Ridin' the bus

pain

2011-11-15T22:15:00.001-05:00

Mine and theirs. Somedays I feel like I wear the pain of all those I have encountered. Weighing me down like a heavy coat in the rain. Suck it up buttercup. Yes I know. Find an outlet. Yes I have. Who cares? I still do. Over ten years of anger, pain and fear. And somedays no matter how far I run, no matter how much I write,no matter how much I laugh,I wear their pain along with mineHeavy like the rain.

PTSD Survey

2011-06-15T18:06:00.003-04:00

I know it has been a ridiculously long time since I have blogged about anything. But I have been buried to my eyeballs in college. I am currently writing a paper on PTSD symptoms in first responders. I have created a survey to collect some data. It is completely anonymous. I would love it if any of you out in blog land would take 10 minutes and fill it out, maybe pass the word to your first responder friends? If you wish to add any information you can email me at my gmail account. Anything you send me will be kept confidential and no names will every be used in my paper.

THANK YOU ALL!

http://www.surveymonkey.com/s/Q62F3Y8

Crass Pollination

2009-10-27T21:02:00.000-04:00

Hey I can't seem to access Nurse K's blog! anybody know whats up and how I get an invite? I miss reading her stuff

The case for critical care

2009-09-01T11:31:00.001-04:00

I know it's been a while guys. I just wrote this for a friend who wants to go to criical care to give him some ideas. It is by no means complete, I thought you all could expand on it for me.

Critical care is not merely vent settings, balloon pumps and lab values. It is a deeper understanding of what we already do. Medicine is an ever changing field with great advances being made all the time. How often do you pick up patients with new unfamiliar medications or medical devices you have never seen? How do we know what to do with them when they are in extremis? How do we know our normal course of action will be sufficient or if it will do more harm than good? The answer is that we further our education to become more well rounded providers that have a better understanding of how the body works, how certain disease processes effect us and how medications work. Every city in this region runs mutual aid into the surrounding areas. Do we know all of the special needs patients in these other cities? When the weather is bad and the helo isn't flying there are times when we run critical ground transports to other facilities. How many street medics know how to manage multiple drips when there is no nurse to go with you on the run? How do they handle chest tubes and central venous access? How many medics can manage a propofol drip? Do they know how it works and what to watch for? EMS is diverse, we walk not only into patients homes but into doctors offices, military clinics, shipboard clinics, and a multitude of other places. They call and we go, it doesn't matter where they are. We as providers should be able to handle anything that we walk into with more than a very basic understanding. We may accept a patient who has had treatment started by a doctor and we should know what that treatment does and what else we can do for this patient. To have medics that are critical care certified is not only an asset to your department on the street it is an asset to your training division. These medics can put together classes to help the other field providers improve their knowledge base thereby improving the quality of prehospital care and patient outcome. Patient care and patient outcome are really what we are all here for, and critical care does nothing but improve on an already strong system.

SANE cases

2009-07-21T10:40:00.003-04:00

People. We deal with people everyday. But how often do we deal with the victim of sexual assault? When we do, do we allow our perception of the world to color our views of them? These patients are a breed all their own and require a certain amount of special handling. These assaults can occur on both sides of the gender fence, though they are more reported when the victim is a woman. They can happen to anyone; Black, white, rich, poor, drug addict, prostitute, lawyer, doctor, old or young it is a crime that crosses all social barriers. Rape is a crime of violence and usually less about the sex and more about domination. So how do we deal with these patients who are in a moment of crisis, knowing that how they are handled can effect them for a very long time? I have had no formal training on this but life and quite a few psych classes have taught me a few lessons. Hopefully this can help others to deal with these psychologically complicated patients. If any of you have any thing to add I would greatly welcome any suggestions.

First I always approach my patient slowly and maintain a "safe" personal space distance. I don't want to violate their space any more than they have already had it violated.

I speak with a low even tone. I maintain an open stance and squat to their level so they can see me. I try never to stand over them or to have what appears to be an aggressive posture.

Before I do anything with them, I ask permission. I tell them up front what I would like to do and explain what is going to happen while I am doing it. I will not cross that personal space barrier until they give me permission. This is an attempt to give them back some control over what is happening to them.

I ask minimal questions, just do the basic assesment, treat any obvious inuries and I don't ask specifics regarding the assault unless they relate to the injuries I treat. ie were you struck with a fist or an object? kicked ect. I stay away from rape specific questions. I think that is more the place of the detective and the SANE nurse.

I let them talk. If they choose to talk to me I just let them say whatever they need to say. I assure them that they are safe with me and will continue to be so when they arrive at the ER.

The last thing I do is explain some of the process they will go through in the ER. This gives them an idea of what is next and also people feel more in control if they are informed.

In our area we have what are called SANE nurses. They are forensic nurses, SANE stands for Sexual Assault Nurse Examiner. They examine and collect evidence and help point victims in the right direction for further care. They are invaluable in my mind and I think all ER's should have atleast one.

I hope some of the things I have learned will help you guys deal with your patients. I am hoping to get some training with our department and a local SANE nurse. If it happens I will pass the info we get on. Remember when we are dealing with these patients that no matter what their life circumstance no one deserves to abused this way and they deserve the utmost of care and gentle handling.

Loss

2009-07-14T18:05:00.002-04:00

Our department lost a man today. A firefighter,paramedic, brother and friend. He was my preceptor when I came to the city. He terrified me at first but we got into a comfortable rhymth and when I was done we moved out of our preceptor/preceptee relationship and onto the comfortable banter of coworkers. He was a teacher and friend. He could be a butthead but it didn't last long. He had a dry wit and a sarcastic sense of humor. He could make me laugh until I cried. The loss of him is a huge loss from our lives. He will be sorely missed.

Rest well Brother you'll be in our hearts.

Airway Class

2009-07-09T18:59:00.002-04:00

Today we had airway training. Our numbers have not been so good even though we have multiple different airway devices on board. Our OMD came and taught our class. We got to practice using our ILMA, the King LT and the bougie. He talked about crash airway, and failed airway. We were able to ask him as many questions as we needed and practice over and over. I know I feel much more comfortable with the ILMA and the King now than I did before. This was the best class I have been to in the last 4 years and our training officer has other ideas forthe near future to get us a broader range of classes and experience. I am excited.

a lesson in dosing by a drug seeker.

2009-07-06T22:42:00.000-04:00

A local pharmacy called the Er to let them know they received a stolen prescription. It was written for "morfeen 1 gallon"

That is a whole new dosing system made strictly for our heavy duty narc seekers.

One less

2009-06-30T18:04:00.002-04:00

The loss of anothers life can be tragic. After a few years on the job you see many different types of death. Natural and unnatural violent death. The man who walks to the store to by ice cream and gets shot in a robbery, the child who dies in the cross fire of a gang war, the woman targeted for nothing other than being a woman and murdered in her bed. Cancer victims who fought for their lives. Sad, each and every one of them. Lately it is difficult for me to find outrage, sorrow or even a minor twinge for the drug dealer who is Missing and found dead, the criminal shot, stabbed or otherwise taken out of the world. I do have a moment of sadness for the family. Everyone has someone who cares, and for them the loss is painful. To me they have become "one less". One less person to rob a store, car jack someone, break into my home, sell drugs, or catch a kid in the cross fire. I find myself thinking that the world is better off for their demise. They are just one less. One less drain on the legal system, one less person who doesn't want to hold a job, pay taxes and live a law abding life. One less person my tax dollars have to provide for.

When I have these thoughts as I am pronouncing another gang banger I wonder where my compassion has gone. I wonder when I became so jaded about the life of another. Sometimes it gives me pause. Until I have to pick up another victim of these criminals who have no regard for anyone but themselves and don't care who they damage in the process of doing what ever they wish.

Conflicted. The whole thing makes me angry,sad, and very conflicted about how I view the world.

things you dont want to hear over the intercom

2009-06-22T12:49:00.000-04:00

"Medic 9 is on fire and I'm not joking!" good job to the guys at 4 who put out M9 that was on fire on the front ramp. You guys rock!

The sugars

2009-06-19T17:16:00.002-04:00

We have all had some patients with low blood sugar who do some really bizarre things. Today my good friend had one that topped it for me so far. This dood was lying on the porch, he got up ran over to the ambulance looked at it, LICKED it then went back to the porch to lay down. haha I really wish I could have seen it. I am not sure I would have been able to hide the giggle.

patterns

2009-06-16T20:28:00.002-04:00

In school our head is filled with shiny brand new knowledge that we have no idea what to do with. We want to get it all out and play with it like a kid at Christmas. When you are more seasoned you are always learning new things. New con ed classes, journal articles, studies and a vast landscape of new possibilities. We don't want to take it all out at once anymore, we want to hold onto it and find the right moment to actually use it. Information is being fed into our brains at an alarming rate. This is medicine and it changes very very quickly.

No matter how things change in medicine, our job as medics relies heavily on our physical assesment,and pattern recognition. If we can assess and recoginize the pattern our patient fits then we can be aware of what may come next and be prepared for the change. Most of us have a mental file cabinet that files away past patient assessments, especially the things that stick out or are different. Not everything presents classically like in the book so when we have patients who don't fit the norm then we learn something and file it away for later use. Combine that experience with education, and our ability to pick the doctors brains in the ER, the mental file cabinet makes an impressive assessment tool.

So build your mental file cabinet. Talk to the nurses, the PA's and the docs. Absorb the knowledge that you are gaining. Read up, go to class, hit the internet. Do what you can to make yourself better, faster, and smarter. You aren't doing anything but improving yourself and improving the care your patient will receive.

(For all you old folks out there, mental stimulation is good for your brain so ward off the dementia and pick up a journal)

Happy filing!

G

Thank you

2009-05-25T14:13:00.002-04:00

For doing what I could not. For leaving your loved ones to hold down home so I can live the life I do. For taking care of your buddies when they need you the most. For giving more than you ever thought you had. For leaving yourself on the battlefield and for coming home to rest. For enduring a hardship many can't stomach. For coming home and carrying on with dignity, honor and respect. For not coming home at all. For all the things you have experienced that cannot be put into words. Thank you.

breathing difficulty

2009-05-20T14:25:00.003-04:00

I have been running a special on breathing difficulties that aren't lately. They all have been dispatched as breathing difficulty but have ranged from cardiac arrest to "I shut my foot in the car door". Where do callers come up with breathing difficulty?? I have had so few true respiratory patients lately. It is odd.

mine

2009-04-30T20:29:00.001-04:00

Patients have a way of becoming ours. When you are responsible for the care of another you feel some obligation. How many times have you heard stories start out with "my kid with the...." or "my dood that had..." It is such a normal part of our conversation with other providers that we don't think before we say "my". Imagine my surprise when at breakfast this morning my good friend and colleague says to me "So my mom got arrested the other day."
Needless to say we had a good laugh over that.

word

2009-04-29T08:48:00.002-04:00

There are some words I just love. In french class it was the word travailler. It just sounds so cool rolling off the tongue. In this job there are also words I just think are great.

