Sometimes I can't believe I made it this far!
Accomplishments during my past (very busy) few weeks - finishing cardiology with a above-average grade, registering for my National Registry exam on 7/10/10, and finishing more rotations. I also finally wrote a paper on hypothermia therapy use in the field that ended up being nearly as long as my college thesis.
This week I start rotations on medic units, first as a "team member" and not long after as a "team leader". It's so great to me that I'm trusted enough now to be set free to practice on a medic unit!
I did my ICU rotation last week and was surprised to find that I really liked it. It was a whole new challenge and completely different area of medicine. I'm not sure I could be an ICU nurse or provider, because I really enjoy variety and constant change.
Then on Friday I had an ER rotation with a bunch of interesting patients. We had one with a Potassium level of 8 that we were able to get down to 6 before she was admitted to the ICU. There was a 21 yom who jumped off a big bridge in town - about a 75 foot fall - and managed to survive. He was in major shock when he got to the ER with a pressure of 90/43 and a heart rate of 140. I got to see a woman get cardioverted out of a ventricular tachycardia with pulses into a junctional rhythm. For about 4 seconds she was asystolic, and I was starting to worry. The cardiologist, however, seemed very unconcerned. I guess he's used to that sort of thing.
More posts to come as I start medic rotations and finish out the class!
Sunday, May 16, 2010
Thursday, April 22, 2010
Getting Better
I nailed EKG interpretation in lab last night. The instructor ended up telling me what strips to find in the giant pile so he could then show them to the rest of the group and have them interpret. He congratulated me on knowing my rhythms but told me not to get too comfortable, because they never look textbook in real life.
The preparation for the CPAT is getting a little better too. I've been at it 3 days now and am getting ready to meet Shane, my trainer, for our session in half an hour. I've lost 8 pounds in 3 days! I wanted to do a weigh-in in front of Shane later today, but I just finished my lunch and don't think it would be accurate. He plans on doing an official weigh-in on Monday.
I'm getting a little better at the exercises, I think. It's a lot of arm work and strength training. My heart rate routinely climbs to 180 bpm. He showed me on one machine how I can burn 110 calories in 10 minutes. Downside - it's at a 21 incline (!!!) at 3 mph. It's actually a series of slightly higher inclines up to 21. 21 is almost straight up and I really thought I was going to fall off the back.
I feel full - maybe I ate too much lunch, even though I skipped the salad and only ate half the chicken salad. I didn't eat snack today because breakfast came late, so I ate almonds and peanut butter with lunch. Tomorrow I'm going to try to stick with the exact plan.
I must leave in 15 minutes...after the workout, I only have about an hour to come home, change, prepare dinner, and get going to an EMT-B test site tonight. I love working test sites, but I'm pretty tired. These workouts are tough.
The preparation for the CPAT is getting a little better too. I've been at it 3 days now and am getting ready to meet Shane, my trainer, for our session in half an hour. I've lost 8 pounds in 3 days! I wanted to do a weigh-in in front of Shane later today, but I just finished my lunch and don't think it would be accurate. He plans on doing an official weigh-in on Monday.
I'm getting a little better at the exercises, I think. It's a lot of arm work and strength training. My heart rate routinely climbs to 180 bpm. He showed me on one machine how I can burn 110 calories in 10 minutes. Downside - it's at a 21 incline (!!!) at 3 mph. It's actually a series of slightly higher inclines up to 21. 21 is almost straight up and I really thought I was going to fall off the back.
I feel full - maybe I ate too much lunch, even though I skipped the salad and only ate half the chicken salad. I didn't eat snack today because breakfast came late, so I ate almonds and peanut butter with lunch. Tomorrow I'm going to try to stick with the exact plan.
I must leave in 15 minutes...after the workout, I only have about an hour to come home, change, prepare dinner, and get going to an EMT-B test site tonight. I love working test sites, but I'm pretty tired. These workouts are tough.
Wednesday, April 21, 2010
Updates
Cardiology has been going surprisingly better than I anticipated. We've had 2 quizzes (out of 4 total) in this unit, and I got an 81 on one and an 88 on the other. No complaints here. My course coordinator seemed proud. I'd like to say I'm in the home stretch, but that's not really true...I have quite a ways left to go. All of May and all of June, but the class final is June 28th. So I guess I'm closer to done than to the start.
I usually don't talk about things in fears that I'll "jinx" them, but I'm in the hire process to be a James City County firefighter/medic. It would be a great position, but it's also very competitive. It's the only medic job I've applied so thus far because they were more than happy to take my application for the position even though I haven't obtained my medic certification yet. By the time I do finish the class, the hiring process still won't be over.
I realized after I got past a hurdle last week in the hiring process that the next big thing was the CPAT - Candidate Physical Ability Test. It's a series of very difficult obstacles designed to test your ability to be a firefighter, basically. I found a trainer at my gym that specializes in training public service professionals, and I feel like I might have a chance working with him. He has me on a rigorous plan, and I'm sore. All over. My food is very strictly regulated...I need to go walk for an hour, and then I get an apple, some almonds, and one serving of organic peanut butter. Lunch is chicken salad, a big green salad, and wheat toast with coconut oil and raw honey.
Labs in class tonight - transcutanous pacing and cardioversion. As one of my instructors says, "make 'em ride the lightening!"
I usually don't talk about things in fears that I'll "jinx" them, but I'm in the hire process to be a James City County firefighter/medic. It would be a great position, but it's also very competitive. It's the only medic job I've applied so thus far because they were more than happy to take my application for the position even though I haven't obtained my medic certification yet. By the time I do finish the class, the hiring process still won't be over.
I realized after I got past a hurdle last week in the hiring process that the next big thing was the CPAT - Candidate Physical Ability Test. It's a series of very difficult obstacles designed to test your ability to be a firefighter, basically. I found a trainer at my gym that specializes in training public service professionals, and I feel like I might have a chance working with him. He has me on a rigorous plan, and I'm sore. All over. My food is very strictly regulated...I need to go walk for an hour, and then I get an apple, some almonds, and one serving of organic peanut butter. Lunch is chicken salad, a big green salad, and wheat toast with coconut oil and raw honey.
Labs in class tonight - transcutanous pacing and cardioversion. As one of my instructors says, "make 'em ride the lightening!"
Friday, April 9, 2010
Advocate
I was down in my rural EMS agency for 24 hours riding with their career paramedics yesterday. One of the career medics is also a lab instructor in my class, so I really enjoy the benefit of spending time on a unit with him.
We had one call from a nursing home for a man who had vomited 3 times 5 hours earlier in the day. No n/v/d on our arrival. We ran some fluid and took him in. He was pretty tachy, but I think he was just nervous for the ride.
Our second big call came out in the early evening for a teenager involved in a car-hit-tree accident. It was the first time I've seen real, full windshield, starring. The patient was originally entrapped, but sitting straight up when we got there. We packaged her very quickly and got on our way down south to a major Level I trauma center. She seemed pretty stable with A,B,C's intact - the two very concerning things were repetitive questioning and loss of memory and also an obviously broken and dislocated jaw. There was blood pooling out of her ear, something else I had never seen. The medic and I got things done well and very quickly in the back.
The most rewarding part of that call was when she could remember her Aunt's phone number (she couldn't remember her Mom's). I called and talked to both Aunt and then Mother on the phone while reassuring her the entire time. I felt like I was really doing something for this family in their time of need. The first question the mother asked me through repetitive sobbing was "Can my daughter breathe?" I assured her yes. When we were rolling her into the ER and then into the Trauma/Resuscitation Bay, I asked her if there was anything I could do for her. She said "Please just stay with me." I took her hand and didn't let go until the trauma docs forced my partner and I out of the room so they could do their jobs.
Nothing we did for that girl medically compared to the little comfort we were able to provide her and the conversation I had with her family members. It felt like I really did some good for a distressed patient.
I've been in and out of clinicals lately. I've seen some interesting things - a teenage burn patient, a no-PMH woman that was going into recurrent v-tach and felt "dizzy", a rapid A-Fib at a rate of over 200 (I initially misidentified it as SVT...always more to learn!), and a teenage knee dislocation. Lots more standard things too.
We took our fourth unit test on Wednesday, and I got a 94%. There are only six unit tests in class, plus the exams for ACLS, PALS, and ITLS and the final. We have 8 hours of cardiology lecture tomorrow.
We had one call from a nursing home for a man who had vomited 3 times 5 hours earlier in the day. No n/v/d on our arrival. We ran some fluid and took him in. He was pretty tachy, but I think he was just nervous for the ride.
Our second big call came out in the early evening for a teenager involved in a car-hit-tree accident. It was the first time I've seen real, full windshield, starring. The patient was originally entrapped, but sitting straight up when we got there. We packaged her very quickly and got on our way down south to a major Level I trauma center. She seemed pretty stable with A,B,C's intact - the two very concerning things were repetitive questioning and loss of memory and also an obviously broken and dislocated jaw. There was blood pooling out of her ear, something else I had never seen. The medic and I got things done well and very quickly in the back.
The most rewarding part of that call was when she could remember her Aunt's phone number (she couldn't remember her Mom's). I called and talked to both Aunt and then Mother on the phone while reassuring her the entire time. I felt like I was really doing something for this family in their time of need. The first question the mother asked me through repetitive sobbing was "Can my daughter breathe?" I assured her yes. When we were rolling her into the ER and then into the Trauma/Resuscitation Bay, I asked her if there was anything I could do for her. She said "Please just stay with me." I took her hand and didn't let go until the trauma docs forced my partner and I out of the room so they could do their jobs.
Nothing we did for that girl medically compared to the little comfort we were able to provide her and the conversation I had with her family members. It felt like I really did some good for a distressed patient.
I've been in and out of clinicals lately. I've seen some interesting things - a teenage burn patient, a no-PMH woman that was going into recurrent v-tach and felt "dizzy", a rapid A-Fib at a rate of over 200 (I initially misidentified it as SVT...always more to learn!), and a teenage knee dislocation. Lots more standard things too.
We took our fourth unit test on Wednesday, and I got a 94%. There are only six unit tests in class, plus the exams for ACLS, PALS, and ITLS and the final. We have 8 hours of cardiology lecture tomorrow.
Thursday, April 1, 2010
OR / Anonymity
Today I was in the OR all day.
The morning started out badly. When my alarm went off I groaned and thought "20 more minutes of sleep won't kill me. I should still get to the hospital 15 minutes early as long as I only take 20 minutes to get ready." The bad thing about sleep-induced decisions?
To commute to the hospital where we have to do our OR rotations, I have to commute up the I-95 North corridor towards Washington, D.C. Surprise - backed up traffic for miles! I took a bunch of back routes and made it there on time. I went to get changed to OR scrubs, which didn't really do much for my 5'2 height.
I loved the OR. The routine, the focus, the control, the precision. The sheer power of the people in the Operating Room - a surgeon, an anesthesiologist, the scrub nurse, the OR nurses. The silence.
Basically the exact opposite of everything I'm used to in the ER and on the rig! I can think of exactly one sterile field - the surgical cric kit. Everything else has a mere hope of aseptic or "medically clean". The noise is constant, the control varies, and there always seems to be at least one agitated, annoyed, or irate person.
