Author: Amir Louka

Go Go Gadget Defibrillator: What I Do and Don’t Carry on Duty

Everything lies on a spectrum, especially in the world of medicine, and a medic’s choice of personal kit is no different. From Mr. “I don’t care if it’s a rectal bleed, gloves are for rookies,” to your favorite Rescue Rambo, who would use a Medivac unit as his daily commuter if he could, we each choose a few (possibly) useful things to keep within arm’s reach while on duty. While Steph and I may work at the busiest Level 1 in the state, and have any and all imaginable technology at our disposal while there, being outside the hospital is a different story entirely. So here’s a look at what I choose to bring along and what I feel can make a difference when the tones go off.

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Photo copyright: The Lonely Medic

1. My very own pulse ox

A few years ago these things could set you back a few hundred dollars, but now you can pick one up on Amazon for about $20 with free shipping. Beyond the general appearance of a patient (Again, a spectrum: from “Ugh, why 3am?” to “Oh… that can’t be good.”) few things can give you as much information about the person in front of you as this tiny device. Patient looks like he’s working to breath? Maybe it has something to do with that O2 sat of 65% – better call back the engine you just cancelled.

It’s part of my approach to almost every patient I encounter – I introduce myself while lowering myself to their level (standing over a patient is imposing and dominant, even if you’re not 6’5” like me, and not generally comforting to little old ladies). I slip on a pulse ox while taking his/her hand and wrist to feel a pulse. As well as instantly assessing perfusion, motor and sensory function, that simple, brief human contact goes a long way in gaining trust and establishing rapport. Fun fact: the servers at Hooters do exactly the same thing.

2. A radio

We take them for granted, but this thing is your ticket to unlimited resources on-scene and your lifeline when SHTF (like this day in Virginia Beach in April 2012). Need manpower? Engine’s en route. Leave something in the truck? Someone can grab it on the way in. When my partner had a seizure on duty and wasn’t breathing, I hit that little orange button and said a few words… You’d have thought WWIII had broken out. When every unit in a five mile radius was headed my way in seconds, I realized that motorola is more than a faceless voice that tells you where to go. I keep mine in a reflective shoulder strap for added safety, to which I also attach the pulse ox for quick and easy access.

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3. A knife/multitool/trauma shears

I carry one of the above, depending which I can find while getting ready for duty at 4am. I don’t carry all of them. I don’t carry multiples of any of them. No boot knives or ninja stars, no Ka-Bar combat bayonets. It’s volunteer EMS, not Vietnam. I use it to cut stuff.

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Every squad has this dude.  You know who I’m talking about.

4. A mini maglite

One of the things I love about getting outside the hospital are the places we go. We often see another side of society we otherwise never would – dark alleys, abandoned buildings, and deep ditches in the dead of night. I’ve had a mini maglite since day one, and it’s never let me down. If I have a funny feeling about a place, I might bring along one of the big D cells we keep in the truck, but 99% of the time the mini gets the job done.

5. Steel toed boots and well made pants 

Steph regularly wears shorts and sneakers on duty. I just don’t get it. Even if it’s 100F in the shade, you’ll find me sweating in my 5.11s. Who knows where you’ll find yourself, or what you’ll find yourself in, on the next call. Safety first.

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6. My brain 

Forget everything I’ve said up to this point. Brainpower is the only thing you NEED to bring along. This is how you’ll navigate tough problems, assess complex patients and choose the right interventions. Without it, you’re no good to anyone. With it, you’re a real-life hero. Signing up to take care of people in need is also a commitment to lifelong learning. You owe it to your patients to practice, stay up to date, to learn new things and continually improve. If you’re reading this, you’re probably on the right track. And keep in mind, your partner probably has one too, complete with its own experience, training and know-how. Use ‘em.

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Honorable Mention: A stethoscope 

You might have noticed the most ubiquitous piece of medical equipment missing from the list above. Truth be told, these things are living dinosaurs. This year happens to be the 200th anniversary of the stethoscope’s invention, but contrary to what Mr. Littman would have you believe, they have barely changed in all that time. Too often, the scene is just too noisy and chaotic get an accurate exam, and in most circumstances requiring immediate intervention you can get the same information in other ways. Breathing difficulty with a history of both CHF and COPD? Try a neb while looking for other signs like JVD and pitting edema. It’s rarely exclusively one or the other. Tube placement? If you’re not using end-tidal you’re behind the times. Trauma and hypotension? Prepare to dart the chest and get moving.

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For the record, using the shared stethoscope in the jump bag is not an option. This is what grew from swabs Steph took off a stethoscope.