Epistaxis- how cool is that? It sounds so severe and dramatic when really it's not so much.

Hemoptysis- coughing up blood. Sounds way cooler to say my patient has hemoptysis rather than he's coughing up blood.

Emesis-So much more civilized sounding than upchuck, puke, spew or any other variation.

Anasarca- Generalized massive edema. In other words "He all swoled up"

Babinski's sign- plantar reflex named after some french dood with an awesome name that I just like to say.

OK thats the short list. I know you guys have to have some words that just make you smile. What are they? Add to my list.

attention L&D nurses

2009-04-23T06:57:00.000-04:00

Please please try to remember when we are giving you turn over that we tell you what the patient tells us and what limited info we find on our assessment. No matter how absurd it may sound it usually came straight from the patients mouth. As far as our findings go please be advised that our assessment does not include fishing around in there looking for stuff. If we have to we will make sure no babies are making their escape at the moment but we're not going to check their teeth from the bottom. Just sayin. Love you guys you have an interesting and difficult job but please try not to shoot the messanger.

A

2009-04-19T23:10:00.000-04:00

Is for AIRWAY. Um not accuchek. Thank you

And here comes #9

2009-04-16T21:36:00.002-04:00

Late 20's female G-9 P-8. Not due for 2 more weeks. Has pain for an unknown amount of time, sits down on floor and here comes #9. By the time we got there she was holding number nine who was still attached to a placenta that was also on the floor. Wet, cold, uncovered, central cyanosis and barely whimpering and wiggling. After some of the basics of newborn care and a little blow by there was a warm, pink, cranky and vocal little one. Mom was not bleeding, vitals wnl. The only thing that was off was that she had a completely flat affect. Never asked about the baby, looked at it and when we tried to pass baby to mom to hold she declined. Depression? drugs? apathy? who knows. But that beautiful baby deserves more and we all just wanted to wrap her up and take her home.

Condoms are free at the health department. You don't have to have a job or money to get them. Birth control is not a bad thing.

Can a girl get a wheeze? Please?

2009-04-14T21:11:00.002-04:00

I like lung sounds. I like hearing different types of lungs sounds. I listen to lung sounds on pretty much all my patients and depending on your problem I may listen to them over and over. Your lung sounds tell us so much about you. In the absence of x-rays and lab tests, all we have to "see" into your lungs are our ears. Wet noises, nasty chunky thick rhonchi noises, squeaky musical wheezes. They each tell us a story. The worst lung sound to hear? silence. Not the familar woosh of air moving in and out that says clear lung sounds, but nothing. A cavernous omnious absence of any sound. Have an asthma attack and wait too long and you get silence. Spontaneous or traumatic pneumo or hemothorax and you get zip for noise. Immediately the mind shifts into gear and the possiblities on how to fix it start bouncing around. Take this case for example:

50 y/o female asthma pt. Out of meds for 2 days. seen frequently for uncontrolled asthma. Waited all day to go to ER.She is known to compensate well then just wear out quickly. Working hard to breath, non speaking, accessory muscle use. Absent lung sounds on the left upper and lower, right side has barely a squeak when she exhales. What do these lungs say to you? What do you "see" when you listen? I saw teeny irritated little passages that air could barely move through and had wicked inflammation. She and I are on a first name basis I see her so much. She gets an Albuterol/Atrovent tx and 125mg solumedrol IV. By the time she got to the ER she was wheezing everywhere.

I guess my point to this is that not all wheezing is bad. I will take a wheeze over silence any day. I think sometimes in class we make a big deal of the lung sounds and what they mean and how we treat them but we don't spend as much time on silence and how afer silence some noise is good. If there is noise then something has to be moving around in there when before nothing could.

So. Can a girl get a wheeze, please?

Don't make mom angry.

2009-04-09T17:57:00.002-04:00

This was the conversation between mom and patient at 4am after a call out for groin pain and painful urination.

Mom: 3 WEEKS?! You have had this pain for 3 WEEKS!

patient: yes maam but it hurts more tonight.

Mom: I thought I told you to wrap that Sh** up!! You know better.

Now stammering patient: I did! I swear. I have only been with one person.

Mom (getting louder): That don't matter none. Have you been getting head with out a condom??

patient hanging head: Yes Maam

Mom: DIDN'T I TELL YOU ABOUT THAT!? The mouth is the dirtiest place on the body. You can get nasty things from someones mouth.

Hard of hearing grandma from the other room: What did you say girl??

Mom: I SAID HEAD MA HEAD!

Grandma: (muttering) stupid boy..

Don't make mom angry. She will embarass you and she doesn't care who hears her.

The Wall

2009-04-05T21:16:00.003-04:00

I was not even a glimmer during the Viet Nam war but for some reason I have been drawn to this era my whole life. I wear a bracelet with the name of a Navy pilot that was shot down in 1965. He is my 3rd bracelet and I have worn his name without fail for almost 15 years. I have a place in my heart for all vets, but Vietnam vets especially. I wrote a paper for school last week about The Wall. These are my last paragraphs, it is what I feel The Wall does for people and how it moves me. I felt like I needed to share it.

One of the most profound aspects of The Wall is the immense emotion it invokes when you are standing in front of it, looking at yourself reflected in the names of those who have died. A person cannot help but be in awe of the sacrifice. James Kilpatrick wrote in the Washington Post in 1982 this about his experience at the wall “We walked through the usual litter of a construction site, and gradually the long walls of the memorial came into view. Nothing I had heard or written had prepared me for the moment. I could not speak. I wept. There are the names. The names! . . . etched enduringly upon the sky.”(Lehigh.edu,10). It is an overwhelming feeling to be surrounded by so many names. You know there is a story and family behind each one of them. To be able to reach out and touch the name of someone on that wall has a lasting effect. To stand in front of the wall one feels almost drawn to it, to raise a hand and form a connection.

Despite the controversy the memorial generated, it has become a place of reflection and healing. People come to the wall and leave flowers, flags, candles, dog tags and bits of the human experience that relate to the person on the wall and whomever came to visit. They are a way for family, friends and brothers in arms to find peace and closure with their own personal Viet Nam. Whether for or against the design of the Vietnam Memorial people flock there to touch a name, share a memory and let go of some of their grief. Long lost brothers find each other there and reconcile the past with the present and future. Bonds that were worn with time forge stronger while the names of those they lost bear witness to life moving forward despite the tragedy that was witnessed. They leave behind these small offerings of memory and personal times. To stand on the mall watching the miracle of reconciliation and healing is thought provoking and deeply moving. This design allows you the freedom of being within your own thoughts while giving the visitor the ability to reach out and touch not only a name or a flower but another human being. That alone makes it a fitting tribute to veterans who for so long had only themselves and the hands of their brothers to rely on for comfort. When you see yourself reflected amongst the names and as you walk down the wall you are reminded that these people were not unlike you or me.

Pittsburgh officers killed

2009-04-04T17:05:00.003-04:00

I don't know if I have suitable words to express how I feel about the recent loss of police officers we have seen. Today 3 Pittsburgh officers were killed. Public safety is a dangerous jobs and police officers put themselves out there everyday for all of us. It is with a heavy heart that I post this.

Here is a link to the story.

Say a few prayers, and if you aren't the praying type then think a few good things for their families and for police officers in general. Better yet find one and tell them thank you.

radio traffic

2009-04-03T16:58:00.000-04:00

My latest line to get the ER to answer the radio? City hospital this is medic one I have a patient that is intubated would like to answer the radio? They picked right up. Its amazing.

Note: I should make it clear that my patient was actually tubed and I had called 3 times already with no luck.

a tip

2009-03-30T05:42:00.000-04:00

Or a polite suggestion. When I ask you how much rock you smoked tonight don't look at me with your version of an innocent look and respond "how much rock did I smoke?" before you go sleepy night night and have a seizure hide your drugs better.

pucker factor

2009-03-23T22:45:00.000-04:00

You walk into the house to find a late 20's woman on the couch actively in labor. Contractions coming on top of each other. She states she thinks her water may have broken but is unsure. Your patient is G7 P5 with little to no prenatal care during this pregnancy. Getting info is difficult. She complains of vaginal pressure but no urge to push. Enroute to the hospital she starts telling you how she has never delivered naturally and all her other babies came by C section. When you finally get the why of the story out of her she tells you that she had htn, pre eclampsia, and sepsis. With ALL of her other kids.
And you think oh hell just get me to L&D please.

Things that make you go hmmm.

2009-03-17T10:06:00.000-04:00

We are taught that we do not diagnose in the field. This is true we do not. We do a field differential diagnosis. This becomes almost automatic during the assessment of our patients as we decide what we can treat and what we can’t. We have to decide what we think is going on so we can appropriately treat our patients.
To do this we take into account our patients past history, medications, current assessment findings, history of present illness and other information provided by the patient, family or by standers. This is where we have to trust ourselves. We have to listen not only to our gut but to everything we are hearing, seeing, touching. Because it is from here we make our treatment decisions.
Doing these differentials helps us learn from our patients. We learn from all of them, but the difficult or confusing ones stick with us. These are the ones we try to follow, these are the ones we sometimes learn the most from. Take this patient for example:
Male patient found severely agitated. Rapid pressured speech, paranoia, delusions, fidgety, combative. Vitals RR-24 BP-180 systolic HR- 130 regular, lungs clear, skin n,w,d pupils perrl. Per family no known ETOh or drug usage. Recent hx of insomnia x2 weeks, fasting, diet pill usage. No medical or psych hx. Pt was seen 5 days prior in ER for insomnia and prescribed Valium and Ambien. Last night pt also took an Advil PM before bed which contains Benadryl.
I had 3 thoughts about this patient.
1. Insomnia, fasting and diet pill usage = no sleep, no nourishment and ephedra. All of these alone can cause some of these symptoms, combined I didn’t know what it would do.
2. Benadryl reaction- some people can have this type of reaction with Benadryl usage. In fact it happened to a friend and it looked very similar to this.
3. New onset psychosis- The patient had no psych hx but was at the tail end of the age range that adult onset schizophrenia is known to show its self.
Pt was combative and had to be restrained for his and our safety. I was unable to accucheck this patient even while in restraints, because to get near his hands meant that he would grab you and not let go.
As I made my list of possibilities in my head for this patient I found there was not a single thing I could actually treat. So restrained and unhappy he went off to the ER on the stretcher, with me ready to treat something should it arise. He got turned over to staff in the same state that I had him. I gave them all the history I had and my thoughts regarding the patient. Not to tell them how to proceed but because I was hoping one of them would catch up with me later and let me know if I was even close in my thinking. This guy is a good learning experience for me and he really makes me curious.
Later I found out he was detained into the psych ward with new psychosis. Interesting. I did some research later online because I was still curious. I found that people taking ambien and mixing it with Benadryl have been known to have similar episodes that mimic true psychosis. Now I really want to know if he truly had a psychotic break or it really was a reaction to the combination of medication. Has anyone else had a patient with these medications doing something similar?

