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.

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??

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.

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!

#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.

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.

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!

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.

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!

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.

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.