Archives for October 2010

Flight V. No Flight

So yeah, I’m hopping on the ambulance for this one. Everyone is remarking about the Freeway Patroler Video: The One with the Mechanism of Injury.  If you’ve been living under a rock, or in solitary confinement for the last few weeks, here’s the link to the video: Freeway Patroler Episode 5.

Mechanism of Injury is the catch all phrase that is used in ITLS/PHTLS/whatever it is today to describe how an injury occured:

High Speed Motor Vehicle Crash.
Fall from a roof.
Ejection from a car during a crash.
Electrocution.
Gun Shot Wound.
Stabbing.
Assaulted with a golf club.
Attacked by Ostriches.
Death in same passenger compartment.

All of those are Mechanism of Injuries, or as I will refer to them now, MOI’s.  These are not reasons to call a helicopter, they are a reason to keep a high index of suspicion for severe injury. Too many people fall back on the MOI being the reason they called a helicopter, not because of patient presentation.

Now, I am a firm believer in being over-cautious when it comes to trauma patients.  I would much rather take a patient who swears they just have a scrape on their elbow to the emergency room after a roll over collision to find out that the scrape is their only injury, than to let them refuse and bad stuff happen later, but that’s just me.  I also cut my teeth in EMS in an area where we were close to Trauma Centers by ground and Medical Command also hid behind MOI and mandated anyone involved in what could be considered a Level 2 Trauma incident or above be taken to a Trauma Department, but I digress.

Now that I’m in an area where I would need to fly my patients to the local Trauma ER. I have watched multiple patients be flown out under the guise of MOI versus any major Signs or Symptoms of actually needing the flight (Abnormal Vitals, poor GCS, more than two bones on the outside of the body, major neurological problems.) 

This isn’t complicated.  If they need the flight, you’ll know. Look at it from a Sick/Not Sick perspective. 

We all know a sick patient; poor GCS, abnormal vital signs, piss poor respiratory patterns, bones poking out of flesh, or body parts missing.  Skin signs don’t lie.  Pale, cool, clammy skin with the blue hint of cyanosis around the lips and nail beds.  It doesn’t take much to figure out these patients; you can spot them the minute you arrive on scene. Where it gets tricky is when you have those patients with the awful crazy MOI’s, where everything screams “Fly Me!!!”, but your patient doesn’t.

Take a common MOI Fly Reason: Prolonged Extrication. I may have just worked around Fire Departments that couldn’t cut a car apart in 20 minutes, but I don’t think I have ever been on an “extrication needed” MVC that didn’t take longer than 20 minutes. 

With many of the extrication calls I’ve been on, the vehicles were stuck between a car and a hard place; another car, a telephone pole, a wall, ect.  Due to all the airbag and safety devices that can now be found in every surface of a vehicle these days, the patient has the possibility of having minor to no injuries, but if protocol states, “Extrication lasting 20 minutes or longer requires a Trauma Center” then many patients who really don’t need it will be whisked off to the local Trauma Hospital via the great Whirly Bird.

When it comes to medical care, we focus on all the right things: Vital Signs, Skin Signs, and an overall appearance of the patient.  We need to do the same thing to our Trauma Patients. Why is it that we allow something like a MOI come between us and proper patient assessment?  Yes, they are two different patient sets, but at the same time, we still have to approach them with the same eyes.  We preach, “Treat the patient, not the monitor!” So why are we treating the MOI instead of the patient?

Until next time.  Have fun and Be Safe,
~MT~

Nurses!

So, I discovered an article today about Nurses pushing for a bigger role in health care.  You can read it here and here.

These are my two cents:

I have a very love/hate relationship with nurses in all parts of the medical field.  There are some nurses that I would give my left arm to treat me over some doctors and there are the nurses that I would escort out of the patients’ room, crooning to them softly as if I were talking to a three year old about going and finding something else to do while the big boys and girls play with their toys.  Most nurses are competent, some are better than others, while the rest need to return their license to the Cracker Jack box they got it from.

They want more responsibility and a bigger role where they work; they want the autonomy that is granted to Doctors in hospital and Medics in the field.  What they have to work past is the same hurdle as us EMSers have to work past: they have to show they are capable of handling the responsibility of that care.  Nurses have an understanding that, we as Medics, can do whatever, whenever, wherever, but at the same time, I don’t think they see the other work we have to put into getting that autonomy.

