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Pericarditis for EMS – A Short and Sweet Case Review

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“Man it’s hot!” you think to yourself while cleaning the back of your rig in the hospital ambulance bay. Those glass garage doors they put on here might make the garage look pretty, but they sure heat the place up in the summer time. You convince yourself that it was nice of them to install a sauna for the EMS crews and let the thought sustain you as you mop the floor of the truck. You and your partner have been running steady since you came on shift this morning, and the noontime sun is really blazing down out there. As the tones come across your radio and the dispatcher calls your unit, you realize that you’re not getting a break anytime soon.

Your partner comes out from the report room as you check the address on the map book. You’ve been called for the 47yo male patient complaining of chest pain. It’s not too far away and you arrive within a few minutes of the call. The patient’s wife lets you in to the house.

“He’s been sick in bed all day, really sick” she tells you as she leads you inside to the back bedroom of the house. “He’s been running a fever and having trouble breathing. I told him I was going to call you when he started telling me that his chest hurt.”

You find the patient sitting on the side of his bed leaning slightly forward and crossing his arms across his chest. His skin is flushed and warm to the touch. He’s breathing slowly and carefully, wincing slightly as he finishes every inhalation. You introduce yourself to the patient and ask him how he’s doing. He answers that his chest is killing him and that it’s been becoming progressively more painful to breathe. He denies feeling short of breath but states that it’s just too painful to get enough air in. He indicates with his hand that the pain is sub-sternal, and that it radiates to the bottom part of his left shoulder blade. He describes the pain as intense, “sharp and raw” and constant. He says that it’s worse when he lies down and when he moves.

Your partner checks the patient’s vital signs while you continue your assessment. You notice what you think may be a little bit of jugular venous distension when you look down at him but it’s hard to see in the light. His lung sounds are clear, His abdomen is soft and non-tender, and His recent history includes a slight fever and chills with progressive upper respiratory illness over the last two days. He adds that he’s been sick since he came home from his dentist’s office after having a cavity filled the other day and he’s wondering if the numbing medicine the dentist gave him had anything to do with it. Your partner tells you that his vital signs are: Pulse 112 and slightly irregular, BP 106/74, respiratory rate 18 with a pulse-ox of 98% on room air. Your partner said that something seemed strange when he listened for the patient’s blood pressure and he had to check it a few times. He says it was almost like the systolic pressure disappeared when the patient took a breath in.

Your partner places him on 4-litres of oxygen via nasal cannula as you strap the patient on the cot. He seems very uncomfortable when you try to lay him down and asks to be sat almost completely upright. You wheel him out of the house and put him in the rig. You decide to place the patient on the monitor, both the 5 lead and to acquire a 12-lead although you’re pretty sure that the patient’s complaint isn’t cardiac in nature. Your partner starts an IV with Normal Saline and you decide to transport the patient to his hospital of choice. You choose to follow the chest pain protocol just to be safe, and administer 4 baby aspirin and one nitro-tab sublingually. Then you look at the 12-lead and are horrified to see all of the changes. The patient has flipped T-waves and ST-segment changes in nearly every lead. This just got serious, and you ask your partner to flip on the lights and sirens as you transmit the 12-lead to the ER.

So what do you think this is?

We all know that not all chest pain is a heart attack and that many conditions that can lead to a patient feeling pain in their chest. This patient describes his pain as increasing with motion and respiration and as feeling “sharp” and “Raw” with radiation to his back under his scapula and states that the pain is relieved by sitting up and leaning forward. As any chest pain can be a symptom of a myocardial infarction or pulmonary embolism, it’s important to look at the total picture and try to rule out immediately life threatening conditions as best as possible. The medic in this fictional case followed protocols and “treated for the worst while hoping for the best” but even he was surprised to see the changes on the 12-lead.

The heart is contained in a tough, fibrous sac called the “Pericardium” which encases and protects the heart inside the chest. This sac positions the heart properly within the chest and keeps it from rubbing directly against any other structures within the thoracic cavity as it moves. Usually, the sac contains a small amount of fluid for lubrication. When the sac becomes inflamed, it is called “pericarditis”. This condition causes pain and other symptoms as described above, which include:

  • Diffuse pleuritic chest pain that tends to lessen with sitting upright and leaning forward but increases with breathing and lying flat. The pain is worsened by movement, but not necessarily by exertion. It does not decrease with administration of nitroglycerine.
  • The patient may present with a fever, or a cough. Usually the patient has the pain for hours or days before presenting for care.
  • The presence of diffuse EKG changes is usually associated with pericarditis, showing non-specific T-wave inversions and ST segment changes in multiple leads as shown on a 12-lead EKG. This is caused by the inflammation of the pericardium and the vasculature of the heart rather than a blockage in the arteries. However, occasionally a coronary artery can spasm and cause classic MI symptoms.

Pericarditis has many causes, including a bacterial or viral infection, an autoimmune response, or inflammation following a heart attack. While there may be a possible link between the condition and dental procedures, research has not yet discovered a direct link. However, some dentists prefer to place their patients on prophylactic antibiotics prior to an invasive procedure to help prevent infective pericarditis and/or endocarditis, which is a rare but serious infection within the inner chambers of the heart.

Field treatment for pericarditis includes judicious use of the system’s chest pain protocols. Place the patient on oxygen and administer aspirin and nitroglycerine as per protocol. Pain may be relieved with opiates but is not generally reduced with nitroglycerine. Acquire and transmit a 12-lead EKG early in the treatment so that the patient can go to an appropriate destination for care.

