Lame excuses

My employer runs a paramedic program. When I say that the company runs a paramedic program, what I want you to take away from that is that the company supplies a physical location for a paramedic program, and students to fill the chairs.

But, they attached the words “EMS Academy” to it, so maybe it is sorta-kinda-official.

Whatever. It’s a moot point.

My employer runs a paramedic program.

Being one of the company’s Field Training Officers, I get to see the aftermath of the paramedic program, when the newly graduated paramedics spend several shifts riding with me. Some of them aren’t prepared, but most are.

I was having a talk with another FTO, Tony, while at the hospital a few days ago. This must have been early in a shift, because I actually cared about the topic.

Tony mentioned that he rarely sees the same paramedic student more than twice, and that each student does at least twenty rides at our company. He thought it would be wise for a student in our paramedic program to be ‘assigned’ to an FTO for the duration of their preceptor rides.

While we’re on the subject…our program is putting paramedic students on ambulances for their preceptor rides after three months of school. They don’t know how to read a monitor, and they aren’t allowed to perform any ALS interventions. What the hell is the point of riding for twelve hours on an ambulance if you can’t do anything?

Anyway.

Tony made a good point. After ten rides or so, there should be a pretty good rapport between an FTO and a student. They should be able to communicate openly with each other, so the student can get the most out of their classroom time, and their ambulance time. After twenty rides, any bad habits should be corrected, and the FTO can feel confident in his evaluation of the student. Alongside the FTO’s confidence in his evaluation, the course director can feel confident in the evaluations he gets from the FTO.

But instead, the students just ride whenever, and wherever. Rarely more than once with the same paramedic, or even with an FTO.

So Tony and I brought it up to the director of the program.

“Assign each student to an individual FTO. We have twenty-five students, and eighteen FTOs. Surely we can come up with a list of seven competent medics to fill the roster of needed FTOs. Once a student is assigned to an FTO, that student does all of their rides with that FTO. It only makes sense.”

We got a reply:

“Well, that would just be too hard, and we don’t want to make it any harder on the students.”

This is why I don’t care.

Lame-ass excuses.

Tachylawdy

“What’s wrong with her?”

“Nothing. She’s got the tachylawdys.”

“Geez. Take her to triage.”

***

‘Tachylawdy’ is a thing down here. Along with sick rags, but that’s a whole different post. Never have I seen tachylawdy present in a sick patient. Not once. The only times I have seen tachylawdy present in the field are:

  • anxiety
  • doesn’t want to be at work
  • [pick your male family member] is getting arrested
  • anxiety because of being at work
  • getting pulled over

I have never seen a patient present with the tachylawdys without the presence of other concerned family members. Nor have I ever seen a male patient present with the tachylawdys. I have, however, seen the tachylawdys present in female family members that were present while I was caring for another person, be it male or female.

Basically, you walk into a house and find a female, usually with the back of her hand on her forehead, always with her head turned away from you, eyes closed, not a damn thing wrong with her:

“Oh, lawdylawdylawdylawdylawdy…. OOOOOOOH, lawdylawdylawdylawdylawdylawdyheppmelawdylawdylawdy…”

***

Bradyjeezus now, is much, much more serious.

Yonder

Yesterday, I wrote about how Slimm and I were discussing the definition of ‘yonder’ while on the way to a call to pick up a bossy lady.

Seriously, that’s what we do.

We suggest that everyone eschew the common, accepted definition of yonder, which can be found at dictionary.com. While it may be used to describe some “place, more or less distant; over there,” we propose a new definition:

yonder

[yon-der]

adjective

1. further than you can throw, but not too far to walk

“I’m going to head over yonder to pee. Holler if we get a call.”

Now you know.

Estoy aprendiendo español

Slimm is out again today. Sometimes, I think that guy calls out just because he doesn’t like me. He gave me some lame excuse about his daughter getting her tonsils removed.

Whatever.

My partner today seems to be a nice guy. He obviously showered, doesn’t make me listen to country music, and leaves me alone while I’m reading.

We get a call for a “person down at a bus stop.” No doubt called in by some hero roaming the streets of our county, saving victims from themselves with phone calls. We never get to meet this hero, likely because he or she is always off in a rush to save the next poor soul, and can’t stick around the scene.

It’s a drunk guy laying on a bench at the bus stop. He is obviously Hispanic, or a really tan Texan with a penchant for western wear. He’s awake, but groggy. I think ‘somnolent’ is the correct medical term.

“Hi.”

“Ayyyyyy”

“Hola. Cómo estás?”

“Estoy bien.”

“¿Habla usted Inglés?”

“Eh, pero un poco. “

“Mi español no es muy bueno, pero lo intento.”

“Suena bien.”

¿Estás bien? ¿Tiene dolor en alguna parte?

“No. No tengo dolor.”

“¿Está usted enfermo?”

“No, cansado.”

“¿Cansado?”

“Sí.”

“¿Borracho?”

“Sí. Muy borracho.”

“¿Beber toda la noche?”

