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Thanks for the cool scenario! :occasion5: -Trevor

Pinpoint and brady? I think I'm gonna stick with my notion of insecticide poisoning. Let's put dinner in the bag to take with us (not for leftovers) and get rolling. I want to call med/poison control soon. -Trevor

Thanks for the info. How do her pupils look? Maybe organophosphate/carbamate insecticide poisoning? -Trevor

I take it the couple did not eat the same thing for dinner? Let's hear a little more about what she ate. In the meantime let's get her head/upper body elevated (being mindful that more sezires may occur) and go 02 via NRB ...and get the nasal airways handy. -Trevor

The PE isn't particularly telling so beyond adding a FS BGL check I'd want to know more about this new onset dizziness. An alert and oriented patient is a great resource for figuring out what is going on. I'd like you to tell me a little more about what made you call EMS. Describe what you are feeling right now. Describe what you felt before you called. Any change in how you are feeling between then and now? Have you ever experienced anything like this before (and if so what happened)? What were you doing when this occurred? What have you been doing today? Yesterday? How about meals/fluids for the past 24 hours or so? Any chance you may be pregnant? ~~~~ This scenario is one where the overall presentation of the patient (agitated, etc) probably tells the most about the situation. Unfortunately this aspect of the scene is hard to communicate in a post. ~~~~ I'd say about 50% of medics I've dealt with would have me take the patient in BLS and the other 50% would ride it in. -Trevor

This works with vehicles too. On the subject of MVA's, why does the patient with retrograde amnesia always "come around" the moment he gets into the ED? patient "What happened to me?" EMT "You were in a car accident." (wait two minutes) patient "What happened to me?" EMT "You were in a car accident." (wait two minutes) patient "What happened to me?" EMT "You were in a car accident." (wait two minutes) patient "What happened to me?" EMT "You were in a car accident." (Arrive at the ED) ED Doctor "Do you remember what happened?" patient "Oh yes! I was in a car accident!!" #-o -Trevor

That's about what I figured as well. Makes good sense from a Biology 101 perspective (cellular respiration and all). -Trevor

Of three agencies I have worked with only one required EVOC training. -Trevor

I've heard of this phenomenon from one of our local medics. Here is a link that describes a possible reason for the differences. In essence, the authors state that capillary blood is closer in profile to arterial blood than venous (and there is evidently a difference in glucose levels between the two types): http://www.medicine.uiowa.edu/cme/clia/modules.asp?testID=1 -Trevor

Hi all, I recently found this little snippet on an emergency medicine PA message board. It was part of a set of "golden rules" presented by an ER PA: (The original thread is on a forum that is for "members only" of that mesage board. Let me know if you want me to copy/paste the original list of golden rules here to save the effort of signing up on yet another board just to view one topic) SpO2 and Finger Stick BGL are two things that even EMT-Bs can do in many states. I've heard the good and bad about their use/misuse/overuse/underuse by EMS folks here and in other areas too. What are your thoughts on these two? do you agree with the PA author and consider them to be "vital signs"? -Trevor

I would say the majority of lay public I encounter understands that we in EMS are part of the team of healthcare providers that works with them from the moment they decide to call 911 to the moment they are discharged from the hospital. Although we don't necessarily dress like the ER docs we are a part of that continuum of care and most people seem to realize that we are dressed more for the rescue than the physical exam. I think that much of the lay public does not realize that so many of us (in my region at least) still do this kind of service for free. And that many folks in volunteer EMS would love to make a living out of it but cannot because of the low pay rate. The folks that do this professionally around here tend to work very long hours to make ends meet...again due to the low pay rate. The low pay rate tends to be a function of (comparatively) low educational requirements and easy access to volunteer opportunities. In many ways, our individual tickets into the world of EMS is also what holds our collective industry back. This problem seems to be unique in my experience; I don't see the same problem affecting other fields in the arena of medical care. Despite these problems we EMS folks still arrive on your doorstep when you call for us. You may not realize that the guy or girl that is helping mom with her chest pains has about 10% of the training required for a hairdresser in your state, or that they spent all day at their "real" job (the one that can pay the bills) before signing on to ride all night on the ambulance....and that they've therefore been awake and working for the past 20 hours straight. Or that this person is doing all of this for free. Yet if you were told by the EMS folks they were turning over care of mom to an ER doc that had very little formal training, was coming in after working their non-medical "day job" and was doing the work for free would you feel that you were getting the best possible care for your loved one or would you feel obligated to ask for someone else to handle it? If I could let the lay public know something about EMS it would be this: (1) We do a lot with a little because we care so much. (2) I may not remember every patient's name but I do remember each "thank you" I get. -Trevor