Posted by on June 25, 2012 • Filed under: Emergency Medical Services, EMS, ems education, ems scenario, ems scenario based education, EMS Topics, EMS training, paramedic education, Patient Management, scenario, scenario based training, Training, Training & Development

What Difference Does EMS Make? Choose Your Own Ending

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John didn’t need his alarm clock this morning. In fact, he was wide awake just a few minutes before it went off. He turned it off so as to not wake up his wife and got up quietly to start the day. Today was going to be great. It was huge. Months of work at the office were finally going to be recognized today in the biggest project meeting he’d had in a year. Today’s meeting would launch his career faster than almost anything he’d done before. He was excited. He was ready.

John showered, shaved, and got dressed up in his new suit that he’d bought the day before. He wanted to look his best for this meeting. Everything was counting on it. His wife Joanne had coffee and a quick breakfast ready for him when he came down the stairs. He sipped on his coffee for a bit as he ate his breakfast. It was really sweet of her to do that, He thought and he told her so with an extra hug and kiss as he left for his commute. He wanted to be to work early today to make sure that he was there to answer any pre-meeting questions. This was the day.

Traffic was light on the interstate that morning and John was moving at a good clip. It was strange, he thought, for traffic to be this kind to him on a Monday morning but he figured it was a good omen. His phone buzzed with an e-mail and he glanced at it. It wasn’t anything that couldn’t wait until he was in the office, he thought. Then a great song came on the radio. John reached down to turn up the volume so he could get pumped up for the drive…

He never saw the cars stopped just in front of him.

Mary took care of herself pretty well for a type one diabetic. Her doctor had told her that. She stuck to her diet, maintained her sugar levels meticulously, and took her insulin on a sliding scale that seemed to be working perfectly. Her blood sugar readings were always right where her doctor said they should be. Mary was proud of that. She worked out and tried to get out walking or jogging the trail at the park at least 3 or 4 times a week. She felt good, looked good, and thought that she was doing all she could to take charge of her health.

It was a beautiful Saturday morning and Mary thought that she should take her dog Patches out for a walk around the pond. Patches was a 1 year old Golden Retriever and loved jumping in the lake to fetch sticks. Mary had taken her morning dose of insulin, popped a multivitamin tablet from her new bottle that she’d bought the day before, and ate a quick bit of breakfast before she put Patches on his leash and started walking to the park. It was about five blocks away and patches knew the route well. Everything was great, until the nausea hit… Mary tried to fight it but knew that she was going to throw up when she started salivating and breathing heavily. She ended up throwing up in some bushes next to the sidewalk. She thought that she was lucky. Nobody saw her hurl up her breakfast and she immediately felt better. It must have just been the new vitamins that made her stomach upset, she thought as she continued walking to the park. She figured that she just wouldn’t take them again.

Mary never felt sick. She just thought that she should take a nap. The rock over there looked like a good place. Why was she so sleepy? Never mind… Just lay down and nap. Nap good.

Luckily, another jogger happened by to find Mary unresponsive.

Work had been scarce lately and Steve was happy to get his truck back on the road. He drove a live-bottom trailer hauling asphalt for a big local paving company and they hadn’t had many big projects come their way lately. Driveway work was steady, but rarely did the company need Steve to drive a big truck out to a site for a driveway job. Steve made his best money and hours when the company had highway work and today was the first day of a big job they’d just gotten. He’d been in line with the other trucks waiting his turn to dump his load into the paver for hours and even though he was happy to be working, he had to pee. Minutes turned into hours and finally it was his turn to drop his blacktop and head back for a new load. He couldn’t wait to be done. He really had to pee by this time and he knew exactly where his next opportunity would be. He backed his trailer up to the paver and raised the bed. Then through his rear-view mirror he saw the people scramble and jump off of the paver. He felt his truck lurch forward as the paver machine was pushed into it from the impact of a car travelling too fast in the construction zone. When he jumped out of his truck after looking to make sure there was nobody coming at him, he saw his friend Luke laying on the ground. Luke was bleeding, bad. The car and the paver were a tangled mess of metal and there was someone screaming at an unmoving figure in the passenger seat of the car.

Steve no longer had to pee…

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Note to blog readers:     I can’t quite decide on what I should do from this point on. I can take two paths, one is a rallying call to community members asking them to put themselves in the place of the people in the above cases and get out there and support their local EMS. The other, is a rallying call to us EMS people… I’ve written it both ways. You can see what you like best.

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Option #1

Every day, Paramedics and EMTs put on their uniforms, fire up their ambulances, and get ready to face the onslaught of whatever mayhem the streets produce for them during their shift. They do a job that is unpredictable, complicated, and vital to the community. These three stories could happen to you or someone you love tomorrow and each of them will require the response of a highly trained, expert Emergency Medical Services (EMS) provider. There are times when your local ambulance service makes the difference between life and death but there are far more times when they make a big difference in a person’s continuing quality of life. By interceding in the first few moments of a medical emergency with highly trained experts, EMS makes a difference for us all. Communities that support their local Emergency Medical Services have better services and community members that are more educated about what makes quality EMS are better suited to support their local services.

You may not think about the people who respond to your call when you dial 911, but all we do is think about you. Get informed, get involved, and support your local Emergency Medical Services.

We’re there for you. We need you to return the favor.

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Option #2

As you come in to work today, lace up your boots, or turn on your pager, think about the patients in the above cases. They’re people just like anyone you see in your day to day life. They and others like them didn’t intend to be placed in the situations they’re facing and to them; theirs is one of the most intense situations of their life. Their very life and the continuing quality of their lives could rest in your hands today. They are depending on you. Their families are depending on you. Your knowledge, skill, and preparation to perform your best are paramount to these people. Their care rests on you. You owe them your best and there is no excuse they’ll accept for poor performance.