“Toda la noche. Muchas bebidas.”

“¿Cerveza? ¿Vino? ¿Tequila?”

“Sí.”

“¿Cuál tomaste?”

¡Todos ellos!”

“¿Quieres ir a un hospital?”

“¿Por qué?”

“Mi jefe me pregunto.”

“Su jefe suena estúpido.”

“Buenes noches.”

I look at my partner and the fire guys. “Alright, let’s pack it up. I think we are done here.”

“What the hell just happened?

“He says he is just tired because he is absolutely wasted, then he called our boss stupid.”

“Really?”

“Yeah. He doesn’t want to go to a hospital, either.”

“He called our boss stupid?”

“Yep.”

“Smart guy.”

Listen and learn

Newguy is out today. He and his wife are finding out the gender of their new baby, so he is going to the appointment. Well, Mrs. Newguy says they aren’t going to find out, but Newguy says he is going to cheat and sneak a peek at the ultrasound. He even has a plan and everything for how he is going to do it.

Nobody tell Mrs. Newguy, okay?

I’m working with a kid today. I did the math, and he was in diapers when I started in EMS. And he already has a bad attitude.

There is a difference between burned out and a bad attitude.

We get a call for a lady who is sick. It turns out the lady is visiting her daughter from Oregon, and has been confused, febrile, and weak for the past few days, and it is getting worse.

Daughter hands me an insurance card and says she needs to go to the hospital about 45 minutes away. While she is saying this, Babyface pipes in.

“Well, we could take her to Local Hospital, and they can just transfer her if needed, but they will probably just let her go if she just has a fever.”

Daughter looks excited, then goes on to explain that the sick lady is allergic to Tylenol and Penicillin, and has a diagnosis of primary biliary cirrhosis. No other medical problems though, which is good for a grandmother in her late seventies.

Finally we see the patient. She’s confused, sure enough. She’s pale, and the jaundice is pretty apparent in her sclera. (What is the plural of sclera? Is there one?) So, she’s sick, and probably needs to spend a day or two in the hospital for some IV antibiotics.

“Okay, we’ll take her to Westside Hospital. We are going to go bring our stretcher in here, and we’ll be out of the way.”

Babyface is absolutely apoplectic. “Why can’t we just take her to Local Hospital? It’s across the street. Westside is forty-five minutes away.”

I get stern with him. “I know where we are, and I know where the hospitals are, and we are going to take her to Westside Hospital.”

Later, at Westside, he decides to assert his position once again.

“Man, we should have just taken her to Local. This doesn’t make any sense.”

“What is primary biliary cirrohsis?”

“She’s probably an alcoholic, and she drank too much, and now her liver is shutting down.”

“Wrong. What is the first thing that comes to your mind when you hear that a person is confused, weak, and febrile?”

“Sepsis?”

“Fair enough. Does the diagnosis of primary biliary cirrhosis change that? You still thinking sepsis? What about her jaundice?”

“I don’t care about her cirrhosis, she just has a fever.”

“No, her ammonia levels are high, and she needs lactulose. She is very confused, and only responds to verbal stimuli, which suggests hepatic encephalopathy, and she needs an ICU. Taking her to Local Hospital would have been a bad decision, and a waste of time.”

He was still mad at me for the rest of the shift.

TBD: Think Before Denying

Newguy and I are inside the home of a delightful lady who was complaining of chest pain, at least according to our dispatchers.

Our intrepid local first responders are huddled around the patient, in a mad dash to save her from the throes of death.

They seem to be succeeding at preventing her imminent demise, and also are sucessful in their attempts to create a large pool of blood all over the patient’s hardwood floors.

It’s a win/win situation so far.

One of the patch-wearing heroes rattles off some vital signs, and they are all better than mine, with the exception of her blood sugar: 331. Alas, she is a diabetic.

I really enjoy when the pieces of the puzzle assemble themselves.

Our infirm female has said several times now that she needs to “tinkle,” and asks if she can go. Newguy wants to get the 12-lead first, so he asks her to wait just a minute or so. It’s normal, by the way.

“Okay then, can I have a glass of water while I wait? I’m really thirsty.”

“Nothing to eat or drink until you see the doctor” the intrepid hero reflexively replies.

Newguy is nonplussed. “Why can’t she have anything to drink?” he asks.

“I don’t know” is his reply. Clearly, he has no idea.

“Were you guys going to put saline in that IV over there?”

“Well, yeah…”

 

Why don’t we think about these things? Don’t we all recognize what is going on here? This lady is hyperglycemic, and polydipsic and polyuric. Because her blood sugar is ridiculous. Granted, I’ve seen higher, but she’s going to get a large amount of fluids in her IV on the way to the hospital, so is there really any harm in giving her a glass of ice water?

A post about a comment on a post

So I posted what I found to be a humorous exchange between a first responder and a paramedic that I witnessed not too long ago.

As he is wont to do, TOTW posted a comment on my post. Some times, I think he and my mother are the only ones who actually read my blog, and I enjoy his comments. (Mom never has much to say. She really doesn’t read, anyway.)