Would I trade my environment for a clean OR room? For a day or two, it might be nice. In the long run? Absolutely not!
I learned a lot today. Watched part of a T&A on a 4-year-old and a multiple dental restoration on a 2-year-old. The 4-year-old got nasotracheal intubation. That was interesting to observe. The child's EtCO2 went from 38 to 49 after Rocuronium. I want to study that a little when I get the time. That's a high number.
I then had an adult, 39-year-old, R ear Myringotomy (ear tube insertion). She got some Propofol, but didn't need to be intubated - just a nasal cannula for support. Her oxygen saturation stayed at 100% and her EtCO2 between 32 and 34 for the length of the procedure, which was maybe a total of 2 minutes. I usually tried to exit the surgical suite after everything got underway, because I was there to primarily concentrate on airway procedures. I wanted to get to the next operating suite before a new patient came in. This one though, I didn't even have time to extract myself before the entire procedure was done! The anesthesiologist told me she'd be gone within the hour.
The last procedure I was in for was a direct laryngoscopy and rigid esophogoscopy with a possible tonsillectomy. This woman in her 50's had esophageal cancer after never smoking a day in her life. I was surprised that her airway structures were so clear; I expected some kind of swelling or blockage or something. About 2 minutes after her Propofol and Succinycholine for RSI, she got a little tachy and her blood pressure went down. EtCO2 stayed steady around 35.
It was an interesting day; I really feel that I learned a lot. I'd like to return to the OR again.
___________________________________________________
On another quick subject.
Something I've noticed a lot in the ER and now the OR is the relative anonymity of patients. I'm not saying that's bad, and I don't think it makes much difference to the patients. But, come on, how often to we near healthcare staff referring to the "chest pain in room 15" or "that loud baby with a cold in 20"?? You know it happens. And in the OR, they aren't even referred to by their procedure, as that would often take too much breath to accomplish. They become "the 10:30 in OR 1." And just in case you forget the time or room or procedure, it's all written on a wall-long white board right before the entrance to the sterile area. Hey, however you keep track of everything, right?
But let's us remember that while we have our patients, they're our only responsibility. They don't have to be anonymous. They're not a set of orders or a bed...they're "Mrs. Smith" from "123 Anywhere Street", that beautiful old house on the corner. They're just not feeling well tonight and want to go to the hospital for a nice checkup. And, by the way, did you notice all the afghans on the living room couch that she made herself?
Give them their time to be the only focus and responsibility before they become a hospital statistic.
The morning started out badly. When my alarm went off I groaned and thought "20 more minutes of sleep won't kill me. I should still get to the hospital 15 minutes early as long as I only take 20 minutes to get ready." The bad thing about sleep-induced decisions?
To commute to the hospital where we have to do our OR rotations, I have to commute up the I-95 North corridor towards Washington, D.C. Surprise - backed up traffic for miles! I took a bunch of back routes and made it there on time. I went to get changed to OR scrubs, which didn't really do much for my 5'2 height.
I loved the OR. The routine, the focus, the control, the precision. The sheer power of the people in the Operating Room - a surgeon, an anesthesiologist, the scrub nurse, the OR nurses. The silence.
Basically the exact opposite of everything I'm used to in the ER and on the rig! I can think of exactly one sterile field - the surgical cric kit. Everything else has a mere hope of aseptic or "medically clean". The noise is constant, the control varies, and there always seems to be at least one agitated, annoyed, or irate person.
Would I trade my environment for a clean OR room? For a day or two, it might be nice. In the long run? Absolutely not!
I learned a lot today. Watched part of a T&A on a 4-year-old and a multiple dental restoration on a 2-year-old. The 4-year-old got nasotracheal intubation. That was interesting to observe. The child's EtCO2 went from 38 to 49 after Rocuronium. I want to study that a little when I get the time. That's a high number.
I then had an adult, 39-year-old, R ear Myringotomy (ear tube insertion). She got some Propofol, but didn't need to be intubated - just a nasal cannula for support. Her oxygen saturation stayed at 100% and her EtCO2 between 32 and 34 for the length of the procedure, which was maybe a total of 2 minutes. I usually tried to exit the surgical suite after everything got underway, because I was there to primarily concentrate on airway procedures. I wanted to get to the next operating suite before a new patient came in. This one though, I didn't even have time to extract myself before the entire procedure was done! The anesthesiologist told me she'd be gone within the hour.
The last procedure I was in for was a direct laryngoscopy and rigid esophogoscopy with a possible tonsillectomy. This woman in her 50's had esophageal cancer after never smoking a day in her life. I was surprised that her airway structures were so clear; I expected some kind of swelling or blockage or something. About 2 minutes after her Propofol and Succinycholine for RSI, she got a little tachy and her blood pressure went down. EtCO2 stayed steady around 35.
It was an interesting day; I really feel that I learned a lot. I'd like to return to the OR again.
___________________________________________________
On another quick subject.
Something I've noticed a lot in the ER and now the OR is the relative anonymity of patients. I'm not saying that's bad, and I don't think it makes much difference to the patients. But, come on, how often to we near healthcare staff referring to the "chest pain in room 15" or "that loud baby with a cold in 20"?? You know it happens. And in the OR, they aren't even referred to by their procedure, as that would often take too much breath to accomplish. They become "the 10:30 in OR 1." And just in case you forget the time or room or procedure, it's all written on a wall-long white board right before the entrance to the sterile area. Hey, however you keep track of everything, right?
But let's us remember that while we have our patients, they're our only responsibility. They don't have to be anonymous. They're not a set of orders or a bed...they're "Mrs. Smith" from "123 Anywhere Street", that beautiful old house on the corner. They're just not feeling well tonight and want to go to the hospital for a nice checkup. And, by the way, did you notice all the afghans on the living room couch that she made herself?
Give them their time to be the only focus and responsibility before they become a hospital statistic.
Wednesday, March 31, 2010
All I Have...
I'm exhausted. ER, class, OR, class, ER...no sleep. Naps in the car if I get to a shift early.
Nothing holds much interest or sparks much anymore - on the way home from class, excited to get 5 hours of sleep tonight, I ran into a ton of traffic. I merely thought "what an interesting curio" and half closed my eyes.
Getting much better at IV sticks. Pt in septic shock today; I wish I knew if he made it. He was very unstable when I left ER clinical this afternoon with a pretty low MAP and compromised circulatory system. Maybe I will ask when I go back to that ER.
Other than that, routine things. Kidney stones, chest pain, sports injuries, abdominal complaints...it all runs together.
I need sleep now.
Nothing holds much interest or sparks much anymore - on the way home from class, excited to get 5 hours of sleep tonight, I ran into a ton of traffic. I merely thought "what an interesting curio" and half closed my eyes.
Getting much better at IV sticks. Pt in septic shock today; I wish I knew if he made it. He was very unstable when I left ER clinical this afternoon with a pretty low MAP and compromised circulatory system. Maybe I will ask when I go back to that ER.
Other than that, routine things. Kidney stones, chest pain, sports injuries, abdominal complaints...it all runs together.
I need sleep now.
Thursday, March 25, 2010
Edge
I'm very on edge, and I think I can expect to feel the same way until the 10th of July.
It started on the rig a couple nights ago. I ended up without a preceptee, so I got to run my own calls with two assistants. The first call was a typical nausea/vomiting/abdominal pain...easy and quick transport. The second call, around 4am, was dispatched as an "Emergency Illness", and the dispatcher told me it was for a sciatic nerve. I didn't know anything about a sciatic nerve, but my Blackberry internet service bailed me out. I still felt bad. Rescued by technology.
In case anyone's interested, sciatica results in extreme back and lower leg pain secondary to some kind of problem with the sciatic nerve - in my patient's case, a herniated disc.
Yesterday, I had to go to a hospital about 45 minutes away to get a badge made to do rotations there. I got all the way to the hospital HR office only to realize that I left my rotation paperwork at home in a binder I hadn't brought with me. Luckily, I had an extra copy in the car. However, my homework that was due in class was also in that binder - the 150 question unit homework assignment due in less than 3 hours. I rushed to a library near class to redo the homework. I didn't have the time to study that I wanted to.
So, therefore, I didn't do as well on the quiz as I wanted to. A lot of it was respiratory physiology, which I didn't expect. I thought it would be more practical information - ETT placement, Combitube, RSI, surgical airways, BLS airway management, etc. I expected questions on lung sounds and assessment findings. I didn't expect over half the quiz to be on physiology.
The only redeeming factor was nailing all my practical stations. I haven't missed a dummy intubation yet. Still, it wasn't a great day overall.
Today I have several errands to run and some important things to take care of. I also really need to study, and I don't even know where to start. I guess respiratory physiology would be a good place! Tonight, I was suppose to hop on a unit down south again. I think I will, but only because in the morning, one of my instructors will be there for his career job. He offered to let me ride with him. It would be beneficial to stick around there for a few hours and learn some things.
But then, I really MUST study for Saturday's test.
What am I going to do when the Cardiology unit hits in 1 week??
It started on the rig a couple nights ago. I ended up without a preceptee, so I got to run my own calls with two assistants. The first call was a typical nausea/vomiting/abdominal pain...easy and quick transport. The second call, around 4am, was dispatched as an "Emergency Illness", and the dispatcher told me it was for a sciatic nerve. I didn't know anything about a sciatic nerve, but my Blackberry internet service bailed me out. I still felt bad. Rescued by technology.
In case anyone's interested, sciatica results in extreme back and lower leg pain secondary to some kind of problem with the sciatic nerve - in my patient's case, a herniated disc.
Yesterday, I had to go to a hospital about 45 minutes away to get a badge made to do rotations there. I got all the way to the hospital HR office only to realize that I left my rotation paperwork at home in a binder I hadn't brought with me. Luckily, I had an extra copy in the car. However, my homework that was due in class was also in that binder - the 150 question unit homework assignment due in less than 3 hours. I rushed to a library near class to redo the homework. I didn't have the time to study that I wanted to.
So, therefore, I didn't do as well on the quiz as I wanted to. A lot of it was respiratory physiology, which I didn't expect. I thought it would be more practical information - ETT placement, Combitube, RSI, surgical airways, BLS airway management, etc. I expected questions on lung sounds and assessment findings. I didn't expect over half the quiz to be on physiology.
The only redeeming factor was nailing all my practical stations. I haven't missed a dummy intubation yet. Still, it wasn't a great day overall.
Today I have several errands to run and some important things to take care of. I also really need to study, and I don't even know where to start. I guess respiratory physiology would be a good place! Tonight, I was suppose to hop on a unit down south again. I think I will, but only because in the morning, one of my instructors will be there for his career job. He offered to let me ride with him. It would be beneficial to stick around there for a few hours and learn some things.
But then, I really MUST study for Saturday's test.
What am I going to do when the Cardiology unit hits in 1 week??
Tuesday, March 23, 2010
Overdrive
I've been studying advanced airway management in class, so CPAP has certainly been weighing on my mind. I keep thinking about different things I want to write about it, but haven't had a real chance to sit down and think it through yet.
