Tomorrow I go for the state test. 150 questions that determine if I get to practice what I have been going to school and working for the past 2 1/2 years. I've studied and went over everything that I can think of and a little extra on the things that I had difficulty with. I think I am ready....
P.S.- Thanks for all the comments on my last couple of posts. I have talked to several other medics that I know and respect both as medics and as educators about the questionable calls of late. Through them and the comments that I have received I believe my course of thinking and treatment were right, which in turn has increased my confidence in my abilities. I thank my readers and commenter's for that....
Thursday, May 31, 2007
Friday, May 25, 2007
A lot to learn #2.....
Here we go again..... I have had the opportunity to run some decent calls here lately. But all of them have made me re-think my critical thinking skills as a prospective new Medic. I don't see myself as a sparky kid that wants to push every drug in the box and use all the nifty tools I have available. But I think that if the patients need it, well...they need it. That's what we're there for. I'll let you decide...
Called out for decreased level of consciousness. Arrived to find an elderly lady sitting in a chair and you could hear the snoring from the hall. History from those on scene was non-existent, something like GERD and insomnia. We get her loaded up and start doing our thing. In the midst we find that her blood sugar is 48. OK, we can fix this, started a line and gave her some D-50 and she perked right up. Vitals were otherwise OK. She is slightly cool and very diaphoretic, both could be explained by the hypoglycemia. Her only complaint is slight, diffuse abdominal pain. I put her on the monitor and saw some depression, so I decided to do a 12-lead.
Called out for decreased level of consciousness. Arrived to find an elderly lady sitting in a chair and you could hear the snoring from the hall. History from those on scene was non-existent, something like GERD and insomnia. We get her loaded up and start doing our thing. In the midst we find that her blood sugar is 48. OK, we can fix this, started a line and gave her some D-50 and she perked right up. Vitals were otherwise OK. She is slightly cool and very diaphoretic, both could be explained by the hypoglycemia. Her only complaint is slight, diffuse abdominal pain. I put her on the monitor and saw some depression, so I decided to do a 12-lead.
You tell me what you see, (I know that the clarity isn't that great, but it's the best I could do). Maybe I need to go back to 12-lead class, but I see depression in leads II, III, AVF, 5 and 6; elevation in V1, V2 and V3; with a left bundle branch block. She is completely alert now so I ask about her history. She has no cardiac history what-so-ever, only other things were diabetes and hypertension.
This is where me and the Medic I was working with differed in opinion. I saw an elderly lady with atypical pain and 12-lead changes who also happened to be hypoglycemic. We fixed one, and now we need to work on the other. I was proposing 325mg of aspirin and a spray of nitro, (she was already on O2), and a no-delay transport. In my mind she was a poster child for atypical presentation for MI. But, alas I was overruled. My partner saw an elderly diabetic that we fixed. He was not concerned with her 12-lead or her presentation. So we did nothing, just ran her in routine traffic and that was that. I didn't even ask him why afterwords.
So, am I right or wrong? Am I thinking correctly? Or am I the over-eager, sparky new kid? I think I am right, I think that the other medics that I have worked with are either burnt out, lazy, incompetent or scared. I don't know which, possibly a combination of all 4. Then again, sometimes I'm not so sure. This is just one call out of several here lately that me and the Medic have disagreed on the level of care that was needed. And I am usually wanting to treat the patient. Either because I think that something needs to be fixed right now, or for preventative reasons to try to head off something before it gets worse. The other thing is that I have been working with someone different just about every shift for the past month or so. So it's not just one person that this has happened with.
On the other hand, I have ran a few calls with 2 different medics that pretty much let me run the show and agreed with my decision making. One call was a trauma from a MVA that ended up coding on us. The other ended up being a head-bleed that had been down for almost 12 hours. That lady was in bad shape, she had fallen and puked. She was all bruised up and it looked like point lividity, except she had a pulse. She had also been laying in her own vomit for those 12 hours and had aspirated. I wanted to tube her but she was clenched and I couldn't get a nasal tube to pass. So I gave her a couple doses of Versed and then tubed her. The only thing either Medic did was bag the patient and hand me stuff when I asked for it.
So, do you see my delima? On one hand I am being told that I shouldn't do anything and the other we went all the way. I'd appreciate any and all comments on this matter.
