You respond to a 65 y/o Male at his residence. His daughter, on scene, called 911 because she is worried about her father’s health. She states that he just hasn’t been acting right. “He is weaker than normal, and becomes short of breath very easily”. The patient himself is not thrilled about your presence. He is a rather obese man (about 400 lbs), and he is sitting in his recliner sans shirt or pants. His immediate area provides evidence that he doesn’t move
S – The patient states that he is always weak and it is normal for him to get short of breath when he gets up.
A – NKDA
M – Glucophage, Gabapentin, Albuterol, Singulair, Prevacid, Carevedilol, Enalapril, Digoxin, Aspirin, Oxygen
P – AMI, CHF, Asthma, Non-insulin dependent diabetes, AICD
L – Oreos and Orange Juice
E – Sitting in his chair
B/P: 61/37, Left Arm
SpO2: 83, on 2 lpm O2,
Pulse: 40 & regular
Resp: 30 & regular
Skin: Pale, cool, & clammy
You place your patient on the monitor and obtain the following 12-lead. What would you immediately ask your patient? What is your interpretation of the ECG? What treatments would you provide?
I’ve been at it again with the video tutorials. Here is a quick, two-part explanation of Bundle Branch Blocks. I explain what causes the ECG changes associated with bundle branch blocks to the best of my abilities within the short amount of time that Youtube allows.
Did you know that both types of bundle branch blocks require you to look at more than just lead V1 to truly identify them? If not, make sure you see part 2.
I posted this article over at http://www.lifeunderthelights.com/ a few days ago and I thought it would good for here as well. I’m sorry that I’ve only rarely posted here, but I read this blog quite often and recommend it to all of my peers. Enjoy
A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.
On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.
It’s amazing when I have my maul how every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.
Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to reasons of wanting to remain employed.
And, like a lot of posts I write, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.
For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.
As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed, I must say) IV stick into an impossibly small and crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy and obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.
The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.
But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.
I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.
We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.
This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.
Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.
It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.
The original post has some pictures of the fire and of the doggies that my wife and I saved on our first “Fire Date” – It can be seen HERE
Please read the following links before continuing:
In the Shakespeare play, Romeo proclaims that his love for Juliet transcends their family names and political differences by saying
“…That which we call a rose
By any other name would smell as sweet.”
And this line certainly conveys that feeling, as does the rest of their exchange, but try calling Rose, your 78 year old patient, by another name and let’s see if she stays as sweet.
It can not be repeated enough so I will keep repeating it until I either snap and become un-Happy or until I stop hearing certain words at the scenes of emergency responses.
If you choose to use profanity I have issues with you.
If you use inappropriate terms to describe ethnic groups, I have issues with you.
If you can’t learn and use your patient’s name then we not only have issues, but you are lazy.
Things I have heard on scenes throughout my travels are terms like Pal, Buddy, Honey, Sweetie and my least favorite, Dear.
Let me assure you I have fallen victim to the occasional frustrated or suddenly confused Buddy or Dear comments, but constantly using such terms only proves you don’t care enough to even learn their name.
And another point of clarification, while we’re on the topic of names, your patients are not expected to remember yours. Notice I said remember, not learn, because of course we are introducing ourselves to our patients, then using the names they tell us to address them.
When entering a scene keep in mind what you look like. Uniformed, carrying bags, wearing gloves, possibly even a mask and asking questions. Not to mention all that ruckus outside. That’s scary. Not just for the kiddos, but everyone.
Now imagine the confusion when I come racing up the stairs in full turnouts fresh from a fire call doing the same thing.
So when you approach these folks, put them at ease from the first words out of your mouth.
I prefer a simple phrase like, “Hi there” or “Good (afternoon, evening, morning)” just to remind them I’m a human being too.
Now to the tricky stuff that comes from experience, the introduction.
“What’s wrong?” is a poor opening line,
“What happened?” can lead down roads not concerning the present Chief Complaint, and
“Why did you call 911?” often leads to people looking away and saying “um…”
Start by offering a hand and simply saying hello, then your name. When they reach to shake in introduction not only do you have an ABC assessment complete, but you make them smile and feel at ease.
Now remember the name they give you.
Repeat it to them.
“Hi Jessica, how did you end up on the floor today?”
Write it on your glove if you must, but remember it. Use it. Call them by it.