EMS providers transcend their self when they lace up their boots and sign on for duty. Society needs us. Our patients need us. We need us. We will never know the impact we’ll have on the lives of our patients, their families, and their communities… but it’s huge. We as EMS providers play a pivotal role in our communities. They’ll never acknowledge it en masse… but that doesn’t diminish its importance. Recognition for our skills isn’t necessary for our skills to be vital. EMS people do their jobs because they’re important. We do our jobs because our guts tell us that what we’re doing is right… and even when we stumble and find ways to improve ourselves and our care, it doesn’t diminish the importance of what we’ve done. We have acted, and we continue to act in the best interest of humanity.

Today you can make a choice. You can make the choice to seek out and become the best EMS provider you can be or you can choose not to. I suggest that you make the right choice but no one will ever be able to force you. Your care is an art and a science. Your performance is based upon hard science and soft intuition. There can never be a book that will tell you exactly what is right for every situation… you simply have to learn it and learn how to make the right decisions to fit the situations you find yourself in.

My advice to all EMS providers is to take the high road. Err on the side of what you truly feel is best for your patient. Do your best. Study hard and learn from those you consider the best among us. As an EMS provider, you bear the burden of an overloaded system that pays poorly and garners little respect. I feel it too. I say that it doesn’t diminish the importance of what we do and it isn’t the individual patient’s fault. They deserve our best no matter what the system is doing to us. It’s our responsibility and our calling. It has been said that the definition of a “Professional” is one who can perform their duty adequately in conditions that would cause the amateur to turn back. I’d say that we’re living in those conditions today, but we still have to perform. Do your best and know your stuff. Lives depend on your commitment.

It is our job to promote ourselves. It is our job to elevate EMS. It is our job to speak out and optimize the system. The fault for its failings lies within our profession and it is our job to change it. All of us, individually and collectively have the responsibility.

Will you answer?

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So I got a little philosophical in this one. Which ending do you like better?

Posted by on September 7, 2010 • Filed under: 911, edemse, Emergency Medical Services, EMS, ems 2.0, ems education, EMS Motivation, EMS pep talk, ems scenario, ems scenario based education, EMS Topics, EMS training, Ethics, everyday ems ethics, Fire Rescue Topics, In the Line of Duty, inside the mind of a paramedic, letter to the editor, Line of Duty, Paramedic, paramedic education, Patient Management, pride, profession, professionalism, Public relations, scenario, scenario based training, stories, Training & Development, training-fire-rescue-topics

Should EMS Improvise? And the Recipe for the “Kaiser Cocktail”

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Here’s the recipe for what I call the “Kaiser Cocktail”:

  1. Look in the patient’s kitchen cupboards until you find a box (or a bag) of some type of granulated sugar, powdered sugar, or brown sugar. (in a pinch, you can use honey or syrup)
  2. Find one of the patient’s own cups or glasses, wash it if you have to.
  3. Dump a bunch of the sugar in the glass.
  4. Look in the patient’s refrigerator until you find some soda pop or some type of sweet juice like orange, apple, or grape juice.
  5. Pour that in the glass with the sugar.
  6. Mix it up really well with some type of stirring device. Don’t use your pen or your finger. (Your partner’s pen or finger is ok though.) (Not really.)
  7. Serve warm, chilled, or tepid. Garnish with a peanut butter and jelly sandwich.

Have you guessed what the “Kaiser Cocktail is used for? If you’re in EMS I’m pretty sure you may have figured it out. It’s for sweetening up your local mild hypoglycemic… and no, it’s definitely not for serving to my son right before I drop him off with the in-laws for revenge purposes. The Kaiser Cocktail is for those patients who have blood glucose levels in the mid double digits but that still have the mental faculties necessary for drinking fluids and for protecting their airway while they do it. It’s a home remedy of sorts and it isn’t exactly the kind of thing that they teach you in EMT school. It works like a charm every time and I’ve never seen it not be well tolerated by the patients I’ve used it on or by the families that watch me do it. In fact, the families always seem more than willing to help whip one right up when I ask them to do so.

Picture this scenario: Your ambulance is dispatched to the “Known Diabetic with Altered Mental Status” at an address a short 8 minutes away. You respond to a well kept address in a nice neighborhood and are directed into the residence by a twenty-something female who tells you that her grandfather “Just isn’t acting right and won’t get out of bed”. Seeing no obvious hazards, you enter the residence with the granddaughter and follow her to the back bedroom of the residence to find a 60-something male patient sitting on the bed. He acknowledges you when you introduce yourself and you can see that he’s trying to talk but that he cannot seem to form the words. You say to him “Howdy! How are you feeling??” He answers: “Um… hello…” with a normal voice quality. His airway is patent, his skin is pink, warm, and sweaty, and he doesn’t appear to have any hemispheric neurological deficit. His pulse is bounding and regular at the radial and his respirations are normal. The granddaughter tells you that the patient is diabetic and that he takes insulin.

Got the case diagnosed yet? I’d bet you do. The next thing I would do with this patient is to take a quick finger stick glucose check. For the above fictional scenario, the reading would be 40mg/dl (which is um… “something’ MMOL for you British folk). It’s mild hypoglycemia. I ruled out a possible stroke (CVA/TIA) with the Cincinnati Pre-Hospital Stroke Scale and he patient’s cardiac function seems very normal with his bounding, regular pulse rate. The diaphoresis (sweating) and skin color are differential signs of hypoglycemia, and the patient’s past medical history helps clinch the field diagnosis. This patient’s blood glucose level dropped too low for his brain to function normally and he needs more sugar coursing through his veins in order to feed his brain.

You may be wondering why I brought forth such a common, run-of-the-mill patient presentation on the blog today. As pre-hospital providers, we have a few options available for us that could be considered proper care for this patient. Most EMTs have oral glucose paste at their disposal and a growing number of EMT-Basics carry Glucagon for IM injection. EMT-Intermediates and Paramedics usually have both of the previous medications available and almost all of them carry D-50, or 50% Dextrose solution in water, for IV administration. All of these treatments could be considered for this patient; however I would pull out my namesake concoction in this case. Call it experience, but starting an IV and giving D-50 seems like it would be risky overkill for this patient and an IM injection of glucagon saps the patient’s natural reserves of glycogen for quite a while after administration. Patients seem to hate the taste of oral glucose paste (Lemon?? Really??) and one tube never sees to do the trick. We only care two of them anyway.

