June 25, 2010

Doing the minimum necessary

That phrase is ground in to our heads in school. Do just what needs to be done to your patient to get them to the hospital alive. If they don't need an IV, don't do an IV. If they can suffice off an OPA, don't use a King airway. If a King works, don't intubate. Etc etc. The problem is learning what the right amount is for us new Paramedics.

At this point in my career, I truly am uncomfortable making some of the decisions I make in terms of patient care, yet still make them because I know I have to.


Last week I had an OD at a rave who has a pulse rate well in excess of 160, and unconscious, BP 150/90 initially. We quickly got him to the ambulance and en route to the hospital, 5 minutes away. I did a quick assessment, did an EKG (SVT), made the (5th OD) call to the hospital, and tried fighting with the guys mouth to suction his gurgling respirations caused by him vomiting, to which he would clamp down on the catheter.

We got him to the hospital, they RSI'd him to get a tube, and he promptly went in to Vtach, which they shocked, and his BP went to 60/30, even with 5 liters of NS infused in two IVs. Body temp was 108.8* F... frying his brains right in front of us.




So that leads to my questioning of myself after this call. Did I do the minimum necessary? Did it suffice that I got him to the ER as quickly as possible, or should I have done more? Should I have attempted to cardiovert his SVT, with or without an IV, even though his BP was fine (elevated?) Should I have tried pushing Valium to ease his teeth so I could suction? Should I have put in an NPA? Should I have tossed on a few ice packs, seeing as he was warm, but I didn't have a thermometer?


Why do these thoughts only come to me AFTER a call, and not during?

This is why I want to do 911, and not IFT, so I'm in these situations more, and can get more comfortable with making the decisions necessary.



Stopped by the hospital a couple of days later, and one of the nurses said the guy survived the first little bit, and they had him up in the ICU, but the docs still don't have much hope for him. Even if he does live, his brains are fired.


And before anyone asks... it's not really eating me up. I'm not depressed, not sad, not mad. Just wondering if it could have gone better.


Until next time.

June 15, 2010

Can I Poke You With My Needle?

IVs. Generally one of the most used physical skills a Paramedic does on a regular basis. Medics tend to pride themselves on their IV ability--- I mean who else in the healthcare field can start an IV upside down in a car wreck, or while bumping down the highway in the back of a rig? None from what I can tell.


All other healthcare professionals tend to have a much more controlled environment when starting IVs. Nice, well lit, white wash room, with a patient sitting there, all the IV supplied laid out, and all the help you could ever want or need in the form of every other person in the hospital.



Back in my Medic clinicals, I was nailing IVs left and right. I seriously only missed at most, 1 or 2 a day out of 20 attempts. The ones I DID miss, I had the luxury of having much more skilled people at the hospital that I could pass the buck off to.



Yet, somehow, in my practice as a lone Paramedic, I haven't been able to hit a thing. I'm probably getting 1 out of every 3 or 4 lines actually started. There are some patients where I can't even get a line in. I have an EMT partner, so he's unable to help.


Take yesterday for example. I had a chest pain patient with T-wave inversion on V2 and V3, pain dull and radiating to L arm 9/10. Obviously I wanted an IV, so we load her up and bring her to the rig. I look at the left arm, and found an ok AC... just barely there, but I was going to go for it. Poke it in, no flash. Work it for a little bit (which I hate doing, but I hate poking again all that much more) still no flash. Pull it out and the patient starts letting loose all the blood that I wanted in the flash chamber, on to my ambulance floor. Darnit. Well, atleast I knew I was IN the vein at some point, just didn't know why I wasn't getting a flash. So I switch to the right arm. Try the AC there after finding nothing on the hand... no flash again.

I hate giving Nitro without an IV, but I had to, as she was still in pain.



I don't know what it is. Maybe it IS just because I'm in an ambulance instead of a hospital. Maybe it's because I'm just unlucky lately. Or maybe it's because I'm psyching myself out being the only person able to get an IV. But I need to definitely start working on being able to get a majority of IVs again.


I have a long ways to go before I'm the ace at IVs like Paramedics are expected to be.



So, on to you guys (the whole 2 I have right now :P ), do you have any special ways you like to do IVs? Special equipment? Vein you go for? Angiocath size?

June 10, 2010

Did You Just Bite My Partner?

So this was my long weekend on for work, and it was actually rather action packed.

We often get sent to the local psych hospital for transportation, and every once in a while it's an emergent call. My partner and I have a system worked out where I generally pick up most of the psych calls because being a Paramedic gives me a few different methods at controlling them if something goes wrong, mainly in the form of Haldol and Valium. Plus I tend to be a bit more outgoing than he is (which is odd considering how shy I am in my personal life).