I've been slammed with class and the start of rotations lately. I got a 92% on the exam last weekend (couldn't believe it!), which enabled me to start my clinical rotations. We have about 300 hours to do to pass the class, and they're all divided up into different units. I spent all of Saturday in class, then 12 hours of Sunday on an ER shift, and 8 hours yesterday in the Psychiatric unit before going to 4 hours of class. Today I had "off" to study for a quiz and catch up on a little sleep. Unfortunately, I didn't end up doing much of either.
I got the pediatric IV access I needed to check off. It was on a 17 year old, but it still counts! I've administered a lot of medications in a variety of different routes. I had to give a shot (IM administration) in the behind! I felt a little bad because he didn't speak much English so I'm not sure I conveyed well how much it would hurt - Bicillin. Very thick. We had a lot of respiratory cases (I need 10 cases of adult and 4 of children), so it got repetitive but at least served a purpose. I like the routine of emergency care. Most of the time, I'm starting to be able to anticipate what treatment the patient will get.
Quiz tomorrow on advanced airway, then a test on the same on Saturday. Friday I have another 12 hour ER shift. Getting tired. I feel like I'm constantly in overdrive and can't calm down. July 10th - National Registry test day - can't get here fast enough.
On the rig tonight as AIC, but I have a preceptee. Hoping for a mostly restful night.
I've been slammed with class and the start of rotations lately. I got a 92% on the exam last weekend (couldn't believe it!), which enabled me to start my clinical rotations. We have about 300 hours to do to pass the class, and they're all divided up into different units. I spent all of Saturday in class, then 12 hours of Sunday on an ER shift, and 8 hours yesterday in the Psychiatric unit before going to 4 hours of class. Today I had "off" to study for a quiz and catch up on a little sleep. Unfortunately, I didn't end up doing much of either.
I got the pediatric IV access I needed to check off. It was on a 17 year old, but it still counts! I've administered a lot of medications in a variety of different routes. I had to give a shot (IM administration) in the behind! I felt a little bad because he didn't speak much English so I'm not sure I conveyed well how much it would hurt - Bicillin. Very thick. We had a lot of respiratory cases (I need 10 cases of adult and 4 of children), so it got repetitive but at least served a purpose. I like the routine of emergency care. Most of the time, I'm starting to be able to anticipate what treatment the patient will get.
Quiz tomorrow on advanced airway, then a test on the same on Saturday. Friday I have another 12 hour ER shift. Getting tired. I feel like I'm constantly in overdrive and can't calm down. July 10th - National Registry test day - can't get here fast enough.
On the rig tonight as AIC, but I have a preceptee. Hoping for a mostly restful night.
Monday, March 15, 2010
New Protocols!
It's been a long couple days studying for a quiz in class tonight on pharmacokinetics/dynamics and Alpha/Beta therapy. Amazingly, I got a 100% - how good it felt!
My council got some new protocols today, several of which I was very glad to see. The highlights -
Medication - dosages for Valium and Dopamine changed.
Clinical Procedures - decompression is now allowed at the EMT-Enhanced level (a certification probably unique to my state with only 80 hours more than an EMT-B has), as long as the provider has current PHTLS or ITLS certification. Naso/Orogastric tube protocol added. Impedance Threshold Device protocol added (yay!). Protocol for the EZ-IO added.
...and the big one, which I'm happiest about, is that an EMT-B or EMT-Enhanced can now use CPAP with the medical control permission. A Medic doesn't need permission.
Now I'm more even inclined to make CPAP my #2 wish. Even though it's in protocols, my agency doesn't have it and doesn't look to be getting it any time soon.
Stay tuned - next post will be on CPAP!
My council got some new protocols today, several of which I was very glad to see. The highlights -
Medication - dosages for Valium and Dopamine changed.
Clinical Procedures - decompression is now allowed at the EMT-Enhanced level (a certification probably unique to my state with only 80 hours more than an EMT-B has), as long as the provider has current PHTLS or ITLS certification. Naso/Orogastric tube protocol added. Impedance Threshold Device protocol added (yay!). Protocol for the EZ-IO added.
...and the big one, which I'm happiest about, is that an EMT-B or EMT-Enhanced can now use CPAP with the medical control permission. A Medic doesn't need permission.
Now I'm more even inclined to make CPAP my #2 wish. Even though it's in protocols, my agency doesn't have it and doesn't look to be getting it any time soon.
Stay tuned - next post will be on CPAP!
Saturday, March 13, 2010
#1: Induced Hypothermia Therapy
Yesterday, I wrote about the things that I most want to see added to anywhere where I am practicing. I really enjoyed writing the post, and it made me think a lot about the future of field practice and question if the things that I want so badly would actually be useful for patients. I believe that some of the things I listed – CPAP in particular – would be enormously beneficial for patients with relatively little side effects and reasonably priced for the benefit it would give. It definitely meets the EMS “Rules of Evidence.”
Some of the greatest EMS bloggers are doing series lately on what they think is most important in their rig, what medications they think are the most beneficial, etc. I’ve decided to focus on a series as well. Of the list I wrote yesterday, I will each day pick what I want most and work downwards to what I want, but can live without. My views aren’t necessarily reflective on what might be most useful or do the most overall good. My countdown will simply focus on what I want the most. That being said, I will give reasons as to why I believe my wants are important.
#1: Therapeutic (Induced) Hypothermia post-ROSC
First, I will provide a brief background on Hypothermia Therapy. Secondly, I will move into the use of Hypothermia in EMS. Third, I will focus on success – why is this most important to me?
Part I: Background
I have been a proponent of Hypothermia Therapy for a while. It sounds almost medieval: make someone very cold to ultimately keep them alive longer. Sounds like one of those medical myths that we end up thinking 30 years later: “Why in the world did we do that?!” However, while this therapy is fairly new to the United States, it has been successfully performed all across the world for decades. It’s success is not deniable. I have had the honor of meeting someone who went into cardiac arrest (ventricular fibrillation) with a still-unknown position at the age of 39, received prompt aeromedical hypothermia treatment en route to a major trauma center on the east coast, and woke up five days later fully alert and oriented. He is now 41 years old and a flight paramedic. Hard to argue with that.
Hypothermia Therapy is used for many different reasons – traumatic brain injury, prolonged high fever, as an adjunct to anesthesia in some surgeries, or as this entry will examine, as a neuroprotective aid after return of spontaneous circulation (ROSC) post-cardiac arrest.1 Protocols are different, and I’ll examine them more later. I will describe the therapy now using the protocol employed by Inova Fairfax Hospital in Virginia. Their indications for use include: age 18 or older, survived cardiac arrest with eight hours previous, significant alteration in neurological function (comatose but not brain dead), systolic blood pressure equal to or above 90 mmHg, and mechanical ventilation. Contraindications: irreversible neurological damage, platelet count less than 75,000 mm3, pregnancy, and terminal illness.2
Once patients meet the indications, they are pre-treated with 1 gram of magnesium in 100 mL normal saline over the course of one hour to decrease shivering (since shivering attempts to rewarm the body). The patient’s face, hands, and feet are counter-warmed, perhaps using a Bear Hugger blanket. They are administered 25-50 mg Demerol IV. Finally, they are given 2 liters of cold normal saline over 30 minutes. The goal is to cool to 33.5 degrees C as quickly as possible, preferably within two hours.
During the entire hypothermia process, patient’s vital signs and chemistries are monitored constantly. Blood pressure, heart rate, temperature, SpO2, and output are constantly assessed. Every eight hours, laboratory studies are taken– a full chemistry (K, Mg, Phosphate, ionized calcium), CBC, Coagulation, Lactate, and Troponin. Continuous sedatives, analgestics, and paralytics are administered. The patient receives no heat from the ventilator, insulin on a drip, DVT prophylaxis, GI prophylaxis, and no electrolyte replacement for eight hours before rewarming.
When it is time to rewarm, Acetaminophen is given before and every six hours after warming (to prevent overshoot). Rewarming is accomplished in incriments of 0.5 degrees C per hour up until the target of 37 degrees C (about 6 to 8 hours). At 36 degrees, paralytics are discontinued, and at 37 degrees, sedation is attempted to be removed. To prevent overshoot into rebound hyperthermia, the Arctic Sun counter-rewarming is set up for at least 24 hours.
Initiating this therapy has lead 57% of patients receiving this therapy at this hospital facility to have good neurologic outcome. According to a New England Journal of Medicine study in 2002, 55% of patients in induced hypothermia have a good neurological outcome as compared to 39% of patients without the therapy.3
This therapy comes highly recommended. The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation in conjunction with the American Heart Association Science Advisory and Coordinating Committee recommended in 2002 that “unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest.”4 ACLS guidelines hold the same criteria as a level IIA recommendation – or otherwise, highly recommended.
But what does therapeutic hypothermia do?
Primarily, it affects brain injury and reperfusion response. It is the only post-arrest therapy that has proven itself to increase survival rates post-ROSC. Brain injury is the cause of death in 68% of out-of-hospital cardiac arrest compounded by the brain’s limited tolerance of ischemia. The therapy can reduce intercranial pressure, reduce heart rate, and reduce demand in the brain for oxygen.5 All of those things can leave a patient with increased neurological function upon re-waking after their hypothermia-induced stupor – or simply put, these patients will not end up as an ICU vegetable, but have a higher chance of going home with the same neurological function as they had prior to arrest.
Part II: Hypothermia Therapy in EMS
Looking at the criteria I described above in Part I, the therapy is obviously complicated and carefully monitered. How would we as field providers be able to know if someone is pregnant? We certainly can’t perform a platelet count. How would we keep the saline regulated to an exact temperature? Counter-rewarming? The questions are endless.
But several agencies across the country have found ways to at least initiate therapy. Wake County EMS in North Carolina was a pioneer in this therapy. If their patients meet a select few criteria: ROSC not due to blunt/penetrating trauma, age 12 or older, temperature greater than 34 degrees C after ROSC, and an advanced airway in place, Hypothermia Therapy can be considered. See their algorithm below for a detailed process of how and when the therapy is initiated and maintained.6
Wake County EMS then monitors Mean Arterial Pressure (MAP) using the Lifepack 12 to keep it between 90 and 100. If MAP is not naturally between this range, Dopamine is used as a pressor.
Another progressive area, North Central Connecticut EMS Council, also utilizes the hypothermia protocol in their post-resuscitation care. Their protocols, dated June 2009, require a patient to have ROSC post-arrest not related to trauma or hemorrhage, be older than 18 years old, have no obvious gravid uterus, no signs of initial hypothermia, no purposeful response to pain, and be intubated. After meeting these criteria, they have an algorithm quite similar to Wake County’s. See below for their algorithm—7
Is this therapy used? Yes, it’s expected. It’s an ACLS algorithm in these protocols. Just as a provider would treat ventricular fibrillation or pulseless electrical activity with a certain protocol, this is an expected part of treatment for patients meeting the criteria.
In an e-mail message on March 6, 2010, I discussed this therapy with a career paramedic in one of these councils that utilizes induced hypothermia on a regular basis. He informed me that he had in fact used the therapy three times that day, but all the patients all ended up passing away in the ICU. The therapy is not foolproof, but side affects are fairly limited as compared to the potentials.
EMS worldwide, particularly in Australia, also uses induced hypothermia – although hospitals in many areas outside of the United States are quite fewer and far between than we are accustomed to here.
Part III: Why #1?