rap�port Pronunciation: ra-'pOr, r&-, -'por Function: noun Etymology: French, from rapporter to bring back, refer, from Old French raporter to bring back, from re- + aporter to bring, from Latin apportare, from ad- ad- + portare to carry -- more at FARE : RELATION; especially : relation marked by harmony, conformity, accord, or affinity Hi all, just a quick survey for the group at large. As an EMS provider, how much of a priority do you make out of establishing a good rapport with your patient and/or the patient's family during the call? It's not the sort of thing that gets documented on the PCR. It's not an intervention that will make the difference between life and death. It's not a skill that is part of any EMS training curriculum (as far as I know). It doesn't seem to be a hot topic of discussion among providers. Yet it's one of the things that all providers incorporate into patient care. It's the part of treatment that is not covered by protocols and hence is our opportunity to have autonomous control over one aspect of the patient contact experience. One of my local (and very well respected) EMS supervisors tells a great story of working a full arrest during a large dinner party at a local banquet facility. As his crew worked the patient this supervisory medic worked with the patient's family and helped defuse the calamity that might have erupted given the conditions. As the medic tells it, most of the dinner guests assumed that "our dear friend who had the heart attack was very lucky! The people who showed up to help him were obviously friends of his family based on the way they were talking to his close relatives!" I've seen an intoxicated, combative MVA patient refuse and resist all treatment...even when ordered to be compliant by on-scene police....until the right EMS provider showed up and made that breakthrough. That wild animal that needed 5 men to get him onto the backboard turned into a docile patient....one who allowed (and consequently recieved) a much more detailed physical exam. On that note I've also seen good rapport between an EMS provider and a grumpy ER charge nurse take the turnover of patient care away from an exercise in frustration to one where everyone gets along and learns something. It seems that rapport is an important but often unsung aspect of what we do. How much of a priority do you give it in your everyday practice? Is it right up there with the ABC's? Do you try to establish it with any (conscious) patient right from the get-go? Are there any "tricks" you can share in regard to building that relationship with your patient/patient's family? Thanks! -Trevor