In the article, it stated that Nurses were all for the elimination of “regulatory and institutional obstacles” to include, “scope of practice”.  Scope of practice is there so that health care employees who feel they are more intelligent than they really are, don’t do something stupid.  That’s why Medics have them.  I know *how* to do a surgical crichothyroidotomy, but my SOP doesn’t let me do them.  Am I upset about it? No, because we don’t get the chance to do them enough for me to feel competent.

You are still doing the same procedures, what’s the difference if you get permission or not?

(Hrm…wonder how many nurses I’ve pissed off so far…)

I’ll be the first to say that, as a Paramedic, I wish I had more autonomy to do what I need to do, but I also understand why I don’t.  Unfortunately, there are too many people who would take advantage of it and possibly hurt or kill someone because they didn’t have to make sure it was okay first.

Even in the article, a nurse turned doctor admitted to that, the time put in by Physicians to hone their craft versus nurses, is much more intensive than a Nurse had gone through.

As for getting paid to do the same thing as a Doctor…don’t get me started on that…I’m leaving it alone.  Just be happy they you are getting paid what you’re being paid.
 
My question, to all you nurses out there is, are you willing to take that extra step; those extra classes, extra time in school, extra interning, what have you, to be allowed to play without a safety net? 

I will now entertain any questions, comments, complaints, what have you starting now.

Our Special Patients…

I’ve had a wealth of Pediatric patients the last few days…I mean A LOT.  I’m used to dealing with children in the ambulance, hell, enough tried to be born in them and enough spit up all over me in them.  What I have seen recent is, people who are very uncomfortable with our little bambina’s and bambino’s when we get on scene.  The mere utterance of a patients’ age being measured in days or months is enough to curl the toes of everyone around.  I found myself giving an impromptu lesson on how to deal with a scared child while I watched everyone try to busy themselves with other things.

First things first:  They are scared more than you could ever be.  A bunch of adults are running around, putting strange objects on them, talking over them, and generally not being comforting like mom and dad would be.  Remember what your parents would do if you got a “boo-boo”? We have to think back to that.  We need to pull out all the mushy-gushy stops on these patients and treat them like they were our own.

Never under estimate the power of a stuffed animal. Sometimes, the smallest stuffed animal can smooth over the relationship between tiny patient and provider. Even if you don’t have a stuffed animal, the same age group that would squeal with delight at a new toy would also giggle with glee at an inflated glove with a smiley face drawn on it.

Oxygenation:  Kids need to be oxygenated, but the fight to get (and keep) a nasal cannula or non rebreather mask near them for blowby O2 sometimes not worth it, especially in the younger crowd.  If it’s blow by, basically doing it out of sheer precaution, I like to skip the middle man and hand them the oxygen tubing.  The teething set loves to chew on the end that is blowing air at them, or they keep it near their noses and mouths because they like the feel of the cool oxygen against their cheeks and faces.

Make it a game: If they’re old enough to interract on this level, turn the simple exam into a game.  Let them hold your stethoscope while you wrap the cuff around their arm, then let them hold the bulb of the BP cuff while you get everything else situated. Let them listen to your lung sounds, then listen to theirs.  The fear of something causing either new pain or more pain can make the simplest procedure a fight to the death.  Allowing them to play with the more…non-breakable equipment that you are going to use will prove to them that at least upon application, the procedure won’t hurt.

We also can’t lie to them.  It would be easy to just constantly say, “Oh, this won’t hurt” but that won’t accomplish anything other than you completely destroying your relationship with the patient in the end when something does hurt.  Explain it to them showing the benefit of the action:

Instead of: “Oh, the IV won’t hurt at all!”

Try: “It’s going to hurt for a minute, but it won’t last long and I can give you medicine to make you feel better through it.”

In the end, we all know these rules.  I’m just giving a review, but hopefully I taught someone a little something that may make treating your next pediatric patient a bit easier.

Have fun and be safe out there, please!

~M. Trommashere~

(Name of Disease) Awareness Year.

Taking a page from TOTWTYTR, I am passing on the idea of (Insert name of disease) Awareness Year.  First of all, October being Breast CA awareness month, I am sporting my pink.  While I have never had a family member stricken with this disease, I have known several friends whos’ family has been devistated by this illness.  I have posted several links on my Facebook page, but I will repost them here:

This is what started the ball rolling this year:  Pink, Warm, and Dry is an epic blog.  I would hope that you’d read her before you read me.  She is great with words, and I love what she does.  Then The Happy Medic picked up the ball and kept it going with his declaration.

