Tag: Education

Emergency Medicine, EMS, Travel Adventures

Rwanda Day 9: Seeds to Blooms

January 29, 2018

This morning Jane and I returned to Central University Hospital of Kigali (CHUK) for Rounds and then to give lectures on Event Medicine, MCI and START triage. Here in Kigali SAMU is often called upon to staff everything from high profile international business meetings to football matches with 50,000 fans. They are challenged by short notice for the events, which sometimes leaves little time for planning. Fortunately everyone seems to recognize that Rwanda is growing and becoming more high profile, and with that the need for Event Medicine management increasing.

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Dr. Noah and the team see patients on Rounds
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Coffee and tea at the ready in the SAMU office – a sign of a well-prepared EMS agency

The lectures were well received, probably because we started by passing out Toblerone chocolate bars Dr. Sudha bought in the Amsterdam airport. Free food at a meeting or lecture is universally well received.

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USA far left, Germany back left corner and the rest CHUK ED staff, a diverse crowd discussing Event Medicine this morning.

After lectures at the hospital, Jane and I rejoined Dr. Sudha and Basil at the SAMU Trauma Course. Last week we taught this course to 25 of SAMU’s brightest providers with high potential to be great educators. Friday, Basil taught them fundamentals of medical education in the adult learner. Today and tomorrow, those 25 are now teaching the same course to 25 more SAMU staff from district hospitals all over Rwanda.

The change can be felt already. Yes, the test scores were significantly improved last week, but more importantly, the SAMU staff have already incorporated their trauma training into their regular practice. While at CHUK this morning, the residents told us that SAMU was no longer performing reductions on extremities with intact pulses. The residents asked for clarification so that everyone would be on the same page. The change in practice was apparent to the hospital staff.

Sitting back and watching these instructors teach was quite inspiring. Just a few days ago, they too were uncertain and had only a fragile confidence. The preparation they invested over the weekend was obvious. Switching between three languages to ensure they are meeting the needs of all students, they delivered the content with enthusiasm and grace.

It’s a good thing these new instructors are strong, because I can barely follow what they are saying in French or Kinyarwanda. Every few sentences I recognize words or phrases like “stay and play” or “scoop and run.” It’s amusing to discover that some of these expressions are universal no matter where you practice EMS.

One thing I’ve been asking myself is “how important is creating a culture of EMS?” What does a star of life patch signify? How do awards and recognition of heroic calls help motivate providers? In a line of duty death, the traditional funeral exercise that follows…

Are these traditions specific to EMS in the US, or are they something universally necessary to growing and sustaining a productive EMS system? Would SAMU of Rwanda benefit from connecting with other International EMS agencies? How can we help SAMU grow without imposing too many of our own values that may not be what’s right for SAMU. It will be interesting to watch the SAMU staff grow and develop over the next few years. I’ve seen them grow so much just this short week.

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The very first class of course organizers and instructors

~Steph

Explore more days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 5 | Rwanda Day 6 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9 | Rwanda Day 10/11

Emergency Medicine, General, Patient Anecdotes

Ups and Downs of My Intern Year in Emergency Medicine

Everyone warns you that Intern year is hard. It’s a year of little sleep; a rollercoaster of emotions both good and bad. Frustration and guilt in wanting to know everything NOW, because everything you don’t know might be what matters for this patient, this time. And trememndous successes. Some of the things I did this year, I really can’t believe I was able to do. And survive. Mostly, I’ve learned a lot about myself, and have been reminded yet again, that I work with an amazing group of people.

UP – Running a trauma when I thought I could never do it

I have a distinct memory of standing in the Trauma Bay at Norfolk General Hospital, watching the Trauma Team work its perfectly organized chaotic magic. I paid particular attention to the young female physician leading the whole thing – inserting an airway, calling out physical exam findings, doing an eFAST ultrasound to look for bleeding. I remember hoping, wishing I could ever have her confidence and calm demeanor. That thought was followed quickly by being thankful I wasn’t yet in that spotlight myself. I could never do that, right? In September I ran my first Delta Trauma at a Level I Trauma Center, and I survived to do it again.