Lots of students get tripped up on assessment practicals. I think part of the problem is because half of the exercise is "imagined" (a healthy 20-something sits in the chair and plays the part of the 65 year-old CP patient....hard for some folks to look at one person and describe another) and the other half is "scripted" (there is a definite sequence to follow and questions/tasks to perform). The bottom line is that the exercise is not going to change between now and when you take your practical exam. As PRPG suggests, your best plan is to determine exactly where/how you are having problems and focus on addressing them. If you are unsure where the problem is then may I suggest video/audiotaping yourself? Pick a scenario and either alone or with a friend go through the assessment. When done review the tape with your checklist in hand...perhaps this will highlight the place or way you are going wrong. Beyond that I can only give general advice based on what I have observed. The students I've worked with (assuming they're putting in an effort to study and understand the material) seem to fall into two categories when it comes to problems with patient assessment: (1) Conversant interviewers (2) Literal Learners (1) A conversant interviewer is generally the type with lots of ride-along experience. They tend to want to replicate what they see on real calls; they ask a lot of questions of the patient....and thus run into trouble verbalizing something they would normally do inside their mind. These students usually have more of a problem with the unconscious trauma victim scenario. (2) Literal learners need to recite back the "script" exactly and can lose their stride if they believe they "missed a point". For these folks it seems imperative that they follow the sequence in the checksheet. If the checksheet does not agree with what feels comfortable for their scenario (e.g., some folks might have trouble indicating that they would take and hold C-spine prior o introducing themselves to the patient) then they can get into trouble quickly. For both types of students I recommend a "be the teacher" approach. Although the elements of assessment as evaluated in your practical exam are in fact the ones you will be using in real life I about guarantee you that the practical exam itself is in fact a unique experience that you will not be in again until recert time. Better then to treat the practical as its own event; this will help to create a new "logic" to follow that might help you to keep your place and perform well. Here is what I suggest in that context: Pretend that your evaluator knows nothing about patient assessment. This evaluator needs to have everything spelled out for him or her; including the little things that we normally take for granted. Be the "teacher" for this evaluator; show them how to perform a patient assessment, rather than how you perform an assessment. Take an "outline" approach, spelling out what each section of the assessment is and what needs to be done. For example: "The first thing I will do is make sure that I am protected. I will take BSI precautions in the form of donning exam gloves at this time". "Now that I have met the minimum BSI requirements, I'll size-up the scene to find more about my situation. First and foremost I need to determine if the scene is safe. Is the scene safe for me to enter?. Next I will determine what the mechanism of injury or nature of illness is. This call came in as chest pain. Do I see any obvious evidence of trauma at the scene? (no) Since I see no evidence of trauma at the moment so I will presume the nature of illness to be chest pain for the time being. Next I will determine the number of patients. I see one patient. Are there any other patients at the scene in this scenario? (no). OK. My EMT assistant and I are equipped to handle one patient so I will not call for additional manpower at this time. Next I will consider the use of C-Spine stabilization. C-spine stabilization should be considered in the event any significant mechanism of injury or in the case of a patient with altered level of loss of consciousness. As a precaution, I will instruct my EMT assistant to take and hold C-spine stabilization at this time. Now that I have the scene sized up and under control I will move on to assessing my patient. I begin by making a note of what I see...in other words my general impression. I see a 65 year-old male sitting upright in the tripod position in a chair. This patient appears to be conscious, and I do not see any obvious bleeds, deformities, accessory muscle use of breathing. I will now determine this patient's level of consciousness. This first bit of interaction will help me to solidify my general impression and give me clues as to how helpful this patient will be in determining his history and chief complaint. If the patient is alert and responsive I will make an attempt to determine his orientation in terms of person, place, and time. I will also ask for his permission of treatment. Hello sir, I am Trevor from F&B Ambulance. Do I have your permission to treat you? (yes) My his response I presume this patient's level of mentation to be alert. I will ask further questions to determine his orientation. What is your name sir? (Bob) Bob, can you tell me where you are right now? (I'm at the rescue station). And can you tell me what day this is? (It's Monday). This patient appears to be alert and oriented to person, place, and time. This tells me that he will likely be a good historian and help me to determine why he called EMS today. I will now ask him to tell me that information in the form of is Chief Complaint: Bob, can you tell me why you called EMS today? (I am having chest pains). OK. Now that Bob has informed me of his chief complaint I want to perform the rest of my initial assessment on him. The purpose of the Initial assessment is to identify and treat per protocol any apparent life threats. The physical part of this assessment deals with the "ABC's"...that is, Airway, Breathing, and Circulation. I will begin by assessing Bob's airway by ...... ~~~~~~~ ..and on and on. This same outline methods can be used all the way through the exam and helps to spell out the OPQRSTI SAMPLE questions, etc. If you like the feel of this "be the teacher" method, give it a try. It might help you to stay focused and relaxed during the practical exam. Definitely figure out exactly where you are going wrong and work on it whether or not you choose to use the "be the teacher" method. Good luck! -Trevor

If you feel like visiting the northeast Colonie EMS is a great place to check out. Have a look at their site for some details: http://www.colonie.org/ems/ -Trevor