In my experience, the rubber necklace acts more like a police officers badge or firefighter’s helmet than a diagnostic instrument in the field, clearly identifying you as medical personnel. That’s a perfectly good reason to keep one with you though, so feel free. But if you’re like me, it usually stays in the truck.

All that said, the day they come out with a pocket defibrillator, I’ll be first in line.

~Amir

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Be Heard in the Bay: Tips for Turnover on Critical Patients

Apparently 12-1 is not an acceptable ratio when it comes to his & hers blogging… So in the interest of continued marital harmony, here’s a few thoughts to newbies on making yourself heard in the resus room.


It happens to the best of us. You’ve been sitting around the station all night and finally decide it’s safe to slip the boots off, only to be immediately reminded that the trauma gods do in fact enjoy tormenting you. On come the lights, quickly followed by a dispatcher’s pressured voice. As you glance at the clock reading 3am, a few words stand out. Gunshot wound. Bleeding. Unconscious.

For the next fifteen minutes you’re on autopilot – reflexively cutting away clothing, occluding that bubbling hole in the chest and dropping a needle down through the second intercostal space, just like you were trained. You watch the vital signs move back towards normal and you justifiably feel like a total badass. Time to load and go.

As you wheel into the trauma bay at your local Level 1, you’re confident you’ve done everything right. There’s the team, gowned and gloved, ready to take over.

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“………..”

Inside your brain is screaming, “Work mouth, you bastard!” Now is the time to prove to all these doctors how awesome you are, how you saved this guy’s life. “I’ve done all the hard work. Speak damn you!”

“Ummm.. This is Steve, he’s a male..”

“SPEAK UP.”

“Steve! He’s a male! And.. we found him outside the bar – the one over off Main, well Main and 3rd… closer to 4th. He has asthma and…”

“Airway’s patent! Breath sounds clear bilaterally!” It’s too late. You lost them.


Want to keep the brief attention of your ED colleagues and trauma team? Here’s how:

1. Figure out who’s doing the talking – most critical patients roll in flanked by a entourage of medics, EMTs, fire fighters and/or police. Add to that the near-limitless helping hands in a large ED and there’s usually no need for the AIC to be occupied with distracting tasks like moving the patient off the stretcher or switching O2 from the portable tank to wall supply. Instead, the AIC should be at the foot of bed, addressing the entire room. Yes, everyone – the doctors, nurses, techs, social worker, chaplain and ogling med students ALL need to hear what’s going with this guy, so be ready to project your voice and speak clearly.  And if you are the trainee, don’t disappear to clean the stretcher – stick around and listen.  It’ll be your turn before you know it.

2. Take a deep breath – You made it. Even if the patient is actively coding, you’re here and your job is almost done. The blood splattered sidewalk, flashing lights, noise and confusion are all behind you. It’s our job to shut up and listen, and we will – for about 30 seconds. Starting your turnover in a calm and collected manner is the first sign to us those precious seconds will be well spent.

3. Age. Sex. Chief complaint/most pressing issue. – The first two always go off without a hitch. The third seems obvious, but every now and then it just takes an inexplicably long time to get around to mentioning the multiple stab wounds or EKG reading ***STEMI***STEMI***STEMI***. By the end of your first sentence we should know who your patient is and what went so wrong with their day to now be spending it with all these highly trained individuals.

4. Stay focused – This is not the time for an exhaustive presentation of the history and physical. A remote history of paronychia isn’t of much interest in someone with hemiparesis, but the time of onset certainly is. We can wait to hear she takes 500mg of Vitamin C daily, but Coumadin is a med I want to know about up front. By far this is the most difficult thing to master, because it often means reading our minds, knowing what’s important and what isn’t. A few stand out items in no particular order would be: loss of consciousness yes or no, symptoms improving or worsening, mechanism of injury, relevant surgeries, and medications including blood thinners, cardiac drugs such as beta blockers, and insulin.

5. Vitals – What are they now? Were they different at any time? What do you mean you only got one set?

6. Injuries, EKGs, physical exam and what did you do about it? – This is your chance to brag. “Patient was altered and EKG showed sinus bradycardia. I gave 0.5mg Atropine x1 with improvement in heart rate and mental status.” “The right leg was shortened with deformity at the mid-thigh. I gave 100mcg of Fentanyl and applied a traction splint.”

7. Access – ET tube, King airway, NPA? What size IVs and where are they? Did you drill IOs instead? Kudos if you did.


That’s it really. In 15-30 seconds we should hear what’s wrong with this person, how did it happen, what changes happened while he/she was with you and what did you do about it.

Giving a concise, accurate turnover takes practice. The pressure is on and your adrenaline is already up. You’re mentally exhausted, but those last few moments before he or she is off your stretcher are often the only insight doctors get into what’s going on, so make them count. Once the dust has settled, feel free to pull any of us aside for some feedback.