He says:

There’s a difference between knowing what’s going on with the monitor and what’s going on with the patient. Unfortunately, a lot of people don’t see that.

And he is right. Absolutely right.

I have always viewed the cardiac monitor as a tool to aid in my diagnosis and treatment, rather than as something that guides my treatment. There is a difference there. A slight and subtle difference, but one that I think is very important.

Really, it is the difference between a cook and a chef.

A cook follows directions, and adds a certain amount of ingredients to a dish at certain times. A chef knows how foods and ingredients interact with each other, and is not afraid to experiment and let the dish guide how he prepares it.

Now I’m getting hungry.

I used to work with this guy. He was a huge jerk. A stereotypical, 50-something Jersey Shore jerk. He used to wear his shirts with several buttons undone so he could show off his manly chest mane, and his gold chains. No, I’m not kidding.

But he was a great clinician, and took very good care of patients.

One day, I asked him if he wanted me to put the monitor on a particularly sick patient.

No, I already know what it is going to say. No need for the monitor just yet.”

That confused me. It confused me a lot. I was a fairly young EMT at the time, and I thought things had to be done a certain way, and here was this guy who was doing it his own way. But what he said later when we talked about it made sense:

“A good assessment will tell you what the monitor will say. A person complaining of chest pain, presenting with Levine’s sign, with pale, diaphoretic skin and weak pulses is going to have a sinus rhythm, perhaps with a first-degree block. Then the 12-lead will show ST elevation. And if it doesn’t, I will be surprised. Granny, with her 47 bottles of medications and nausea and vomiting with an irregular heart beat will be in atrial fibrillation.”

Granted, there are no absolutes in EMS, and people won’t always present the same way. But there is a big difference in reading the monitor and knowing what the monitor will say.

Well, there is one absolute in EMS: nobody will be critically injured in an MVC in which the cars have pulled into a McDonald’s parking lot.

Traffic by Tom Vanderbilt

Burned-Out Medic wrote a post a little over three years ago about a book he suggested everyone read. Traffic:Why We Drive the Way We Do (and What It Says About Us).

I always enjoy a good read, and usually have two books in rotation.

Lately I’ve been a fan of Malcolm Gladwell and Gavin de Becker. That is also where I get ideas for the next book to read: from authors citing books in their writings.

Somehow, Traffic: came up in a conversation, and I remembered the post from Burned-Out Medic.

So I bought the book.

And I can’t put it down.

Everyone should read this book.

 

Those are all Amazon links, but I’m not an affiliate or anything like that. I don’t get paid if you buy those books through my link. But you should buy them anyway.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”

“Yes.”

I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”

A conversation about plethysmography

“What’s that?” asks a student on another ambulance, pointing to my cardiac monitor.

“It is the plethysmograph” I replied, most likely butchering the pronunciation.

“What’s it for?”

—–

After dropping my patient off, I made my way back to the EMS room where I found the student. It turned out he is a paramedic student, just finishing up his intern rides. He has a few weeks to go before he takes his exam. He has been an EMT for roughly 4 years, and by all accounts, is a good student, and a fast learner.

The fact that he asked a paramedic whom he didn’t know bodes well for him. He is engaged, and wants to learn.

We spent the next 15 minutes or so discussing the plethysmograph and its usefulness in assessing patients. What struck me most about our conversation was the fact that he had no idea whatsoever that there was even such a thing, much less that it could be used to assess patients.

We talked about how vasoconstriction can cause an increase in amplitude, and what could cause vasoconstriction. We talked about how vasodilation would cause a decrease in amplitude, and the causes of vasodilation.

We discussed how waveforms would change in a hypertensive patient with chest pain to whom we were administering nitroglycerin. The mechanism of nitro’s action, in decreasing systemic vascular resistance through causing vasodilation. It seemed to make sense how waveforms would change, and how that was directly related to afterload.

My patient happened to be septic, and I could show him how plethysmography could help confirm that diagnosis. My patient was an infirm older woman who had a mildly altered mental status, hypotension, and some mild tachycardia. The fact that she had a chronic Foley catheter with cloudy urine in the bag made the diagnosis of a UTI fairly easy, but the plethysmograph showed a very deep, prominent dicrotic notch.

He asked, appropriately, how the waveform would help me in my assessment, and I explained that the deep dicrotic notch showed me a low SVR, and there was no need to assess orthostatic vital signs.

He was receptive, inquisitive, and it was a refreshing conversation.

—–

I’m just a regular paramedic, and nothing special. I only learned about this stuff because I asked and because I wanted to learn. I enjoy showing students, and other EMS personnel, things that I have learned along the way, and I enjoy learning from others. Our education doesn’t stop when we get that paramedic patch, it begins.

What is disheartening is the fact that a paramedic student, only weeks away from testing to become a paramedic, had never heard of a plethysmograph, a dicrotic notch, and did not understand the relationship between waveforms and vascular resistance.

We have a very, very long way to go in the education of our paramedic students.