If Jessica introduces herself as Mrs Johnson, you call her Mrs Johnson until she tells you otherwise. Not Jessica and certainly not Dear or Sweetie.
Not using a patient’s name when speaking to them shows not only disinterest in your patient but disinterest in your profession.
If you lose the trust of your patient then all you are is an expensive ride.
Earn their trust and do it from the beginning with a smile, an offer of a hand, a hello and referring to them by their name.
It’s a little step that goes a long way and will not get you noticed when you do it, but will stand out glaringly if you don’t.
Imagine if Juliet showed Romeo the amount of interest many in EMS do and called out,
“Buddy, Guy, oh where for art thou Pal?”
I think Romeo would have turned tail and found someone that could at least remember his name.
Speaking of names, I broke my own rule there didn’t I. I’m Justin Schorr from HappyMedic.com and the Chronicles of EMS, a recent addition to the contributors here at Paramedicine101.
It is an honor to be considered worthy of inclusion in such an influential forum and I hope to live up to the standard set by those who came before me.
You can reach me at firstname.lastname@example.org with any questions, comments or concerns. So until next time, see you in the interwebs.
Firstly, I would like to say thank you to Paramedicine 101 for the invite to start posting some of my thoughts on this blog. I am flattered to be asked, and I look forward to having some discussions with some new readers about my thoughts and musings.
I figured that I should read it as I am due on the EMS garage podcast in 20 mins and we will be discussing it!
However, it has left me with more questions that I expected.
I am already aware of the recent move to disprove the concept of the Golden Hour, and when I have been talking to colleagues at work about it, I have basically said that all it proves is that if your injuries are going to kill you, then it doesn’t matter if you are on scene for 10 minutes or 30 minutes (or so the current thinking is telling us), and likewise if you are going to survive, then you will unless you are kept out of the hospital for a significantly prolonged period of time.
I know that this goes against all of our training and is pretty much against the core values of how we look after our trauma patients.
It has also got me thinking about other things.
Mrs999 and I have just had a conversation about it, and I came to a conclusion that I want to put out there and I would love to hear your thoughts on it.
There has and always will be the need for an ALS component to pre-hospital care. However, in the future (very near future in the UK already) will an ALS provider be defined by his or her ‘intervention capability’ or will a true ALS provider be defined by their assessment and diagnosis ability.
More and more in the UK, we have more varied options open to us for our patients. If I have a patient who is having a CVA, they go to a certain hospital or unit. An M.I will go to a different unit. Potentially significant head injuries go to one hospital whilst ‘less’ serious head injuries can go to a normal A&E unit. The list goes on and on, but shows that it is becoming more and more the paramedic’s responsibility to actually provide a provisional diagnosis to base their transport decision on.
If you get it wrong, then you can place your patient at risk by taking them to a hospital that may not be equipped to look after their needs at that time.
It also moves into the realms of minor injury and illness. Our experienced paramedics can ‘treat and refer’ or’ respond not convey’, which is completely reliant on a sound and thorough clinical assessment and a professional and eloquent patient care record.
Just take a look at how often you pull out the magic box of ALS tricks and be honest and see how often they actually make a real and significant difference.
Now, don’t get me wrong, I am not saying that we should lose these skills and interventions. I have seen the benefit of them, and they are the times where we really, really feel good about what we can do and the differences that we make. All I am saying is, as we move forward with EMS 2.0, what really is the most important tool in our repertoire?
Is it our ‘awesome’ intubation, cannulation and drug therapies?
Or, is it our ability to make a clinical diagnosis, based on highly developed assessment skills and move our patient to the correct place for them to receive definitive care?
I agree that treatment and assessment are intertwined and to be an efficient and effective EMS provider, you need to be proficient at both, but I also think there is another way to think about it.
Are we now getting close to the limit of what we can do with interventions for our patients?
I for one cannot see much more that would be of benefit or that would be practicable to try and perform in an out of hospital setting with our current level of technology (who knows ones we get into Star Trek land though!).
I have been on a number of courses around assessing and treating a patient suffering from traunatic injuries (ATLS, PHTLS), but there are very few advanced general assessment courses, primarily aimed at the medical patient for me to go on.
If we take it as I said that we cannot physically do much more for our patients, then should we now be looking at where we can go to further help our patients by concentrating more on our assessment and diagnostic abilities?
Or maybe I am just barking up the wrong tree??