Thursday, May 17, 2007
A lot to learn....
It's funny how sometimes you think, "Yea, I can do this job", only to find out that you don't have a clue....
Get called out for an elderly lady that is sick, nausea/ vomiting for the past 3 days. When we get there she is just sitting on her chair, her husband fills in all the details for us, because she is stone deaf. The over-sized hearing aids are malfunctioning and a high pitched squeal is coming from one of them. We have her take it out and it makes us feel better, if not her, because she couldn't hear it in the first place.
We get her in the truck and go to work. Vitals, IV, a little O2 via nose-hose and monitor. Hhmmm... Her pressure is like 80 over nothing and she's got a rate of 32. Well, the BP could have been explained by her lack of intake and excessive output for the last 3 days, then again it could be compounded by her rate. She is pale and cool to touch, but dry. Radials are weak and her breathing is OK. History of CHF and a few other things.
We start down the road as I am thinking of exactly how I want to treat this woman. I don't know what her normal vitals are, so I don't know how far off what I am seeing now is. I've always been told error on the side of the patient, and to treat the patient, not the monitor. Another look at her and to me, she's slightly lethargic, or she could just be sleepy. Skin is not so great, and her breathing is a little faster now, but her lungs are clear. I decide on a small fluid bolus and recheck her BP. It is about 72 over nothing. 12-lead shows sinus brady, nothing else. Well, she is obviously deteriorating. I pull out the atropine and push 0.5 mg. while I am thinking I may have to pace this woman.
I take another look at the monitor screen and the little yellow blips are getting more numerous, but wait....those are the dreaded PVC's we've been taught about. OK, I can do this, check a pulse and see if they are perfusing.....nope...they are not. Damn. Change her over to a face mask and pour the O2 to her. I call for orders for Versed because she is not out of it enough to pace her without it. I get it, give it and start to try to pace her. It doesn't work. Shit, what now? The PVC's are continuing and getting worse. I am thinking she is getting ready to code on me any minute. The only other thing I can think of at the moment is R on T. OK, lidocaine first and then maybe dopamine. I pull it out and before I can push it, she goes into v-fib. Fuck me sideways. I shock her. Flatline. Damn. How in the hell can I do this own my own? I do the best I can. Luckily we are just a few minutes out from the ED. We pull in, pumping and pushing and grunting, trying feebly to bring her back. She never recovers.....
None of this ever happened. Well, some of it did, this was a call I ran, the woman did have a rate of 32 and a BP of 80. But I was driving. I am still an Intermediate, I haven't taken my state test yet, so my paramedic partner rode in with her. She is still alive. She never coded. But, if I was the medic I probably would have treated her at the time. And this could all be true instead of something that scares the living hell out of me. After the call, riding back to the station, I asked my partner if I would have been wrong to treat her. He outlined pretty much what I just wrote about. He wasn't an asshole about it, he was just talking and teaching. But in my mind, I could have killed her. I layed awake that night thinking. I realized that the classroom world and the real world are two totally different things. You can be the best in class, ace every test, know all the protocols back to front, be able to recite everything about every drug in your box, and you still don't know shit. I realized that I still have a lot to learn....
Get called out for an elderly lady that is sick, nausea/ vomiting for the past 3 days. When we get there she is just sitting on her chair, her husband fills in all the details for us, because she is stone deaf. The over-sized hearing aids are malfunctioning and a high pitched squeal is coming from one of them. We have her take it out and it makes us feel better, if not her, because she couldn't hear it in the first place.
We get her in the truck and go to work. Vitals, IV, a little O2 via nose-hose and monitor. Hhmmm... Her pressure is like 80 over nothing and she's got a rate of 32. Well, the BP could have been explained by her lack of intake and excessive output for the last 3 days, then again it could be compounded by her rate. She is pale and cool to touch, but dry. Radials are weak and her breathing is OK. History of CHF and a few other things.
We start down the road as I am thinking of exactly how I want to treat this woman. I don't know what her normal vitals are, so I don't know how far off what I am seeing now is. I've always been told error on the side of the patient, and to treat the patient, not the monitor. Another look at her and to me, she's slightly lethargic, or she could just be sleepy. Skin is not so great, and her breathing is a little faster now, but her lungs are clear. I decide on a small fluid bolus and recheck her BP. It is about 72 over nothing. 12-lead shows sinus brady, nothing else. Well, she is obviously deteriorating. I pull out the atropine and push 0.5 mg. while I am thinking I may have to pace this woman.