VCU Medical Center Resuscitation Bay, Richmond, VA
VCU Medical Center Resuscitation Bay, Richmond, VA

DOWN – Those 2-week stretches not seeing my husband

I had no idea how much I need my husband to help me feel like a normal, healthy, centered human being. Amir and I had about four 2-week stretches this year where he was on nights and I was on days, or vice versa. One day we were so desperate for a date we coordinated a 20 minute coffee meet-up at the au bon pain in the hospital. Let’s not talk about what the house or laundry pile looked like during those stretches.  This is the video we play each other if we ever need a pick-me-up:

UP – Procedures, procedures, procedures

Open Thoracotomy

Paracentesis

Lumbar Puncture

intubations, central lines, suturing, joint reductions, even a c-section… you get the idea. I get to work with my hands a lot.

DOWN – Crying in the ICU

So I’m a crier. Always have been. I have distinct memories of my dad trying to help me with math homework as a kid, me getting frustrated and crying (my stress response), and my dad getting frustrated because I was crying. “What’s crying going to solve?” he used to ask me, which of course, made me cry more.

To be honest, I was expecting to cry multiple times the first few months of residency. tumblr_inline_mhsu6v3NBF1qz4rgpI actually made it to late February before it happened. Combine working 12-14 hours a day, 11 days in a row, with little sleep, food, potty break or non-medical human interaction (one of those 2-week stretches) – and now add to that a dozen of the sickest patients in the hospital. I broke down – red face, tears, snot, the whole nine yards. The nice thing about Intern year though is that everyone around you has been there, so I had about 4 senior residents plus 3 PAs sharing their crying stories right along with me to help pick me up. And that’s what you learn to do – pick yourself up, learn and keep going.

UP – Finally learning my way around the hospital (which is actually 4 hospitals)

Anyone who works in an old hospital knows how the building just gets added onto over the years, creating a behemoth maze of windowless hallways and floors that don’t match up. “Take the elevator to the 5th floor of North Hospital, turn left and you’ll be on the 1st floor of Main Hospital.” As if there weren’t enough to learn as an Intern.

DOWN – Cancer. I diagnose a lot of cancer.

I didn’t go into Oncology for a reason. It takes the smartest, strongest, most energized people to be cancer doctors. As an Emergency Physician, I expected to treat people with cancer, but I hadn’t thought of cancer as something I would diagnose. I guess I assumed that people would present to their PCP with concerning symptoms, get an outpatient workup and diagnosis by a specialist. But people do come to the ED for hematuria (blood in the urine), anorexia (lack of appetitie), back pain and weakness. And sometimes at the end of the workup, it’s cancer.

UP – Baby Mint Mochachino for a dying patient

Baby Mint Mochachino made with honor
Baby Mint Mochachino made with honor

I’ve seen a lot of amazing, caring people do a lot of touching things in the medical setting, but one moment stands out from this year. I had a patient who had chosen to pursue hospice care. He couldn’t stop telling me how beautiful his wife was and how he looked forward to seeing her soon. He had stopped eating and drinking days ago, so when he asked me for a “real coffee,” I was intrigued. He’d requested a cup of coffee from the medical student who poured him a cup of the hospital grade mud available to all employees. His dying wish was to have a real cup of coffee. How reasonable. I went to the ABP counter, told the story to the barista, and she whipped up the only coffee worthy of such a role – a baby mint mochachino, which she made with honor and pride in her work, even adjusting the temperature down to avoid any burned tongues.

So that’s it – Intern year is coming to a close, and July 1 I’ll be a “Senior Resident,” fraught with its own challenges and lessons to be learned.

Emergency Medicine, EMS

Top 3 Ways EDs send mixed messages to EMS Providers

I think that on a whole, people who work in the ED (doctors, nurses, techs alike) really don’t know how much your average EMS provider is trying to do the best job with each call – recognize all concerning exam findings, make smart decisions on treatments, and communicate all of that in a useful way to the ED.  Being on both sides, I’ve noticed quite a few ways EDs send mixed messages that can be confusing to even the most seasoned EMS provider.