~Amir

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5 Things I Learned in EMS I Wish I’d Learned in Medical School

Hello world. Mr. TeamLouka here.

I hear my wife started a blog… and in typical Steph fashion, three days later she has hundreds of viewers in 10+ countries?! Well, I can’t let her have all the fun, and its TEAMlouka afterall. So here’s my take on…


5 Things I Learned in EMS I Wish I’d Learned in Medical School

1. ABCs

Airway. Breathing. Circulation. Often boiled down to the ever-popular “air goes in and out, blood goes round and round, and any variation of either is bad.” Seems simple enough. You might even think such a simple, crucial concept would be covered on day one of medical school, just like it was in EMT class.

False.

I distinctly remember sitting in the auditorium at EVMS back in August 2010 and thinking to myself, “OK. Let’s do this. Doctor training, go!” The lecture topic? Intro to medical molecular cellular biology, of course! Because when that critical patient rolls in, all attention should be directed towards the golgi apparatus and endoplasmic reticulum first. Funnily enough, I didn’t leave that class feeling any more clever.

Now in all fairness, ABCs were covered in medical school. The problem is that the single most important concept in the assessment of an undifferentiated patient was sandwiched somewhere between memorizing The Krebs Cycle and the chapter on brain eating amoebas.

So out of four long, expensive years, just half a day was smushed in there for a shoddy BLS/CPR course. By that point, most of my compatriots had drunk the Kool-Aid – BLS was a boring day off for some and an unwelcome eviction from the library for others.

The effect? Time after time, I have watched medical students, residents, and even some attendings rack their brains for a diagnosis, visibly straining to remember what medicine or scan should be ordered next, when called to the bedside of someone going downhill. THE PATIENT ISN’T BREATHING. But is it multiple endocrine neoplasia type 1 or 2? THE PATIENT ISN’T BREATHING. Did she say her great-great-grandmother had psoriasis? I DON’T FEEL A PULSE. Did you do a rectal exam? MAYBE WHEN I FINISH THESE CHEST COMPRESSIONS.

(OK all you sticklers for AHA guidelines out there. I know it’s CAB now. But no one says that. It’s ABC. Forever).


2.  Acuity is just a number

In every ED there is some kind of triage coding system. Usually it’s a numerical assignment, 1-6 in ours, given to patients when they arrive, which roughly translate as:

  1. “We need a doc in here!”
  2. “Doc, my chest hurts since this morning.”
  3. “Doc, my belly hurts since yesterday.”
  4. “Doc, my toe hurts for the past 18 years.”
  5. “Need a med refill, Doc.”
  6. “He’s dead, Doc.”

We’ll that’s great when it works. But one EMS call in particular taught me to maintain a healthy dose of skepticism with those low acuity patients.

It was early in the morning. My partner and I had just signed on were still fueling up on coffee and pancakes. So when the call crackled over the radio for a priority 3 injury, “patient stubbed his toe,” we understandably finished our coffee and waited for the check. We drove to a house about 10 minutes away in no rush at all. Why the hell would someone call 911 at 6am for a stubbed toe?!

The question was partially answered when we walked into the house to find a pale, diaphoretic man sitting in his kitchen… holding a slightly bruised toe.

Turns out this guy walked outside to pick up his newspaper and collapsed down by the mailbox. He spent half an hour crawling back up the driveway, and at some point along the way managed to stub his big toe, much to his dismay. He also just happened to be having a massive heart attack.

Moral of the story: Lay eyes on the patient, then finish your coffee. Just in case.


3. Where Patients Come From

Well when diabetes and high blood pressure love each other very much…

No, that’s not what I mean. I mean physically, socially, emotionally. You see, most patients arrive to me looking more or less the same – propped up on a stretcher or in a wheelchair, clutching some form of puke receptacle, and flanked by a pair of overworked, underpaid EMTs and/or an overworked, underpaid nurse. They’ve usually been cleaned up a bit to meet some unwritten, undefined minimal standard and bare few traces from whence they came. By the time they get admitted upstairs, patients are in a standardized gown, on a standardized bed, eating a standardized turkey sandwich.

This creates a poorly recognized issue for us as doctors. We fail to see the idiosyncrasies of a patient’s life outside of the hospital and tend to place them into one of three broad categories: homed, homeless, or living in some kind of facility (nursing home, rehab, assisted living, jail – take your pick). Each of these then receives the ultimate American qualifier – insured or uninsured. That assignment basically dictates more about a patient’s care and treatment than their actual medical diagnosis. And it is horribly flawed.