I take another look at the monitor screen and the little yellow blips are getting more numerous, but wait....those are the dreaded PVC's we've been taught about. OK, I can do this, check a pulse and see if they are perfusing.....nope...they are not. Damn. Change her over to a face mask and pour the O2 to her. I call for orders for Versed because she is not out of it enough to pace her without it. I get it, give it and start to try to pace her. It doesn't work. Shit, what now? The PVC's are continuing and getting worse. I am thinking she is getting ready to code on me any minute. The only other thing I can think of at the moment is R on T. OK, lidocaine first and then maybe dopamine. I pull it out and before I can push it, she goes into v-fib. Fuck me sideways. I shock her. Flatline. Damn. How in the hell can I do this own my own? I do the best I can. Luckily we are just a few minutes out from the ED. We pull in, pumping and pushing and grunting, trying feebly to bring her back. She never recovers.....
None of this ever happened. Well, some of it did, this was a call I ran, the woman did have a rate of 32 and a BP of 80. But I was driving. I am still an Intermediate, I haven't taken my state test yet, so my paramedic partner rode in with her. She is still alive. She never coded. But, if I was the medic I probably would have treated her at the time. And this could all be true instead of something that scares the living hell out of me. After the call, riding back to the station, I asked my partner if I would have been wrong to treat her. He outlined pretty much what I just wrote about. He wasn't an asshole about it, he was just talking and teaching. But in my mind, I could have killed her. I layed awake that night thinking. I realized that the classroom world and the real world are two totally different things. You can be the best in class, ace every test, know all the protocols back to front, be able to recite everything about every drug in your box, and you still don't know shit. I realized that I still have a lot to learn....
Free at Last!
Free at last, free at last, thank God Almighty I'm free at last! Paramedic class is over! I have now completed all clinical time, all class time, the final mega-codes and passed my final exam with a 97. Damn, it feels good. Now all I have to do it pass the state and national registry exams.
Friday, April 27, 2007
Exams....
Sorry for no posts in awhile, it's crunch time in Medic class. We have but 3 short weeks to go and I'm trying to study up for the state and national registry exams, not to mention the final in-class exam. Had a pretty good shift the other day though, a code in the morning and a trauma arrest from a MVA later on. Hopefully I will get to post about it in the next couple of days, if not sooner.
Tuesday, April 17, 2007
Monday, April 9, 2007
Ninjas.....
Just got home from 48 hours straight. 24 at my regular gig, another 24 at my part-time one. We didn't do a whole lot at either place. A few transfers, a couple of nausea/vomiting and one drunk.
The call came out as a 10-73, (our radio code for a person in need of psychiatric help). We staged with the rescue squad at the top of the street while the local cops went in to see if there was any danger. We got cleared and went on in. As we entered the house, a run-down two story with fading paint and creaky steps, we could smell the beer that she had apparently been drinking all day. The patient was a middle-aged woman that was arguing with the cops that she wasn't going anywhere. Then she sees us and jumps up and runs behind the couch. We stop mid-stride, wondering what to do next, the cops are looking bewildered. One of them slowly walks around the couch and asks her if she's OK. I hear some whispering and then the cop turns to look at us and starts snickering that slowly changes to guffaws. Wondering what in the hell is going on, I walk over and look behind the couch. She sees me and starts screaming, startled I jump back. The cop is trying to tell me something, but unable to because he is still snorting through his moustache. I stand there, waiting for him to let me in on the joke. He finally drys up and motions for me to walk back to where my partner and the 3 squad members are standing. He then tells us that we are scaring her. I return with a "no shit". He starts snickering again then motions to our heads. We are all wearing black toboggans, pulled low over our ears to keep out the cold night air. "She thinks you guys are all ninjas and here to get her!" We all bust out laughing. I take off my head-gear and walk over to the couch. I stand back and start talking to her, letting her know that we are EMT's here to help her. That we were definitely not ninjas. After a few minutes, she peeks around the side of the couch and asks me if I am sure. I tell her yes, I am sure. She slowly comes out from behind the couch and looks around at us. Everyone had taken off their toboggans and I guess she didn't see the threat that her alcohol-fogged eyes had shown her. So she sat down and started drinking again, which of course was the only logical thing to do. She then starts to flirt with us. Telling us that we were