That’s why I use a Kaiser Cocktail with these patients. As long as the patient can maintain their own airway and there’s not an aspiration risk, I can’t think of any contraindications once you rule out a possible stroke. It’s cheap, easy, and it has worked like a charm for me every time I’ve tried it. I like using it too, as it feels like a “Mr. Wizard” type home remedy that always fascinates the patient’s family members who watch me make it up.

Here’s the rub though, nowhere in my protocols does it give me authority to give a patient any nourishment or fluids by mouth. In fact, I can’t give a patient anything to eat or drink that isn’t specifically allowed by my standing orders. In EMS, even something as innocuous as sugared-up orange juice can be a legal difficulty. Common sense isn’t allowed by lawyers, unless of course they’re saying you should have used some. The reality is that every time I whip up a Kaiser Cocktail, I’m putting my license at risk.

I used a Kaiser Cocktail as recently as of the day I’m writing this post and I’m asking for a debate here. I’d like it if you would please answer some questions for me below the post in the comments section:

  1. Do you think that the Kaiser Cocktail is an appropriate treatment for mild-to-moderate hypoglycemia in a known-diabetic patient with a patent airway?
  2. Do you see any contraindications or risks that I have missed?
  3. Would a tube of oral glucose paste (or tablets, if you use them) be more appropriate than the Kaiser Cocktail?
  4. Should EMS providers be allowed to improvise treatments such as the Kaiser Cocktail for these and other like situations? Why or Why not?

I can’t wait to see your answers.

Posted by on June 21, 2010 • Filed under: Administration & Leadership, Ambulance, Emergency Medical Services, EMS, ems 2.0, EMS ethics, EMS protocols, ems scenario, ems scenario based education, EMS Topics, EMS training, medical ethics, Paramedic, paramedic education, Patient Management, Protocol development, scenario, scenario based training, SMG, SMO

When all you have is a hammer… Every problem looks like, lasix?

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A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.

My wife and I fighting our first fire "as a couple" - We're the ones in turnout gear

On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.

It’s amazing that when I have my maul that every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.

Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to “I want to remain employed reasons”.

And, like a lot of things on here, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.

The doggies were SHOCKED that Gina took MY maul

For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.

As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I got in the truck and continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed) IV stick into an impossibly small crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy. I obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.

The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.

But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.

I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.

We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.

This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.

Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.

It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.

Posted by on June 14, 2010 • Filed under: Ambulance, Emergency Medical Services, EMS, ems education, ems scenario, ems scenario based education, EMS Topics, Fires, funny, In the Line of Duty, Paramedic, paramedic education, patient care, Patient Management, professionalism, scenario based training, stories, Training & Development

Mental Quickness – Do Smart Alecks Make Better EMTs?

8 comments

Alright, I admit it. Driving to work this morning was a bit of a challenge. We had two inches of fresh snow and the tires in my car are in desperate need of replacement. Yes, I drive a Subaru and usually it’s all-wheel drive does awesome in the snow… but I cheaped out on the tires, and they’re honestly a bit mismatched size-wise. Therefore driving it in conditions even remotely slick is hard as heck. I would have driven the SUV and had no problems at all but the wife had to drive the kid to school and then had to drive into the city afterwards and I wanted her to have the safe vehicle. Who cares if I go into the ditch? Work can do without me if they have to, but I need my family to be safe.

Since I think of things to write about when I drive, this morning brought my thoughts to how hard I had to concentrate on the road and the minute adjustments of the steering wheel and the accelerator needed in order to keep the car safely on track. Like everyone who knows about driving in slick conditions, I kept my eyes on the road ahead of me in order to “read” the changes in the road surface before I got to them in order to be ready to quickly make the adjustments needed to keep the car heading in the right direction. See a dark shiny patch? Foot off the gas, be ready to steer slightly away from it when the car slides in that direction. See a pile of snow with a frozen rut running through it? Minutely avoid it if possible and steer into the slide with just enough change in the gas to power through the slide. I made it to work, but I had to call in a favor to have a guy stay over for me for ten minutes. I let him know the night before that he might have to, and I did leave early… but I’m not wrecking the car just so I can save a few moments.

I consider myself a pretty good driver in the snow. In a vehicle with good tires I wouldn’t even worry about anything less than 6 inches this far into the winter season, but today was hard. I’m not patting myself on the back here, because if I would have put good tires on the car in the first place I wouldn’t have been in this position, but isn’t that most of what we do in EMS? We end up using our mental prowess to clean up other people’s messes caused by their lack of planning all the time. Today wasn’t much different. The amount of mental power and concentration needed to keep a car moving forward safely in snow-covered conditions is actually quite staggering when you think of it. You have to make quick observations of rapidly evolving conditions, surmise what you think the presentation of the road surface means to vehicle’s path of travel using your limited observations paired with your past experience and knowledge, and come up with a near simultaneous decision on how to handle the situation ahead of you. If you find yourself to be wrong, based upon the car not reacting the way you want it to, you have to instantaneously correct the situation while adjusting for the conditions ahead… or crash.

