careful in what they write, as you should even in a larger service. Write as if you were standing in front of the town, giving a public reading.
The one area where people seem to get in the most trouble is with photos. I have been tempted a number of times to post a photo of an accident scene, even once going so far as uploading a photo of one managled car very relevant to the story, but was unable to push the publish button out of fear I was crossing a line. A newspaper or TV station can show the pictures, but health care providers cannot. I would think the only way you could post the photos safely would be to show a photo that does not in any way identify a person or specific car or accident scene and post it at a date different than that on which it occurred. When in doubt I would always first check with your company’s policy. If your company doesn’t have a policy, you might want to work with them to develop one.
As important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.
As far as a personal policy, I would say this:
Don’t use writing to put someone else down, particularly someone who cannot properly defend themselves. Don’t be cruel. Write to elevate what we do. Write to elevate the spirit you have seen in people you have cared for -- in their worst and best moments. Write to share your human experience with those who can benefit from it. Record your stories, your thoughts, your revelations. Use your writing to try to understand the world, not to condem it. Share your victories, your defeats, your frustrations and your hopes. Write to show that you have walked down the EMS streets, that you have left footprints on the earth.
Stay safe and keep the faith!
***
* The MacMedic no longer posts. His blog has been taken down. I miss checking up on him. He recently moved to a new state and started working for a new service. Whether his new bosses objected to his blogging or he just felt he had done it enough, I don't know. He certainly helped blaze a path for the rest of us.
The link below is the latest story:
Warning Issued to Kentucky Paramedic After Web Site Posting
When I first considered starting a blog, I consulted with "the MacMedic,"* (a paramedic who at the time was working in my state) who was a forerunner of EMS bloggers. He gave me some advice as well as directing me to a blog post written by Tom Reynolds, an English EMT, and author of the blog, Random Acts of Reality. (Probably the most famous (as well as prolific) EMS blogger, Reynolds turned excerpts from his blog into a book, Blood, Sweat & Tea: Real-Life Adventures in an Inner-City Ambulance
, that has done very well. Reynolds incidently mentions the MacMedic in his book.Here is Reynolds' post on blogging:
How To Blog And Not Lose Your Job
I followed Reynolds's advice, as well as advice given to me by the Macmedic, and made certain my employers knew I was writing a blog. I emphasized to them I valued my job and was open to any changes or suggestions to prevent any problems. My policy is not to rank on anyone or the company, or at least not in a hateful way. (I occasionally rail against the system, but not against any individuals. Generic subjects can be fair targets, identifiable ones are not.) While in my books I used the real names of my partners and coworkers believing they deserved credit for the fine work they do, I have chosen for the most part not to follow that course on the internet. Consequently sometimes my posts appear as if I am the only responder there or if I have a partner, they are largely faceless, unless the story is centered around their involvement on the call.
I have also taken great strides to protect patient confidentiality. In addition to changing identifying details, I often use a randomized method of selecting sex and age to further obscure any case that might be known to the public. In only a few cases have I not written about a call for fear that I would reveal personal details that could be readily identified. In other cases, I have written about a call months out of sequence. It is easier for me to write about calls when I am working in the city and can respond to any of a number of towns beside the city, than when I am working in the one suburban town to which I am assigned.
I think it would be very difficult to write a blog in a small town with a low call volume and still protect confidentiality. The greater the population you serve, the easier it is to safely write about a call. I have heard many stories of small town bloggers offending fellow crew members or even town residents. I would advise anyone writing about a small service to be extremely careful in what they write, as you should even in a larger service. Write as if you were standing in front of the town, giving a public reading.
The one area where people seem to get in the most trouble is with photos. I have been tempted a number of times to post a photo of an accident scene, even once going so far as uploading a photo of one managled car very relevant to the story, but was unable to push the publish button out of fear I was crossing a line. A newspaper or TV station can show the pictures, but health care providers cannot. I would think the only way you could post the photos safely would be to show a photo that does not in any way identify a person or specific car or accident scene and post it at a date different than that on which it occurred. When in doubt I would always first check with your company’s policy. If your company doesn’t have a policy, you might want to work with them to develop one.