2 things

2009-03-16T02:52:00.000-04:00

Saying things like "I'm a nurse" to me over and over while I'm trying to assess and /or treat my patient is not helpful. I appreciate all you had to do to get there but if you have nothing about my patient to add you're just making yourself look silly.

If you stop at an accident to render aid and you are going to tell me how you are an EMT please actually hold cspine. That means the patient isn't tilting his head back or attempting to stretch his neck while your fingers are on either side of his mandible. Thank you.

It's not...

2009-02-28T11:11:00.002-05:00

Good to run from the police. They get really angry. You get your butt whooped. I have to get out of bed.

The worst headache, chest pain, abdominal pain of your life if you are eating a big mac, talking on the phone and giggling.

A stroke if your hair is too tight and the side of your head is burning.

An emergency if you can't get your doxy script filled until the morning.

Going to make it better if I pour water on your face then rub it wih a towel after you get the OC. Just quit whining and let it wear off.

Breathing difficulty if you are lying flat on your stomach or curled up like a shrimp on the ground screaming at me that you can't breath. Screaming=breathing.

A good idea to climb on the ambulance. You will either get snatched down by the cops or I may not see you, open the door and knock you out. Then you'll get snatched up by the cops. Either way handcuffs are involved.

Really going to make a difference how many times you tell me that I HAVE to take your baby momma, grandma, sister or husband to the ER.If they aren't dying,confused or unconscious they have to tell me themselves. So quit yelling at me. I'm not really listening.

This has been a Ridin the Bus PSA. Thank you.

Life

2009-02-15T13:04:00.003-05:00

The worst feeling in the world is the look in your patients eye as life slips away from them. You can see it, you're watching them die. You work hard, to keep the glimmer there. Working working working. Airway, Breathing, Circulation. Give me this, I need that, pass me the BVM. Where the hell is my O2? Call the hospital, let them know we're coming with a bad one. Working working working. In your mind nothing is going as it should but your mouth and your hands keep moving.The patient turns their head with what energy they have left from their own internal fight and looks at you. And you know. 10 more seconds until we are there. Just fight a little bit harder for me, I won't give up if you don't. Then there you are. The cavalary meets you. They swarm your patient,work work work. Get the vent, where's my ABG, I need some Epi. You allow them to do their work and you talk to the family. Can you hear me? You don't have to look at me just hear the things I am telling you. He needs to rest, the medicine has to work, yes sometimes it happens that fast. They are the best here, they will watch over him, can I call someone for you? And then you are gone. Back on the truck, back in service and ready for the next one. Later you hear he came off the vent before the end of the night. He hung on, and so did you and he gets to go home.

Quote of the night

2009-02-08T08:49:00.000-05:00

"A lot of people run from the police. It doesn't mean they are criminals!"

heres one

2009-01-25T15:03:00.002-05:00

2 y/o child. cold s/s for a couple days. won't eat, won't drink. 2 diaper changes in last 12 hours. pink but sticky mm. dark smelly urine. alert and playful, though not to the normal energy level. cough,and fever present. If you had a patient that presented in the ED this way what would you do?

The award for...

2009-01-22T19:06:00.002-05:00

Funniest patient shoes of the night goes to...

When I am 46 I want a pair just like them.

typealyzer

2009-01-22T18:03:00.001-05:00

The Doers-

The active and playful type. They are especially attuned to people and things around them and often full of energy, talking, joking and engaging in physical out-door activities.

The Doers are happiest with action-filled work which craves their full attention and focus. They might be very impulsive and more keen on starting something new than following it through. They might have a problem with sitting still or remaining inactive for any period of time.

Oh this is me. Fo Sho! It's kinda of fun. try it out. www.typealyzer.com

Chest pain 2

2009-01-20T09:05:00.002-05:00

So get the guy in the back of the truck. His EKG looks good. Start him out on an albuterol Neb. By the time that one has finished his chest pressure has lessened, and his cough is still productive but no longer black, it is white. He continues to wheeze only now it is strictly expiratory and there is much better airmovement heard. After his 2nd albuterol neb his chest tightness has gone away and his wheezing is scattered. After a few hours of observation in the ER, the patient was discharged. Thankfully there was no significant airway burns, no injuries from the fire, and no pulmonary edema.

Thanks for giving me your input. I really like to see how other providers would have treated him and especially how providers in other countries would have treated him. I think we all learn from each other and hashing out calls like this one help.

Chest pain

2009-01-18T12:11:00.002-05:00

2 part post. I give you the scenario then you tell me whatever comes to mind. Ready? Good here we go.

Residential structure fire. 30's male attempts to gain access to neighbors burning house with the thought that someone or someones pets are inside. While making the attempt the house flashes over causing the windows where the patient was standing to blow outward. Patient was enveloped by heat and smoke which knock him over. Patient is immediately up and moving. 30 minutes later patient develops nonspecific chest tightness and has productive cough with black mucus. Pt is in care of medic on scene who has called you to assume care and transport. Pt is on O2 by cannula, SR on the monitor no ectopy, has IV established. Upon your arrival to scene you find patient sitting on couch a&ox3, pupils perrl, skin p,w,d. pt has soot on face. Upon inspection no obvious burns around or in nose or mouth, no obvious soot in mouth or nose. Patient is unable to take deep breath without coughing but is able to speak clearly with no stridor or hoarsness. Patient has inspiratory and expiratory wheezes heard throughout upper and lower front and back. His only complaint is of chest tightness and cough.

Ready? Treat my patient. GO!

Rumors

2009-01-17T11:53:00.002-05:00

It is hard to be a woman in this field. People assume a great many things about you. There are rumors galore. We are assumed to be too tough/not tough enough/too weak/lesbian/wild party girls/ out to bag us a fireman/medic/cop/doctor or nurse. It takes time to earn your place, to allow them to get to know you, and to build a reputation. Your reputation in this business will get you far. It is a small world in public safety. If you build your reputation as a strong provider, honest, hard working and you seem to fit well in the community then it will serve you well. If you choose to act like or actually chase every guy in uniform that you come across, you complain all the time and don't play well with others then your life in this business is going to be very very hard. Perception is reality. It would do us well to remember that.

problems

2009-01-13T12:40:00.002-05:00

I have more questions than opinions today. I know that every combination department has it's problems and there are arguments for and against the cross training of our people. How do you deal with a brand new medic, a preceptee who just doesn't care? In it for the raise and not the medicine. How do you teach someone like this? How do you not throw up your hands in defeat when you know they will be released no matter what you write? More importantly how do you make them understand the need for a strong assessment and that the medicine is actually important? These are grown adults. It's very difficult to instil a work ethic when the have never had one. How do you all deal with these problems? I know they are not just issues I have noticed but they span across the board.

Time away

2009-01-11T20:31:00.002-05:00

I won't get on this forum and air my departments dirty laundry, but over the last 3 months things have occured that have made me cranky, cynical and sarcastic. Ok maybe just made me more so than I already am. So I am taking a much needed break off the box this month. It will restore my sanity. When I am back on full time the semster will have started again and we will be awash in fresh faces from the medic progam. I will be knee deep in newbies and school work of my own. Hopefully this will bring about new and exciting tales from our fair streets. I know if nothing else my attitude will have had it's proper adjustment and the world will be right again. Hope all of you are well.

surrogates

2009-01-03T11:49:00.002-05:00

EMS encompasses many facets and it is a continually evolving profession. At every level we are caregivers, taxi drivers, hand holders,and professionals. We have also become surrogate family for those who have none. How many times have you contacted APS or CSB for an elderly adult who needs home care or placement? Changed someones clothes who are bed bound or cooked a meal for a diabetic who needs to eat? Things that their family should be doing for them. 2 nights ago I brought a patient to the ER with a dissection. I was there at 7am holding their spouses hand when they made the decision to make them a DNR. An elderly couple whose family had left them behind for whatever reason. A couple who had only been married 12 years. Relative newly weds who had an obvious love and affection for each other that even the alzheimers couldn't take away. She didn't know who her husband was but you could see the love for the stranger who took care of her daily and alone. I sat for a while with them listening to stories from their last 12 years and the fears that this new crisis had brought to light. The knowledge that one of them was not going home weighed heavy in the room.

While it is not in our job description it is in the best interest of our mental health and well being that sometimes this is the best thing we can do for someone. We can hold their hand, we can provide people with a slice of the strength that it requires to do this job well. That is our gift to society. Not the taxi rides, the abuse, or all the other countless problems in the system. It is the ability to stand strong for someone else while they face their own personal hell. Even if we go home and cry in the shower, we have given someone a gift that cannot be replaced. Peace.

medication error

2009-01-03T07:59:00.002-05:00

This is weekend I had my first "med error" while more of a techincal protocol violation it did involve meds. I caught it. I documented it. I talked to the doctor about it. My patient had no adverse effects, in fact she had to be dosed with something more when I got her to the ER. I talked to my shift supervisor about it, I even talked to the EMS chief about it because he happened to be working at my station that day. I wrote it up and did all the paperwork for it.

Yesterday I had to go see the captain over it. He was surprised that I had caught it, fixed it and reported it. I hear that not many people will do that. Why not? Isn't it better to admit it and take the hit for it than trying to hide it? Is integrity really that hard to find in people in this business? If so what does that say about us as a whole?

Lost art

2008-12-28T15:57:00.003-05:00

'Tis the season for CPAP. Atleast where I live when the weather changes the CHF patients fluff up and we break out the CPAP a few times a week. I have watched it turn around some patients that just a few years ago would have went rapidly downhill. There is no doubt that CPAP has been a useful addidtion to the ambulance. Before it was added we would bag our patients in an attempt to create that airway pressure or when they got too tired but before they respiratory arrested we would nasally intubate them.It's a blind intubation and takes a little finesse. The act of placing an ET tube in the nose and down into the airway can be a scary thought not only to the provider but to the patient as well. Scary but necessary and potentially life saving. When I was in paramedic school we were actually taught to nasally intubate. It isn't a skill that is widely used anymore. We still teach it but it is not as heavily emphasized now that we have CPAP. Many providers are not comfortable with it and many ER personnel are not used to seeing it nor are they comfortable with using it as an airway however temporary. Normally it is immediately removed no matter the consequence. This is a skill that we need to keep up on. While not as common any more it still has it's place and can be a good tool when your patient doesn't have enough effort for the CPAP but is still breathing. Airway always comes first and the lost art of nasal intubation can serve you and your patient well.