Now picture yourself managing a challenging patient presentation, one requiring a handful of pharmacological and physical interventions. You’re pretty much doing the same thing as driving in snow. Just like playing a game of chess, you have to be “thinking a few moves ahead” in order to keep up with what the patient’s physiology is going to throw at you. Do you have a fall victim with a broken hip in need of pain control? Did you think that they’re possibly going to drop their blood pressure with a dose of morphine? Well then you better be ready to give fluid to bump it back up to acceptable levels. However, what if you’re treating a CHF patient that would suffer further from the added fluid? What if they were a patient with Chronic Renal Failure? Would that affect your initial dose of morphine based upon the unknown factor of untoward hypotension? In my Northern system, I’d choose to use Fentanyl over Morphine in that case because of the lessened risk of hypotension, but in my Southern system I’d just have to start with a lower dose of Morphine and slowly titrate to an acceptable level of pain control once I gauged the patient’s response to the med.

How about a patient with a large anteriolateral MI? Their Left Ventricular function is soon to be compromised if not treated in a cath-lab. You need to increase blood flow to the Left Ventricle and decrease overall cardiac work by decreasing afterload with use of nitrates, but that’s going to decrease their cardiac output and blood pressure by decreasing their preload as well. You need to stabilize the infarct as best as possible while maintaining the patient’s hemodynamic state, and you may need to consider supporting their left ventricular function with the use of a vasopressor such as dopamine to treat possible cardiogenic shock. In this case, careful observation of the patient’s presentation and all information available to you is of paramount importance in order to make the minute treatment decisions necessary for your patient’s best possible outcome.

It all comes down to “Mental Quickness” or having the mental prowess and state needed to rapidly intake complex information, process it against your knowledge base, and then make reasonable decisions on a course of action in a very short period of time. We call people who are good at this “Quick Witted” and it applies to myriad situations in daily life. People who are good at this are usually funny, are quick to react to new situations, handle change fairly well, and make darn good EMS providers. I practice by trying to have a joke ready for any situation… so you could also call a person who’s mentally quick a “smart ass”.

You can practice your skills at being mentally quick the same way I do. Use humor and try to make good comebacks to the hooks and barbs that your coworkers and friends throw at you. When we’re sitting around busting each other’s chops… we’re actually practicing our EMS skills, right?

Think about it. Exercise your mind through reading, learning new things, and trying to come up with new ways to think of existing information. You’ll be funnier, more popular, will be able to knock your buddies down a peg better, and will improve your patient care.

Posted by on February 2, 2010 • Filed under: Administration & Leadership, change, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS Humor, EMS paramedics, EMS practice, ems scenario based education, EMS Topics, EMS training, Fire Rescue Topics, inside the mind of a paramedic, mental imagery, Paramedic, paramedic education, patient care, Patient Management, scenario based training, Training & Development, training-fire-rescue-topics

EMS practice

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Did anyone else play a sport (or sports) in high school? I did, actually I played football for a few years. I was on the line, which in my small high school meant that I played every position on the line, both offense and defense, because there just weren’t that many kids out there to play. My graduating class was 83 in my small, small town.

I didn’t touch the ball though. Coach told me just to go out there and hit people. I haven’t touched a football since.

Every day after school we went out there no matter rain, shine, snow, heat, or better things to do and practiced for three hours every night. We did this all season and I hated it. It sucked and sucked bad. However, it did make me a much better football player. It kept my mind focused and kept me in shape. I was a much better “Go out there and hit people” guy than I would have been had I just taken a football class and then played parts of the game every day.

Does anybody do this with EMS? Sure, we all do Continuing Education, but do we really practice as hard as we should as much as we should?

We play parts of the game every day but just as sure as I didn’t intercept a pass and run in a touchdown every game, I don’t perform a pericardiocentesis every shift. I can plink in an IV in my sleep (and do… a lot…) and I probably can treat a STEMI as good as the next guy. Playing the parts of the game that we do more often than the others gets us good practice on what we do most often, and if we don’t allow ourselves to get complacent, that’s just fine. However, how many times have you calculated a dopamine drip lately? Even if you live in the busiest, most dopamine swillingest jurisdiction on the planet you’ve still interpreted Normal Sinus Rhythm a lot more than you’ve shown off your math chops.

The other day I missed a tube. I was caring for a patient who crashed in front of me while heading to the ER. The Pt went from CAOx3 to very obtunded in a matter of a minute or two. The first time I went to tube, (the Pt) was clenched and by the time I got the etomidate ready we were close enough to the hospital that bagging was my best option. When the Pt got sux and sedate juice in the ER I tried again…. and missed.

I freakin hate that! Man, I never miss a tube! At least almost never. I hate it when I do and beat myself up about it. Probably more hard than I should, but that’s just me. I take this stuff seriously if you can tell. The next shift I spent an hour playing with our two intubation dummies and our “Fred the head”. I tubed over and over again every way I could think of. For an hour. Yes, I know that it’s not exactly like the real thing, but it was all that I had access to for practice.

Something cool happened right after I got done with my hour long tubing pennance. I sat down for lunch and immediately got toned out to intercept a code with CPR in progress. I pointed my SUV towards the rural address and hit the gas. When I got on scene, the BLS crew told me over the radio that they were having difficulty with the airway. I walked in, and got the most beautiful tube that I think that I’ve ever gotten. Right in, right through, and right hole.

I think that my football coach would have been proud.

Posted by on February 1, 2010 • Filed under: ALS Intercept, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS practice, ems scenario based education, EMS Topics, EMS training, EMT, ET Intubation, Fire department, intubation, Paramedic, paramedic education, Patient Management

Education vs Training: The “Professional Ambulance Cleaner”

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Imagine if you will this hypothetical scenario:

You and your roommate have just graduated EMT school together and go to work at competing ambulance companies in the same city. He works for HIS ambulance service, and you work for YOUR ambulance service. Both services have similar fleets, similar deployment patterns, and similar call-volumes. In fact, there’s really no way to tell them apart other than the fact that the HIS ambulance service uniforms are sickly green jumpsuits, and YOUR ambulance uniforms are Macho Blue Shirts with navy blue pants.