Only through EMS did I have a first hand, and a first nose, perspective of just how different life can be for a fellow human being. I have clambered over mountains of hoarded garbage in what looked like a upper-middle class home from the street, been in nursing homes which would put North Korean labor camps to shame, and even pulled a young woman out of the bottom of a port-a-potty where she spent the night sleeping in a tub of chlorine and human waste. There is a spectrum to everything, and the circumstances of a person’s life leading up to his or her encounter with me can tell me as much or more about their condition, and what I can do about it, than the symptoms they describe.

I distinctly remember a call to assist a man complaining of some ambiguous pain complaint. He had just been discharged from the hospital that morning. But at well over 600lbs, he was entirely unable to care for himself at home. Never before, and never since, have my nostrils known such misery. He couldn’t fill his prescriptions, get a glass of water, or even get out of the bed to use the toilet. He was, literally, a mess.

The medics bringing me patients now have my full attention. I want to know what they know. They also have my respect – I know what their noses have been through.


4.  It’s their emergency, not mine.

This one is simple. Every person arriving in the ER is there because they feel that their condition – be it crushing, unbearable chest pain or thirty minutes of life-shattering hiccups – just cannot wait another moment to be addressed. But as a newbie EMT recruit, doing my EVOC and driver training, I was taught, on multiple occasions, a memorable and poignant philosophical lesson:

“Dude. It’s their emergency, not ours. Slow. The Fuck. Down.”

-Socrates, Field Training Officer

Now that might have had something to do with the pedestrians diving into the bushes every time we responded to a call, but it sticks with me. On a busy scene, with lights flashing, sirens of approaching units blaring, family and bystanders screaming in my ear, multiple patients and limited resources, the public looks to the collective “us” that is Police, Fire and EMS to take control of situation. In the ED that role shifts to the doctors.

Approaching even a critically ill patient, with nurses, medics and techs racing around grabbing equipment and medicines, my job is to remain calm, cool and collected. Allowing my own tumblr_ls44cgafCl1qaa241level of anxiety to meet that of my patient won’t get anything done more quickly and certainly won’t hasten the cure.

Unfortunately medical school does a terrible job of teaching this. Learning about the management of truly sick patients takes place more in the classroom than at the bedside. There is infinite time to think, weigh the options, and look up the answers. The student is usually sent to see the less acute patients, or tags along to observe when things get dicey. Then, day one, intern year, with that long white coat tickling the calves of someone who has never ordered morphine or a blood transfusion or called a surgeon in the middle of the night to say I need you down here now, many struggle when it comes to taking a step back. Looking. Listening. Thinking. Acting.

So when grandpa rolls in clutching his chest, don’t be alarmed if I’m not barking out orders like you’ve seen on TV. I’ll be at the bedside, taking his pulse, followed quickly by taking my own.

5.  Scene safe, BSI

If you had asked me five years ago for my thoughts about the pervasive mantra of EMT recruits everywhere, “Scene safe, BSI,” my response would have been an incomprehensible tirade of expletive filled muttering. I’ll wear gloves. I get it. STOP MAKING ME SAY IT. Every skills station, every practical exam, every day. As if the mannequin we were pretending to bandage had actually just escaped some Liberian Ebola quarantine zone and standing in the doorway with jazz-hands to show I remembered to put on my imaginary gloves would somehow protect me. F&*%#$#!

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For those of you who don’t know, BSI stands for “body substance isolation.” The idiom is a reminder to EMT students to look for potential danger first, to protect themselves and their partner before even attempting to help anyone else, and to wear gloves. One thing is certain – no one gets extra points for getting hurt on scene and doubling the number of patients, and if you get hepatitis, you lose.

While this definitely remains true in the hospital (i.e. Steph’s “nonverbal” psych patient who wasn’t talking because of the razor blade hidden in his mouth), it goes further than that. It’s a reminder to take care of ourselves, and each other, through the emotional and physical demands of our work. Believe it or not, watching people in pain and dying every day can be rather taxing on the psyche.

Medical school spends a lot of time teaching us how to help others through the process of aging, illness and, ultimately, death. We learn every aspect of disease, how various ailments ravage the body, each in their unique way. But little time is spent learning to carry the weight of our responsibility or dealing with the death of a patient.

In that respect, EMS excels. CISM (critical incident stress management) is a program which helps medics through the worst of calls. The team, staffed by members with specialized training, provides everything from one on one counseling to group debriefings. All hospitals should have such a system.

And for God’s sake put some gloves on when you go in the room. C diff is a terrible, terrible thing.


So that’s that. 5 things which make me a better doctor, all learned at the bottom of the medical totem pole. From the basics of taking care of someone else, to the more complicated task of watching out for myself, EMS has played a huge role in my training. Even as a doctor, I continue to learn on every shift, and that is what keeps me coming back for more.

~Amir

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