rocket

Ambulance Operations. :oops: I always thought I understood the book and course material very well but then I would do a little worse than anticipated on the state exams. In retrospect I think part of it might have been the way the questions on the state exams were worded. Many of my classmates had difficulty remembering all of the details (sequence, etc) of the medical and trauma assessments. The students I helped teach recently seemed to have the same type of problems; They understood and were capable of asking the right questions, etc but worried about stating things out of sequence. The best advice I can give any EMT student is to take every section seriously and try to completely understand each of the concepts and practices. If you go on to Medic school you will find that much of the material is touched upon again...in some cases repeated almost verbatim. The better you understand the rudiments now the better you will be able to focus on the more advanced stuff...somewhat like the student who finds his high school physics class to pay dividends once he gets in to college. -Trevor

A.A.S Humanities B.S. Geological Sciences + a little Master's level work. I support the idea of a mandatory 2-year degree program. -Trevor

Try to find out what book your instructor will be using and then purchase a different one and read it prior to taking the class. Reading a different textbook allows you to gain some information from a slightly different perspective (different authors, etc) and also gives you one more reference text when you are looking up various concepts, etc. Some of the more popular textbooks in my neck of the woods are referred to by cover color: The "yellow book" aka the "Brady book". Pretty good detail and content. They used this in my -B class: http://www.amazon.com/Emergency-Care-10th-...TF8&s=books The "orange book" aka the "AAOS book". I've looked through this and IMHO it is probably superior to the Brady book in terms of helping someone completely new to EMS learn their way through the thought and action processes used on a call: http://www.amazon.com/Emergency-Care-Trans...TF8&s=books Keep in mind that both of these texts are phonebook-sized and may be difficult to read in a month's time. A nice alternative plan would be to learn/brush up on your Human Anatomy & Physiology this month. Depending on your instructor and the pace of your course you may not get nearly enough A&P...you really cannot learn too much of this stuff and a solid understanding will pay lots of dividends not only in class but also out in the field. I think the AAOS A&P book has a decent amount of content (and can easily be read in a month's time). Don't let the 'paramedic' title scare you away: http://www.amazon.com/Paramedic-Anatomy-Ph...TF8&s=books Good luck (and have fun!) -Trevor

I like FormerEMSLT297 and Bushy's use of the term "postural hypotension" since it seems to communicate what is happening so clearly. FWIW I think I've heard/read the terms postural hypotension and orthostatic hypotension in pretty much equal measure. Can we get back to the mechanics of it for a moment? As I understand it a person stands up and some volume of blood "pools" in the lower extremities. Baroreceptors (pressure sensors in the plumbing up above so to speak) recognize this as a drop in pressure and call for an adjustment in container volume, etc by way of kicking up a release of catecholamines via the autonomic nervous system. As such, shouldn't anything that could affect this system be considered when we are thinking about checking for orthostatic changes in BP? Although I have mostly observed medics checking this (along with skin turgor, etc) as evidence of dehydration it seems like ANS failure or even alpha-blocker use (say to control hypertension or prostate conditions) would also be potential causes of such findings. -Trevor

Good on ya for wanting to get some true patient care experience prior to embarking on your PA certification training. 8) IMHO the primary reason new EMTs/students freeze up in a situation is not because they cannot handle the situation. If they couldn't hack it they wouldn't have climbed into the back of the ambulance in the first place. That leaves us with uncertainty and gravity. The provider is aware of the gravity of the situation and therefore wants to be absolutely certain they are doing not only the right thing for their patient but also doing it the right way. This is a good sign; it means the provider has the best interest of their patient in mind. Better to realize how dire things are than to be oblivious to the nature of the situation....for the sake of not only your patient but also yourself. Here are a few tips that I have found to help bridge the gap between book learnin' and the actual blood-and-guts stuff: (1) Coursework is solitary stuff. So is testing. Unlike your coursework, you will not be alone when 'tested' in the field. More often than not you will have the counsel and help of your crew and other EMS, etc. This is a truly invaluable resource. (2) It is very infrequent that you actually see a complete breakdown of provider activity in the midst of the call. While you might be beating yourself up inside for not thinking to do something 'fast enough' chances are others on the scene never picked up on what feels like an eternity of inactivity to you. Chances also are that a moment's pause for thought won't break the flow of care being delivered to the patient nor will it affect the patient's outcome. (3) This is not a hard and fast rule but it can be appropriate for getting your head around a lot of the basic stuff: The patient will (either by word or presentation) often "guide" you in the direction of doing the right thing, just like strangers, friends, and loved ones do. If I said I was hungry you would feed me. If I said I was thirsty you'd give me something to drink. If I was cold you would cover me up. If I was hot you would cool me down. If I were bleeding you would stop the bleeding. If I was having trouble breathing you would help me to breathe. The message is that you will probably have a pretty good idea of what needs to be done as soon as you recognize what is wrong with the patient. Hope that helps suppress your anxieties a bit. I have a feeling that many of them will go away even more once you get out ther e and find yourself doing it. Wanting to always do what is best for your patient is a "good problem to have". :wink: Good Luck! -Trevor