You both go off for your first day on the job which understandably includes several hours of training on company policies. For both of you, the whole day turns out to be a long class on how to clean the inside of ambulances.

Here’s the differences, though. At YOUR ambulance, you learn about the biological functions of bacteria and viruses. You learn their strengths, their weaknesses, how they reproduce on inanimate environmental surfaces, how they create biofilms to increase their reproductive capabilities and life span, and how pervasive they are in randomized samples from real-life ambulances. You learn how grime collects in the ambulances, how it adheres to the surfaces that you will be cleaning, and what the various types of substances are that you will most commonly find in real-world applications. The whole first day is spent on nothing but learning about dirt, grime, and germs and how they contaminate ambulance interiors. They even threw in the types of materials that the ambulance interior is made from and what the specific dirt-holding and germ-breeding properties of each material are. You see samples and scenarios pertaining to germ and dirt proliferation on ambulance interiors.

Not only that, there’s homework, reading material, and a report due the next day.

The second day that you report to YOUR ambulance service, you learn all about different types of cleaning products, tools, and disinfectants. You learn how to properly choose the detergent needed for optimum dirt-dissolving power on what type of surfaces you may have to clean; You learn the proper disinfectant to choose for each type of commonly encountered bacteria, virus, and fungi spore; and you learn the proper contact times to leave each product on for optimal disinfection and/or dirt dissolving power. Then you learn about every different type of sponge, mop, rag, fabric, and tool used to clean the ambulances. You spend a few hours in the laboratory they have testing out the material and performing experiments in the name of learning.

Oh, and after that day too, there’s a lot of homework and reading material.

Your roommate, on the other hand, went to work and found out that he too had to learn about ambulance cleaning. He learned that they also expect clean ambulances, however his choices and training are much simpler. He is told to clean the ambulance using two bottles: One marked “Cleaner” and the other marked “Germ Killer”. He is given ten rags and is told to clean the ambulance for inspection by the owner of the company using the tools given in the time allowed. He does so and is told “Good, now do it again tomorrow”. The next day, he again cleans the ambulances using the tools and training provided, and is again told “You did a good job”

In the above scenario, the first ambulance service, “YOUR Ambulance, uses a form of advanced education to teach their people how properly to clean the ambulances to their specifications. The education is rigorous and in-depth.

At “HIS Ambulance” they use training, and vocational experience to teach their employees how to properly clean the ambulances.

Here’s some questions I have:

  1. Which ambulance service do you think will have cleaner ambulances in the long run?
  2. Which employee do you think will do an overall better job in cleaning the ambulances?
  3. Which employer, “YOUR Ambulance” or “HIS Ambulance” do you think has the better philosophy?
  4. Which ambulance cleaning class will result in the better, more motivated, happier employee?

Anyone else see the relationship to EMS training/education here? Which one results in a more “Professional Ambulance Cleaner” that is better equipped to handle the job?

Posted by on November 12, 2009 • Filed under: Ambulance cleaning, Ambulance maintenance, disinfection, Emergency Medical Services, ems 2.0, ems education, EMS Management, ems scenario, ems scenario based education, EMS Topics, EMS training, Management, Paramedic, paramedic education, profession, professionalism, sanitize, scenario based training, Training & Development, training-fire-rescue-topics

Will your career survive a decade or more in full-time EMS? Take this three question quiz!

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This is a simple test that you can use to see if you have the proper mindset to make it a decade or longer in this insane profession we call EMS.

NOTE TO NON-EMS PEOPLE: This post is geared especially to those in the industry. It explores humor that we employ to keep us with a healthy degree of insanity. If you’re not in the industry and you find this to be disagreeable in some way… well then in the words of Motorcop: “You’ve got the wrong frikkin’ blog pal!” Go read about scrapbooking or something.

This is a simple three question blog based quiz that you can use to determine if you have the right mindset needed to make it more than a few years in this crazy, wild profession we call EMS. If you fail this quiz, um… well then you should tear up your EMT card immediately or not. Nevertheless, if you find this at all funny, you’ve come to the right place. Howsabout that?

Question #1:

You’re working a service that employs two paramedics per day to support BLS ambulance crews in your jurisdiction and beyond. The other paramedic on duty with you that day responds to a neighboring jurisdiction and manages to resuscitate a patient in cardiac arrest. He transports the patient on-board the BLS ambulance to the local community hospital that does not have ICU admitting capabilities on site. Shortly after he transports the patient to the small ER he contacts you asking you to respond down with the ambulance to stat-transfer the patient to a tertiary ICU approx 1.5hrs away lights and sirens. The patient’s got three drips going, is receiving bolus cardiac meds, is on a ventilator, and is not doing well. The ER doc wants the patient outta there as soon as he can get him reasonably stabilized for emergent transport. Oh, and before you ask, the helicopter’s not flying due to weather. You’re it, Buddy.

You arrive at the ER with your EMT-Basic partner and um, you’re “enthused” about the “challenge” you’re about to face. Walking into the ER you hear more than the expected commotion coming from the patient’s room. You enter the room to find the ER staff performing CPR and attempting to resuscitate the patient after he went into cardiac arrest again. You and your partner assist, but despite everyone’s best efforts, the patient unfortunately expires.

When you return to service and get back to quarters, you expect your coworkers to:

  1. A.      Be supportive and consolatory, understanding that you’ve just been through an intense, traumatic experience.
  2. B.      Make fun of you and suggest that you’re an incompetent paramedic because, after all, the other paramedic “saved” the patient… then you showed up and killed him.
  3. C.      Insist that you’re an agent of the grim reaper and pin up another chalk outline with a line through it on your “Bulletin Board of Death” they’ve got going.