High School

2008-12-21T16:01:00.002-05:00

I had the realization yesterday that EMS is just like high school. There are the obvious cliques. Urban EMS, Rural, Hospital, and transport. Then there are the subcultures of EMS. Tactical,flight,SAR,educators and other specialized fields. Every single group in their own environment think they are the cool kids and everyone of them has a group they want to be like. In the rural EMS system anyone with a cert over the level of first responder is "cool", the ultra cool kids get their ALS. Secretly they want to be like the city kids. Usually in this group you find a mixture of hopsital based and transport providers as well. In the urban system, being ALS is no big deal, so everyone is in the cool group. These guys all secretly (or openly) want to be apart of the subculture, SWAT, Flight and SAR are the really cool kids. usually found here are also a mixture of rural providers, educators and city dwellers. These guys work transport and in the Hospital as second jobs but don't think it is "glamorous enough". All of these groups have a social hierarchy and are very difficult to break into. All of them "eat their young". Once accepted though they begin to mold how a provider thinks and acts. Sometimes causing them to forget where they began and how humbly we all started. So the next time you are with a group of providers from different places sit back and watch. It is like reliving your teenage years.

Picture perfect

2008-12-14T14:38:00.002-05:00

Do I need to say anything here?

a small thought

2008-12-06T10:23:00.003-05:00

I think it should be mandatory for people to put up numbers on their houses. And not little ones that blend in with the paint. Decent sized reflective ones.

When it's drug raid night in the neighborhood the narcs should warn us they wil be out causing hate and discontent. They don't have to say when or where, just thats it's going down. Then we will know to get a good nap during the day.

A funny thing last night on teh way to work, I stopped at the 7-11 and the guy behind me in line had a giant bottle of wine, brown shiny velvet pants and was singing "You told me you loved me baby... You said you'd be coming back for me one daaaay..." At the top of his lungs. Isn't that the Carpenters? Good times.

I haven't stopped the blogging guys, I am working on a couple things. Come back for more very soon.

vacation

2008-12-01T08:29:00.001-05:00

So I have been in Houston since Thanksgiving day. Travel at the holidays is such a strange time. People are so stressed. Even more than they normally are at the airport. I did learn a few things this trip. If you have anything on your bag that has to do with law enforcement TSA leaves you alone. One of my students is secret service and gave me a pin. I put it on my back pack not even thinking of it and TSA avoided me. I also wonder why the TSA guys that are standing around watching or checking boarding passes are wearing gloves. What exactly will they be coming into contact with while they are standing in a corridor? Are they really afraid of exposure or does it make them look more official? Is there some briefing that they go to and are told that people may dip their tickets in anthrax? Or maybe bleed on them? The airlines will do anything to make a buck. They offered to upgrade to first class on a plane so small it didn't have first class. They also offered to upgrade me to a seat with more leg room. All for a nominal fee of course. And 15 bucks just to check one bag that wasn't even over weight. The weather was great and much warmer than what I left. A few funny things happened while I was here. I learned that I never want to hear my grandmother say the words "dick extender" ever again. (we saw one too many commercials for some magic pill) and that it is very funny to listen to my mother try to explain how to "google" something. Everyone was fascinated with my Blackberry and kept asking me to google things. Even at the dinner table it was "hey go get your blackberry and google this". All because I looked up directions to the train station for my grandparents. Good times with the fam. It will be good to be home tonight and back with my friends, my pups and my peeps. Hope eveyone had a Happy Thanksgiving and it was equally as entertaining.

another funny registry

2008-11-23T10:00:00.002-05:00

So I didn't do airway this time. My station didn't yield nearly as much funny stuff as some of the others but here's what I heard.

Best line of the day in my station:

"Now maam you're going to feel a big prick. Try not to jump."

This is what not to say when you go to registry:

"I didn't study for this. I want to come back later."

Walk out of your station, thats how you earn a retest.

chief complaint

2008-11-17T20:27:00.002-05:00

Saturdays chief complaint of the night was "I have a cold and my right elbow is aching" at 4 am.

The lay person medical suggestion of the night was by a guy who got into a bar fight and cut his wrist on a glass. "Just heat up a lighter and stick it in there to seal it up." At least he believed me when I told him it wasn't a good plan.

Seven days

2008-11-13T14:39:00.002-05:00

Of riding the box and the best I could come up with is that I got a drunk guy to call me lady godiva and tinkerbell in the span of a 5 minute transport to the ER. I am amazed at the amount of mature DQ's we have living in my first run area. (I promise just because you had a fight over the phone with your boyfriend there is no reason to pant "I can't breath" over and over at me.)And it's amazing how fast an abdominal painer can sprint when he realizes he is free of the policia. The best would have been if he really had gotten nailed by that fast moving car when he bolted into the main road. Then I would have had to transport him twice.yippee

Dueling Banjos

2008-11-09T19:28:00.002-05:00

A guy I work with looks just like this cat.

Can't you just hear the music?

Day 2 of 7

2008-11-07T21:40:00.000-05:00

So the title says it all this is day 2 of 7 on the box. Nothing of note except I seemed to have been running a special on nitro and lasix. Maybe the next 5 days will bring some good blog fodder.

VOTE!

2008-11-04T12:10:00.002-05:00

So today is the day. The day we all go out, stand in line and pick our next president. There are also a great many house and senate seats up too. It's cold and it rainy here,but the lines are long. It's a beautiful thing. Voter turnout is more than it has been in the last few elections. Remember no matter who you vote for this election and no matter who wins we are watching history being made. So do your part and go VOTE! You're doing your country a disservice if you stay home.

P.S. If you don't vote and don't like who gets in don't whine!

I don't like to discuss or even argue politics and it is pretty charged around here. I'm just going to tell who ever asks that I voted for Ralph Nader. I didn't but I have to give the guy props for running in every election.

Decisions

2008-11-03T19:52:00.002-05:00

As adults we make decisions everyday. What's for dinner, what bill do I pay this payday and I think I'm sick maybe I will go see or doctor or maybe not. These are just a few decisions in the course of the average day/ week/ month for the average person. Do we make bad choices? Yes we do. Is it my place as a medic to force you into something you don't want to do? No it isn't. Take this case for example:

45 y/o female with small puncture wound on her left flank. She states it is from a kitchen knife. (when I say small I mean less than a 1/2 inch big) This occurred aproximately 45 minutes prior to the first call for EMS being made. She has been up walking about and rode in the car over to the police station where we were called. This injury has no bleeding or swelling. Her vitals are wnl,abd soft,flat and nontender,skin n,w,d. Her only complaint is that it hurts where she was cut. She doesn't want to go with me to the ER. She wants her boyfriend to take her. No matter what I say to her she is adamant. Now she is not intoxicated or impaired in any fashion. She is A&Ox3, and answers all questions appropriately. She has had a previous head injury 2nd to a GSW approx. 2 years prior. She functions as normal, lives on her own and has no POA. She makes her own choices. She signs the refusal.

30 minutes later I am called to the police station again for the same patient. Her assessment is exactly the same as before and she still does not want to ride with me to the ER. The difference this time is that one of the officers threatened to detain her if she did not go. So I question the officer on it. He says she has to go because she is a danger to herself, because she is making a bad decision. When I tell him I can't force her to come with me, he said well she needs an ECO (Emergency Custody Order.)We don't do those. The police do that. They have to put the person in custody and see the magistrate. I told him that. Then he said she wasn't competent to refuse because of her previous head injury. Still he would have to do the paperwork and put her into custody. Then the officer has to ride with them and wait in the ER with them. We went around and around. Finally I told her since she was done with her paperwork she didn't have to stay. She left. He was mad because he wanted me to put her in the truck and just take her.

I guess the big thing for me was that he wanted to do an ECO on a person because she made a stupid choice. Granted it could have been detrimental to her health but I think it was still her choie to make. If he could ECO her for that, how many times could any of us been detained and forced into something just because we make a bad decision? She wasn't threatening to kill herself or someone else. So why force someone to obtain medical care if they don't want to or they don't want to go to the facility they would be taken to? Does this really make much sense to any of you?

Paragods

2008-10-28T17:26:00.003-04:00

The title I think speaks for itself. Paragod. It's not a term of endearment. Usually spoken by other medics or EMT's about someone who thinks and acts as if they know everything, they are never wrong and they do nothing but "save lives". They diagnose in the field, talk patients into refusals, act as if they don't care about anyone but themselves and are all around pompous buttheads. A person with a God complex.

Examples of paragodness include such things as "I will tell you like I tell my own family...Why you're breathing better than I am." and seeing how many refusals you can get in a shift,leaving the on coming crew to pick up your rejects.

Want to be a paragod? First and foremost you must be a paramedic. (Thats where the para part comes from)Then you aspire to be the guy with the biggest ego in the place. Never ever listen to your crew (especially if they are not paramedics), argue with the doctors on every case and talk smack about them even if you are WRONG. Don't listen to your patients when they tell you things. Assume everything. Snap, Snarl and Snatch things from your EMT's. Talk to everyone you come into contact with as if they are small and slightly MR. Never ever fail to tell people how great you are and how great your skills are. Bore people to tears with war stories that top anything anyone has ever done and never shut up.

Any questions? If you're smart, you never want this label. You will not have earned the respect of your colleagues and most people will think you're a twit.

Adventures in babysitting

2008-10-28T16:03:00.002-04:00

Patients that is.

Yesterday brought a rash of obserdity and foolishness. I felt like I was babysitting. Let me tell you a bed time story or two.

3rd party "suicide attempt" call. 50ish female sitting in living room tearful, but medically stable and she denies being suicidal. We are waiting onscene with PD for the family member who called to show up. Meanwhile the bebe daddy shows up, yelling at bebe mama, smoking and towing a puppy on a leash. He starts trying to take bebe from mama. The officer in the house with me tells him nicely multiple times to either sit down and calm down or go outside and calm down. This officer took much abuse from this guy in the forms of F*** YOU! and you don't pay bills here you can't tell me... blah blah blah you get the picture. The final straw was as bebe daddy was going out the door he threw out a " Stupid cop I wish he would shut up". Officer Friendly had enough. The officer steps outside and calls bebe daddy over to him. Bebe daddy looks at the officer, grabs two handfuls of his droopy drawers and takes off running. Which of course begins the police chase. Puppy tries to follow. This upsets bebe mama even more, who is now screaming for someone to GET MY DOG!!! and WHY YOU DOING THIS TOO MEEEEE!!? Then she runs to the back of the house and locks herself in the bathroom. Family shows up and talks her out. She doesn't go but provides us with a decent story for the day. Cops bring back bebe daddy hemmed up in cuffs and he is still talking. LET ME OUT OF THESE CUFFS I WILL KICK YOUR A**!! and more stupid people phrases. I guess he really wanted to go to jail yesterday. Lesson from the day: Droopy britches make it harder to run from the cops and you could have avoided all that work and cardiovascular excercise if you had shut your yap and sat down.

