Cuff Links and Hijinks

November 18, 2012 by 5 Comments

Any decent EMT can take the austere equipment he’s got and use it to craft all manner of weird and wonderful solutions for the challenges of prehospital medicine. Of course, doing this means understanding the tools you’ve got and all of their powers. Here are a few ideas for using the ubiquitous blood pressure cuff or sphygmomanometer. (We’ve mentioned many of these in passing before, but it’s nice to see them in living color.)

 

Calibrating the gauge

How to use a pair of pliers to zero the needle on a mis-calibrated dial.

 

Measuring airway pressure, tourniquets, and cushions

Three handy tricks: first, a method of repurposing common items to create a BVM that provides real-time measurement of the pressure created during positive-pressure ventilation (a very handy teaching tool). Second, using the BP cuff as a tourniquet. Third, using it as an air pillow to fill voids during spinal immobilization.

 

Do you have a trick for the blood pressure cuff we haven’t mentioned? Let’s hear it!

Filed Under: Tools and Tricks Tagged With: , ,

Managing STEMI Mimics in the Prehospital Environment: Video Lecture

October 26, 2012 by 1 Comment

A while ago we shared a PowerPoint presentation, Managing STEMI Mimics in the Prehospital Environment. This diverges somewhat from our prime directive around here by focusing on an ALS topic (ECG interpretation), but for the medics, it’s a topic that I think is important.

It’s also dense and difficult, in this case amounting to a 190+ slide presentation. In an attempt to unpack things a little, and to further explore our recent forays into multimedia content, we’ve got ahead and created a narrated slideshow walking through this subject.

This is still tough material, but as an overview it should be fairly approachable. The trick, of course, is to follow it up by viewing a large volume of pertinent ECGs to get some practice in applying the concepts. See our Links page for some great sources for practice strips, or visit the old standby, EMS 12-Lead — probably the best source on the internet for ECG education.

It’s broken into three parts, with total time of about 1:45. Treat it like a continuing education lecture, take your time if needed, and feel free to print the slides themselves for review. (Unfortunately, the lecture does assume at least a baseline ALS-level knowledge base, so if you’re just getting started with electrocardiography you may want to start elsewhere.) For any questions, throw ’em out here!

Part 1 (43:26):

Part 2 (34:06):

Part 3 (26:57):

Filed Under: Knowledge Tagged With: ,

Welcome to Scenarioville!

October 15, 2012 by 2 Comments

Scenarios are just great.

We’ve posted a number of scenarios here over the past couple years as part of our Live from Prospect St. series. These are usually nuanced cases requiring a critical diagnostic approach, and we love to dive deep and discuss all the nitty-gritty angles and considerations. It’s a nice way to learn.

There’s another benefit of scenarios, however, which I don’t think we’ve been able to achieve. The simple fact is that when you first graduate from EMT class and enter the field, there’s a great deal of stuff you need to learn. Not the textbook stuff, but the street stuff. How to manage the flow of a call, approach a scene, identify people with useful information. What kinds of diseases are common and their typical presentation (versus the uncommon, atypical stuff that textbooks love). How to monitor a radio, find an address on the map, and coordinate with other responding resources. Clinical judgment and how to apply it. That sort of thing.

It’s what you learn over time as you develop experience. And while one of the goals of a good education is to shorten that learning curve, there are some aspects you just can’t teach; you have to live it.

But scenarios can help. Because they resemble real life, they can help you understand what real life “looks like,” before you’ve spent enough years on the road that you’ve learned it the hard way. A handful of interesting scenarios isn’t enough; you need to see all the other stuff, the sheer volume of humping routine, typical patients through routine, typical situations.

So while we plan to continue the Live from Prospect St. series, we’re kicking off a new project as well: Scenarioville!

Scenarioville is an imaginary city in a parallel universe, and you work there — so to speak. Unlike our previous scenarios, this will be a consistent environment that you can learn your way around. There’s a fixed map with specific destination hospitals, an emergency system and resources you can get to know, and an equipment list that won’t change on you.

Just like in real life, this means you can “get the hang” of working in a real EMS system. You’ll be dispatched with an audio clip (a transcript is provided if you’re playing via smartphone or other device without audio capability, but if possible, try to use the recording for realism), locate the address in the “mapbook,” respond to the scene, make the decisions, and later learn the outcome. We’ll be posting at least one scenario per week — broken into segments as we usually do, but to minimize clutter, updates to each scenario will simply be added on to the existing story rather than posted as separate chapters.

These cases won’t all be interesting or emergent or in any way unusual; many will simply be standard EMS fare. They’re based on reality, but they’re fiction, and debriefing discussions will be short and to-the-point. Over time, as you play our little game and slog through call after call, you’ll hopefully start to develop something suspiciously like experience. It won’t be the same as really working out there… but it’ll be closer than the textbook.

Make no mistake, this is intended for new folks. The truly green EMT fresh out of class without any experience needs this type of drilling, and it’ll bring him much closer to functional competence prior to the day he puts on his first uniform. Experienced providers may find this suspiciously like, well, work, but they’re still encouraged to play along and lend a grizzled voice.

The first scenario is up now. Take a look, let us know what you think, bear with any initial rough edges, and stay tuned for more!

Filed Under: Administrative Tagged With:

Missing your Manners

October 12, 2012 by 4 Comments

 

“Hi, my name is Brandon. I’m an EMT with Save-a-life Ambulance. Can I help you?”

Anybody remember that? I think it was on page 6 of the EMT textbook.

I suppose it’s about communicating your name, which is nice. And it’s about obtaining consent, which is important, although in reality, consent in EMS is usually handled the same way as consent in sexual activity — you just go until someone says stop.