Well, as I stated, the side affects are few compared to the possible outcome. The science is proven by AHA, New England Journal of Medicine, and countless other studies and agencies.
The therapy isn’t expensive. The main proponents are cold saline and some additional medications. No fancy equipment or maintenance cost. No expensive training. And it truly changes people’s lives. To be able to be in cardiac arrest, and several days later, have the possibility of leaving the hospital with normal neurological function shows what strides in medicine that we are making.
Would it be used routinely? Depends on how many cardiac arrests your area gets. It has the potential for wide use.
The downside is that only 27% of hospitals in the United States are using this therapy now.8 Obviously, a provider cannot initiate something that the hospital can’t finish. There are no hospitals within 60 miles from my primary agency that has this therapy, so wishing for this as my number one is moot at this point. The closest center is in my state’s capital at a major trauma center.
My solution: fly out. If I had a patient meeting the major criteria, I wouldn’t hesitate to call aeromedical to fly my patient down to a hospital that does support this therapy. The therapy is not something that can be postponed to get evaluated at another hospital, then transport considered, etc. It needs to happen quickly.
My protocols state: “The use of helicopter […] may be considered in situations where the use of the helicopter would speed a patient’s arrival to a hospital capable of providing definitive care and that is felt to be significant to the patient’s condition.”9 Sounds good to me – I think I could probably get away with flying out a patient post-cardiac arrest if I feel he would benefit from and receive this therapy. I would certainly call a patient walking away with neurological function in tact “providing definitive care.”
In the words of Peter Safar – “We need to treat brains that are too good to die.”
1. Mosby’s Dictionary of Medicine, Nursing, and Health Professions, 2009, pg 924.
2. Linda Schakenbach, presentation – “Cool Therapy”, February 2010.
3. Ibid.
4. J. P Nolan et al, “Therapeutic Hypothermia After Cardiac Arrest,” Circulation 108, (2003): 108-121.
5. Nancy Diepenbrock, Quick Reference to Critical Care, (Philadelphia: Wolters Kluwer Health, 2008),191.
6. http://wakeems.com/ICE2008/index.html
7. http://www.northcentralctems.org/Online_Forms.htm
8. Linda Schakenbach, presentation – “Cool Therapy”, February 2010.
9. Rappahannock EMS Council Pre-Hospital Patient Care Protocols, 19.
Some of the greatest EMS bloggers are doing series lately on what they think is most important in their rig, what medications they think are the most beneficial, etc. I’ve decided to focus on a series as well. Of the list I wrote yesterday, I will each day pick what I want most and work downwards to what I want, but can live without. My views aren’t necessarily reflective on what might be most useful or do the most overall good. My countdown will simply focus on what I want the most. That being said, I will give reasons as to why I believe my wants are important.
#1: Therapeutic (Induced) Hypothermia post-ROSC
First, I will provide a brief background on Hypothermia Therapy. Secondly, I will move into the use of Hypothermia in EMS. Third, I will focus on success – why is this most important to me?
Part I: Background
I have been a proponent of Hypothermia Therapy for a while. It sounds almost medieval: make someone very cold to ultimately keep them alive longer. Sounds like one of those medical myths that we end up thinking 30 years later: “Why in the world did we do that?!” However, while this therapy is fairly new to the United States, it has been successfully performed all across the world for decades. It’s success is not deniable. I have had the honor of meeting someone who went into cardiac arrest (ventricular fibrillation) with a still-unknown position at the age of 39, received prompt aeromedical hypothermia treatment en route to a major trauma center on the east coast, and woke up five days later fully alert and oriented. He is now 41 years old and a flight paramedic. Hard to argue with that.
Hypothermia Therapy is used for many different reasons – traumatic brain injury, prolonged high fever, as an adjunct to anesthesia in some surgeries, or as this entry will examine, as a neuroprotective aid after return of spontaneous circulation (ROSC) post-cardiac arrest.1 Protocols are different, and I’ll examine them more later. I will describe the therapy now using the protocol employed by Inova Fairfax Hospital in Virginia. Their indications for use include: age 18 or older, survived cardiac arrest with eight hours previous, significant alteration in neurological function (comatose but not brain dead), systolic blood pressure equal to or above 90 mmHg, and mechanical ventilation. Contraindications: irreversible neurological damage, platelet count less than 75,000 mm3, pregnancy, and terminal illness.2
Once patients meet the indications, they are pre-treated with 1 gram of magnesium in 100 mL normal saline over the course of one hour to decrease shivering (since shivering attempts to rewarm the body). The patient’s face, hands, and feet are counter-warmed, perhaps using a Bear Hugger blanket. They are administered 25-50 mg Demerol IV. Finally, they are given 2 liters of cold normal saline over 30 minutes. The goal is to cool to 33.5 degrees C as quickly as possible, preferably within two hours.
During the entire hypothermia process, patient’s vital signs and chemistries are monitored constantly. Blood pressure, heart rate, temperature, SpO2, and output are constantly assessed. Every eight hours, laboratory studies are taken– a full chemistry (K, Mg, Phosphate, ionized calcium), CBC, Coagulation, Lactate, and Troponin. Continuous sedatives, analgestics, and paralytics are administered. The patient receives no heat from the ventilator, insulin on a drip, DVT prophylaxis, GI prophylaxis, and no electrolyte replacement for eight hours before rewarming.
When it is time to rewarm, Acetaminophen is given before and every six hours after warming (to prevent overshoot). Rewarming is accomplished in incriments of 0.5 degrees C per hour up until the target of 37 degrees C (about 6 to 8 hours). At 36 degrees, paralytics are discontinued, and at 37 degrees, sedation is attempted to be removed. To prevent overshoot into rebound hyperthermia, the Arctic Sun counter-rewarming is set up for at least 24 hours.
Initiating this therapy has lead 57% of patients receiving this therapy at this hospital facility to have good neurologic outcome. According to a New England Journal of Medicine study in 2002, 55% of patients in induced hypothermia have a good neurological outcome as compared to 39% of patients without the therapy.3
This therapy comes highly recommended. The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation in conjunction with the American Heart Association Science Advisory and Coordinating Committee recommended in 2002 that “unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest.”4 ACLS guidelines hold the same criteria as a level IIA recommendation – or otherwise, highly recommended.
But what does therapeutic hypothermia do?
Primarily, it affects brain injury and reperfusion response. It is the only post-arrest therapy that has proven itself to increase survival rates post-ROSC. Brain injury is the cause of death in 68% of out-of-hospital cardiac arrest compounded by the brain’s limited tolerance of ischemia. The therapy can reduce intercranial pressure, reduce heart rate, and reduce demand in the brain for oxygen.5 All of those things can leave a patient with increased neurological function upon re-waking after their hypothermia-induced stupor – or simply put, these patients will not end up as an ICU vegetable, but have a higher chance of going home with the same neurological function as they had prior to arrest.
Part II: Hypothermia Therapy in EMS
Looking at the criteria I described above in Part I, the therapy is obviously complicated and carefully monitered. How would we as field providers be able to know if someone is pregnant? We certainly can’t perform a platelet count. How would we keep the saline regulated to an exact temperature? Counter-rewarming? The questions are endless.
But several agencies across the country have found ways to at least initiate therapy. Wake County EMS in North Carolina was a pioneer in this therapy. If their patients meet a select few criteria: ROSC not due to blunt/penetrating trauma, age 12 or older, temperature greater than 34 degrees C after ROSC, and an advanced airway in place, Hypothermia Therapy can be considered. See their algorithm below for a detailed process of how and when the therapy is initiated and maintained.6
Wake County EMS then monitors Mean Arterial Pressure (MAP) using the Lifepack 12 to keep it between 90 and 100. If MAP is not naturally between this range, Dopamine is used as a pressor.
Another progressive area, North Central Connecticut EMS Council, also utilizes the hypothermia protocol in their post-resuscitation care. Their protocols, dated June 2009, require a patient to have ROSC post-arrest not related to trauma or hemorrhage, be older than 18 years old, have no obvious gravid uterus, no signs of initial hypothermia, no purposeful response to pain, and be intubated. After meeting these criteria, they have an algorithm quite similar to Wake County’s. See below for their algorithm—7
Is this therapy used? Yes, it’s expected. It’s an ACLS algorithm in these protocols. Just as a provider would treat ventricular fibrillation or pulseless electrical activity with a certain protocol, this is an expected part of treatment for patients meeting the criteria.
In an e-mail message on March 6, 2010, I discussed this therapy with a career paramedic in one of these councils that utilizes induced hypothermia on a regular basis. He informed me that he had in fact used the therapy three times that day, but all the patients all ended up passing away in the ICU. The therapy is not foolproof, but side affects are fairly limited as compared to the potentials.
EMS worldwide, particularly in Australia, also uses induced hypothermia – although hospitals in many areas outside of the United States are quite fewer and far between than we are accustomed to here.
Part III: Why #1?
Well, as I stated, the side affects are few compared to the possible outcome. The science is proven by AHA, New England Journal of Medicine, and countless other studies and agencies.
The therapy isn’t expensive. The main proponents are cold saline and some additional medications. No fancy equipment or maintenance cost. No expensive training. And it truly changes people’s lives. To be able to be in cardiac arrest, and several days later, have the possibility of leaving the hospital with normal neurological function shows what strides in medicine that we are making.
Would it be used routinely? Depends on how many cardiac arrests your area gets. It has the potential for wide use.
The downside is that only 27% of hospitals in the United States are using this therapy now.8 Obviously, a provider cannot initiate something that the hospital can’t finish. There are no hospitals within 60 miles from my primary agency that has this therapy, so wishing for this as my number one is moot at this point. The closest center is in my state’s capital at a major trauma center.
My solution: fly out. If I had a patient meeting the major criteria, I wouldn’t hesitate to call aeromedical to fly my patient down to a hospital that does support this therapy. The therapy is not something that can be postponed to get evaluated at another hospital, then transport considered, etc. It needs to happen quickly.
My protocols state: “The use of helicopter […] may be considered in situations where the use of the helicopter would speed a patient’s arrival to a hospital capable of providing definitive care and that is felt to be significant to the patient’s condition.”9 Sounds good to me – I think I could probably get away with flying out a patient post-cardiac arrest if I feel he would benefit from and receive this therapy. I would certainly call a patient walking away with neurological function in tact “providing definitive care.”
In the words of Peter Safar – “We need to treat brains that are too good to die.”
1. Mosby’s Dictionary of Medicine, Nursing, and Health Professions, 2009, pg 924.
2. Linda Schakenbach, presentation – “Cool Therapy”, February 2010.
3. Ibid.
4. J. P Nolan et al, “Therapeutic Hypothermia After Cardiac Arrest,” Circulation 108, (2003): 108-121.
5. Nancy Diepenbrock, Quick Reference to Critical Care, (Philadelphia: Wolters Kluwer Health, 2008),191.
6. http://wakeems.com/ICE2008/index.html
7. http://www.northcentralctems.org/Online_Forms.htm
8. Linda Schakenbach, presentation – “Cool Therapy”, February 2010.
9. Rappahannock EMS Council Pre-Hospital Patient Care Protocols, 19.
Friday, March 12, 2010
Christmas in March!
