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.

 

Phone calls

FEM/22YO/BLEEDING FROM MOUTH” says the MDT.

We arrive on scene to find a pleasant looking female, approximately the age stated on our mobile dispatch terminal thingie. We don’t notice any obvious trauma or distress, but we haven’t made it to the apartment door yet.

Slimm takes point.

Good morning, ma’am. What seems to be the problem today?” he asks.

I’ve got this thing on my mouth and it burns.”

And then we see it.

A cold sore.

I bet that burns and hurts. How long have you had it there?”

I woke up with it this morning.” (and decided that a call to 911 was in order, apparently…)

Have you tried putting anything on it?” Slimm asks, knowing full well the answer will be a resounding ‘duh, of course not.’

I don’t know what it is! Shouldn’t I see a doctor or something?!”

Well, ma’am,” Slimm replies, being the consumate professional that he is “it appears to be a cold sore. There are lots of treatment options at the pharmacy.”

What is a ‘cold sore’?”

It is a type of herpes infection. They are pretty common, actually. They usually go away in a few days, but they can come back at any time really.”

Sometime in the past few days, Slimm has become a dermatologist.

I HAVE HERPES?! ON MY FACE!?”

It really isn’t that big of a deal. Most people get them…”

OhmygodIhaveherpesonmyface!”

We are sliding quickly down the slope towards an anxiety attack.

Am I, like, contagious?

Well, yes ma’am. If you share utensils, or drinking glasses or straws, or kiss, or have oral sex, you can pass the virus to the other person.”

A gasp audible from ten yards escapes her mouth.

I need to make some phone calls…”

We make our way back to our ambulance and climb in. Slimm turns to me. “I wonder who she is going to call?”

Yes, Community Medics

I’ve been low on blogging inspiration, so a big thanks to Mr. Morse for his post on Community Paramedicine. He seems not to care for it much, and lists 10 of his top reasons why.

My reply to his ten reasons:

  1. I may not know much about insulin pumps and how best to maintain proper insulin levels, but I want to learn. I don’t care to learn about how to perform high-angle rescues, but I won’t put down the person who wants to learn how.
  1. The emotional well-being of our patients should be a priority of ours. This includes counseling drug addicts, or at least referring them to the persons who can provide them with adequate psychological care. When we revive a heroin overdose, do we just spend the next several minutes ignoring the patient in the back of the ambulance? Or do we initiate a conversation with the patient?
  1. See #10. Why are we afraid to learn about drugs and therapeutic regimens?
  1. “Ambulance” is not synonymous with “Paramedic.” If a registered nurse can provide the same level, or higher level of care than a paramedic, then why are we concerned? Isn’t the care of the patient our foremost concern?
  1. I don’t see this as a “cradle to grave government funded approach to healthcare” at all. Even though Congress and our President would disagree with me. But I also work for a private service.
  1. It probably takes more thought to learn how to counsel people on how to avoid things that may trigger allergic reactions. We might as well stick with what we know, right? See # 10 and # 8.
  1. I also like nurses. Especially pretty ones who smile and talk to me. Nurses like what I do as a community paramedic, because I can reduce their workload. If I can prevent one readmit to the Emergency Room, that makes triage times quicker, allows nurses to focus more on their patients since they have less of a workload, and can raise reimbursement rates for the hospitals.
  1. At least 80% of our job consists of responding to non-acute problems. But yes, we should forget about that 80 percent and instead focus on the remaining 20. I work in a very busy area of the country, and probably run one or two true emergencies per month.
  1. Why would the concerns of another group be a concern of the community paramedic? There is a void in healthcare, and nobody is stepping in to fill it. Paramedics already work in the community, and are a logical solution to the puzzle.
  1. Ah, yes, the image of EMS.  Maybe, just maybe, members of the community will see the paramedics in a different light: perhaps they will have the image of the paramedic that is willing to make appointments to follow-up, check-up, and to help them meet their healthcare needs.

He is right, we should “be excellent at what you do, and respect those who are excellent at what they do.” Mr. Morse seems to only focus on one-third of the initials in our profession: the “E.”

Emergencies is what we do. But we also do Medical Services. There is a huge gap in our healthcare system, and we are positioned to fill that gap.

We should be more invested in the health and well-being of the members of our community. We should be proactive and prevent emergencies from happening, instead of reacting to them.

Community Paramedicine isn’t just about checking insulin pumps or reconciling med lists. It is about preventing the little old lady from the fall, and answering questions, and so much more. It is about keeping people from needing the trip to the Emergency Room. I believe community medicine will play a large part of the future of EMS and healthcare in general.

We can either lead or follow.

Those who don’t want to lead, and aren’t willing to follow, should simply get out of the way.

What is said and what is heard

What it said is “treat the patient, not the monitor.”

What I really hear is “I don’t know how to accurately interpret the monitor, so I can just ignore what is on the monitor.”

For example: your patient is a 73 year old male. He is pale, cool, and diaphoretic. He has normal mentation and complains of weakness. His heart rate is 40, and weak at the radials.

Do we seriously not base our next treatment off the interpretation of the monitor?

He could be in symptomatic bradycardia, and might need a little atropine. He could be having a humongous inferior MI and need a large bolus of diesel. He could be in a complete heart block and need to be paced. He could be in ventricular bigeminy and need some oxygen and a fluid bolus.

But no. You treated your patient, and not the monitor.

What is said is “I know he doesn’t have neck or back pain, but I’m going to board him anyways because of the mechanism.”

What I really hear is “I totally have no idea that immobilization causes harm, and besides, I don’t know how to perform an accurate assessment anyways.”

For real. If you are going to immobilize someone to a spine board, at least have the cojones to say “I was legitimately concerned about the possibility of an unstable cervical spine fracture, so I performed the immobilization.”

We shouldn’t base any treatment based on mechanism alone. Should every victim of a gunshot wound get bilateral lines, oxygen, and transport to a trauma center?

What is said is “I have to do treatment x because it is protocol.”

What I really hear is “I’m just doing what I’m told, and may or may not know better. I might be interested in changing the protocol, but probably not.”

If your medical director wrote a protocol that instructed EMTs to apply a brown paper bag to the face of any tachypneic patient, would you do it?

If your medical director wrote a protocol that instructed you to perform spinal immobilization on every patient who might have a head injury, would you strap down the old demented lady with kyphosis who rolled out of bed on the wrong side?

Or would you stand up for your patients, and for your profession, and point out the wrongs?

I guess I’m just irritated.