:roll: If it makes you feel any better a similar thing happened in another "what's wrong with this picture" thread not so long ago: http://www.emtcity.com/phpBB2/viewtopic.ph...ing&start=0 And like this thread here, it got silly (and obviously so) too. -Trevor

You guys are missing the forest for the trees. What is wrong with this picture is the setting. When this photo was taken the EMS provider was actually wheeling the patient through the local fast food drive-thru lane rather than into ambulance or definitive care facility. -Trevor

Yup. Let's have the driver run "distraction" (asking the husband about the call, her meds, Hx, etc) and since by description she seems to pass the look test we will hold off on any interventions for the moment and just ask: "Hello. Can you tell us why we were called here today?" I'd like to know her answer and also her demeanor when she responds. Is she acting like this is no big thing or does she seem agitated? I'd also like to get a quick pulse asssessment (just a hand on the wrist to get a feel for the quality, I don't need a number just yet). And If she didn't admit anything about the balance issue yet then I'd like to add the following question: "You looked a little bit unsteady when we first came in to see you. Can you tell me a little more about that? Has this happened before?" Next questions and treatments will be based on the "picture" she presents via words and body language. -Trevor

Thanks for the scenario chbare! 8) -Trevor

I would like to know: -Is the scene safe for my crew to enter? -What are the physical conditions on scene (very hot, cold, etc)? -What are the social conditions on scene (evidence of substance abuse, violence, etc)? -What is the patient's location in the residence? -What is her general appearance (what do we see when we first see the patient)? -Trevor

That is what I understand as well. This protocol (from Wisconsin) isn't from my home state but it does a good job of describing the indications/contraindications/etc: http://dhfs.wi.gov/ems/system/PDF_files/CPAP_Protocol.pdf As we have now learned that this patient has gone deeper into the rabbit hole I agree that we are now out of the realm of use for CPAP. tube 'em, spock!! 8) -Trevor

Do we have CPAP on this rig? -Trevor

Hrmm.. interesting topic! I've not read On Call Cardiology so I may be in danger of mistaking the context of the section mentioned in this text... ..but the one difference between ambulance thoughts and elevator thoughts that seems to stick out in my mind is the is the setting of that provider-patient meeting. If the student or intern is arriving at bedside then the meeting is in somewhat of a controlled environment. Although it might still be an acute care/stabilization type of visit chances are the provider came in through the doorway. Whereas in a prehospital environment the provider might come come in through the back window of the demolished car. IMHO scene survey (and in some cases control) is a big part of what we do in the field due to the uncontrolled nature of our environment. My ambulance thougts tend to include a review of stuff like what did I overlook on the last case that sounded like this? or what did I take too long to recognize the last time I had such a call?. This type of thing might be assessment-related or it might be as simple as eyeballing a path for the stretcher through a tight area of the patient's residence. Certainly this type of thinking hooks into the information I receive from dispatch...but I try to limit the DDx to a few general ideas and focus on putting together a bigger picture just as soon as I arrive and get to see more of what is going on. Then again there are some times when all I can do en route is keep asking myself if I am actually fully awake yet. :wink: -Trevor

Yup. With those numbers I'd agree. I'll be following along and learning now :wink: -Trevor

What he said, most especially the bilat B/Ps (help to r/o AAA). The other DDx on my mind was appencitis so I'd like to ask about rebound tenderness just to get a better picture. She could be tachy/palpy from anxiety or it could be something more. Since I am on a BLS rig it's time to get packaged and moving...let's get her into a comfortable position (if possible) and do the vitals, PE and history. I'll defer on my option to call for ALS until I hear the vitals and findings of the exam. -Trevor

OK. Let's start O2 therapy as a precautionary measure and ask a few more questions. She's a little young for Biliary Colic but the physical location and some of the complaints somewhat fit the bill so maybe we can get some more info to help rule it in or out. How long ago was lunch? Was the chicken fried? what else did you eat with it? And N/V? How long ago did this pain start? You said the pain is diffuse; does it come in waves or is it constant? Did the pain increase in intensity or start at the level it is now? This call was dispatched as CP and ABD pain; do you hurt anywhere other than your stomach? -Trevor

D'oh! typed those questions while you were giving some answers! I'm still curious about the character or pulse and resps though. -Trevor