Last night, I spent one of my first evenings at the new rescue station I joined. It's about 25 miles south of where I live in a rural county. Someone once told me that to fly, I should have a lot of different kinds of EMS experience, including rural response.
When I got to the station, I asked the AIC (a good friend of mine) if he could show me around the rig and how everything operates. The more I saw, the more excited I got. This agency has a lot of the things that I think makes EMS a true medical operation: CPAP, Sam Splints, Broselow Bags, continuous capnography as a vital sign, several IO's, 12 leads with wireless transmission capability, an autopulse, and electronic PPCR's. The agency also has access to several Primary Stroke Centers and a Level I Trauma and Burn Center. There are also career paramedics somewhere in the county at all times. Truly cutting-edge technology and uses of resources. I got more and more excited the more I saw. It felt like Christmas with tons of new toys to play with!
I've been thinking a lot lately about all the new things coming out in EMS. Every convention and conference I go to there's always tables and tables of shiny new things. It's overwhelming and commercial. But, if you know how and where to look, some of those pretty things will really make a difference to EMS. There's several material things and protocols that I wish I could have (or that I wish I could have when I'm an ALS provider here in a few months):
CPAP
12 Lead EKG with Wireless Transmission
Coordinated Pediatric Bag (like a Broselow)
Capnography Monitoring as an ALS vital sign
Autopulse - Automatic CPR Compressions
Chest Seals
Thermometers
Infusion Pumps (yeah, right - but I wish!)
ResQPOD (Impedance Threshold Device and an AHA IIA recommendation)
Field Cath Lab Activation
RSI
Some kind of Induced Hypothermia Protocol
I believe, with proper training, that everything on that list could make a real difference in patient care. With 12 Leads and cath lab activation from the field, we could save the patient up to 45 minutes of ER time. Capnography monitoring can truly alert to patient changes and status. For more on this, please see one of the field experts - 10 Things Every Paramedic Should Know About Capnography. There are few sources that explain it better and simpler.
Autopulse, ResQPOD, and Induced Hypothermia go together a little bit. In EMS, we make great "saves" every day, but I am occasionally hesitant on playing God. If we bring someone back, I'm disheartened to think that they will most likely never get out of the hospital. Even if they do make it out of the hospital, will they ever recover from the save that we performed?
In most situations, of course, we are ethically bound to at least work a cardiac arrest to the best of our ability. And I say, if we're going to do it, we might as well do it right. SCA - Sudden Cardiac Arrest - is the leading cause of death in the US and Canada with most patients at least initially in Ventricular Fibrillation.* Good, deep, strong, and probably most importantly, continuous, CPR provides the best chance for survival. AHA Guidelines note that we should be compressing 100 times a minute to get optimal forward blood flow. Human observational studies show that interruptions of chest compressions are common - far too common - and NO compressions were provided for 24-49% of time in cardiac arrest. Obviously, naturally, studies have consequently shown that prolonged interruptions in compressions reduced the likelihood of ROSC (return of spontaneous circulation).** In short, AHA recommends interruptions only when absolutely needed - pulse checking, analyzing rhythm, defibrillation. Compressions should not be interrupted for gaining vascular access, intubation, medication administration, etc.
Autopulse is very new technology, and I'm sure there is research both for and against it (does anyone know if they're making bariatric autopulses yet?). However, in my opinion, at the very least it provides continuous deep compressions. The machine doesn't get tired. It doesn't stop to try to do something else. It even beeps and tells you when to provide ventilation. ResQPOD is a threshold device and prevents unneeded air in the abdomen. This is an AHA IIA recommendation, and it also flashes when it's time to ventilate. No need to make our patients alkalotic, folks. If they're at the point of needing a ResQPOD, they have enough problems to begin with!
Induced Hypothermia. See old posts for some of my prior discussion on this, and await a case study that's in progress. I am a huge, huge supporter of this therapy. I believe it saves lives and prevents long-lasting neurological deficit. My protocols are JUST loose enough for me to have the ability to fly out a patient if I feel it's needed. My local hospital facilities don't have hypothermia protocol. I've spent time learning the protocol of our local flight companies, and if the event ever prevents itself, I'll fly someone immediately if it meets their criteria. I wish we had some kind of protocol here to get the process started, even if it was only through cold packs or very mild cold saline. But when the hospital doesn't even have the therapy, why should we? Time to call that helicopter.
Chest seals and thermometers - would be nice. Not necessary, but a chest seal will operate better than a regular occlusive dressing any day, and it'd be nice to tell the hospital or a patient's family what their temperature is. Same with a Broselow Bag. I could calculate my own dosages and size my own ET tubes, but it would be so much easier, quicker, and less stressful to simply have a nice color-coded bag.
Infusion pumps - I've never seen even a little one less than several thousand dollars. The Dial-A-Flows have decreased my all encompassing desire for a pump prehospitally, but I'm still a little wary. One drop off of an infusion can be a 10-15% error in medication, and who wants to take that risk? Dopamine, Amiodirone, Lidocaine - all drugs I wouldn't want to miscalculate. I don't know one assistant that I believe would sit there and count drops in the middle of the night on the way to the hospital. A pump would be very beneficial.
Airway, airway, airway. Isn't that what's pounded in all of our heads starting with basic first aid and continuing all the way up to EMT-P? If we should concentrate most on the airway and breathing, we need the tools to do so. CPAP. RSI. Capnography. CPAP is something that's more and more common, and I'm surprised it hasn't made it's way to this area as prominently yet. First of all, CPAP reduces the need for RSI to begin with. There are very few complications or side effects, with the most common being anxiety due to the mask. It saves patients in severe respiratory distress from being intubated, or it at least holds the intubation off. It decreases the need for the sometimes dangerous and far too-oft misgiven pre-hospital drug - Lasix. You can hook up a nebulizer treatment. The machine is small. Why isn't every agency using this?! For a good article on pre-hospital CPAP, see: Prehospital Use of CPAP.
RSI is something a little more serious, and I think there would need to be significant, individualistic training to make this an option pre-hospitally. For those who are unaware, RSI essentially involves paralyzing and sedating (typically using succinylcholine and etomidate) a patient that still is somewhat breathing and has a gag reflex for the purpose of intubating them and breathing for them. It's a life-saving procedure, but it's obviously not without risks. In the heat of the moment, suppose a provider administers the medications and then for whatever reason can't intubate the patient? You've just killed someone. But with proper training, this would be very valuable protocol to have.
That's the end of my wish list and it's reasoning for today. Of course, I'd love a little teddy bear nebulizer for the kids - but that's not exactly going to help save any lives or do anything new, is it? :)
Standby at a structure fire this morning lasted well over 3 hours, and was still going strong when we left. I'm tired - going to sleep to dream about all these new toys that I want!
* Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001; 104: 2158–2163.
** Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L, Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005; 293: 299–304.
When I got to the station, I asked the AIC (a good friend of mine) if he could show me around the rig and how everything operates. The more I saw, the more excited I got. This agency has a lot of the things that I think makes EMS a true medical operation: CPAP, Sam Splints, Broselow Bags, continuous capnography as a vital sign, several IO's, 12 leads with wireless transmission capability, an autopulse, and electronic PPCR's. The agency also has access to several Primary Stroke Centers and a Level I Trauma and Burn Center. There are also career paramedics somewhere in the county at all times. Truly cutting-edge technology and uses of resources. I got more and more excited the more I saw. It felt like Christmas with tons of new toys to play with!
I've been thinking a lot lately about all the new things coming out in EMS. Every convention and conference I go to there's always tables and tables of shiny new things. It's overwhelming and commercial. But, if you know how and where to look, some of those pretty things will really make a difference to EMS. There's several material things and protocols that I wish I could have (or that I wish I could have when I'm an ALS provider here in a few months):
CPAP
12 Lead EKG with Wireless Transmission
Coordinated Pediatric Bag (like a Broselow)
Capnography Monitoring as an ALS vital sign
Autopulse - Automatic CPR Compressions
Chest Seals
Thermometers
Infusion Pumps (yeah, right - but I wish!)
ResQPOD (Impedance Threshold Device and an AHA IIA recommendation)
Field Cath Lab Activation
RSI
Some kind of Induced Hypothermia Protocol
I believe, with proper training, that everything on that list could make a real difference in patient care. With 12 Leads and cath lab activation from the field, we could save the patient up to 45 minutes of ER time. Capnography monitoring can truly alert to patient changes and status. For more on this, please see one of the field experts - 10 Things Every Paramedic Should Know About Capnography. There are few sources that explain it better and simpler.
Autopulse, ResQPOD, and Induced Hypothermia go together a little bit. In EMS, we make great "saves" every day, but I am occasionally hesitant on playing God. If we bring someone back, I'm disheartened to think that they will most likely never get out of the hospital. Even if they do make it out of the hospital, will they ever recover from the save that we performed?
In most situations, of course, we are ethically bound to at least work a cardiac arrest to the best of our ability. And I say, if we're going to do it, we might as well do it right. SCA - Sudden Cardiac Arrest - is the leading cause of death in the US and Canada with most patients at least initially in Ventricular Fibrillation.* Good, deep, strong, and probably most importantly, continuous, CPR provides the best chance for survival. AHA Guidelines note that we should be compressing 100 times a minute to get optimal forward blood flow. Human observational studies show that interruptions of chest compressions are common - far too common - and NO compressions were provided for 24-49% of time in cardiac arrest. Obviously, naturally, studies have consequently shown that prolonged interruptions in compressions reduced the likelihood of ROSC (return of spontaneous circulation).** In short, AHA recommends interruptions only when absolutely needed - pulse checking, analyzing rhythm, defibrillation. Compressions should not be interrupted for gaining vascular access, intubation, medication administration, etc.
Autopulse is very new technology, and I'm sure there is research both for and against it (does anyone know if they're making bariatric autopulses yet?). However, in my opinion, at the very least it provides continuous deep compressions. The machine doesn't get tired. It doesn't stop to try to do something else. It even beeps and tells you when to provide ventilation. ResQPOD is a threshold device and prevents unneeded air in the abdomen. This is an AHA IIA recommendation, and it also flashes when it's time to ventilate. No need to make our patients alkalotic, folks. If they're at the point of needing a ResQPOD, they have enough problems to begin with!
Induced Hypothermia. See old posts for some of my prior discussion on this, and await a case study that's in progress. I am a huge, huge supporter of this therapy. I believe it saves lives and prevents long-lasting neurological deficit. My protocols are JUST loose enough for me to have the ability to fly out a patient if I feel it's needed. My local hospital facilities don't have hypothermia protocol. I've spent time learning the protocol of our local flight companies, and if the event ever prevents itself, I'll fly someone immediately if it meets their criteria. I wish we had some kind of protocol here to get the process started, even if it was only through cold packs or very mild cold saline. But when the hospital doesn't even have the therapy, why should we? Time to call that helicopter.
Chest seals and thermometers - would be nice. Not necessary, but a chest seal will operate better than a regular occlusive dressing any day, and it'd be nice to tell the hospital or a patient's family what their temperature is. Same with a Broselow Bag. I could calculate my own dosages and size my own ET tubes, but it would be so much easier, quicker, and less stressful to simply have a nice color-coded bag.
