Tag: EMS

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.

ambulance rookie
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.

image (2) RAMBO
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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Understanding the Origins of the Cincinnati Prehospital Stroke Scale

We all learned it in EMT-B class.  The Cincinnati Prehospital Stroke Scale (CPSS) is the core assessment tool for EMS providers to evaluate possible stroke patients in the field.  But, have you ever wondered where it came from?  Why does it have 3 parts? Why test speech and not eyesight?  What part of the brain is really injured? Let’s take a deeper dive.

What is the CPSS?

For a quick review, the CPSS is comprised of three individual tests, each of which get interpreted as either normal or abnormal by the EMS provider.   The tests as well as interpretation are summarized in the table below.

Components of the Cincinnati Prehospital Stroke Scale

Adopted from Kothari, et al, 1996 

Test

Normal

Abnormal

1

 

Facial Droop

 

Patient smiles or shows teeth Both side of face move equally One side of the face does not move as well as the other (or not at all)

2

 

Arm Drift

 

Patient extends arms out, closes eyes, and holds in place x 10 seconds Both arms move the same, or both arms stay in position One arm does not move or drifts downward compared to the other

3

 

Speech

 

Patient repeats “You can’t teach an old dog new tricks” Patient repeats back correct words with no slurring of words Patient can’t speak, says the wrong words, or slurs words

The CPSS is positive if any one of the three tests is deemed abnormal.  In studies comparing Physicians vs EMS providers when performing the CPSS, when performed by an EMS provider, if the patient scored positive for one component, the sensitivity was 59%, meaning just over half of the patients who indeed had a stroke were identified by the EMS provider as having a stroke.  The specificity was 89%, meaning that 89% of people who had a positive CPSS (1/3 components) indeed had a stroke.  In other words, they caught just over half of the true strokes, but they also obtained a positive CPSS on some patients that didn’t have a stroke. The best example is a patient who is intoxicated.  They likely have slurred speech, and therefore a positive CPSS, but aren’t actually having a stroke.  Most tests in medicine are like this, you miss some, and you catch some that don’t really have the disease.  We call these false negatives and false positives.  Oh, and did I mentioned that EMT-Bs scored just as reliably as the Paramedics in the study?

The CPSS intentionally misses some strokes

To understand what the CPSS is looking for, it’s important to know a bit about the history of how it was created and why.  The CPSS was developed at the University of Cincinnati Medical Center in 1997.  tPA had just been approved by the FDA in June 1996.  The CPSS is derived from the NIH Stroke Scale (NIHSS).  You can read more about it here, but simply put, it’s a 15 part assessment where the patient gets scored according to their symptoms.  The NIHSS was developed to identify neurological deficits that correspond to specific geographic tissue damage in the brain.  MDCalc offers a great online calculator for helping determine a patient’s NIH Stroke Scale score.  The NIHSS was condensed down, with some categories eliminated and some combined, to make the CPSS simple and easy to use, but also to help identify those patients who would be potential candidates for tPA.   Not all strokes are created equal, and not all strokes are elligible for tPA, even if identified within the 4.5 hour time window.  Strokes of the anterior cerebral artery and middle cerebral artery are better tPA candidates that other types of stroke.  The CPSS focuses on identifying those strokes, but not posterior strokes for example.

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The future of the CPSS and prehospital stroke identification

As I mentioned, the CPSS is not designed to detect things like posterior circulation strokes that affect the cerebellum, the balance center of the brain.  Historically, efforts focused on early identification of tPA candidates.  As new surgical and pharmacological advancements develop for other types of stroke, there’s a greater emphasis on early identification of all strokes.  As such, there’s a lot of research going on right now studying new or modified prehospital stroke assessment tools.  One front-runner is the B-FAST, which adds one more test to the CPSS to test for balance, and potentially identify posterior circulation strokes.  The posterior circulation (basilar artery in the diagram above) supplies blood flow to the cerebellum, the balance center of the brain.

B – Balance, tested by having the patient walk

F – Face, same as CPSS

A – Arms, same as CPSS

S – Speech, same as CPSS

T – Time, to remind us that time is brain

If you want to impress with your turnover on your next stroke patient, be sure to test for balance disturbances by (carefully) ambulating your patient.  If the patient stumbles or can’t walk without assistance, that’s a pertinent positive.  In the original Cincinnati study by Kothari, the CPSS missed 13 patients with stroke, but 10 of those were posterior circulation strokes, notoriously difficult to diagnose clinically, and often missed by even the best Emergency Medicine physicians.


 

As always, feel free to share any tips you have on helping assess for stroke in the field.

~Steph

Some references:
Kothari R1, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med. 1997 Oct;4(10):986-90.
Kothari RU1, Pancioli A, Liu T, Brott T, Broderick J. Ann Cincinnati Prehospital Stroke Scale: reproducibility and validity. Emerg Med. 1999 Apr;33(4):373-8.

