Medic rotation woe's!

[tskstorm]

You all might be right to say we are getting sent out too early, however, this is the way it is right now. So I'm forced to deal, I suppose. If we could focus on improving the situation instead of badgering the situation I would appreciate it.

Anyone have tips on vectored exams? or appropriate questions to ask? Things like this?

[spenac]

SAMPLE

OPQRST and other acronyms

palpate

auscultate

EMS is about all your senses.

For the most part do just like you did as a basic then based on answers you will treat except now you can treat at a higher level than before.

[scott33]

Mate,

No one is badgering. If the requirements of the program contradict how other programs are run, and to the detriment of the student, then perhaps those who run it should apply some introspection. No one is having a go at you, but what is the point in having you out this early, when all you can do is start lines? I don't go near my ride time until March / April, and have lots of static clinicals to do before then, as well as the all important cardiology I and II.

Put it down to experience, you will soon be on top of the game. You have now discovered the down side to taking one of the few medic programs in the state, which offers an associates degree at the end.

[kitkat]

At this time we precept student that come in after there total classroom time and some hospital time in ER.

What I find both as an instuctor/preceptor, is when doing scenarios, these students don't have a hot clue on what to expect or how to even communicate with pts in a real setting.

I would love to see the program intergrate time on the ambulance during the program, just so they have an idea of how things are run, let alone smell, touching/lifting pts. (eg:, not do an interview halfway across a room in a whisper, shaking in their boots) that are actually sick instead of practiceing B/P's on their healthy classmates.

So in that way of thinking, after let's say a module of V/S assessment, just have them preform that skill for a few days, and observe the rest of the call, and get familiar with the concept of how to manage a pt. or run a call with the rest of the crew.

It has been interesting to hear the other side of this situation. There would need to be a very clear layout to the preceptor of what the students expectations are at each time of evaluation.

[medicpmc]

Dear Troubled:

After reading your comments, i feel that there is a problem with your ride time. When ever i get a student the first thing I do is introduce myself, then if this is the beginning of a shift we all go over the rig together this does a couple of things first we talk bs whatever get to know one another, and while doing soI ask questions such as how much experience do you have how much ride time where are you in class what you can or cannot do. Then I explain how I do things and since i work for a busy county and know the calls will come I usually let the student walk and stans right next to me so they get the understanding of questioning a patient to come up with a plan to start treatment, and ask my student to do vital signs listen to lung fields so they can relay them as a crew member. during transport, I allow them to do the skills they are allowed to do, after the call we all sit down and talk about it or just the 2 of us it totally depends on the students comfort.

my advise to you is next time you do a ride along talk to your preceptors tell them what you are comfortable with what you have covered in class in other word communicate with them. ride time should be with as little stress as possible a time to learn how to take care of patients before you get thrown to the wolves.

[OVeractiveBrain]

To answer the original question:

(1) "whats wrong"?

If something wrong, get the easy stuff:

(2) Pain?

(3) SOB?

(4) N/V?

OPQRST not bad.

If bullshit:

(2) Revert immediately to BLS.

Hx, All, Meds is a freebie.

"Any past medical history? Diagnoses (plural), Procedures or Surgeries?"

"Do you take any medication?"

"Are you allergic to any medications?" / "any medication you CANT take?" and WHY

SAMPLE and acronyms are fine, but never hold them as rigid. They are just good guides to develop a picture. THe picture you want to paint is where did it come from, how is it now, and what should you do about it.

On first approach, the "initial assessment":

- Greet the patient to determine LOC

- Put your hand on their wrist to take a pulse. Dont tell them youre doing it, and be gentle and subtle about it. Ive had some elderly patients take my hand, as though I were consoling them. Thats the gesture i make, and determine "strong/weak" and "slow,normal,fast"

- Rule out critical stuff (CP, SOB, N/V) by asking closed questions (nursing style)

Secondary Assessment (flushing it out)

- OPQRST

- SAMPLE

- CP = Smoke? DM? Age? Pain scale? Inteventions

- SOB = Smoke? Cold? Others Sick? Fever?

-

[OVeractiveBrain]

Medical School "Medical History Outline"

CC / Hx

FARCOLDER

Frequency of Occurence

Associated symptoms (CP + NV, SOB + Fatigue, Cough + Fever)

Radiation

Character of Symptoms ("whats it like?" i use "knife, fire or like an elephant")

Onset ("When did you first notice it?" If they cant get anything "minutes, hours, days?")

Location ("point to the pain" "

Duration ("how long have you had it?" "each episode lasts x time")

Exacerbating factors ("anything make it better?")

Relieving Factors ("anything make it worse?")

Time Course Expanded

This is where stuff really changes. Prehospital medicine gives you about 15 minutes with your patient, not an hour. So here is where discresion comes in to play. For medicals, as a medic, I try to get the important things, listed in the previous post. Hx, All, Meds. You can ask things like travel, childhood diseases, or family history, but they are usually not relevant for prehospital medicine given your time limit.

For CP or SOB i like to get a good social hx: Smoking, Drinking, Drugs, DM, Living environment (SOB and "diaphoresis" in an 108 degree house without A/C) and work.

For cardiac events (CVA, ACS) family history is important. "Anyone else in your family ever have a heart condition? how about a stroke?"

When getting the CC and FARCOLDER (i hate the pneumonic but its just an idea) you want to use OPEN questions. For Hx, All, Meds, especially with family history and social history, i use CLOSE questions. I want them to paint the picture of the current illness, but I do not want them to dominate the conversation with blibbery blab.

I can conduct an interview in about 10 minutes, including the physical exam. I NEVER run through a pneumonic. Pausing to think of "which letter is next?" will make you sound incompetent.

On a final note i was often very impressed with my preceptors. They knew just what to ask for every situation. They never seemed to ask more questions than was necessary. How did they do that?

Well, they did that because they thought they knew the answer to what was wrong and got tunneled. In retrospect, even if they were right in their assumption, they often did a poor assessment. The nuance questions will come in time. You will know when to ask if there is a fever or if some one else in the house is sick or not, because you will have asked it 100 times. Of the 100 times, only 2 times will it have had relevance. You will then probably still ask it because it is ingrained in your thought process, but know that it doesnt matter except when you see that 2% again.

As a beginner, you are going to fail. You dont know everything yet, and even when you graduate you still wont. Your skills develop perpetually over your career. In general, realize that there are about 500 questions you could ask each patient. Upon hearing the chief complaint and their history, you will have to decide which questions are relevant. You are not going to ask a trauma patient about their framingham scale (unless they suffered a heart attack resulting in the accident, of course), like you would not cinncinati some one with a fever from a nursing home (of course, there is always the chance of cavernus sinus thrombosis from an infection spread through the facial vein through the inferior opthalmic vein, incidence is about 1/100,000). At the same time, that doesnt mean you cant do a neuro exam on them to get a better picture of their condition, or even their general state of awareness.

Good luck!