Infusion pumps - I've never seen even a little one less than several thousand dollars. The Dial-A-Flows have decreased my all encompassing desire for a pump prehospitally, but I'm still a little wary. One drop off of an infusion can be a 10-15% error in medication, and who wants to take that risk? Dopamine, Amiodirone, Lidocaine - all drugs I wouldn't want to miscalculate. I don't know one assistant that I believe would sit there and count drops in the middle of the night on the way to the hospital. A pump would be very beneficial.
Airway, airway, airway. Isn't that what's pounded in all of our heads starting with basic first aid and continuing all the way up to EMT-P? If we should concentrate most on the airway and breathing, we need the tools to do so. CPAP. RSI. Capnography. CPAP is something that's more and more common, and I'm surprised it hasn't made it's way to this area as prominently yet. First of all, CPAP reduces the need for RSI to begin with. There are very few complications or side effects, with the most common being anxiety due to the mask. It saves patients in severe respiratory distress from being intubated, or it at least holds the intubation off. It decreases the need for the sometimes dangerous and far too-oft misgiven pre-hospital drug - Lasix. You can hook up a nebulizer treatment. The machine is small. Why isn't every agency using this?! For a good article on pre-hospital CPAP, see: Prehospital Use of CPAP.
RSI is something a little more serious, and I think there would need to be significant, individualistic training to make this an option pre-hospitally. For those who are unaware, RSI essentially involves paralyzing and sedating (typically using succinylcholine and etomidate) a patient that still is somewhat breathing and has a gag reflex for the purpose of intubating them and breathing for them. It's a life-saving procedure, but it's obviously not without risks. In the heat of the moment, suppose a provider administers the medications and then for whatever reason can't intubate the patient? You've just killed someone. But with proper training, this would be very valuable protocol to have.
That's the end of my wish list and it's reasoning for today. Of course, I'd love a little teddy bear nebulizer for the kids - but that's not exactly going to help save any lives or do anything new, is it? :)
Standby at a structure fire this morning lasted well over 3 hours, and was still going strong when we left. I'm tired - going to sleep to dream about all these new toys that I want!
* Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001; 104: 2158–2163.
** Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L, Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005; 293: 299–304.
Tuesday, March 9, 2010
Drained
It feels like I haven't written in ages, but it actually hasn't even been 2 full days. Ran 5 calls on Sunday in about four and a half hours. Nothing too critical. Chest pain, difficulty breathing, another chest pain with projectile vomiting, MVA (no patient injuries), and one more for the life of me I can't remember.
The school event went well; I hope we got some promising new junior members out of it.
Last night's shift with my partner went well - two calls, a 1 year old with a slight fever around midnight and a chest pain around 3. I was hoping for something mildly challenging to show off some knowledge a little, but to no avail.
I don't feel much like writing today - my partner resigned our rescue squad for reasons well out of either of our control at this point, but I'm pretty unhappy right now. It's pretty cool to think that we started when I was a BLS student and went through me getting my BLS clinical hours, precepting BLS, released BLS, being a BLS preceptor myself, and finally an ALS student. At least I have the perfect example of how to be when I'm a released medic one day!
The school event went well; I hope we got some promising new junior members out of it.
Last night's shift with my partner went well - two calls, a 1 year old with a slight fever around midnight and a chest pain around 3. I was hoping for something mildly challenging to show off some knowledge a little, but to no avail.
I don't feel much like writing today - my partner resigned our rescue squad for reasons well out of either of our control at this point, but I'm pretty unhappy right now. It's pretty cool to think that we started when I was a BLS student and went through me getting my BLS clinical hours, precepting BLS, released BLS, being a BLS preceptor myself, and finally an ALS student. At least I have the perfect example of how to be when I'm a released medic one day!
Sunday, March 7, 2010
Role Models
I've ended up back down at the station to staff a BLS unit from now (2pm) to 7, when the next crew comes in. Someone didn't show up to run their duty. Topic for another post: responsibility in EMS. Seems like it's sorely lacking these days. I have the same preceptee I had earlier in the week. I kind of want to boss my own calls today, but I know it's better for me to help someone else learn.
Tomorrow, I go with a good friend and fellow medic student (although he's taking his class some 5 hours away, as he's still in college) to a local high school to show off a unit and our equipment to a group of high schoolers enrolled in a general health and wellness class. A lot of them, from what I hear, want to be EMTs, so I'll bring along some PR material. That will occupy us most of the day, I believe. Then, in the evening, class - more on medication administration. Overnight, I have duty with my flight paramedic partner.
I've been working with Matt for just over a year now. His journey to EMS was an interesting one, but he's now a full-time flight paramedic and loves it. I want to follow him in a few years, after finishing my education and getting some critical care experience. I'm lucky to have such a great EMS role model.
I think role models are extremely important in all walks of life, but especially in a field where there's disappointments, confusion, and chaos a lot of the time. We have an informal "mentorship" program at my rescue squad, but only for people who expressly say that they want a mentor. I think everyone should be assigned one, and they can choose to dissolve or keep that relationship as they wish. I just got lucky with meeting someone who I asked to be my permanent partner and then him also becoming a great friend and mentor.
There's other people I look up to, naturally. The Training Officer I've worked with for awhile just recently left our station, much to my dismay. She was tough and didn't like incompetent or unwilling providers, but she was fair and one of the smartest women I've ever met. She's always one of the first people to know if I'm stressed about a certain skill or passed something. She always responds with the same level of enthusiasm, which most people would start to dwindle in after awhile. It's great to see a strong, competent woman working in EMS. They seem few and far between sometimes.
Peter Canning is probably one of my ultimate role models. He's written probably the country's most well known books on EMS - Medic 471 and Paramedic. He also keeps detailed and very educational blogs. Despite all of this, he replies to comments, posts, and e-mails, and I've had the honor of writing to him a couple times. I'm hoping for a possible face-to-face meeting next month. Someone who is that well-known, yet still kind enough to talk to his admirers, shows that he is the perfect person for EMS - patient, personable, kind, and open.
Since, I've mentioned them, I should plug their blogs.
Matt's - A Day in the Life of a Flight Paramedic
Peter Canning's - Street Watch: Notes of a Paramedic
I better get my unit pretty and prepped for the PR event tomorrow. I want to make a good impression.
Tomorrow, I go with a good friend and fellow medic student (although he's taking his class some 5 hours away, as he's still in college) to a local high school to show off a unit and our equipment to a group of high schoolers enrolled in a general health and wellness class. A lot of them, from what I hear, want to be EMTs, so I'll bring along some PR material. That will occupy us most of the day, I believe. Then, in the evening, class - more on medication administration. Overnight, I have duty with my flight paramedic partner.
I've been working with Matt for just over a year now. His journey to EMS was an interesting one, but he's now a full-time flight paramedic and loves it. I want to follow him in a few years, after finishing my education and getting some critical care experience. I'm lucky to have such a great EMS role model.
I think role models are extremely important in all walks of life, but especially in a field where there's disappointments, confusion, and chaos a lot of the time. We have an informal "mentorship" program at my rescue squad, but only for people who expressly say that they want a mentor. I think everyone should be assigned one, and they can choose to dissolve or keep that relationship as they wish. I just got lucky with meeting someone who I asked to be my permanent partner and then him also becoming a great friend and mentor.
There's other people I look up to, naturally. The Training Officer I've worked with for awhile just recently left our station, much to my dismay. She was tough and didn't like incompetent or unwilling providers, but she was fair and one of the smartest women I've ever met. She's always one of the first people to know if I'm stressed about a certain skill or passed something. She always responds with the same level of enthusiasm, which most people would start to dwindle in after awhile. It's great to see a strong, competent woman working in EMS. They seem few and far between sometimes.
Peter Canning is probably one of my ultimate role models. He's written probably the country's most well known books on EMS - Medic 471 and Paramedic. He also keeps detailed and very educational blogs. Despite all of this, he replies to comments, posts, and e-mails, and I've had the honor of writing to him a couple times. I'm hoping for a possible face-to-face meeting next month. Someone who is that well-known, yet still kind enough to talk to his admirers, shows that he is the perfect person for EMS - patient, personable, kind, and open.
Since, I've mentioned them, I should plug their blogs.
Matt's - A Day in the Life of a Flight Paramedic
Peter Canning's - Street Watch: Notes of a Paramedic
I better get my unit pretty and prepped for the PR event tomorrow. I want to make a good impression.
Saturday, March 6, 2010
Relief!
Another busy few days.
I did end up precepting on Thursday. We had three calls, so I felt like a decent host - I always feel like it's my fault if my preceptee doesn't get any calls! Nothing serious though. Older hypoglycemic (where ALS mostly took care of it with a little D50%) around midnight, mild chest pain that ALS determined they weren't needed around 1, and a young man who had some kind of complication from a joint surgery earlier that day and was bleeding around 3am. It's great to see how fast a student can progress with some patience and education. EMS is so different in the street from class, she said. It's true. Theory and practice are very different. She wrote me a lovely review, and I felt really honored to get to spend time with someone so motivated.
I had a very big test in class today. I studied for it quite a lot. This morning, I left home around 7am, and I actually felt kind of nauseous. The test was 85 questions, and as it started, I was surprised that I knew the material. A lot of it. I finished in 40 minutes, even though we were given 2.5 hours to complete the entire thing. I found out several hours later than I got an 86% - 6 points higher than I needed to pass! Relief.
Spent the afternoon in IV and drip labs. It was a great moment when I finally started getting my lines! I only got stuck once because my veins are nearly nonexistant. And that one stick wasn't in my hand...forearm...or AC, but right in my foot. Ouch! The student blew it, but getting a foot line is hard for anyone. So now I'm walking around with a slight limp and a band-aid. She got a blown IV in her thumb thanks to me, so I won't say much. :)
The other good part of the day - we got our class polo shirts. They identify as "Student" on one side and have the company logo on the other side. They're very nice. It feels good to get them; like the coordinators and instructors think we're going to make it. And today is one of the first days I feel like I'm really going to make it too. I'm going to continue this hard ride for the last three-quarters of the class and then proudly take my National Registry exam.
A little self-esteem never hurt a medic student!
I did end up precepting on Thursday. We had three calls, so I felt like a decent host - I always feel like it's my fault if my preceptee doesn't get any calls! Nothing serious though. Older hypoglycemic (where ALS mostly took care of it with a little D50%) around midnight, mild chest pain that ALS determined they weren't needed around 1, and a young man who had some kind of complication from a joint surgery earlier that day and was bleeding around 3am. It's great to see how fast a student can progress with some patience and education. EMS is so different in the street from class, she said. It's true. Theory and practice are very different. She wrote me a lovely review, and I felt really honored to get to spend time with someone so motivated.
I had a very big test in class today. I studied for it quite a lot. This morning, I left home around 7am, and I actually felt kind of nauseous. The test was 85 questions, and as it started, I was surprised that I knew the material. A lot of it. I finished in 40 minutes, even though we were given 2.5 hours to complete the entire thing. I found out several hours later than I got an 86% - 6 points higher than I needed to pass! Relief.