It's 3pm I haven't had lunch, been running all day and I'm hungry, cranky and tired. We go to an allergic reaction call. It's a 20ish male wh is having difficulty talking to me because he can't open his mouth. His teeth are clenched, mouth twisted, he says it hurts and he says it has happened to him before. So I'm thinking ok I can do something about this. Sit him down, start his line while my partner draws up some benadryl. I flush the line by letting the bag run for about 3-4 seconds. As soon as I close the line off he turns his head and says " I feel so much better." Now I'm pissed. I say " yeah that stuff works like magic doesn't it? " to which he replies " Oh yes that benadryl is great." So the next part I couldn't resist because the filter from my brain to my mouth has been gnawed on by my stomach. I say "Thats funny cause I didn't give you anything! If you're going to fake a reaction atleast make it last longer." He got mad but what could he say? So I take him to the ED where he insists on going. I take out his line and inform him he has to go to the waiting room to be checked in. As we are walking to triage he breaks away and starts running through the ED screaming YOU HAVE TO HELLLLPPP MEEEE!! I HAVE THESE ATTACKS!! I FEEL ONE COMING ON I NEEEEEDDDD BENADRYLLLL NOOOOW! Security wrestles him out to the waiting room where he continues his peformance for the crowd until they threaten to call PD and he can go to jail. Then he sat down and went to sleep. Lesson for the day: Always remember not to open your drug box until you have flushed your line with the magic normasaline!

random stuff I have seen in 24 hours

2008-10-25T10:11:00.001-04:00

A honda civic with the front end missing... Street racing is a bad idea.

A dude put 2 fingers down his throat and spewed all over the back of my truck...Chunks are not easy to get out of diamond plate.

A dude on a bike with a blue dust buster on the handle bars.

A guy who got jumped who acted like he may just die right then. He walked to the truck.

A guy on a bike with taken apart crutches in the basket and balancing a bedside commode on the handle bars.

Maybe tonight will bring even more entertainment.

Crying wolf

2008-10-22T22:42:00.002-04:00

We go to a 40 something female very frequently. She has legitimate medical concerns, Htn, Chf,GERD and psych. We normally go at the same time each call. The same complaint each time. Midline cp, nonradiating, reproducable with palpation. Sometimes she complains of SOB. Lungs clear, no distress, speaks full sentences clearly. In fact she chatters her head off all the way to the ER. She hasn't been admitted recently except for psych. All her work ups have been normal for the last few months. I tell you all of this because we have gotten to the point where we don't believe her anymore. Thats not to say we don't assess her each and everytime, we just have a very high index of BS suspicion. The ER is the same way. We walk in to the place with her and they say oh " is the complaint cp or sob today?"

We all have patients like this. The sad part that you can't seem to get across to people is that one of these days they are going to be actually sick and we aren't going to believe you. Neither will the ER. Don't cry wolf, it's a good lesson to learn.

Good football weekend

2008-10-19T16:49:00.004-04:00

This weekend It was a great weekend for my football teams! UVA beat UNC 16-13 in overtime. It was an edge of your seat nail biter of a game.

Then today my Steelers beat the Bengals easily 38-10. It was a good weekend for me.

EMS Snobs

2008-10-19T14:41:00.003-04:00

I have been fortunate to have worked in different arenas in EMS since I started not that long ago. I have been a volunteer, worked rural EMS, transport via private service, in the ER and now in the fire department. All along the way I have found EMS snobs. These are people who can't see the benefits of any type of system but their own. Vollies don't like paid and vice versa. 911 Ems doesn't like transport. The ER techs are sub part medics in the eyes of most. It boggles the mind how deep this runs. It effects the relationships of people that should be working together. In my area we have the vollie agency by the sea. They have a beef with their paid fire service (who doesn't run ambulances), they pretty much have a beef with everyone who isn't them. It has given the agency a very bad name and makes it difficult when they come to work for some other agency. If you listen to them they invented EMS and their way is the only way. The problem with the fostering of this attitude is that you become shut out by the other agencies around you. People don't want to listen to what you have to say even if you have a good idea. People don't want to help you when you need it. This helps to foster the thought process that we are the red headed step children of public safety. It makes us stuck in a place where things can not be improved and we can't come together to fix the problems.I am using this agency as an example but this attitude is through out EMS/Fire. Does it really matter if you are paid, volunteer, rural or city, transport or ER? Nope. There are subpar providers in every avenue, but in reality we all are here for the best interest of the patient. I am not sure how to curb the problem but a problem it is and something I think that we should work together to change. If we could come together we could be taken seriously and not be the red headed step children of public safety but the younger brother people try to look out for.

I'm so going to get the guys singing!

2008-10-17T17:23:00.003-04:00

If I have the opportunity. I can imagine it now....A truck full of manly firemen singing along to the Bee Gees while we work a code. That would be the most entertainment I have had in a while.

Frontal lobotomy

2008-10-16T17:45:00.000-04:00

He was 15 at the time. Sitting in his uncle’s car, waiting. He found a gun under the front seat. He thought it was cool. He looked at it. He looked down the barrel with his finger on the trigger. He gave himself a frontal lobotomy. Sometime later we heard that he lived and was doing well. In fact he was a new person. Before he had been moody and even a bit of a bully. Now he was friendly and liked most people. He will never be the same because of his brain injury, but at least he’ll be smiling.

oh my...

2008-10-15T19:22:00.004-04:00

To live with this cute face I swear I need one of these.

She is worse than this pup.

But I love her anyway.

lack of responsibility

2008-10-15T11:29:00.002-04:00

I work in a system that runs an EMT-enhanced and a Paramedic on the truck. We do not switch out on calls. The EMT-E does not run any calls in. They do not practice to their level. I am not saying that they are not an asset because they are without a doubt. I am saying that they have been given knowledge and then restricted in their ability to care for patients. This has given them no responsibility. Everything is put off on the paramedic. This feeling of no responsibility has given a few of the people I work with the feeling that they can speak to the family and say whatever they choose. They seem to forget that they make no decisions regarding patient care. I believe that this is the problem with giving people more knowledge and then restricting their exposure and decision making skills. They are exposed to the patients that we see but they do not develop any kind of assessment skill. So when I hear them saying things like "oh this person isn't really hurt." When the patient has an obvious orbit fracture or telling the parents of a kid that got hurt playing football that he can go to his doctor and is fine when I want to board and collar the kid makes the Enhanced look bad and makes us as a whole look like we don't have our act together. Plus it breeds discontent between the medics and enhanced guys when we have to correct them or contradict them. Unfortuantely it happens in front of people because they are talking to our patients or their families.

The only way I can think of to curb this is to give them the responsibility of being AIC. Make them decision makers and make their jobs depend on it like ours do. Allow them to practice at their level. If we can't do that then we don't need Enhanced providers. I can start my own IV's and give my own meds. Let them be EMT-B's and they can function as they do know minus the IV/med administration skills.

So the plot thickens

2008-10-13T18:34:00.002-04:00

I went to check my seizure patient's chart and surprisingly his tox screen was completely clean. His other labs were relatively normal considering his condition. The only other finding was his troponin that was elevated slightly. Urine was clear, cbc was clear. I didn't see his head CT results but they admitted him to ICU for status epilepticus. So no drugs. Maybe he had seized so long that it was messing with his hypothalmus and thats why he was hyperthermic. They did cultures. So we'll see. I will try to get ahold of the CT tomorrow night.

It boggles the mind

2008-10-13T09:55:00.002-04:00

That after 20+ years in the fire service you have to be retaught how to work the blinky lights on the medic.Everytime you get in the truck. Luckily I had nothing taxing.

Guess that problem

2008-10-12T16:03:00.002-04:00

Friday night I head out to our regional jail for a pt actively seizing. Upon arrival pt is truly having a seizure. Full body tonic clonic. He is hot, extremely diaphoretic, pupils non reactive but equal in size. RR is around 30. HR is 184. Pt has been seizing non stop for 45 minutes prior to the call for EMS. He has had no meds other than his normal seizure meds this evening. He is a known seizure patient, that has been in status before and had to be intubated x2. He has never been like this. In the truck pt was given 10mg of valium with no effect. (he actually got 5 then 5 more)pt had an episode of vtach lasting approx a minute. He converted on his own before I could do anything about it. Was never able to obtain a BP. lungs were clear and accucheck was in the 300's. Upon arrival to the ED pt core temp was 106.2 degrees. He went into Vtach again and it lasted long enough for them to cardiovert him out of vtach and into the same narrow complex tach he was in originally. hr never dropped past 160 no matter what they did.

I wasn't able to get back to the ED that night to check on him so tonight I will have them pull up his chart. My thinking was that he ingested something. Cocaine,meth or X. This made him sick which exacerbated his seizure condition. He just didn't sit right as your standard hard to break seizure pt.

So my question to you is what is your theory? Feel free to leave it in the comments section. I want some other opinions on this.

test anxiety

2008-10-11T18:03:00.002-04:00

Today I proctored at the Registry exam. It was my first time on the other side of the table on test day. It brought back memories of my registry day and how nervous I was. I can say I was relieved that it wasn't me but it was funny to watch the kiddos testing. Here are some things I learned while people came through my station.

O2 is not a necessity in the airway station. No matter how many hints I give you, dont' put them on O2.

BSI? We don't need no stinking BSI. I want grandma's lung juice on me.

You don't have to deflate the pharyngeal cuff on the combi-tube before you put it in. Just forcibly insert that bad boy. No worries.

Air in the belly? No problem just deflate the cuff and pull back a little and listen again. Just keep bagging maybe it will work eventually.

Funny? Most definately. Sad? With out a doubt. I'm not a big fan of the registry and the way people are moved through without any critical thinking. But this was ridiculous. It was like they couldn't even memorize the sheets. Some how the airway station next to me passed everyone. I failed about 90%. Everyone looked mad at me because they had to stay and retest students. oh well. Not my problem. Some other funny stuff happened too.

The proctor next to me acted like I was a moron cause the bulb in my laryngescope handle was dim and I wanted a new one. You couldn't see anything in the dummy head. She snorted and rolled her eyes making a smart comment about regarding what I would do in the field. I politely informed her that in the field I would use a flash light if I had to but that really isn't an option during testing. Then we had to have the obligatory converstaion about where each of us work. (I hate that one)She of course runs in the local big city that is all volunteer who think they are the best thing since sliced bread and look down on everyone.I work in the small urban city where it is adapt and over come allthe time and we have a reputation for being aggressive. She left me alone after I told her where I worked. Whats with EMS snobs? I don't care where you work as long as you can do your job and leave me alone.

My friend Dwight got hit on by one of the testers. She wouldn't leave him alone, lurking about in the hallway to talk to with him and boldly giving him her hotel and room number in front of everyone. What can I say? He's a rock star. I'm surpised she didn't throw her panties at him.

I met a girl who dated my exhusband right after we seperated. It was funny because she walked right up to me and started talking to me like we were best friends. She didn't know I knew so when I asked her about it she freaked, wouldn't look at me and escaped as quickly as possible. It was great on 2 fronts. 1. Because I don't really care that she dated him, but she thought it did and she had nerve talking to me like we knew each other and were friends. 2. I am way cuter and it made me laugh that he gave me up for her.