Well it seems like this patient is suffering from a rapidly worsening case of pulmonary edema. And he's asking for exactly what he needs....to get upright. I suppose at some point the criticality of this patient's breathing would supercede the need for spinal precautions....somewhat tantamount to a rapid extrication from a wrecked vehicle but I'd hate to have to justify that on paper or in court. So here are some possibilities: I suppose you could tip the board up a bit on the stretcher to get him somewhat upright. Beyond that maybe you could slide in a KED or short board to maintain as much spinal protection as possible while allowing him to pivot at the hips and get some relief? -Trevor

Yellow vision and a pill from the foxglove plant? Sounds like Digoxin overdose to me. I'm just a basic so I'd whip out that tattered old copy of Jems that somehow made its way from the mens' room at the station to the door pocket of the ambulance, thumb through it 'till I found this article: http://www.jems.com/jems/23-8/13172/ And then hand it to the medic for reference while I go figure out what to do about that flat tire..... -Trevor

I concur with what the others have said so far and have this to add: O2 via NRB 15 L. "lying on top of debris" could mean a million little hidden things underneath him. Any obvious bleeds? Is the 2nd kneecap above of below the first one (in other words, is this a deformity in the femur area or tib/fib). Assuming 02 therapy started with no obvious bleeds I'm gonna let the Medic do the ALS thing (i.e., determine if pain mgmt meds are advisable with those vitals...esp BP, start the line(s), etc) and I will do the BLS thing. Let's get a good feel for the stability of the thorax and tenderness/rigidity of the abdomen. I'll report what I find to the medic and perform the intervetions I can given supplies and protocol for anything I find that is amiss. Let's cut and expose to see if anything else has holes in it/is pointed the wrong way/otherwise damaged etc. As mentioned above I want to get a look at the posterior sections in particular. Let's get a quick set of pulses and neuros on all 4 limbs. What do I find? What is the skin temp like from limb to limb, trunk to limbs, etc. I'll ask quickly why he is on heart meds. This may/may not help explain the lung sounds and/or why he fell. I'll also ask if he is a diabetic. Maybe a BGL check to explain why he fell/why he is "dizzy" right now. Let's grab some towels and build up the space under (and stabilize) that leg. If it's a femur injury then I might pull manual traction now and ask the medic to go get the traction splint. And while you are at the truck could you grab some cold packs, board splints, pillows and cravats? I dunno how we are going to stabilize this limb yet given the scenario but we do want to get moving quickly. I think we need to get him packaged and moving ASAP. That boils down to addressing the ABCs, stabilizing the limb and properly immobilizing the patient. He's already in it deep given the response time and if there is anything else amiss internally he will need to reach definitive care quickly. I'll give the area another quick once-over as I am picking up our toys...do I see anything telling in the accident scene or shall we learn the rest of the story in the truck? -Trevor

I'm inclined to agree with much of this statement. And I'd like to pitch in the suggestion that not every cuff on the truck is likely to be well-calibrated as well. The rough-and-tumble EMS environment can be just as hard on the cuffs (even the aneroid versions) as it is on the LifePaks and Zolls. Aneriods are prone to injury and some maintain they are less accurate than their mercury counterparts (but in the interest of safety I'll take an aneriod over a mercury manometer in the field any day :wink: ). http://www.nda.ox.ac.uk/wfsa/html/u03/u03_018.htm http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract In my young EMS career I've seen a few manometers with the needles resting well outside of the calibration point. Personally I don't like to turn down anything that could make for a better patient care experience. If I have the option of a BP reading by two different methods...say once or twice by cuff and another by machine...and I can see all of the numbers are within a few mm Hg of each other then I feel a whole lot better about the numbers I am presenting in the ED. It's even better if one of the manual BPs was obtained by someone else in my crew. -Trevor