Spent the afternoon in IV and drip labs. It was a great moment when I finally started getting my lines! I only got stuck once because my veins are nearly nonexistant. And that one stick wasn't in my hand...forearm...or AC, but right in my foot. Ouch! The student blew it, but getting a foot line is hard for anyone. So now I'm walking around with a slight limp and a band-aid. She got a blown IV in her thumb thanks to me, so I won't say much. :)
The other good part of the day - we got our class polo shirts. They identify as "Student" on one side and have the company logo on the other side. They're very nice. It feels good to get them; like the coordinators and instructors think we're going to make it. And today is one of the first days I feel like I'm really going to make it too. I'm going to continue this hard ride for the last three-quarters of the class and then proudly take my National Registry exam.
A little self-esteem never hurt a medic student!
Thursday, March 4, 2010
Tired.
After yesterday's entry, I didn't do much more than study. I was disheartened to see in class that I still have much more learning to do before Saturday's test - and only got an 89% on the pre-test assignment (it had been a take home assignment). So I plan to spend much of today and tomorrow reading and watching class powerpoints.
I also felt like an idiot struggling with a fax machine at Staples trying to fax a copy of my Infection Control Officer certificate to the woman administering my exam and my signed contract to the company who I was the "on-site medical professional" for last week. I'm in my 20's, and I do remember the widespread use of fax. My grandparents were farmers, and they use to fax their various clients frequently. But I felt it was fairly outdated technology, and I had to have much assistance.
After class, I went straight to cover an overnight shift for a friend. I got to our station around 10:30 (class let out early!) and went almost immediately to sleep. I was awoken later for an "Injury", and dispatch advised us to stage until PD could get a more accurate picture of the situation. Turned out to be an intoxicated injury from a standing position with some head and neck pain. The man had a laceration on his head he complained about, but it was clearly an old wound and completely clotted off. We backboarded and took to the hospital. Glucose of 98, and he kept asking me if he was a diabetic. He then asked for my phone number and, when I refused, he asked for my driver's phone number. Oy.
One more call around 3am for a public service. Sweet older woman fell trying to get to the bathroom and her son couldn't get her up off the floor. She was very apologetic and kind. Had some bruising, but it looked to be old, and she repeatedly stated "no pain". We helped her to the bathroom, and then back to bed. I'm hoping she'll invest in a walking device to help.
It looks like I may end up back on the ambulance tonight - there's an opening, and one of the assistants is new to the squad, but an experienced paramedic awaiting release in our council. I could benefit from his presence. Also, the other assistant scheduled is a new EMT, and I feel like precepting. She seems to be a very bright University student, and I anticipate she'll do fine.
I'm fairly new to being a preceptor, but I've developed a good rhythm. I ask them to be about an hour early to shift if it's their first time precepting so I can do a thorough discussion on hospital reports and documentation - our HIPPA form, the hospital forms, and the PPCR. I then take several items off of the unit before they go to check it. I once had a preceptee notice every single item I took off the unit other than an Infant BVM. Oops! They ride up front and use the radio en route to calls. They interview the patient. I oversee and only intervene if necessary. At the hospital, I stay present during the report to the nurse. We then go to the EMS room and both write our own narratives of the call before comparing notes. I learn from this exercise too, because everyone notices something a little different after a call. We debrief the call. At the end of the shift, we have a lengthy discussion on the precept report form I have to write. I want them to know why I made the comments I did and gave the ratings I did. I want them to know how they did well and how they could improve. I have left every precepting shift feeling confident that the entire crew learned a little something, including myself. So I'm looking forward to tonight, should I end up taking this.
Right now, I just need to get some sleep.
Oh -- if I do end up precepting this new student, I think I might adopt Peter Canning's "Letter to a Preceptee". It's inspiring and encouraging.
I also felt like an idiot struggling with a fax machine at Staples trying to fax a copy of my Infection Control Officer certificate to the woman administering my exam and my signed contract to the company who I was the "on-site medical professional" for last week. I'm in my 20's, and I do remember the widespread use of fax. My grandparents were farmers, and they use to fax their various clients frequently. But I felt it was fairly outdated technology, and I had to have much assistance.
After class, I went straight to cover an overnight shift for a friend. I got to our station around 10:30 (class let out early!) and went almost immediately to sleep. I was awoken later for an "Injury", and dispatch advised us to stage until PD could get a more accurate picture of the situation. Turned out to be an intoxicated injury from a standing position with some head and neck pain. The man had a laceration on his head he complained about, but it was clearly an old wound and completely clotted off. We backboarded and took to the hospital. Glucose of 98, and he kept asking me if he was a diabetic. He then asked for my phone number and, when I refused, he asked for my driver's phone number. Oy.
One more call around 3am for a public service. Sweet older woman fell trying to get to the bathroom and her son couldn't get her up off the floor. She was very apologetic and kind. Had some bruising, but it looked to be old, and she repeatedly stated "no pain". We helped her to the bathroom, and then back to bed. I'm hoping she'll invest in a walking device to help.
It looks like I may end up back on the ambulance tonight - there's an opening, and one of the assistants is new to the squad, but an experienced paramedic awaiting release in our council. I could benefit from his presence. Also, the other assistant scheduled is a new EMT, and I feel like precepting. She seems to be a very bright University student, and I anticipate she'll do fine.
I'm fairly new to being a preceptor, but I've developed a good rhythm. I ask them to be about an hour early to shift if it's their first time precepting so I can do a thorough discussion on hospital reports and documentation - our HIPPA form, the hospital forms, and the PPCR. I then take several items off of the unit before they go to check it. I once had a preceptee notice every single item I took off the unit other than an Infant BVM. Oops! They ride up front and use the radio en route to calls. They interview the patient. I oversee and only intervene if necessary. At the hospital, I stay present during the report to the nurse. We then go to the EMS room and both write our own narratives of the call before comparing notes. I learn from this exercise too, because everyone notices something a little different after a call. We debrief the call. At the end of the shift, we have a lengthy discussion on the precept report form I have to write. I want them to know why I made the comments I did and gave the ratings I did. I want them to know how they did well and how they could improve. I have left every precepting shift feeling confident that the entire crew learned a little something, including myself. So I'm looking forward to tonight, should I end up taking this.
Right now, I just need to get some sleep.
Oh -- if I do end up precepting this new student, I think I might adopt Peter Canning's "Letter to a Preceptee". It's inspiring and encouraging.
Wednesday, March 3, 2010
Busy, Busy
Been busy the last few days.
On Monday, I went to Washington, DC with a friend who had an interview. I stayed busy during her interview, including visiting the GWU Medical campus, a flight base, and spending a little time at the National Gallery. There were very few people at the museum, which was had a warm and humid temperature control. I settled into a rhythm looking at all the paintings and walking slowly around. There were many rooms I went in with no other people at all! I was hoping to see some of Rembrandt's paintings with the use of light on the operating table, like the one below. Unfortunately, there was nothing quite like that. The day was very crisp, with lots of wind, but the sun was fully out. It was a successful day followed by an evening of Alpha/Beta and fluid administration education in class. I left home around 7:30 in the morning and returned around 11:15 that night. Long day.
Yesterday I spent some time catching up with a friend before going to my squad's business meeting. I've gone through a lot of assistance positions in my squad...I try to go to a lot of the meetings and all the trainings possible. I got my certification in Infection Control Officer, but I haven't had an opportunity to use it yet. I've been an assistant in Quality Improvement, Training, and AIC Release. However, last night I was elected to my first "Officer" position - Recruitment and Retention Officer. I'm excited about this position. I think that some well-aimed recruitment attempts might really make a difference in the quality and motivation of provider we bring in. I'm a big believer in quality over quantity of EMS providers. As medications get more complex and the population gets older, I think it's important that we bring in people that are willing and ready to go the extra distance. The most important aspect of retaining personnel, is stressing the value of the provider while also encouraging additional training. Even experienced Paramedics should be expected to attend (and teach!) educational courses. We had a medic at my station teach a class on "Being an Effective Assistant" for the thirds and fourths on our units. I thought that was great - it helped him teach what he expects on his units while also teaching students and assistants how they can help. Everyone left feeling accomplished. And those feelings make people want to stay and keep contributing. I'm looking forward to brainstorming how I can create positive change using my new position.
This morning, I registered for the "Methods of Instruction" course being offered in April. I got squad funding last night to pay for my hotel for the weekend, so I'm really looking forward to this. It's step I in becoming a BLS Instructor, something I'm really hoping to get around next summer. I also want to use the training to become an OSHA-compliant Infectious Disease Control Instructor, but am waiting to take the pre-test required. I'm sure it will be pretty difficult. I need an 80% to be allowed to be an Instructor.
Tonight is just some medication infusion math review in class. Low grade stuff in preparation for a big test on Saturday, followed by a fun lab day of playing with IO's and other torture equipment. I'm also covering the second half of a friend's duty - midnight to 6am in the city. Probably (hopefully) no calls. I'll be tired.
On Monday, I went to Washington, DC with a friend who had an interview. I stayed busy during her interview, including visiting the GWU Medical campus, a flight base, and spending a little time at the National Gallery. There were very few people at the museum, which was had a warm and humid temperature control. I settled into a rhythm looking at all the paintings and walking slowly around. There were many rooms I went in with no other people at all! I was hoping to see some of Rembrandt's paintings with the use of light on the operating table, like the one below. Unfortunately, there was nothing quite like that. The day was very crisp, with lots of wind, but the sun was fully out. It was a successful day followed by an evening of Alpha/Beta and fluid administration education in class. I left home around 7:30 in the morning and returned around 11:15 that night. Long day.
Yesterday I spent some time catching up with a friend before going to my squad's business meeting. I've gone through a lot of assistance positions in my squad...I try to go to a lot of the meetings and all the trainings possible. I got my certification in Infection Control Officer, but I haven't had an opportunity to use it yet. I've been an assistant in Quality Improvement, Training, and AIC Release. However, last night I was elected to my first "Officer" position - Recruitment and Retention Officer. I'm excited about this position. I think that some well-aimed recruitment attempts might really make a difference in the quality and motivation of provider we bring in. I'm a big believer in quality over quantity of EMS providers. As medications get more complex and the population gets older, I think it's important that we bring in people that are willing and ready to go the extra distance. The most important aspect of retaining personnel, is stressing the value of the provider while also encouraging additional training. Even experienced Paramedics should be expected to attend (and teach!) educational courses. We had a medic at my station teach a class on "Being an Effective Assistant" for the thirds and fourths on our units. I thought that was great - it helped him teach what he expects on his units while also teaching students and assistants how they can help. Everyone left feeling accomplished. And those feelings make people want to stay and keep contributing. I'm looking forward to brainstorming how I can create positive change using my new position.
This morning, I registered for the "Methods of Instruction" course being offered in April. I got squad funding last night to pay for my hotel for the weekend, so I'm really looking forward to this. It's step I in becoming a BLS Instructor, something I'm really hoping to get around next summer. I also want to use the training to become an OSHA-compliant Infectious Disease Control Instructor, but am waiting to take the pre-test required. I'm sure it will be pretty difficult. I need an 80% to be allowed to be an Instructor.
Tonight is just some medication infusion math review in class. Low grade stuff in preparation for a big test on Saturday, followed by a fun lab day of playing with IO's and other torture equipment. I'm also covering the second half of a friend's duty - midnight to 6am in the city. Probably (hopefully) no calls. I'll be tired.