As important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.
As far as a personal policy, I would say this:
Don’t use writing to put someone else down, particularly someone who cannot properly defend themselves. Don’t be cruel. Write to elevate what we do. Write to elevate the spirit you have seen in people you have cared for -- in their worst and best moments. Write to share your human experience with those who can benefit from it. Record your stories, your thoughts, your revelations. Use your writing to try to understand the world, not to condem it. Share your victories, your defeats, your frustrations and your hopes. Write to show that you have walked down the EMS streets, that you have left footprints on the earth.
Stay safe and keep the faith!
***
* The MacMedic no longer posts. His blog has been taken down. I miss checking up on him. He recently moved to a new state and started working for a new service. Whether his new bosses objected to his blogging or he just felt he had done it enough, I don't know. He certainly helped blaze a path for the rest of us.
Thursday, March 01, 2007
The AutoPulse
A reader asked me to comment on the AutoPulse, the automated CPR device that straps around a patient's chest and delievers compressions at a consistent rate and depth.
Let me start by saying I have never used the device. I have talked to many medics who have and who have been amazed at the machine's abilty to provide excellent compressions to the point you can feel a pounding pulse, and who report more than expected return of spontaneous circulations.
While the Autopulse was initially hailed as a miracle device, it performed so badly in a recent multisite randomized study that the study was halted.(1) While very successful at gaining return of spontaneous circulation, it proved less successful than human CPR in the key category of having patients walk out of the hospital alive. (Some services are now removing the $15,000 device from their ambulances.)
In talking with medics who have used the device and in reading the studies, many of us feel that the drawback to the Autopulse may not be the machine, but the time it takes to get it on. The few people who have a chance of being saved to the point of walking out of the hospital alive have a very short window to be saved. If the thirty seconds to two minutes it takes to get the machine on and working properly delays excellent CPR in those critical early moments, maybe that is the difference.
Again, not having used it, I am not really qualified to make a judgement.
In the end I have to defer to the science. There are more studies of the autopulse going on, including a small recent study that showed positive results (2). However, an initial read of the study shows that human CPR was done for quite awhile initially and there was some selection bias in who eventually got the machine and who didn't. I am not the best at reading studies, but I have learned that you really need to dig into the study to determine its worth. Another thing to consider is who is funding the study and what relationship do the authors have to the subject being studied. In some cases, the author is the inventor of the device or is a consultant. They are trying to declare all conflicts, but sometimes it can be deceptive. An author presenting on the topic may declare he has no conflicts, but not reveal conflicts that coauthor have.
I recently read a study comparing two types of cervical spinal clearance, the Nexus criteria versus the Canadian c-spine rule. The study concluded the Canadian c-spine rule was better. Who did the study? The same people who developed the Canadian rule, and the trial was held in the area where all the doctors had been trained in the Canadian rule. This is not to say they are not right, just that you need to consider possible bias.
***
At the regional council we often have vendors come in and give a presentation on an emergency product. I try to study up on the issue before the meeting so I can ask intelligent questions. We recently had a presentation on the Easy-IO. The company sent a salesman and a clinical specialist. The clinical person was awesome. She did a great job describing the product, answering questions and being frank about pros and cons. I was impressed. I have seen other demonstrations on products I actually like and been turned off by the claims that rely on anecdote and which stretch the science. I think too often in EMS, we fall victim to the next best thing -- Amiodarone, the AutoPulse...and then the science comes out and shows if we are not doing more harm than good, we are just spending a lot of money for unproven results. We always want to give our best to the patients, but it makes us susceptible to sales pitches. Unfortunately, budgets in EMS are tight, and we need to watch where our dollars go.
**
(1) Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.
(2) Out-of-hospital cardiopulmonary resuscitation with the AutoPulsetrade mark system: A prospective observational study with a new load-distributing band chest compression device.