all very cute and why didn't we all sit down and have a beer. Eventually we decide that she is just drunk, not a threat to herself or anyone else and try to obtain a refusal. My partner is explaining the form to her and she is listening intently. When he gets to the part about "if you will just sign right here, we will get out of your hair ma'am," she says "one one condition." Intrigued, said partner asks what that condition is. The patient states with a straight face that she wants all of us, 2 EMS, 1 cop and 3 squad members, to line up and turn around so she can take a gander at all of our hind-parts. At that point I lost what little composure I had left and almost fell to the floor laughing. My partner, between bouts of laughter himself tells her that isn't going to happen and just sign the paper. As predicted, she continues to refuse to sign until we all show her our bums. Well, to make a long story shorter, we all took a backwards bow as we made our exit. My partner had to stay behind, no pun intended, to get the paperwork signed. He eventually made his bow as well to the tune of whistles and cheers from the lady of the house. That was yesterday, the story has already gotten around. This morning on the way home I stopped by a gas station that is owned by one of the squad members, one that wasn't on the scene. Behind the counter was the wife of said squad member. As she rang me up she asked me how the ninja training was going. "Fine, just fine," I said as I walked out.
The call came out as a 10-73, (our radio code for a person in need of psychiatric help). We staged with the rescue squad at the top of the street while the local cops went in to see if there was any danger. We got cleared and went on in. As we entered the house, a run-down two story with fading paint and creaky steps, we could smell the beer that she had apparently been drinking all day. The patient was a middle-aged woman that was arguing with the cops that she wasn't going anywhere. Then she sees us and jumps up and runs behind the couch. We stop mid-stride, wondering what to do next, the cops are looking bewildered. One of them slowly walks around the couch and asks her if she's OK. I hear some whispering and then the cop turns to look at us and starts snickering that slowly changes to guffaws. Wondering what in the hell is going on, I walk over and look behind the couch. She sees me and starts screaming, startled I jump back. The cop is trying to tell me something, but unable to because he is still snorting through his moustache. I stand there, waiting for him to let me in on the joke. He finally drys up and motions for me to walk back to where my partner and the 3 squad members are standing. He then tells us that we are scaring her. I return with a "no shit". He starts snickering again then motions to our heads. We are all wearing black toboggans, pulled low over our ears to keep out the cold night air. "She thinks you guys are all ninjas and here to get her!" We all bust out laughing. I take off my head-gear and walk over to the couch. I stand back and start talking to her, letting her know that we are EMT's here to help her. That we were definitely not ninjas. After a few minutes, she peeks around the side of the couch and asks me if I am sure. I tell her yes, I am sure. She slowly comes out from behind the couch and looks around at us. Everyone had taken off their toboggans and I guess she didn't see the threat that her alcohol-fogged eyes had shown her. So she sat down and started drinking again, which of course was the only logical thing to do. She then starts to flirt with us. Telling us that we were all very cute and why didn't we all sit down and have a beer. Eventually we decide that she is just drunk, not a threat to herself or anyone else and try to obtain a refusal. My partner is explaining the form to her and she is listening intently. When he gets to the part about "if you will just sign right here, we will get out of your hair ma'am," she says "one one condition." Intrigued, said partner asks what that condition is. The patient states with a straight face that she wants all of us, 2 EMS, 1 cop and 3 squad members, to line up and turn around so she can take a gander at all of our hind-parts. At that point I lost what little composure I had left and almost fell to the floor laughing. My partner, between bouts of laughter himself tells her that isn't going to happen and just sign the paper. As predicted, she continues to refuse to sign until we all show her our bums. Well, to make a long story shorter, we all took a backwards bow as we made our exit. My partner had to stay behind, no pun intended, to get the paperwork signed. He eventually made his bow as well to the tune of whistles and cheers from the lady of the house. That was yesterday, the story has already gotten around. This morning on the way home I stopped by a gas station that is owned by one of the squad members, one that wasn't on the scene. Behind the counter was the wife of said squad member. As she rang me up she asked me how the ninja training was going. "Fine, just fine," I said as I walked out.
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