1.  Stroke – time is of the essence

Or is it?  At every level in EMS, we’re taught that a stroke is a “load-n-go” patient, that speed of arrival to the ED, potentially to receive tPA, is what counts as there’s a 3-4.5 hour window for the therapy to be administered safely (although more evidence surfaces daily questioning this).

Still, the standard of care is rapid transport, yet how many times have you transported a stroke patient and waited 5, 10, even 30 minutes to get a bed and give turnover?  Certainly obvious strokes get alerted and the patient assessed in the desired timeline.  But what about those that fall in a gray zone?  How does your ED handle these patients?  What message does it send to your EMS providers to have them drive lights & sirens (inherently dangerous in itself), only to wait wait wait?  Do you want them to start making decisions about patients with a positive Cincinnati Stroke Scale for say, slurred speech, but without hemiparesis?  As both an EMS Provider and an ED Doc, I’d rather let the ED make that call.

2.  Handwashing is the best prevention

Plenty of studies have proven this.  We hear it every year in Blood Borne Pathogens training, and it’s posted all over the hospital.  Yet, how many EMS workrooms at the ED have a sink in them, or even close by, to encourage convenient and frequent handwashing?  This is a no-brainer.  We’re not talking about adding free Red Bull or a Starbucks machine (I’m looking at you VCU), but something to keep everyone safer and healthier.

In all seriousness, VCU did do an awesome job with the EMS room (which does have a sink).  Now if only I could get access to the Starbucks machine…

3.  Removing patients from the backboard

I think this one is about to self-resolve with the trend to move away from spinal immobilization in the field.  Flash back to 10 years ago when I was a new EMT-B.  Somehow, somewhere in my mind, I got the impression that spinal immobilization was intended to immobilize not just the head and c-spine, but thoracic and lumbar as well.  Time after time I would transport a patient fully immobilized, and before I had finished saying “23 year old fema…” someone would be unclicking straps and removing the backboard.  This often left me wondering, why I had spent that extra time on scene carefully packing the patient, only to have my handiwork undone?  More groans and moans from nurses, “they could have gone to triage if it weren’t for this backboard.”  I was following my protocol, wasn’t I?  Was I doing the right thing?

We care about cervical spine injuries more than thoracolumbar injuries because they can kill you.  cervical_plexus1342596044233The nerves C3, C4 and C5 in your cervical spine compose the phrenic nerve, which innervates and controls your diaphragm, the main muscle of respiration.  Damage or sever these, and you stop breathing.  Easy way to remember: “C3,4,5 keeps the diaphragm alive!”  In reality, the meat of immobilization is in the c-spine immobilization with a c-collar, and the backboard is more of a transport device to pick the patient up and safely transfer them to a stretcher and hospital bed.  EMS protocols have lagged behind in philosophy and approach to spinal immobilization in blunt trauma, but with current chatter surrounding its efficacy, I think we’ll finally close the gap.

What mixed messages have you seen where you practice?

~Steph

Emergency Medicine, EMS, Medical School

5 Things I learned in Medical School I wish I’d learned in EMT School

Granted, it’s been 10+ years since I went through EMT school, but I still remember the gist of it. I remember often thinking the course was being dumbed down – taught to the lowest common educational denominator, which at least in the State of VA can be a GED. I actually think that’s fine – someone with a GED can do a great H&P, start CPR when needed and fashion a pretty good sling out of cravats. But EMT class is often the entry point for many folks with capability and ambitions to continue well-beyond the EMT level. I’m a firm believer in setting expectations high – assume your students want to learn as much as possible, and believe that they can. Don’t assume that they can’t understand why. Looking back on medical school and a year of Emergency Medicine Residency, I’ve complied a few things I wish I had known earlier.