***
In response to a comment below on amiodarone, I have added a couple links that further discuss the issue of new drugs/devices and research.
Ludwig: Put a Gun to My Head
What's Missing From EMS Research
Discussion of Amiodarone/Lidocaine
The bottom line on the amiodarone issue was three fold 1) despite massive initial publicity about the study (Amiodarone saves lives!), the results showed no improvement in hospital discharge 2) it turned out the study was paid for by the manufacturer 3) the drug is much more expensive than lidocaine.
On a personal note, I have had positive experiences with amiodarone, but realize anecdote does not trump science.
Let me start by saying I have never used the device. I have talked to many medics who have and who have been amazed at the machine's abilty to provide excellent compressions to the point you can feel a pounding pulse, and who report more than expected return of spontaneous circulations.
While the Autopulse was initially hailed as a miracle device, it performed so badly in a recent multisite randomized study that the study was halted.(1) While very successful at gaining return of spontaneous circulation, it proved less successful than human CPR in the key category of having patients walk out of the hospital alive. (Some services are now removing the $15,000 device from their ambulances.)
In talking with medics who have used the device and in reading the studies, many of us feel that the drawback to the Autopulse may not be the machine, but the time it takes to get it on. The few people who have a chance of being saved to the point of walking out of the hospital alive have a very short window to be saved. If the thirty seconds to two minutes it takes to get the machine on and working properly delays excellent CPR in those critical early moments, maybe that is the difference.
Again, not having used it, I am not really qualified to make a judgement.
In the end I have to defer to the science. There are more studies of the autopulse going on, including a small recent study that showed positive results (2). However, an initial read of the study shows that human CPR was done for quite awhile initially and there was some selection bias in who eventually got the machine and who didn't. I am not the best at reading studies, but I have learned that you really need to dig into the study to determine its worth. Another thing to consider is who is funding the study and what relationship do the authors have to the subject being studied. In some cases, the author is the inventor of the device or is a consultant. They are trying to declare all conflicts, but sometimes it can be deceptive. An author presenting on the topic may declare he has no conflicts, but not reveal conflicts that coauthor have.
I recently read a study comparing two types of cervical spinal clearance, the Nexus criteria versus the Canadian c-spine rule. The study concluded the Canadian c-spine rule was better. Who did the study? The same people who developed the Canadian rule, and the trial was held in the area where all the doctors had been trained in the Canadian rule. This is not to say they are not right, just that you need to consider possible bias.
***
At the regional council we often have vendors come in and give a presentation on an emergency product. I try to study up on the issue before the meeting so I can ask intelligent questions. We recently had a presentation on the Easy-IO. The company sent a salesman and a clinical specialist. The clinical person was awesome. She did a great job describing the product, answering questions and being frank about pros and cons. I was impressed. I have seen other demonstrations on products I actually like and been turned off by the claims that rely on anecdote and which stretch the science. I think too often in EMS, we fall victim to the next best thing -- Amiodarone, the AutoPulse...and then the science comes out and shows if we are not doing more harm than good, we are just spending a lot of money for unproven results. We always want to give our best to the patients, but it makes us susceptible to sales pitches. Unfortunately, budgets in EMS are tight, and we need to watch where our dollars go.
**
(1) Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.
(2) Out-of-hospital cardiopulmonary resuscitation with the AutoPulsetrade mark system: A prospective observational study with a new load-distributing band chest compression device.
***
In response to a comment below on amiodarone, I have added a couple links that further discuss the issue of new drugs/devices and research.
Ludwig: Put a Gun to My Head
What's Missing From EMS Research
Discussion of Amiodarone/Lidocaine
The bottom line on the amiodarone issue was three fold 1) despite massive initial publicity about the study (Amiodarone saves lives!), the results showed no improvement in hospital discharge 2) it turned out the study was paid for by the manufacturer 3) the drug is much more expensive than lidocaine.
On a personal note, I have had positive experiences with amiodarone, but realize anecdote does not trump science.
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