Question #2:

Your rural ambulance responds to a local community health clinic for a “Woman in Labor”. Upon your arrival you find a 36 week pregnant female Gravita 3 Para 3 (3 Pregnancies, 3 live births) with contractions 5 minutes apart. The physician wants the patient transported to the local OB unit that is 45minutes away lights and sirens. You load the patient in the ambulance after assessing the patient and find that she is an otherwise healthy pregnant patient possibly in early labor. You initiate ALS care including o2, an IV, and an ECG monitor for good measure. Your partner points the ambulance towards the hospital and you take off lights and sirens. Ten minutes into the transport, the patient’s bag of waters ruptures and the patient states that she urgently feels the need to push.

Do you:

  1. A.      Tell your partner to pull the ambulance over to the side of the road in a safe area so that he can come back and assist while you pull out and open up the OB kit, preparing for imminent birth.
  2. B.      Administer a fluid bolus in the hope that you can slow the imminent delivery.
  3. C.      Calmly tell your partner to “Drive it like he stole it” and coach the patient in “trying not to push” while you try answer “B” and hold her legs firmly closed because hey, who wants to clean up afterbirth all over their ambulance?

Question #3:

You’ve just returned your ambulance to service after a mundane call on a particularly busy day. The other ambulance in the jurisdiction has not had a rough of a day as you’ve had and was out getting lunch when you returned to the station. Before you have the chance to radio dispatch and let them know that you’ve restocked and are back in service from the previous call, the tones drop for an unresponsive male patient that sounds like he has a severe lower GI bleed. Although you’re probably two blocks closer to the call than the other truck, they are dispatched because you haven’t gone in service yet. Their most direct route to the scene puts them right past the front of the station where they’re sure to see you on their way by.

Do you:

  1. A.      Call dispatch on the radio and inform them that you are indeed in service and will respond to the call if they wish you to do so.
  2. B.      Quick, hide! Close the station door and pretend that you’re not yet back in quarters. They deserve to get the call, they’re only out two blocks farther than you are, and you don’t want them to see you and know that you’re ducking it.
  3. C.      Run out to the front apron of the station and smile and wave as they drive by! Hiiiiieeey!! Enjoy the butt bleeder! Don’t forget to write!

Extra Credit Question:

                How many fingers do you think that the other crew will wave back at you with when they pass you in the previous question?

Answers:

If you answered mostly “A’s” – Congratulations, you’re a new, competent, caring EMT. Feel proud of yourself, but you’re probably not going to retire from this job. I could be wrong… but you’re pretty straight laced. Have fun with that.

If you answered mostly “B’s” – You’ve been in the business a while, haven’t you? You’re well on your way to developing the hard outer shell you’ll need to survive for a while in this business. Just don’t lose your gooey center.

If you answered mostly “C’s” – Um, you’re one of my coworkers, right?? Guys, come on… Why’d you go and dump a bucket of water on me last night while I was sleeping? If you’re not one of my coworkers, e-mail me and I’ll send you an application. You’ll fit right in.

Posted by on November 6, 2009 • Filed under: ALS Intercept, ambulance humor, camaraderie, Emergency Medical Services, emotions, EMS, EMS Health & Safety, EMS Humor, EMS Motivation, ems scenario, ems scenario based education, EMS Topics, inside the mind of a paramedic, mental illness, Paramedic, paramedic education, scenario, scenario based training

Daily Training Topics 10/16/09

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Just about every 24 hour shift that I work up in my Northern job I put together a little impromptu training session. It’s a way for me to address things that I think are important for the crews to refresh on as well as a way for me to read up on some things and make sure I remember the stuff I should know. I try to learn the latest things on the chosen topic with a bit of research before I present the class as well. It keeps me sharp, which is good.

Also, (and let’s talk about the important things here) it gives me a cheap and easy blog post which I like because I’m really trying to bump up my posting frequency with this Fancy New Blog and all that.

Today’s training topics were a refresher class on intravenous access as well as BLS Airway Management Skills. We have a good number of EMT-Basics, EMT-IV Techs (here in Wisconsin) and even an EMT-Intermediate ‘99 that are on-duty today. My partner and myself (incidentally, both named Chris) are the duty medics.

So, without further ado, here’s what I taught them. Remember, this was a BLS class, and is geared to newer providers.

- IV Skills: I didn’t do anything on my own here. One of the benefits of the EMS blogosphere is that I have a wealth of training information at my fingertips. A lot of the time, I’ll pop on over to see what Greg Friese is doing on Http://www.everydayEMStips.com – And if I’d like some in-depth EMS knowledge, I’ll head over to Http://paramedicine101.blogspot.com.

For this training, however, I took the tips laid out by Steve over at Http://www.theEMTspot.com – where he wrote “Six Techniques to Nail the IV Every Time” I put it up on the projector and wrote down the bullet points on the white board. (and I gave him the credit for the easy and valuable training both in the class and on here)

- BLS Airway Management knowledge:

For this one, I pulled out every airway and oxygenation management tool we carry in the truck, which in my service includes:

- The Oropharyngeal and Nasopharyngeal Airways

Do you know when to use one over the other? Here’s some tips. First, if the patient is unresponsive enough to take an oropharyngeal airway without triggering a massive gag reflex, the patient NEEDS an oropharyngeal airway. (or an ET tube/Combitube/King LT for that matter)

Nasopharyngeal airways are used for patients unresponsive enough to need an airway adjunct but that still have an intact gag reflex. DO NOT USE nasopharyngeal airways in cases of head or facial trauma. (Why? Because the nasopharynx is separated from the rest of the cranial vault by the Cribiform plate, which is a very thin piece of bone that can be fractured very easily with significant head trauma. If it is fractured, you run the risk of placing the nasopharyngeal airway – or the nasogastric tube for that matter – right into the cranial vault… which is bad. 

The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw. The Nasopharyngeal airway is measured from the nare (nasal opening) to the earlobe.