Caring for criminals: How to provide good medical care to people who have done bad things

As an Emergency Medicine Physician and EMS provider, I get a lot of questions about my job.  #1 “What’s the worst thing you’ve ever seen?”  #2 is “How do you stay motivated and not let it get to you?” And #3 is what I’ll address in this post, “How do you take care of murderers, rapists and other people who have done horrible things?”

It’s an unfortunately common scenario: high-speed MVC, multiple vehicles, one DOA (dead on arrival), two adults in critical condition, being flown by helicopter as the highest level trauma alert, alcohol involved.  And all too often, Paramedics, Nurses and Physicians have to take care of everyone involved, including the intoxicated driver that caused the mayhem.  How do you have compassion, empathy and care for someone that by all evidence just killed someone in a completely preventable way?  I’ve been in Emergency Medicine for 11 years, and I still struggle with this.  It’s never easy, but I’ve found a few strategies to help cope.

1. Don’t Ask, Don’t Tell

A few months back I was taking care of an ICU patient that I knew was a prisoner in a maximum security prison due to the vigilant watch by 2-3 armed security guards at all times.  Clearly he had done something bad, but for me, knowing exactly what would only potentially worsen the medical care I could give him, not improve it.  So I didn’t ask, I didn’t Google.  Unfortunately someone else did, and shared it with the whole team.

Turns out he beheaded a total stranger, a husband and a father of two, because he didn’t have cash in his wallet when he tried to rob him.  Once I learned that, I couldn’t unknow it.  I struggled to walk in his room each morning with a smiling face and open, non-judging mind.  For the human in me, it was a battle I had to consciously fight.  My advice to anyone who might care for inmates or anyone in police custody, don’t ask, and encourage the whole team not to ask.  And if you find out, don’t tell.  99% of the time it’s not relevant to patient care, and can only cause you (and everyone else on the team) to make mistakes.

2. Be an Advocate

Incarcerated people have difficulty accessing medical care.  Although prisons and jails have a medical clinic, studies show that prisoners get less frequent and timely care for both chronic and acute conditions.  A 2009 report published in the American Journal of Public Health, unearthed some worrisome stats:

  • “Among inmates with a persistent medical problem, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local jail inmates had received no medical examination since incarceration.

  • Prior to incarceration, slightly more than 1 in 7 inmates were taking a prescription medication for an active medical problem routinely requiring medication (as defined in the Methods section). Of these, 3314 federal (20.9%), 43 679 state (24.3%), and 28 473 local jail inmates (36.5%) stopped the medication following incarceration.

  • Only a small portion of prison inmates (3.9% of federal and 6.4% of state inmates) with an active medical problem for which laboratory monitoring is routinely indicated had not undergone at least 1 blood test since incarceration. However, most local jail inmates with such a condition (60.1% [SE = 1.8%]) had not undergone a blood test.

  • Following serious injury, 650 federal inmates (7.7%), 12 997 state inmates (12.0%), and 3183 local jail inmates (24.7%) were not seen by medical personnel.

Incarcerated persons have to “prove” to prison staff they are truly sick and need to go to the Emergency Department.  Yes, many prisoners fake or exaggerate symptoms for the secondary gain of getting a break from behind bars: better eye candy, different food, and maybe some good pain medication.  But, 38-43% of inmates have chronic medical conditions, which by all evidence, may not be properly addressed and managed by the prison clinic.  When these patients present to the ED, I play it safe and assume they have been sick a few days longer than a regular person, as they probably had to fight to make their case to prison staff.  Guilty or innocent, these patients all need an advocate for their medical care.  I take pride in being that person, which allows me to keep my personal judgements out of the encounter.

3. We are guilty, too

Last week I took care of a woman addicted to IV heroin.  By all accounts, she was pitiful looking – shivering, sweating, unable to sit still.  She was also curt, demanding and liked to cuss at us.  The medical student with me asked how someone could make such poor choices and then be so demanding.  I didn’t disagree, and I found myself starting to judge.  I had to redirect my thoughts and remember that prescription opioids can be a gateway to heroin for many people.  Heroin is 1/10th the cost of prescription drugs bought on the street.  People get hurt or have surgery, and we (doctors, NPs and PAs) prescribe them pain medication.  When people can’t afford their prescription drug addictions, they turn to the cheaper alternative.  And who writes the most prescriptions for these drugs?  Us. We contribute to this, so we need to accept treating it.

handcuffs

That’s my limited advice.  It’s still a daily struggle, with some days easier than others.  Do you have any tips to offer on how to approach this difficult patient population?  If so, I’d love to hear them.  I encourage you to comment below.

~Steph

Advice on Switching Careers: How I made my decision to move from Marketing to Medicine

I’ve had a few people ask me to write about this, so here goes.  First off, my story is just that – mine and potentially not entirely applicable to others looking to change careers, but nonetheless I’m going to attempt to pull out the pearls and advice that I can.  Here’s the step by step process I took to a total career and life change, from President of a boutique Interactive Advertising Agency, to Emergency Medicine Physician, in the span of 7.5 years.