What a day. and after last night it's no wonder I came home and fell into a coma.

Sweet people = bad things part 2

2008-10-09T21:01:00.003-04:00

Back in May I wrote a post about a patient in their 40's who had a head bleed in sweet people=bad things. I wasn't sue if I would ever see them again then a couple of weeks ago a nurse int he ED came up to me and said ne of his patients wanted to see me. Evidently they had seen me walk by their room and recognized me. It was my patient from May. They are doing out patient rehab, and they still have residual dificit but their attitude was just as good, they are being well taken care of and up and walking on their own with a cane. They were very happy to see me and couldn't stop saying thank you for taking care of them. It made my week. More often than not we never get updates on our most intriguing patients and to get a sincere thank you is even rarer. I felt like we actually made a difference that night. I'm glad they are doing so well.

language barriers

2008-10-08T11:13:00.004-04:00

In the last week I have had patients that spoke no english and only spanish and a mother who is deaf and was so upset I couldn't get her to focus so she could read my lips. The longer I do this the more I think that we should be making our new medics take medical spanish and medical sign. Then atleast we would be able to communicate with our more challenging patients. Spanish is the second biggest language in this country. And sign just makes sense. In this area we have more than one school for the deaf. Language barriers can impede our patient care and cause us to miss something that may be important. To make us more well rounded and effective providers bridging this gap is very important. For us and our patients.

note to the drunks

2008-10-05T00:25:00.001-04:00

A huge pet peeve of mine is a drunk guy who says he's a vet when he's probably not. If you are going to claim vet status then you must pick a war in which you are actually old enough to have participated in. If you were born in 1965 you weren't in Vietnam. Don't shame veterns everywhere by claiming to have done what they have. It does them a disservice when you are drunk and acting like a fool. Feel free to say things like "rambo aint got shit on me!" and "I'm a trained killer, I could kill you with my bare hands and no one would know!" because that gives us entertainment for the rest of the night.

itchy

2008-10-04T20:26:00.000-04:00

Early in the morning. A small old man sits on a chair telling me about his itchy painful rash that sounds suspiciously like shingles. He seems to have dementia and is paranoid. But he is a sweet old guy. It takes me an hour to talk him out of the house. He chatters with me all the to the er. When we are getting him into the bed he looks at me seriously and asks "dear do you think I have the seven year itch?" what do you say to that? I said probably not but he should ask the doctor when he comes in.

MD trooper 2 crashes

2008-09-28T19:36:00.004-04:00

Last night, early this morning Maryland State Police lost one of their helos,trooper 2. It went down with the pilot Stephen J. Bunker, flight medic Mickey C. Lippey , EMT Tonya Mallard from Waldorf station 12 and 2 victims of an MVA. The only survivor was one of the MVA victims. This is a tragic loss for the flight community and for the EMS community in general. Please take a moment to say a word or a prayer for our fallen and their families.

hit a nerve

2008-09-26T10:22:00.002-04:00

In my last post I had to rant about the pulse ox. I am tired of people giving me a pulse rate off the pulse ox. I had a comment from one of my readers who is a new intermediate that struck a nerve. I am going to break it down so my position on this is easily understood. I believe this goes back to our education as providers. We are educated not only in the classroom but by the providers who trained us in the field.

"A valuable tool for us field medics, however, it is over used...there are lots of reasons why the pulse ox could be inaccurate."

He is correct. There are many reasons why your pulse ox can be inaccurate. I will not name them all. A valuable tool for us field medics? That I am not too sure about. More often than not a pulse ox is slapped on someone for a short amount of time to get a "quick pulse ox". I am guilty myself of this when I know the ED is going to ask me for a pulse ox reading on the radio. Really what this device is for is trending. How are your patients sats doing over time and what are they doing when you obtain them. (sleeping,talking,moving around, ect)It is not an absolute diagnostic tool. The pulse ox doesn't get covered enough in the classroom,then students and young providers make it into the field and see medics using it improperly. This teaches them the wrong way to use this device and can make them lazy. Just because the pulse ox says 99% doesn't mean their lungs are clear. You actually have to listen.

"But I think you may be more upset about the fact that the person is giving you a pulse rate off of the pulse ox probe and not counting a manual pulse (or at least put them on the monitor)."

See now a serious nerve has been struck. Yes I was mad about them giving me pulse rates off the pulse ox. That is inappropriate and lazy. But for a new intermediate to say to me "or at least put them on the monitor." says that he has been taught incorrectly by his FTO's. That is a bad habit to get into and a mark of laziness if witnessed by other medics. We have all heard the stories of the medic who thought their patient was alive only to arrive in the ED with a patient in PEA. Urban legends or horror stories are here to teach us a lesson. This one is to not be lazy and acutally assess your patient. These stories are like warning labels. Usually one idiot has done it now we all have to read the label.

A full set of vitals to me is manual BP, pulse, respiratory rate and lung sounds. Yes I consider lung sounds a vital sign. Does it say in there anywhere about puting the pulse ox on the patient or the monitor to obtain a pulse? NO. Why is that you ask? Because those are machines. They can be wrong. Our biggest assessment tool is ourselves. If you have to trust the machines than it is time to relearn your basic skills.

When you go from basic to ALS in class, your head is full of all these advanced procedures. In the field you want to try out all this nifty new knowledge. An FTO should be directing the student or new medic in the way it should be done. Trusting yourself is a big deal. There are times when what you hear,see, feel and smell are going to do more for you and your patient than the monitor or pusle ox. If you use your senses and learn to trust yourself you will begin to develope the inner voice or gut instinct that save many a medic and their patients trouble.

So what have we learned? BLS before ALS, holds true. Trust yourself and sharpen your instinct. Your classroom education is important. Your field education is important. Don't take everything your FTO says at face value. Learn to question, ask thier reasoning. It will only make you a better provider in the end.

I'm just saying.

2008-09-22T16:00:00.002-04:00

That if I hear " the pulse ox is 97% and the pulse is 87" one more time I am going to throw that damn pulse ox out of the truck and run it over.

A good save

2008-09-21T10:12:00.000-04:00

There has been much talk of death and how we dela with it lately. It made me think of all the codes I have worked that we "got back" or didn't. What makes it easier on me to deal with it? We hear about good saves all the time. They are few and far between. My thinking on them has changed over the years.

What is a good save? We all have our own definitions. I have had one true "save" where the person had arrested and they had ROSC and went home. He was young and healthy and everything worked well that day. I have gotten to the point now, that to me a good save is if I get ROSC long enough for the family to gather around to say good-bye. Most people come to terms with death if they can say goodbye. Not just good bye to a corpse, even though that can be good as well, but good-bye to a person they believe can hear and feel them. If we can get grandma back even if it is or 24 hours and her family has time to get to her and be with her I consider that a good deed done. It helps me as well to think that maybe she didn't die alone on her kitchen floor and that maybe we helped her family to begin the process of healing just a little but sooner.

transport drones

2008-09-20T23:11:00.002-04:00

First let me add a disclaimer here. I know a few of my readers work for private services, and some do nothing but transports. I worked for one of these companies when I was in paramedic school. Please don't get my wrong. I do not believe that all transport providers behave this way or are mindless. I just happen to run into a couple yesterday that left me very angry and shaking my head.

In the area where I work we have a few private ambulance services. These companies do mainly interfacility transport,home to appointment and dialysis runs. A few of them have 911 contracts in the rural areas around here. Most of them are somewhat staffed by people who have full time jobs elsewhere. The hosiptals, fire department or they volunteer somewhere. Yesterday I had a run in with 2 providers that I am ashamed to call colleagues.

A 50 something dialysis patient from the hood. They go Monday, Wednesday and Friday to their appointments. Everyone knows them because they are a regular stop. (for transport and for us). This crew is BLS. They go to the center to take the patient home and the patient is "unresponsive" in the chair. Dialysis wants them gone. They don't want to take the pt in this condition. (good thinking)He begins to "come around" so they decide to take him. (strike one) They load him up in the truck, take his vitals and do nothing else for him. No O2, no thought of hey maybe we shouldn't take him home. The patient is not their normal self, not mentating well at all and is confused. They take the patient home and put them on the couch. (strike two)the family notices that "hey he has vomited and wet his pants and he is not acting right." so they check his sugar. It was 19. The crew from the ambulance give him oral glucose then call 911 to come pick him up! (strike three)

When I get there the transport crew is still on scene with their emergency lights blinking. I ask the guy who rode in the back with the patient how they were and I got the story. Then I made the mistake of asking why they brought him home in that condition when they were closer to the ER than his house. I got 2 blank stares and an answer of "but we are BLS."

Now the dialysis center is in the 2000 block of a the same major street where the hospital is in the 3600 block.

I know this is not the company policy. One of the guys I was working with yesterday works for the same company. I have to ask the question why?

Does it make sense to delay a patients care for that long just because you are a BLS crew?
When I was a Basic I remember thinking whoa that patient is sick. Maybe I should do what I can, even I can't do much, and then get them to someone who can help me out.

When did people begin to think that just because the trip sheet says dialysis to home, that things don't change?
Have these companies sucked the critical thinking or simple observation skills out of their employees? or is it because they don't pay well so you get providers that don't really care.

They looked baffled at why I was questioning them and their decision making ability. The look on the crews face really said "look we're just transport drones. You can't ask us to do more. That's we called you."

This has got to change. No matter what our job, transport, 911,or ED we are all tasked with caring for our patients and trying to do what is in their best inerest when they are sick. BLS or ALS it doesn't matter.

cool feedjit thing

2008-09-18T22:35:00.002-04:00

I was surfing around and found this feedjit gizmo that tracks where people are form when the read my blog. It is very cool. I kind of addicted to it because it's super nifty to see where all these people are. So far my list is pretty cool. In the States I have had readers from VA,NC,DC,NY,CA,OH,TX,GA,PA,MD,WI,RI,Mass.,CT and I think that is it so far. More suprising is that I have found international readers. The list is Tasmania,Germany,British Columbia, and other parts of Canada. I am surprised that people want to read what I have to say. For that I want to say thanks! You guys are great.

from one obscure sport

2008-09-18T22:17:00.003-04:00

To another.

So I can't play Roller Derby anymore. I had to find something else. Now I play kickball. We haven't won a game yet and tonight we scored our first run since the season began 3 weeks ago. The best part? We heckle each other and the other team! I love to heckle form the outfield. We play for the World Adult Kickball Association. WAKA for short. Of course when I saw that I had to run around yelling waka waka waka like Fozzy Bear. It's good times. This picture is from tonights double header. It is my friend Jane and I. (Yes I am wearing green argyle knee socks. affectionately known as the irish dancer socks.)

what can I say?

2008-09-16T23:45:00.003-04:00

I have been especially chatty today. I had to post this though. It made me laugh. Even though it was funny, it just shows that this isn't the safest jobby job out there.