I began posting links for how to do the job.  Ladies, it doesn’t take long; ten minutes tops is all it takes to check your breasts.  If you’re like me who never knew how to really check mine well until I discovered my own lump (story on that later), here are links on how to do it:

Web MD gives a great description of how to do the deed.  Also, here is a description on how to get your signifigant other involved.  It’s a video that does show a partially naked female getting a breast exam done by someone else.   Oddly enough, in talking to Breast CA survivors or those who are battling it, some  have stated that it was someone else, (doctor, signifigant other, ect) that found the lump, not them.

Incidentally, that was how mine was found.   After a rather intimate moment, my signifigant other at the time said he felt something that didn’t feel right.  I shrugged it off, saying it was just probably a swollen gland from being sick, but he wouldn’t let me forget it until I set a date for a doctors’ appointment.  The appointment was three weeks off, and he kept pestering me to set something up sooner.  I didn’t want to; hell, I didn’t see a need.  He reminded me that I knew nothing about my family medical history, so I should be concerned about any lump or bump felt in an area where I could possibly get cancer.

I finally squeezed in an appointment with my doctor when she called and said someone canceled.  As I laid on the table, the paper gown open in the front with my doctors’ cold fingers groping my left breast, she stopped and made that noise, you know that noise, the one we make when we see something we don’t like but we don’t want to alarm the patient.  She took a felt marker and put an X where she felt the lump.  At this point, I had never felt for it myself, I just took everyones’ word for it.  She told me to feel it, see what I thought, and it shocked me.  It was hard but painless and didn’t move much.  I immediately asked if it was cancer, and her response stopped me cold.

“It’s unlikely, but it’s possible…”

She set me up immediately for a Mammogram and an ultrasound.  The ultrasound was to be done first.  I walked across the hall, holding my paper gown closed and sat in the room waiting.  I looked at all the brochures about Cancer and I made my decision; if it was cancerous, I’d have both breasts removed.  Yes, they were important, and yes, I felt that they defined me as a woman, but they weren’t worth dying for.  If a man could love me with a pair of 38 Ds, then he could love me with size 0 Ta-Tas.  I mentally went through and thought of all the lingere I had that I wouldn’t be able to wear if it was cancer, but I didn’t care.  I’d burn my bras and every item I’ve ever bought to accentuate the twins before I’d voluntarily keep them in the face of something like this.

Yeah…I jump to conclusions a lot!

During the ultrasound, the Radiologist was in the room.  I felt good that I could get the report that day instead of having to wait.  He positioned the probe over the X and nodded and went ‘hrm…’ a lot.  I looked over and I thought I could see what they were looking at, but I wasn’t sure.

“Doc, tell me…what do you see?”

“A lump.”

Uh huh…

“A lump?”

“Yes, a lump.  Gotta go for a mammogram to find out what it really is.”

Fuck.

I scheduled the test; they had an opening that day after lunch.  I felt lucky that the Radiologist would read it then since he was there and wouldn’t make me wait a week.   I sat down to a chicken sandwich, but I couldn’t eat it.  Time seemed to drag on, but finally the moment came.  I put my precious boobs in the machine, had them flattened and twisted to the point I thought they were going to come off.  I was barely dressed before the doctor called me into his office to discuss the results.

He explained that I must’ve gotten hit in the breast, or just had some sort of trauma that caused a Traumatic Fat Necrosis.  I thought back, trying to think of if I had hit my boob at any point in time, but all I could think of was when a patients’ dog jumped on me, a large Lab, his paws leaving muddy paw prints on my mammary glands.  We set up a follow up appointment and I left.

From that day forward I became a habitual boobie groper.  I check once every other week and I don’t hesitate to call my doctor if I can’t attribute a lump to my montly hormonal changes or getting hit in the chest. 

Now, there are other diseases to be aware of.  Just as TOTWTYTR said, last month was Prostate Cancer Awareness Month.  Yes, I understand that for most men, that is an exit, not an entrance, but it lasts barely ten seconds and it happens once a year, but please, the same way you men want your women to grope their breasts and get their other feminine screenings, we want you to do the same!   Ten seconds of feeling very uncomfortable can be the difference of spending the next few years planning for your possible death and spending the next ten years happy and healthy with your family. 

We love you.  Please, it’s just ten seconds, can you give up ten seconds so that you can spend the next ten years with us?

