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?”


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


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.


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


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?”