The reporter made me laugh when he said "He was strapped into the gurney when he somehow unbuckled himself." Um somehow? Did the guy not have hands?

Compartments

2008-09-16T15:11:00.002-04:00

Sam over at On The Clock wrote a post about a code and how she is getting stronger. It's called Dead, and it is very good. She got me thinking about how we deal with the things we see everyday or very often.

I think that the providers that last are good at compartmentalizing what they see. I know that for now I am fairly good at this.

I have a place for all the death. The kind that comes too soon, the kind that's slow and the death that comes after a long lived life.

There is a place for the kiddos who aren't loved the way they should be, the lonely, neglected and abused.

I have a compartment for violence against each other and ourselves.

In my mind I even file away (most of the time) the drunken abuse, the name calling and violence that gets thrown our way when we are trying to work.

This has brought me to the realization that I enjoy living my life to the fullest. I have to have an outlet for the things I see, and sometimes I cry for all the things that don't go well when they should.

I can work a code and put away the feelings. I also make it a point to talk to the families in the quiet room when I have released their family member to the care of the ED. I do this because much of what we do is still confusing and a mystery to people. I want them to know that my crew and I worked hard to give the patient a chance even if I know there wasn't one to start with. Why? Because I would want to know that the people I trusted my family member with did all they could. I would want someone to explain procedures I didn't understand.

We cannot forget to feel. The nature of caring for people is to nurture. It is to care. If we become jaded and do not feel for our patients it is difficult to give them the care that they deserve when they are sick. We just have to put it away so that we don't dwell on the things we cannot change and we can continue to function.

Sick

2008-09-16T12:22:00.004-04:00

I've been absent from the NSR group for the last couple of weeks. I have missed you guys but haven't had much to write. Here I am late for the party, but here none the less. Hope you enjoy.

Sick has multiple meanings. Dictionary.com defines it as this:

Noun, Adjective
1. afflicted with ill health or disease; ailing.
2. affected with nausea; inclined to vomit.
3. deeply affected with some unpleasant feeling, as of sorrow, disgust, or boredom: sick at heart; to be sick of parties.
4. mentally, morally, or emotionally deranged, corrupt, or unsound: a sick mind; wild statements that made him seem sick.

For most people this is their definition. When they tell you they are sick they mean " I don't feel well." Or "I feel like I am going to throw up."

For many of us that are medical providers when we say sick we mean something completely different. If I classify you in the sick category you have met a few criteria. For me they are as follows:

1. Your ABC's are severely compromised. I have had to c-pap, intubate or bolus you.

2. You are actively making an attempt to die. Acute MI,AAA,CVA or respiratory failure.

3. I have to request help from an engine company to manage your care.

4. You're mental status changes significantly.

5. You are broken, shot, stabbed or crunched in an impressive fashion.

6. You make me think OH CRAP! after we are on the way to the ED and I have no help.

So that is how I classify a sick patient. If you're drunk and don't want to go to jail or you have had a cold for 3 days, you don't get the fancy bed with the wheels. You,my friend, sit on the bench seat because sick people get on my stretcher.

Death of a regular

2008-09-14T15:34:00.003-04:00

We all know that death is an inevitable part of life and also of our work. We all have our regulars. The frequent fliers with serious conditions, some are compliant, some are not. We develop relationships with these people whether we like it or not. We know their histories, their allergies, their families. They call us by name, joke about inviting us for dinner, or just coming to visit instead of having to call 911. Some of our regulars are rude and mean. Some of them are sweet and kind and funny. They challenge our patience and our skills. Even still we become attached,in one way or another. We lost one of our regulars a few nighs ago. I just happened to be the one to pronounce them. I will remember them as having a hard life, not always compliant but nice and funny. Some will not remember them so fondly. It becomes difficult to remember sometimes that these patients are people. They all have a story and maybe sometimes they need a little tolerance. No matter how much they try our nerves and our patience. So here's to you my frequent flier friend. Hopefully where you are now will not be as hard as it was here.

Off topic but funny

2008-09-14T15:26:00.002-04:00

So I was cruising around the internet today and I found this blog called Hello Kitty Hell. I guess this guys wife is a Hello Kitty Fanatic. He writes about his time in HKH. He is hilarious and cranky and cynical. I laughed until I was crying. You should check him out. He is on my blog list on the side bar and I made a link int he post for your surfing convience. Enjoy. I sure am.

process progress= waiting

2008-09-13T23:41:00.002-04:00

I don't talk much about it on here but I am in the hiring process to become a firefighter/paramedic. It is with the same city in which I currently work. I found a home in this department and I look forward to being able to grow with in it. I will not weigh in on this post about my feeling on the benefits/drawbacks of dual departments. really I just want to share some progress.

First comes the written exam. I did well enough.
Next comes the dreaded physical agility test. I worked out enough that I passed. (Thank you P90X!!)
I had my panel interview a couple of weeks ago. It was awkward being questioned by 3 people i have worked with and partnered with for the last 3 years. Being interviewed like they never met me. We all survived.

Now I am waiting. That is the hard part. The Fire Marshalls have to do my background check. I have to have a polygraph. But it takes what seems like forever.

Anyway. I am more than 50% through the process. So far so good. Let's just hope the Civil Service Board doesn't find a reason to tell me to pack sand.

what a long night

2008-09-11T15:56:00.002-04:00

I don't always have the same partner. When I got in yesterday at 1600 to do my 16 hour overnight I had a clueless partner. Now granted CP is a little new, I cut them some slack for that. The problem(s)? Well CP has no internal compass. Last night CP literally couldn't figure out how to circle the block. We had come in one street off the main drag and when we were leaving I told CP to go back to the main road to go back to the ED. Couldn't figure it out. Trying to get to a scene from the hospital goes a little something like this:

Me: Turn right at the next intersection.

CP: drives through the light.

Me: Ok never mind don't turn right. Turn right at this light.

CP: "What?" as we drive through the light.

Me: sigh. Never mind go the long way and when we get to the fire station pull in on the ramp to switch out.

CP: you want me to pull in on the ramp of the station?

Me: yes. Pull in on the ramp.

CP: You want me to pull in?

Do you see where this is going? All evening it was me repeating myself because CP was off in their own little world. I thought I may have to stab them in the eye at one point. They should have been studying their mapbook.

To top it all off riding in the truck with this CP is like American Idol auditions. Sure we all sing along to the radio. But this is ridiculous. CP was serious. Song not in your voice range? Thats ok. Change it so it is. And sing loudly. With lots of vibrato. Everytime CP would really get going I would reach over and change the station. Sure it's a little passive aggressive, but it's better than snarling out Simon like comments for 8 hours straight.

Roboleg

2008-09-08T20:33:00.002-04:00

I got my fancy new knee brace today. The doctor says that I have so many problems because of the instability of my knee after I tore my PCL. He says my knee doesn't really align like it should anymore. So I got this high speed fancy knee brace. I have only had it on for about 4 hours but I love it so far. I chased my friends 2 year old and walked down stairs with out pain, popping or other nastiness. He even said I can go back to playing sports.

Hello less pain and more mobility.

Hello Hanna

2008-09-06T23:31:00.002-04:00

All night long Friday I was waiting for rain and wind and the storm that was going to keep people inside. Instead it was muggy, buggy and hot. The impending storm brought me a rash of crayzees. By 5 am I just wanted to know if a girl could get a wind gust and a sprinkle!? For pete's sake. My best "emergent, I really had to get out of bed for this" moment came at 0530 when I got called because the bottom of sum doods foot was asleep. He walked with me down 5 flights of stairs got in the truck and after I took his pressure and it was good he decided to go back to bed. I get back into bed and at 7am the wind was howling and the rain was coming down sideways. And of course. My shift was over. I get home, the rain stops. We get the worst of it around 2pm today. Yawn. It was a snoozer. I lost power for about 5 hours. It was hot so I went up the street to the fire station and hung out in the A/C. At work on my day off. yippee. Stupid storm. Hope everyone else faired well.

MONEY MONEY MONEY

2008-09-02T21:44:00.005-04:00

My very good friend has been recently diagnosed with MS. As most of the people who read this blog are medical folks you have seen the effects of this disease process. In the very simplest of terms..it royally sucks. On September 28, 2008 at Redwing Park I will be walking on my friends team for the MS walk. This event is to raise money, awareness and support for MS research and treatment. It's a great cause. So go to my donation page and please make a donation. It doesn't matter how big or small. It all makes a difference. The goal is $125 bucks, but I would like to raise around $300 or more. The name of our team is Walkie Talkies. Go to my donation page,you can read a little about Navasha there and leave some monetary droppings when you are done. For this I will temporarily give up my nom de plume.

Here is the link to my page on the MS society web page.

http://main.nationalmssociety.org/site/TR/Walk/VAXWalkEvents?px=5443716&pg=personal&fr_id=9330

Thank you so very much for everything in advance.

Dawn B AKA Gertrude

Some battles are worth fighting.

2008-09-02T11:36:00.002-04:00

Here's the pt. Late forties, left side flank pain. U/A found pt on knees on floor, rocking back and forth, crying. Unable to sit still, pale, cool, diaphoretic. Pain 10/10. BP elevated, HR elevated RR elevated. Pt is unable to sit still.
HX of kidney stones and lithotripsy in 2000.

My brilliant idea, since I have been down this road myself? fluids and pain management. Not such a bad idea in my mind. I have to call for narc orders when it is not an isolated extremity injury. I call, give them the spiel and ask for some Morphine. (keep in mind the age of the patient, and the vitals) I get Dr. No real pain meds for anyone. The order I get? 2mg MS. I would probably have better luck controlling this pain if I just conked him on the head to knock him out. I'm a nice person so I give my pt the measly little dose. Did it work. Uh, nope. Are we surprised? again nope.

I get to the ED and turn over the pt, crying in the bed. I go to get the paperwork signed by the doc and say "That 2 didn't touch him. I feel bad for him because I know how much that hurts." and I get "Well that is what the ER is for." a huffy snort and a stomp away.

Then she complained about me. Maybe because she doesn't want the medics to treat their patients,or maybe because she doesn't like that I will stand up for them if I need to. So this will be a battle worth fighting for me. There is no reason for us not to manage our patients pain.

Case in point

2008-08-31T14:40:00.004-04:00

So Paracynic was talking about trendelenberg position and the harmful effects of it's use. It was a great post. Well last night I watched the ED make his case. I am going to share the facts you can pick it apart at will.

Nursing home patient. Difficulty breathing. Been that way for "20 minutes". Diminished airmovement and just all around crappy lung sounds. Low BP, tachycardia and smells like infection. As soon as you open the doors of the truck you can smell it. Her pressure's in the 70's. They decide to put her on CPAP, put in a central line. To put in the line they put her flat in trendelenberg. Then they strap on the CPAP and leave her in that position. Hello? Cardiac Function? Respiratory Effort? I am so confused can someone please explain the reasoning here? One of the docs floating around maybe be able to help me.