Sunday, February 28, 2010
Expanding Our Role
So a couple times this week, today being the last day, I've been the "standby EMT" for a television show filming in my area. I'd love to share all the details, but I've been sworn to secrecy by a contract that is many pages with many long words. All I'll say is that this show will be aired on a national cable channel in July, but I look forward to sharing more then!
It's actually not as glamorous as it sounds. I've been sitting in my car, jump bag with all equipment in the seat next to me, for three hours now. I've accomplished a lot of homework and reading, and now I'm going to use my computer until it runs out of battery. Maybe something will happen requiring some use of medical skill, but probably not. The network's insurance policy requires an EMT on set "just in case", so here I am.
Early in my class, we had the typical section on what is expected of a medic, what the role of the medic is in society, etc. We learned about the field growing to primary care, industrial medicine, sports medicine, flight medicine, and more. I guess that me sitting here waiting for something to happen is kind of industrial medicine - I'm on the scene of an industry as the chief (and only!) medical personnel. It's interesting to look back on EMS history and see all the opportunities we've gotten since then...
In my opinion, the earliest we can trace EMS back to is Napoleon's times, where the first triage system was used. 911 was "invented" as the national emergency number in 1968 (to be finalized by President Clinton in 1999), after EMS was established as part of the DOT in 1966. Since then, it's just a big history of laws and changes. We've lost and received funding from Congress several times. We're currently working under "The EMS Agenda for the Future" from 2006, trying to develop more in research, financing, education, prevention, care, and more.
I hope to focus my career on two of the newer aspects of paramedicine - aircare and education. And while I do want to teach BLS and ALS, as well as AHA, I also want to educate the public. I want to go to birthing classes and teach new parents how to properly install a carseat to protect their children. I want to go to local elderly church groups and teach signs of stroke and the importance of early recognition - did you know that every MINUTE during a stroke, 2 million neurons and 14 billion synapses die?! I'm sure I could come up with many more. I think that preventative education could save lives, and it's something that's not nearly offered enough.
My computer's down to 12% battery life. Darn...looks like I'll have to find something else to keep me occupied until filming wraps for the day! Back to the books again.
Tomorrow, I'm taking my good friend up to DC for an important interview she has. I'm looking forward to an interesting morning while she's at her interview and then Alpha/Beta Therapy in class tomorrow night.
It's actually not as glamorous as it sounds. I've been sitting in my car, jump bag with all equipment in the seat next to me, for three hours now. I've accomplished a lot of homework and reading, and now I'm going to use my computer until it runs out of battery. Maybe something will happen requiring some use of medical skill, but probably not. The network's insurance policy requires an EMT on set "just in case", so here I am.
Early in my class, we had the typical section on what is expected of a medic, what the role of the medic is in society, etc. We learned about the field growing to primary care, industrial medicine, sports medicine, flight medicine, and more. I guess that me sitting here waiting for something to happen is kind of industrial medicine - I'm on the scene of an industry as the chief (and only!) medical personnel. It's interesting to look back on EMS history and see all the opportunities we've gotten since then...
In my opinion, the earliest we can trace EMS back to is Napoleon's times, where the first triage system was used. 911 was "invented" as the national emergency number in 1968 (to be finalized by President Clinton in 1999), after EMS was established as part of the DOT in 1966. Since then, it's just a big history of laws and changes. We've lost and received funding from Congress several times. We're currently working under "The EMS Agenda for the Future" from 2006, trying to develop more in research, financing, education, prevention, care, and more.
I hope to focus my career on two of the newer aspects of paramedicine - aircare and education. And while I do want to teach BLS and ALS, as well as AHA, I also want to educate the public. I want to go to birthing classes and teach new parents how to properly install a carseat to protect their children. I want to go to local elderly church groups and teach signs of stroke and the importance of early recognition - did you know that every MINUTE during a stroke, 2 million neurons and 14 billion synapses die?! I'm sure I could come up with many more. I think that preventative education could save lives, and it's something that's not nearly offered enough.
My computer's down to 12% battery life. Darn...looks like I'll have to find something else to keep me occupied until filming wraps for the day! Back to the books again.
Tomorrow, I'm taking my good friend up to DC for an important interview she has. I'm looking forward to an interesting morning while she's at her interview and then Alpha/Beta Therapy in class tomorrow night.
Saturday, February 27, 2010
"There is no Medicine Like Hope"
I spent most of today at a critical care and trauma conference hosted by one of my area's medical flight programs. I make it a point to go to every continuing education and conference that I can - I love to keep up with the new research and what the major hospitals and air crews are doing. Also, I've had the fortune of making many friends in this field through all the ways I've found myself involved, and it's great fun to spend a day learning together.
As I walked in to check in this morning, I was handed a name tag that said "EMT-P" under my name. Oops! I told the registering woman that I was only a student and certified only at the Basic level. She told me that she was confident I would pass and so she gave me the "upgraded" name tag! Ha! So I started the day feeling like a real fraud - what were they thinking?! I haven't even come close to this! I can't be expected to perform at this level!
The lectures started and were very interesting. We first got a lecture from a neurologist from a local Primary Stroke Center hospital facility. I was familiar (of course) with stroke recognition and tPA therapy, but I hadn't heard of the surgical interventions for stroke she discussed. MERCI (Mechanical Embolus Removal in Cerebral Ischemia) involves sticking a tiny corkscrew in the blood vessel througha catheter to remove the clot! Amazing what technology can do. We then had a regional coordinator come and talk with us about pre-hospital care of the mechanical circulatory support device patient. Again, I was amazed at how far we've come from seeing the first generation pump to the new third generation - this specialist told us that her facility, which is about 30 miles away from me, is about to implant the fifth third-generation in the world. Amazing! I had never learned much about these VAD devices, but I feel confident if I ever encountered one now, that I'd at least recognize it and know how to treat simple mechanical problems and transfer. Our final morning lecture was on the cutting-edge and still fairly new Induced Therapeutic Hypothermia with adult comatose survivors of cardiac arrest. I had heard of this before, but it was interesting to see it spelled out. We don't have protocols for it in the field yet, and I don't anticipate them coming soon. Our local hospital, though it is highly accredited and a trauma center, doesn't even perform this therapy.
After a nice lunch, it was time to move on to some small group/skills stations. This is where I was worried that my being advertised as a medic might cause some problems - although I made sure to say that I was only a student! Amazingly, I was worried for nothing. I successfully needle cric'd my pig with no trouble and got my tube in the simulator on the first try with no stylet. The flight nurse overseeing that station said I was an intubation natural, which is one of the nicest things I've ever heard. I then placed in the "Jeopardy!" competition, answering some of the questions on cardiac meds, flight ops, hypothermia therapy, and stroke treatment. Our final small group station was hearing from a 41-year-old cardiac arrest survivor (still unsure what caused the arrest to begin with) who was a successful recipient of the hypothermia treatment. It was incredible to see this patient, now a flight medic for the company that transported him to the therapy facility.
The day finished out with a lecture on battlefield medicine. We learned that the three most common causes of death in combat are: bleeding to death from extremity wounds, tension pneumothorax, and airway obstruction. All things we could fix so easily here at home in the field! It is sad to think of all those soldiers that are dying of conditions we have simple fixes for.
While I still feel a little guilty about that name tag, I left the conference feeling like I had learned a great deal and performed in skills much better than I expected of myself. I left with hope (and significant study!) that I could be a flight paramedic one day too - my ultimate goal. I left with hope and awe at what medicine has accomplished and what it hopes to accomplish in the future. And I left grateful that families and patients have gotten hope out of the truly incredible treatments and specialties I learned about today.
Friday, February 26, 2010
You Thought This Was Going to be Easy??
It's been awhile since the start of my class, but the instructor wasn't lying or exaggerating when he greeted us with a "You thought this was going to be easy?". All of us fresh-faced students sat there flipping through our crammed-full 3" binders and wearing our plastic nametags that will identify us as "Student" in every field rotation, clinical rotation, and class period. Even our program-issued polo shirts identify us as "Student."
Once our expectations were laid out for us that day, students started to leave. Some never even showed up to claim their binders and nametags and were accordingly dropped from the roster.
The ones that have stayed so far are already getting bogged down, and as we were all told last class, we're really only beginning. My head is swimming with lymphatic physiology, hemocrit, blood antigens, pharmacodynamics, and medication schedules. My program is accelerated - we will learn in 5 months what most programs take 10-12 months to complete. This draws people to the class that have a 2, and even 3, hour drive. The ones that have stayed with us are motivated, and we all have our own stories for being here.
For about a year now, I've been fortunate enough to spend about 20 hours a month with a paramedic partner. Rarely, prior to my "release" as a BLS Attendant-in-Charge, had I ever run on a BLS unit. The day that I was released was a typical Southern hot and humid day, and my unit was sent to a park for a referee who was severely dehydrated. He was still conscious, breathing, and was fully oriented. However, I could look at him and tell that he needed some fluid. It occurred to me that I couldn't fix him - I couldn't even start the job that would be finished at the hospital. I got him as comfortable as I could, gave some oxygen and cold packs, and initiated transport. Our transport time is almost always 7 minutes or less, but I still wanted to help this very friendly patient. My skills weren't enough, and I left the call feeling horribly inadequate.
I then decided to begin the road to ALS provider. It's a rough road. I have the fortune of many paramedics to look up to, and I want to make them proud. I want to make my patients confident in their decision to call for me. And most of all, I want to make myself proud in my abilities.
Thanks for reading and joining me on this trip. For now, my instructor has told me to be "as one" with my Paramedic Care book, and it's right on top of that binder...time to get back to work.
Once our expectations were laid out for us that day, students started to leave. Some never even showed up to claim their binders and nametags and were accordingly dropped from the roster.
The ones that have stayed so far are already getting bogged down, and as we were all told last class, we're really only beginning. My head is swimming with lymphatic physiology, hemocrit, blood antigens, pharmacodynamics, and medication schedules. My program is accelerated - we will learn in 5 months what most programs take 10-12 months to complete. This draws people to the class that have a 2, and even 3, hour drive. The ones that have stayed with us are motivated, and we all have our own stories for being here.
For about a year now, I've been fortunate enough to spend about 20 hours a month with a paramedic partner. Rarely, prior to my "release" as a BLS Attendant-in-Charge, had I ever run on a BLS unit. The day that I was released was a typical Southern hot and humid day, and my unit was sent to a park for a referee who was severely dehydrated. He was still conscious, breathing, and was fully oriented. However, I could look at him and tell that he needed some fluid. It occurred to me that I couldn't fix him - I couldn't even start the job that would be finished at the hospital. I got him as comfortable as I could, gave some oxygen and cold packs, and initiated transport. Our transport time is almost always 7 minutes or less, but I still wanted to help this very friendly patient. My skills weren't enough, and I left the call feeling horribly inadequate.
I then decided to begin the road to ALS provider. It's a rough road. I have the fortune of many paramedics to look up to, and I want to make them proud. I want to make my patients confident in their decision to call for me. And most of all, I want to make myself proud in my abilities.
Thanks for reading and joining me on this trip. For now, my instructor has told me to be "as one" with my Paramedic Care book, and it's right on top of that binder...time to get back to work.