1. Appendicitis pain presents around the belly button for a reason

As an EMT, I never understood why appendicitis often presented as periumbillical pain. Understanding things helps me remember better than mere memorization – that’s true for many people.  The classic presentation (50-60% of patients) for appendicitis is pain that starts near the belly button and migrates to the right lower quadrant. To understand this migration, you just need to know a bit about how the abdomen is innervated. When the appendix first gets inflamed, it’s still small and isn’t pushing against other structures. The pain one feels is deep, visceral pain (think “gut”), which happens to follow a course along the midline of the abdomen, known as the splanchnic nerves. This is why patients perceive pain in the middle of their abdomen even though the appendix is located in the right lower quadrant.  As the inflammation and infection worsen, the appendix swells and begins to irritate the muscle and tissues of the abdominal wall, producing pain in the right lower quadrant.

2. Vitals really are as important as everyone says they are

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Abby Hoobler, EMT-E auscultates to determine heart rate

I will concede that my EMT instructors definitely tried to tell us this. Often though, vitals are taught in the second lesson in EMT class, just after the chapter on consent and other medical-legal issues. It’s taught up front in a focused lesson, but really should be a longitudinal study. We spend much more time up front focusing on how to take those vitals, and less time as we go along learning how to interpret and act on those vitals.  Ask yourself – how long is your differential diagnosis for hypotension?  Bradycardia?

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Vital Sign DDx Carry Cards

If you’re struggling for more than 5, try this: at the top of an index card, write “hypotension.”  List all the diagnoses you can.  Now make similar cards for hypertension, bradycardia, tachycardia, respiratory depression, tachypnea, hypothermia and hyperthermia.  Carry the cards with you on shift.  Ask colleagues to help expand your list.  Pay attention to which conditions appear on multiple cards.  You’ll be surprised how much you can learn.  And next time you feel like you are doing EMT-B&%$# work by taking vitals, you’ll realize you’re probably the most important person on scene.

3. If you communicate well, doctors and nurses WILL listen to your turnover

We want to hear your turnover, if nothing else because you’ve probably asked 70% of what we will, and that will save us time. Being assertive, confident and organized in your presentations is 99% of the battle. Believe it or not, we also really really wish we could have access to the patient care report you wrote. Those initial vital signs and early medication administrations can affect medical decision-making downstream, especially if your patient gets admitted.

4. Stomas, Fistulas, Ports & Other Medical Devices

The EMT curriculum fails to educate providers about common medical procedures and indwelling devices. I never learned about the pieces and parts of a foley, colostomy, mediport or dialysis fistula, yet in any given day, 40-50% of EMS calls can be to Specialized Nursing Facilities (SNFs) where patients have problems with any or all of these devices. We do an ok job with complex devices like LVADs, but there are tremendous gaps otherwise.  Here’s one to start:

Stoma – Any man-made hole through skin or tissue that connects a normally internal structure to the outside world. So, the hole in someone with a trach is a “tracheostomy;” the bag attached to the hole coming out of someone’s abdomen and intestines is a “colostomy,” just like the drain in the head of a kid with hydrocephalus is a “ventriculostomy.” If you want to know the grossest thing on the planet regarding stomas, look up “Philadelphia Sidecar” on UrbanDictionary.  Yes, it’s a thing.

5. Normal Values for Basic Labs

Along the same lines as above, many patients are sent to the ED by a doctor due to an abnormal lab value.  Arguably, if the lab is concerning enough that the doctor wants the patient seen emergently in the ED, then you should probably know the normal range for that value, and what to expect if it’s high or low.  If you responded to an urgent care center for a potassium of 8.2, would you think to call a Paramedic?  I know I wouldn’t have 5 years ago.  Turns out hyperkalemia can kill you, but you don’t get to learn that until Paramedic School.  Whenever I need something complex explained eloquently, I always turn to my friends at KahnAcademy.

Familiarize yourself with the components of a Basic metabolic Panel (BMP) and a Complete Blood Count (CBC) and you’ll be 95% of the way there.

Check out the follow-up to this post, written by my husband, Amir: “5 things I learned in EMT School that I wish I learned in Medical School.”

~Steph

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Oceanfront Sunrise, Virginia Beach, VA