Her pressure didn't improve by the way until after she was more upright and had a fluid bolus. Her white count is through the roof and she finally comes off the CPAP because they ruled out failure.

Random snippets from the night before

2008-08-31T14:25:00.002-04:00

"My airbag went off and I have these red spots on my arm and they hurt really bad! Are they serious?"

~~Yes sir I think your arm may fall off at any moment.

"I feel so dizzy. Thats not normal for me. I think I know what caused it. I overdosed, the empty bottles are in my bag."

~~Good information to know. Maybe you should have shared that with the dispatcher.

"You need to come look at my husband. You just do. Are you just going to let im die? You need to come inside and check him." (called for her "breathing problems", we get there she won't tell us anything except we have to go in the house. She has a cut under her eye and there are 4 flat tires on the brand new Hummer.)

~~Do you think I am stupid? I will wait right here for the nice police officer thank you. Dude who is our supposed patient isn't even in the house. He came staggering up after we were leaving.

"Well he's been having trouble breathing for about 45 minutes or so. I noticed at shift change. I'm not sure if it was going on before that."

~~Makes me warm at heart to hear that you practice so much diligence. I can see you really care for the people who trust you.

" There was a wooden plaque on the wall and it fell off and hit her in the head. I didn't know what else to do so I called." (In our dispatch center.)

~~This is why we have dispatch problems. We hire people with the same mentality and critical thinking skills as our patients. Lovely.

Been MIA

2008-08-30T13:04:00.002-04:00

I know I have been seriously MIA lately. I am at a loss for things to write about. Holiday weekend, spent all night chasing GSW's that were either not serious,were serious and left the scene POV or did not really happen. The most entertaining thing that happened in a while was the drunk guy in lock up who kept saying to me(everytime I asked a question)"I want to infringe on my 5th amendment rights!!" I tried to tell him that may not be the best idea and he told me "You don't know" So I bid him good luck with the infringement and left him with the coppers. Hopefully tonight will bring something much more interesting.

Stay safe this weekend y'all! I promise to be back soon.

I'm so excited!!

2008-08-14T16:39:00.002-04:00

I had to write a blog post about it! Those of you who read this and know me, know that I have a bum right knee. Thanks to roller derby, a crappy pair of knee pads and a spectacular body check. I used to have military insurance, and we know how well a few of the mil docs will listen to dependents. But today I got my new insurance and I made an appointment with a sports medicine doc who treats our local hockey team, baseball and soccer teams. He likes knees. Hopefully my knee likes him. Its been a bad week for the knee and it has delayed my progress in the working out arena. I have to get ready for the fire academy just in case I make the cut. So I am very excited. Now I am off to get more ice for the gimp leg.

You were assaulted by what?

2008-08-13T13:28:00.002-04:00

Drunk guy sitting on the ground in cuffs. He has two tiny ouchies. I say to the fine gentleman. "What did you get hit with?" He looks at me and says " A cop." I said "Someone hit you with a cop?" He looks at the police officer next to him and says "He assualted me with his mustache!"

Little did you know that the new police weapon of choice is the mustache. I'm not sure how it works. The officer was unable to elaborate on how his new mustache take down tool works. Maybe it's top secret and still in testing.

That only works in the movies.

2008-08-10T13:47:00.002-04:00

Here we go again folks. Yep it's NSR time. Hope you enjoy it!

When stopped by the police and you want to get away, jumping off the overpass to the ground below is not the way to go. It looks very cool in the movies and the bad guy gets away. In reality you end up with two broken femurs, and a broken pelvis. After you relearn to walk you won’t be faster for the next time, I promise.

I know this one is short. Anybody else have moments where you want to say to people "that only works in the movies."?

Asthma

2008-08-03T11:46:00.003-04:00

This is my contribution to this weeks Normal Sinus Rhythm Our theme this week is kids, hop on over there and check out what everyone has to say.

The engine officer meets me outside the school stating he needs a refusal form for dad to sign. I walk into the nurse’s office to see a small girl in a chair. She is crying. She is in the classic tripod position working hard to breath. Little accessory muscles at work. Before I even talk to dad I put the stethascope to her back and hear nothing but wheezes and rhonchi, everywhere. She has been sick for a couple days with a cold the nurse says to me. Her little “puffer” didn’t help and she doesn’t get all of her meds at home. She needs to go with me now and have at least one albuterol/atrovent combo. Dad doesn’t want her to go. He states he will go home and put her on the neb w/ O2 and then take her to the doctor. We argue back and forth, he absolutely refuses. I tell him the cold air outside will make it worse, she needs treatment now and I can give that to her. He doesn’t want her going with me at all. He is going to just leave with her. I make him sign the paperwork emphasizing again the critical nature of his child. He seems to shut me out. I got sent out on another run immediately. On the way to the ED with that patient, another medic gets tapped out to a very familiar address. It is the address I just wrote on the refusal form. I call the medic and give him a heads up that the child is going to be worse because I just saw them. This time PD responds to keep the parents out of the way. Engine company gets on-scene first. She has respiratory arrested. She didn’t even make it to the neb. They were able to turn her around by bagging in treatments and she regained her respiratory effort and had a very weak cry when she rolled in the ED doors. She is ten years old.

A few months later I went to court over that little girl because social services brought charges against the parents. I never had to testify because they struck a deal. When the lawyer stood up he stated that his client would have let his child go with me but he did not understand the gravity of the situation and did not understand the paper he was signing. I was floored and angry all over again.

Would I have handled things differently if I could go back? I am not sure. Dad at the time seemed as if he understood and was going to follow through. He just didn’t want to hear me talking anymore. It’s a delicate balance when dealing with parents and I am not sure if having PD involved at that moment would have been better or not.

true friends

2008-07-31T18:58:00.002-04:00

When I was working at the trauma center we had a young Naval officer come in from a motorcycle accident. He was hit by a woman on an off ramp. He went over her hood and the way he came down he had a C-1 fracture. He was completely paralyzed and vent dependent through his trach. He was mentally intact and would respond to yes and no questions with blinks. He was essentially a pair of eyes and a brain. He spent a good deal of time in ICU post accident and his buddies would faithfully come in and see him. We found it funny that they would always close the curtain when they came in. One day we found out why. They were bringing in a portable DVD player and letting him watch porn! It was what their contribution to his mental health and a symbol of their friendship with him. He ended up with a systemic infection and dying, but for those few days his buddies showed they were true friends by risking the ire of the staff to do something good for him. It was a simple lesson we all learned. Friendship knows no bounds and should prevail through anything. And well that guys like porn no matter what state they are in.

I help those who help themselves.

2008-07-29T07:49:00.003-04:00

I know what the title is supposed to say but I thought it was a fitting sentiment for the way I feel about rookies.

We were all new once. A little unsure of our suroundings, what we were doing and seeing somethings for the very first time. Really to succeed we had to want to help ourselves. Our preceptors or mentors would guide us and show us things. They would not do everything for us nor would they give us minuit direction at every turn. Now it seems to have become the opposite. The new guys don't have any motivation. They expect it all to come to them. They are expecting to be given direction for the littlest things. When called out on it they get upset saying we are picking on them.

Here it is from my view. If you don't want to help yourself I am going to find it hard to want to help you. If I try to give you suggestions and you get an attitude or whine and say I am picking on you then I am not going to want to try anymore. I don't need excuses like " I'm new" and "It was my first (insert call here)". If you don't tell me that you have never done something or need help with something and tell me you "got it". I am going to be pretty angry when the crap hits the fan and you stand there picking your nose because you don't got it. I am also not going to know I need to help you through it. Because YOU DIDN"T TELL ME. Contrary to popular belief I and all the other preceptors I know are not mind readers. You've been here more than 6 months. You were a vollie somewhere else. Stop blaming everyone and get it done. I will help you if you chose to help yourself.

scared doctors and routine transports

2008-07-21T20:20:00.002-04:00

Rogue Medic talks about defensive medicine. At the ED where I transport mostly, we have a slew of doctors that are scared of everything. They are mired down in "what ifs" instead of looking at things realistically regarding their patients, they float around in a fantasy world where everything goes horribly wrong. I know Murphy can get us all sometimes but if we lived in fear everyday we wouldn't get anything accomplished. Let me tell you a little story.

I was in the ED changing a drug box after bringing in a patient. Our city gets tapped out for an "emergency" transport to the big ED from our local ED. I am already there so I pick up the run from the other medic. I walk to the doctors station and ask the doc about the patient. He says the pt has a subarachnoid bleed. No previous hx except for 2 days worth of a headache. I ask what I think may be reasonable questions since I have not yet layed eyes on the patient. " Is the patient intubated? and Are they running any drips?" He looks at me and snorts. He says "No they are perfectly stable." Ok.

Background lesson: I work in a smaller urban city. During the day from 8am-8pm we have 5 ambulances to cover the city. From 8pm on we have 4. We do truly emergent transports for the ED because the transport services have anywhere from 15 minutes-4 hour wait times. Of course this was at the evening shift change. Now back to the story.

I say to this fine example of emergency physician. "Did you call transport?" He says "Something might happen to the patient on the way." Me: "you know they have paramedics" He says to me "I don't feel like waiting." I tried the but we only have 4 ambulances at night route but he hit my sore spot with "Well good that just means you'll be bringing me less patients while you're on the transport." (He's lucky I didn't stab him in the eye for that. The urge was there)

I called my supervisor. He called transport. It would be a 45 minute wait. No dice he's not biting. So I drive my completely neurologically intact, hemodynamically stable patient, who currently has no complaint and isn't even on O2 to the ED in the next city.

What if something happens to the patient? Well what if something happens to them in the ED before they get transfered? What if we get hit by a bus? What if aliens come down and abduct the doctor before his lunch break? I mean come on. There is a certain amount of risk taken with any type of transport but we should be realistic. A stable patient showing no signs of decline and who has been sitting in the ED all day could probably wait a few more minutes. If we allow fear to paralyze our thought process and become the focus of how we treat patients we will not be able to perform to the best of our abilities. Our patients will suffer.

Recognition

2008-07-20T09:01:00.001-04:00

This is my contribution to this weeks NSR.

The medics brought her in. She was in arrest. The trauma was so bad to her face she was barely recognizable. Something about her seemed familiar to me. A whisper of recognition. Where do I know that scar from? The mole on her arm and way she wears her wrist watch? I hear a first name. A name I know. They don’t know her last name. But I do. I helped teach her ALS class. She dated a friend of mine months ago. What is she doing in the trauma room? Why am I doing compressions on this girl? She is young, late twenties early thirties max. There is nothing we can do for her. The bullet did its job and she accomplished her goal. Now she’s mine. Imprinted on my memory like a silent movie. I recognize her, I remember her as lively and funny. Unfortunately she couldn’t recognize the same in herself.