Thank you sir! No unusual aspects to the residence? excessive heat? odors? evidence of domestic "issues"? Per dispatch Mom called this in? is Mom on scene as well? She might be a helpful (or harmful :wink: ) historian... Are the patient's legs drawn up as well or is she just holding her belly? Presuming the patient is A and O I'd like to get down to her level (bend on a knee), get a quick feel for her pulse (assess te & quality) and observe her breathing while asking her why we were called here today. What is the character of her pulses and respirations and What is she complaining of? -Trevor

Let's start at the beginning and play it step by step. EMS Dispatch: F&B Unit 3854 arriving. 3854 arriving 13:40. Where are we arriving? private residence? Is the scene safe to enter? What do we see upon arrival? -Trevor

..and I answer "I'm not sure yet. Tell me a little more about what you did on that exercise. And let's hear a little more about the progression of your symptoms. In what sequence did the cough, the tightness, and the abdominal tenderness occur?". Did any of these symptoms seem to begin spontaneously? Also The cough is dry now....has it been wet (productive) at all? If so what did the product look like? Any chills, N/V? How has your eating and drinking been recently? any more or less than usual? Ditto for urination/defecation. I wonder if we have something of a compound problem going on here. -Trevor

I agree it can be tough to get a good fix on respirations during transport. This is especially true for patients that (at a glance) appear to be breathing "normally" (no obvious accessory muscle use, regular rythmn, etc). These tips are for "normal" breathers: If the patient is tolerant** I prefer to use my hands to help get a feel for not only the rate but also a little better "picture" of the depth and regularity or respirations. Try laying the palm of your hand over the area that roughly equates to the medial-anterior section of the patient's diaphragm (aim for the very bottom of the ribcage/top of the abdomen; make the xyphoid process the "top" of the area you lay your palm over). Use a light touch. You may have a better feel for movement here than up higher on the chest . If you have a talkative patient then it can be even harder to get an accurate count. In these cases sometimes I will "pace" the patient's breathing with my own. If I determine that the patient is breathing with a regular rythmn (usually I can get a basic assessment of reguarity in 4-6 resps) then I try to match my breathing to theirs. If the patient starts to talking after this quick assessment I will just keep my breathing at that pace and count it out for 30 seconds and do the math from there. Of course it is always preferred to get the real measurement off of the patient but if you've got somebody in the back who won't be quiet for 30 seconds then this estimate can come in handy. :wink: Hope that helps, -Trevor **As for a "tolerant" patient: Laying a hand on someone (and then leaving it there) without informing them of what you are doing may make them uneasy. An uneasy patient may turn into an untrusting, uncooperative, or argumentative patient; such a patient may make the rest of your assessment and history taking more difficult. You can generally get away with this maneuver by sneaking it into your physical exam or just tellng them what you are about to do.

Forgot to add: As BLS provider I'd want to get going now(barring any jaw-dropping info from the family). Let's take a fireman with us (help in the back), call for ALS intercept if possible en-route and go. Hot. I have an idea as to what is going on. If I'm right then I know there isn't much else I can do (BLS) other than to maintain or improve her level of stability and get her to definitive care ASAP. I have a feeling some blood tests are in order. Something that doesn't mix well with bleach.... -Trevor

Is that short for nasopharyngeal airway? if not I'd like to try to get one inserted. And let's get her sat up if possible. No new meds eh? What meds is she currently taking? Let's see the bottles and do some some counting. And some detective work about the PMHx. Per the family, has this type of behaviour (incl posturing) happened before? -Trevor

...and I think that line of thought can be extended right into in-hospital (ED) care as well. Have a look at this article on Trauma Assessment (particularly the primary and secondary survey sections) and compare them to your assessment protocols. There are many similarities. http://www.emedicine.com/med/topic3221.htm The good news of this compatability/similarity between assessments is that they follow a logical sequence. This is not the same as a cookbook list IMHO, but rather they "make sense" in terms of the systems and disease or injury processes that pertain to the part(s) of your patient that you are assessing at the moment. As for medical assessment: Have you tried reading a Pathophysiology text? I like this one: Handbook of Pathophysiology, ISBN 1582550468. Reading this book helped me to see "what makes sense" in terms of medical assessment. Good luck and thanks for caring enough about what you do to want to improve! -Trevor

Any general pathophysiology text will be helpful in the long run. I recommend Handbook of Pathophysiology by Corwin (ISBN 0397552130). You'll likely need to purchase a dictionary of medical terms as a companion book (to get through this and other texts). A note on reading a patho book such as this: read it mostly as a review rather than as a study aid; you don't need to be an expert on every malady...just read it to get a better understanding of how and why body systems fail during the process of disease. Also Find out what your local EMT class is using for a textbook. Then pick out a different EMT-B textbook and read it for content. Good luck and have fun! -Trevor