STEP 1: Recognize you need a change

Sometimes the need for change is obvious – if you find yourself counting down the clock to the end of your workday, then something is likely wrong.  What’s harder is recognizing the need for a career change when it’s less obvious – when you like the job you have, but you have more passion for something else.  That was the case with me.  I’d been fortunate enough to have great success in my last career.  I was well-paid for doing interesting work with cool people.  But, I had been volunteering with the rescue squad for 3 years and had gone back to school to get my Advanced Life Support (ALS) certification.  I felt alive and intellectually stimulated in the course. I was finally getting to learn the deeper pathophysiology behind what I’d been seeing in my patients for the last 3 years.  And, instead of volunteering the required 48 hours per month with my rescue squad, I was logging somewhere just over 100 hours per month.  I was about to cross a threshold where I was spending just as much time pursuing my passion for Emergency Medicine as I was in my professional field of Interactive Marketing.  That’s when I first had the idea of a career switch.  That was October 2007.

STEP 2: Mull it over

A career change isn’t the kind of thing you should decide on a whim.  So, do yourself and those around you a favor and take some time to digest the idea.  One of the smartest things I did was asked my friends what they thought, “Could you see me as a doctor?” “Do you think I’d miss marketing & technology?” “When do I seem most happy?”  If you have great friends & family like I do, they’ll have noticed this and be willing to share.  For the record, my parents did ask me the night of my EMT-B graduation (December 2004), “Are you sure you don’t want to go to medical school?”

That said, be prepared that this is the stage where the naysayers also come out.  I can’t tell you how many people said to me something along the lines of, “So I guess you don’t want marriage and kids then, huh?”  To which I wanted to reply, “No, I’m pretty sure I didn’t say that.”  The implication is reasonable though, and certainly something I took into consideration.  At the time I was 27 and single with no kids.  If I was accepted to medical school, would I ever have time to date?  Even if I met the right person, would I be able to balance marriage, babies and a life as a Med Student/Resident?

But at the same time, was I going to put my dreams and my life on hold waiting for a theoretical knight on a white horse that might never arrive?  I saw myself 10 years later without my knight or my dream career in medicine.  I most certainly didn’t want to come up empty handed on both counts.

What about the financial implications?  Here’s where it helped that I was single with no kids.  Supporting just myself, I’d been able to save a decent lump of money while working.  I was in a position to quit working and go back to school full-time (more on that in a bit).  And if it meant going back to eating Ramen Noodles, it was just me who would have to suffer.

STEP 3: Gather Information

Having not been a pre-med major, I had no idea what the rules were for medical school.  For example, would they even accept someone over the age of 30?  What prerequisite courses are required?  Does it matter that I majored in Computer Science, Marketing & Spanish and not Chemistry or Biology?  What’s on this MCAT thing? Every career field will have some of these rules, written and unwritten.  You need to know what you’re up against.

Do yourself a favor and do what I did.  Make some appointments to meet with the people that matter.  I had two major challenges: 1) identify and take all of the prerequisite courses and 2) understand admission requirements for medical school and assess my competitiveness.  So, I knew I needed to talk to someone at an undergraduate university and at a medical school.  Because I wanted to stay local, I set up appointments with the Dean of Sciences at Old Dominion University (ODU) and the Dean of Admissions at Eastern Virginia Medical School (EVMS).  Getting the appointments was much easier than I had anticipated.  I simply filled out contact forms on the websites for each school; they emailed me back within 48 hours.  That was November 2007.

Also, this is a great time to network.  On a side note, coming out of undergrad I was very hesitant to play the Networking game.  I naively wanted to feel like I achieved everything I had on my own, without “cheating.”  After working for a few years, I learned that success is actually a combination of three things: hard work, luck and help from those around you.  Your neighbor may have gone to college with the Hiring Manager for the job you have your eyes on.  Ask your Facebook friends if they know the people in charge at the place you want to go.  Did you know you can search Facebook for people who work at specific companies?  Simply type in “Friends who work at ________” and you might be surprised to find that someone you know works at the company or school where you need an “in.”  Here’s an example from my page of “Friends who work at Google.”

Facebook example

The last thing I did as a part of my information gathering was organize what I had learned about the situation.  A pro and con list if you will.  It looked something like this:

PROCONlist

STEP 4: Pull the trigger

This was actually the easiest step for me.  By the time I reached the end of my Information Gathering stage, my decision was essentially made for me.  So many people have barriers to making a big career change – no money for classes, family commitments, you name it – I had none of those things.  I knew and still know so many people that would kill to be able to pursue a new life dream but can’t. Most of my CONS were just related to money.  I couldn’t NOT do it.

STEP 5: Enjoy the ride

While med school was downright miserable at sometimes, ok many times, one thing I can say about this whole journey is that it’s been an amazing experience to help me grow as a person.  I’ve learned a ton about myself, what motivates me, what I can survive.  And, I feel true to my soul having pursued what at many points felt like an impossible dream.  Oh, and the icing on the cake, I met and married my best friend.

~Steph

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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