On a side note, do you know how to check for a gag reflex? My almost never-fail method is to use the eyes. If the patient is unresponsive, running your finger lightly through their eyelash should elicit a response (i.e. wiggling) if the patient has an intact gag reflex. Further, a variation on the theme is to lightly open their eyelids with your gloved fingers and lightly blow into their eye. Don’t do it hard, and certainly don’t blow hard or use any pressure with your fingers, but if a person isn’t unresponsive and can tolerate that without flinching… they aren’t human.

- The Combitube

Honestly, I’ve not had a good track record with the combitube. I prefer the King LT. (Sorry Happy)

- The Endotracheal Tube

For this part of the training I looked at the various parts of this procedure that an EMT-Basic might be asked to participate in, such as preoxygenation with a BVM before the procedure, setting up the equipment for the ALS provider before he/she needs it, choosing the various adjuncts to assist the ALS provider in confirming tube placement, and various methods to secure the tube.

- CPAP

This is a miracle treatment. CPAP, or Continuous Positive Airway Pressure has revolutionized the management of congestive heart failure and pulmonary edema. Every EMT should know how to use this, when to use this, and how to properly apply this wonderful thing.

- Non-Rebreather O2 mask, Nasal Cannula (Adult and Peds)

If you don’t know how to use this, you probably should.

- The Nebulizer set up (We use Albuterol (Proventil) and Ipatropium Bromide (Atrovent)

We covered the proper set-up of the nebulizer and the various differing ways that it can be employed. Sure, you can use the duckbill for the patient to hold, but you can also pull the reservoir bag off of a Nonrebreather mask, insert the nebulizer chamber where the bag went and you’ve got yourself a handy mask neb.

We also went over the proper way to connect the nebulizer to the Bag Valve Mask. Depending on your equipment this setup could vary. Ours did like 3 ways. Check yours.

- Bag Valve Masks of assorted sizes

Learn how to properly seal the masks, the proper ventilatory rate (8-10 per minute) and the proper size for each variation in patient population.

- A Pocket Mask

Haven’t used one of these in a while, have you?

- The Surgical and Needle Cric kits

The basics don’t need to know how to use these, but it’s good to practice. Three of us had to hold the student down to do it, but we got it in on the second try!

I’m really liking my new home.

Posted by on October 17, 2009 • Filed under: Emergency Medical Services, EMS, ems scenario based education, EMS Topics, EMS training, ET Intubation, intubation, paramedic education, patient care, Patient Management

Scenarios. A lot of EMS, a little Einstein

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A while back ago I had a kick where I did a scenario-based EMS ethics piece that took a look at a possible situation that could be faced by some Paramedics and asked readers what they would do in that case.

The response was pretty good. You should add your opinion here.

I use a lot of scenario based training for the EMS people that I teach. I teach a lot. Being the old, grizzled veteran that I am (shameless self plug but looking at the kids these days entering the profession sometimes I feel like shaking my fist at them, hiking my jeans up to my navel, and yelling at them to “Get off my lawn!”) I have the opportunity to mentor a lot of newer providers and precept a fair amount of students. During our slow periods, I find that giving the students an informal scenario helps them to step outside their thought processes and really think about what they would do when faced with a like situation.

I like it so much, that I even do it to myself. I’ve mentioned that I come up with most, if not all of my blogging ideas when doing other, mindless tasks. A great deal of my post ideas come while driving. I allow my mind to wander to imaginary concepts and ideas. Since I’m so immersed in EMS on a daily basis, a lot of those thoughts go right back to EMS, and “what if” scenarios come into my mind. Some of them are about patients that I’ve had, the “what if this had happened” kind of questions. Others are completely random scenarios that I wonder what I would do if I happen to be faced with the situation.

Einstein conducted what he called “Thought Experiments” to assess theories that he could not experiment with in a laboratory. One of the ones that I’m most familiar with is his “Flashlight on a Train” thought experiment. In this well documented case, he hypothesized that the speed of light was a constant and was not affected by outside forces. He imagined himself on a long, open railroad train with himself standing at the caboose, or end car of the train. He imagined shining a powerful flashlight from the rear of the train through the cars to the front engine. Using some logic that I am not familiar with because I’m no Einstein, he was able to theorize that the light from the flashlight would hit the train’s engine at the same time and that the light would travel at the same speed no matter how fast the train, and therefore the light source, was travelling. Unlike a missile fired from a jet plane that’s speed would be affected by the speed of the plane that fired it.

So how do Einstein’s thought experiments connect to EMS?

I equate the personal scenarios that I think of and the scenarios that I use to keep my students thinking outside the box to Einstein’s thought experiments. There are things in EMS that we do not do very often. Skills like synchronized cardioversion, surgical airways, and complicated drug administrations aren’t everyday things. Neither are difficult patient presentation with complex layers of comorbid conditions. These are high-risk, low frequency events that trial lawyers dream about. When you need to perform these tasks or think around a list of contraindications when your patient needs action now, having thought about them prior to having to perform is lifesaving.

One of the things I hear the most from paramedics and EMTs is how they run though a list of possible scenarios, patient presentations, and treatment modalities in their heads when dispatched to what sounds like a particularly nasty call. I do that sometimes too, although less now than I used to. Spending the time thinking about these things when you have the time to really ponder the issues is very beneficial and even fun… if you’re an EMS geek like me.

So next time you and your partner are bored sitting in your parking lot waiting for the next call, toss around a few “way out” scenarios. Your care will benefit from it. You might too.

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Posted by on September 22, 2009 • Filed under: Emergency Medical Services, EMS, EMS Blog, ems education, EMS practice, ems scenario, ems scenario based education, EMS training, everyday ems ethics, mental imagery, Paramedic, paramedic education, patient care, scenario, scenario based training, whattaya do
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