Hi all, long time no post. I've been reading the PEPP (Pediatric Education for Prehospital Professionals) course book lately. Something in the Trauma section caught my attention and I wonder if y'all could lend me your collective experience with it. One of the recommendations in the text for dealing with head trauma patients who present with pupil asymmetry is to mildly hyperventilate (the book isn't right here in front of me so I'm paraphrasing here) "..until the pupil asymmetry returns". Again without the text in front of me I cannot verify the edition or publication date so I cannot say for certain if I'm reading the most recent edition of the PEPP text. I am aware of the controversy surrounding the use of hyperventilation in traumatic brain injury. The NYS advisory (I am a NYS EMT) covers it quite well and the recommendations are clear (and I will follow them, giving specific attention to evidence of transtentorial herniation which might include pupil asymmetry). http://www.health.state.ny.us/nysdoh/ems/policy/s97-03.htm So here is my question. I suppose it's more of a curiosity thing than anything else... Has anyone here actually observed a reversal of pupil asymmetry while a patient has been hyperventilated? I understand that hyperventilation can reduce intracranial pressure (at the potential expense of cerebral blood flow) but can it do so to such an extent that you can get a pupil "back to normal" right away ? Thanks! -Trevor

I voted "Patrick Buchanan"... ..but mostly so I could make Buchanan-esque up-n-down-karatechop-handshake motions with my hand (as he does) after doing so. -Trevor

Funny this post should re-surface (pardon the pun) right now; I've just returned from the first of several water rescue classes put on by my agency! At the class (basic water rescue) I learned they also offer swift water rescue and ice rescue in addition to the other stuff I already knew they did (confined space, rope, etc). The agency works with FD on many/most/all rescues though. Someone here once explained it thusly: "We work with FD on situations like this but we often are the first ones to arrive so we train for rescue work and occasionally get to use that training in the field". So I guess you'd say it's something of a co-opted arrangement. -Trevor

So this is in essence a hyperventilation issue? If so then I suppose the issue might require one to reconsider what "hyperventilation" actually means in the prehospital setting. Would tracking resp rate and/or depth be sufficient? I'm thinking no. I'm also thinking that if the effect were as pronounced as (perhaps) suggested in the original article then we'd often see a marked increase in respiratory rates in patients following the administration of oxygen therapy (non those with controlled resps of course). Now I'm just a newbie and have only a "handful" of runs under my belt so far but I don't believe I have seen this occur in the field. Why not? Either counting resps is not terribly accurate in the field (I could see the potential for that occurring) and we "miss" the O2-driven effect or perhaps the leaky adjuncts that T_D_D describes is the culprit. I tend to think it'd be the leaky adjuncts. That makes the most sense to me. Back to measurement: I don't think yer standard ranges (e.g., 12-20) or depths (how can that be measured other than subjectively anyway with say a NRB on the patient?) wouldn't be enough to determine how close a patient was to hyperventilation. Seems to me that you'd need something more tangible to measure the state of the patient's exhaled gases...which is what we are most interested in anyway...to be sure. So maybe capnography...like Buddha suggests...would be the best way to definitively prove/disprove the presence of the condition? Cool discussion BTW. Thanks for posting it. 8) -Trevor

Yup Yup. That was the first thing that popped into my head when I read this poll post. I've seen this occur as well. The relief crew that comes in for a 24 just got off of a 24 at another station, and you know by listening to the scanner that they've been busy all night. How can you tell if they are impared from lack of sleep? Sleep deprivation has been shown to affect judgment and coordination just as profoundly as intoxication (in some cases and individuals). I suppose it boils down to what you want to recognize as "impairment" and how you want to prioritize your reaction(s) to it. Would a call to the Sheriff be appropriate for a sober but exhausted co-worker? -Trevor

It's at least gonna start with that. -Trevor

Well If I had read it then I'm sure I'd know all the things you told me I am supposed to know. But like I said, I'm speaking in regard to what I've heard. Not what I've read. Hence my saying "that's what I've heard", not "that's what I read" :wink: -Trevor