So on Saturday night we got called to the psych hospital for a, and I quote, "Confused patient". Confused patient at a psych facility? Can't be!. We're just up the road so we pull on scene pretty quickly.



Once in the main 'lounge' area, we see our patient, who is apparently having a gleeful ol' time playing with a Dinamap machine.... I felt bad tearing her away from it. Being a new grad Medic I still have half my class run though my head on every call trying to figure out what it could be... aside from psychosis that is, such as hypoglycemia, trauma and the like.


We sit our patient down on the cot and I begin asking her questions. "What's your name?". Her response: "44". Well, that just makes no sense.

"Ok, do you know where you're at right now?" Response: "Jupiter!" Ehh, not quite. I asked the nurse if these types of responses were normal for her, and the nurses stated they were not, and the patient is usually 'with it'.



Mrs. 44 decided she's had enough with this ask/answer session, and decided to undue her straps and get up off the stretcher and wander around. I obviously can't do a patient assessment with no patient, so we quickly catch her and convince her to sit back down. I have my partner start hooking up the EKG while I get the glucometer out. She decides she's going to get up again, and wander around, this time pushing us away when we came to get her.


Deciding this isn't the best way to transport a patient, I called med control. Granted in my protocols, I can give Valium and Haldol without any prior authorization, I still wanted to call since this patient WAS a voluntary committal to the psych hospital, so I wanted my own little safety net barring something going wrong. I get on the phone with the doc (who was apparently at an NREMT meeting, my bad doc!) and gave him an update and he agreed with my plan of action (first time EVER calling med control too, so I was a bit rushy). I thank him and hang up.


I get my partner and the nurse (who up until this point was all too happy just sitting back watching) to strap the patient back in to the cot while I got my Valium ready (I really hate carpuject systems, by the way). I prep the arm and do an IM in to the deltoid, giving 5mg. Surprisingly the patient was ok with me jabbing her with a needle.

My partner continues to try to hook up the EKG while I get a glucose check--- 117. I take a glance up the patient has an EKG electrode halfway in to her mouth. I quickly snatch it out. My partner goes to replace a new one, and she bites my partners hand.


I was shocked. I shouldn't have been, but I was. I managed to muster "Did you just bite my partner?". Her response was a joyful "Yessir I did!" and took a kick at me (not connecting).



Bad choice of words.


I grabbed some cravats and we physically restrained her arms and legs to the cot, she wasn't going to go anywhere. (Though it wasn't cutting off her circulation, I made sure). EKG showed NSR with no abnormalities.


We load her in to the ambulance and make the literally 2 minute drive to the ER door, the whole time me trying to hold her back as she was trying to slip her hands out of the restraints (obviously 5mg of Valium did nothing for her).


Strangely I was able to control her whenever I said "Hey, look at me" and she'd calm down for a second and look at me, waiting for my next command.... odd. We get her to the ER and I do my handoff to the nurse, who obviously was none too happy about getting a psych patient at that time of night, especially one who needed chemical and physical restraints.




After the handoff I did my most favorite part of the call.... The novel of a PCR I had to complete, detailing every little bit of the call, mainly because of the use of physical and chemical restraints.





But hey, she bit my partner, right?

June 8, 2010

New Medic Signing On

So, I'm a brand new medic at the age of 21 (Get it, Baby Medic? HA) been employed as a medic for 2 months, and working as a lone medic with a basic for a couple of weeks now. I've been contemplating doing a blog for a while now as I'm a fan of many blogs and podcasts such as Justin's HappyMedic, Jamie's MedicCast and Chris' EMS Garage (Don't know why I use their first names as I've never met these fellows...yet). I've always respected what they do for the EMS community and profession (yes, I said profession) and thought I'd try, even if failingly, to emulate what they do with my own awesome personality. (Egos... standard issue for Medics, right?)


And so this blog was born. I didn't initially think of doing it so early in my career, because at the moment I'm employed by a company in one of their IFT branches and didn't really think I'd see anything even remotely like what my 911 counterparts see. Man was I wrong. My company, a pretty (in)famous one, has contracts with nursing homes, clinics, and other places to provide pseudo-911 services to them as well. Infact these past couple of weeks I ran on an unresponsive head injury, a combatitve psych patient, a couple of MIs / Angina patients, and a critical care type transfer, just doing "transfers". Granted I still want to move to 911 ASAP, either with my current company or not, but it still keeps me interested.


I hope to regale some people in my adventures, worthwhile or not, and to just put my thoughts on this wonderful career in one place. If people enjoy it, great, if not, I just made you read my words anyway, so guess who won?!


Anyhow, enough with the introduction. I'll post my first true tale probably tomorrow, as for now, it's time to look up some drugs that confused the heck out of me yesterday.