But mainly it’s about courtesy and professionalism. It’s gauche to swoop into a room and just start playing with somebody’s lesions without so much as a how-do-you-do.

The trouble is that the formal intro is so hokey nobody actually uses it. Or uses anything remotely similar. And I think that’s a shame, because although it’s silly, it’s getting at something important.

We understand that people call us mainly to bring some order to their crisis. Obviously, that involves Doing Medicine. But the medicine is just a means to an end.

Why do we call plumbers? When your sink starts flooding water into the kitchen, you don’t know what to do. This situation is alien; it’s outside of your expertise. You may be very good at many things in life, such as fueling your car, tying your shoes, and making cherries jubilee, but you don’t know what to do about this.

You know that there are people who have the answers, though; they’re called plumbers. So you call a plumber, and say, make it right.

We’re the same way. People don’t know what to do when they get chest pain or crash their car. But they know that if they call 911, professionals will come who know what to do. So they call us. That’s why people sometimes ask 911 to fetch cats out of trees or ask when the circus is coming to town. It’s why the first reaction of so many motorists after a crash is to call their spouse or their dad.

The thing is, when we walk in and our first reaction is to Do Medicine, it’s not helping the problem. All that medicine is just more strangeness, unless your patient is a fellow clinician. So now their distress is going to continue until you can finally tell them what’s wrong. Except you won’t, because you don’t think you’re qualified for that. So now they’ll stay confused and scared until they get to the hospital. And on and on.

Throw them a rope!

The fastest way to restore normality to a situation is to reintroduce a familiar activity. And social courtesies are very familiar to everyone.

When you introduce yourself and shake someone’s hand, they’re transported from the confusing world of a medical crisis to something much more comfortable. They know how to do this. Smile, shake, say your name. It’s easy. They’re good at it.

Sometimes patients are visibly shocked when you do this, and seem to reset; you can literally watch them change channels. Now they’re a little calmer, a little happier, and you can work with that. With enough balls, you can pull this off in the most outrageous circumstances. Sing praise for the EMT who can walk in on the triple traumatic amputation and say “Hi! I’m Jim. What’s going on?”

Now, of course, you don’t want to minimize the patient’s distress. In an emergent situation, it can be galling and obnoxious for their freak-out to be met by your apparent apathy or boredom. That’s why you have to find a middle ground between projecting calm confidence and acknowledging the seriousness (perceived or real) of the patient’s situation. Don’t let them drag you along into panic, but don’t try to abruptly pull them to a halt either; strike a balance, pace them, and then gradually slow them back down. The point is that introducing yourself like a regular person is a powerful tool for restoring normality to a crazy situation: use that tool liberally, but intelligently.

I’ve had patients tell me I was the only Medical Person they could remember introducing themselves. That’s a damned shame. People greet each other and make a introduction when they meet. And aren’t patients people?

Filed Under: Principles Tagged With: , , ,

Podcast: EMS to ED Interface

September 12, 2012 by 2 Comments

Streamlining a patient’s entry to the healthcare continuum is one of our main roles in EMS, and the key step in most cases is when we transfer care at the emergency department. This isn’t rocket science, but you can do it well or less well, and frankly I think it’s tough to do right unless you can see the whole picture. We never really know in what ways we’re setting up people effectively for their ED care and in what ways we’re part of the problem, unless perhaps we work on both sides.

So I asked for a little help here. I sat down virtually with Dr. Brooks Walsh, ED attending extraordinaire — author of Mill Hill Ave Command and Doc Cottle’s Desk — and with Jeff, an ED nurse from my area. We discussed how to work and play together better, including topics like handoff reports, useful histories, and typical ED courses of care.

Click here to listen or download (1:15, MP3 format)

A few of the bullet-worthy points:

  • Jeff’s hospital saves time in all trauma, stroke, and STEMI activations by assigning patients an alias immediately upon notification by EMS. That way registration isn’t lurking around while the team is trying to treat the patient.
  • Cath lab activations from the field are still often about trust — whether staff knows the individual provider or the particular service calling. Rightly or wrongly, there’s also a stricter de facto standard for activation during off hours when nobody wants to get out of bed.
  • For stroke, neurology may be in the room when you arrive, but more often, especially in smaller hospitals, they’re available by page or teleconference.
  • When bringing in the stroke, try and ensure that family who can testify to time-of-onset/time-last-seen-normal, as well as consent to treatment on the patient’s behalf, are present — ideally transported with you — not unavailable in a taxi somewhere.
  • When you walk in the room, the typical team is a doctor, a nurse, a tech, then any extras — residents or other students, surgery, pediatrics, whomever. And registration is the dude with the clipboard or computer, of course.
  • When reporting to the doc, focus on: first, anything that needs to happen immediately; second, information he can’t get elsewhere (i.e. not patient medical history unless it’s not available in the records, laundry list of negatives, etc.), such as how you found the patient, general context, changes en route, etc.
  • Written PCRs are usually not read due to difficulty obtaining them and general unfriendliness (hard to find info, obscure writing), but sometimes there’s useful stuff in there, particularly in the narrative itself.
  • Baseline patient info from EMS is great if we know the patient well (frequent fliers); baseline info from bystanders, staff, family etc. is okay but less reliable.
  • Get patients to their usual facility if at all possible, especially those with complex histories, and especially anyone with recent surgical history — otherwise they’ll just get transferred later.
  • “Take me to x, my doctor is there” (meaning PCP or specialist) — less important, but can be nice if there are chronic issues and they’d like to maintain the existing treatment plan.
  • Disagreements over patient triage or treatment: find the attending or perhaps resource nurse and voice your concern. In the long-term: raise issues with the hospital’s EMS liaison (either directly or through your internal chain of command).
Filed Under: Knowledge Tagged With: , , , , ,
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