There’s a list of colors and ribbons and awareness days and months, but why can’t we just remember them all for the entire year?  Especially us medical providers, we need to be preaching the gospel of prevention to everyone we see.  We see the ravages of disease every day.  Why can’t we pass the news along to them every day of every month of every year instead of just saluting a few diseases once a year for a day, a month, or a week.

So, here are some general prevention links:

Anything that deals with the heart goes here:  American Heart Association.  They’re good for more than just CPR and AED cards.  Links are abundant in that site for losing weight, how to eat healthy, and everything in between.

Diabetes hits close to home for me; several of my family members have Type 1 or Type 2.  The American Diabetes Association has great links on how to control blood sugars and how to help keep the weight off.  It also lists warning signs to look for.

For those with any sort of cancer or risk factors for cancer, send them to the American Cancer Society.

And for a list of the Awareness days, months, and weeks go to the National Health Observances website.  It gives you a list of what is in the awareness arena and when.

We need to remember, we’re on the front lines of this stuff.  People use us and the ER as Primary Care Physicians.  They come to us more often than they see their doctors.  Is that good? No, but our main purpose is to never see these people again.  If giving them a pamphlet or a mini speech on where to find help or a phone number to someone they can talk to is what keeps them from dying of something completely preventable, then fine, so be it.

Until then, I’ll proudly sport my rainbow ribbon which is what I use to symbolize my support of everything. Each cause should be represented equally, and I support them all.

Have fun and be safe out there and please, ladies, grope your boobs, and guys, the rectal exam only sucks for a few seconds.

~M. Trommashere~

Perfect world

The Perfect World

In the Perfect World, I wake up in the morning, stretch my arms above my head to greet the sun, excited to go to work.  My uniform rests in my closet, firmly pressed and starched.  I don’t have to grab an extra uniform in case of spatter; there are extra uniforms at the station as well as a functioning high grade washer and dryer I can throw my uniform into.  I glance at my phone, checking out the calls from the night before and I smile at my phone; there were twelve emergency calls and they were all handled by the on-duty crew and others who came in voluntarily to help out.

I get to my station, the vehicles cleaned and shined, fully stocked with the most high tech and advanced eqipmemt that will make my job easier.  The garage floor has no oil spots or antifreeze spots on the pavement and it smells fresh of car soap and disinfectent. Once in the station, the crew I’m relieving is fresh from a good nights’ sleep.  The main room is clean, yet still lived in.  I am told the truck is completely stocked and ready to go and I trust them that it is fully stocked and ready to go.

On calls, no matter the dispatch, people reach out willing to help.  From the mundane lift assist to the three car MVC with a flyout, I get the same response from volunteers willing to help out if needed.  We work well with the local fire and police departments, sharing and sharing alike pertinent information.  I can go into dangerous scenes with little worry, knowing my friends in blue are there to protect me, watching over my every move.

The local fire departments come out without being asked most of the time just to lend a hand.  They hear over the radio about needing a few extra minutes to get the patient out, and within moments, the strong men and women are on scene, ready and eager to help out.

Later in the evening, over dinner, we look at our pre-planning book; everything is documented and written to a T; we all know what we are supposed to do in any event that the three entities come together for a common call.  Landing zones are documented, staging areas planned, everything is planned, even down to which group can, if not otherwise occupied, goes and gets extra supplies from the hospital or getting food and water for those providing care.

 We all double check phone numbers, making sure we have the appropriate number for the Emergency Vet for the K-9 officers, and we know of any major medical problems that may impact care if we have to treat any Police Officer, Firemen, or EMS Provider.  We make a date for an interdepartment training session; those who are unfamiliar with what the fire department does will get the opportunity to watch what they do.  The police officers will go over how to get them out of their bullet proof vests in case of an emergency; where to cut and not to cut and how they need the vest preserved along with any projectile that may fall from it.

We explain how new protocols are requiring us to take any tased person to the emergency department and they don’t get angry about it, they promise to let other officers know about it and they do.

As they leave, we get word paychecks are in.  I don’t have to worry about how many digits are on my check; I know it’s enough to support myself with this one job, and I’ll even have enough left over to splurge on myself and go out of town to take that three day con-ed class I had been looking at, but no worries; in my paycheck I get a note from my supervisor.  He approves my time off and has even paid for me to attend the classes.  I get my travel information; I find a good flight with few connections and a hotel near the site of the class.

I crawl into bed after finishing my reports, falling asleep with a smile on my face.  Life is good; it’s great to be in EMS.

*****************

Hey, a girl can dream, right?