Just one thing...

Dispatched to 37 yo female who has fallen...

On scene, first responders are administering oxygen and getting information from the patient's family.

Allergic to Penecillin/Amoxicillin, took sulfamethoxazole 5 minutes before passing out in the bathroom.

And she is flushed...like really flushed, lobster red flushed...pressure soft, pulse tachy, lungs wheezing and unresponsive.

No urticaria but I guess you can't have everything. Her lower lip is swollen, but it is also bleeding, she probably knocked it on the way down.


0.3 mg IM epi 1:1000, Abuterol nebulizer in a mask, another epi shot. Her sp02 is high nineties with high flow 02.

On the board and on our way. She starts coming to, and her pressure/pulse improves. Once in the back of the ambulance, she has the old 'Eau de Etoh'.

She says she had 2 glasses of wine before going to bed. Her repeated questioning leads me to believe she is concussed. She doesn't remember anything, she said she had gone to bed(it was 6:00 pm in the afternoon).

Oh, she is on Lovenox and Warfarin as well, prone to clots apparently. Did I mention she had an -ostemy bag?

She was somewhat evasive and confrontation about how much she had to drink. She chased that with Flexiril and Oxycodone, she takes that to sleep.

Jeez, maybe the allergic reaction wasn't causing the altered mental status.


Her color improved, her vitals got better, we made it to the hospital.

I'll have to keep this one in my head for training purposes.

Fentanyl

So, we you are administering pain medication to a patient whom you are also administering fluid, especially through a large gauge catheter that flows really well. It doesn't really matter much how slowly your push your 1 ml of medication into the extension set. Because it probably won't get to the patient until you start running the fluid again.

That being said, don't open the roller clamp full bore right afterwards. It might end up in someone in the ambulance vomiting from getting pain meds too fast.

Not that this happened to me, I'm just saying.

First Chest Pain Call...Updated

So, thanks to a comment in this post from Christopher, I have been led on the path that the first patient I did a 12 lead on as a Paramedic may have had something called Ashman Phenomenon.

Ashman Phenomenon, by my understanding, is when a patient in Atrial Fibrillation has a long R to R interval followed by a relatively short R to R interval. During the long R to R, I guess the corresponding refractory period is also lengthened, to the point where it isn't quite finished by the next beat, causing aberrant conduction, typically mirroring a Right Bundle Branch Block, but sometimes other patterns too.

I originally stated that the patient had A.fib with occasional aberrant conduction, which appeared to be a Right Bundle Branch Block.

I dug up the 12 lead that I saved and I saw that it didn't appear to be a right bundle branch block, but in fact a left bundle branch block.

But enough talk, here are 2 of the EKGs I did....

Ignore the Wandering Baseline...

I guess Ashman phenomenon is occasionally mistook for a PVC, but seeing as how this patient had multiple perfusing abnormal beats in a row at a reasonable rate, it seemed more like a block.

Lead II in monitor mode wasn't very useful in showing the aberrant beats(they barely registered as squiggles), in retrospect I could've used MCL1, that might have shown the rhythm better, but I guess that will have to wait for next time.

It is interesting though, because what I read about Ashman Phenomena on the internet (the source of all credible information) it seems to usually just be a single beat. But if this patient's heart couldn't refract (Is a word, no?) fast enough, I guess it would make sense for multiple beats in a row to conduct abnormally.

Now my question for discussion would be, Did this patient prescription to Diltiazem increase her aberrant beats or not?

Any comments?

Finally there...or just started

I have been working as a Paramedic now for...approximately 3 weeks.

I have been thinking like a Paramedic for much longer.

For Paramedic Bag-of-Tricks, I have administered exactly 150 mcg of fentanyl.

My first 12 lead interpretation as a Paramedic consisted of a diabetic chest pain patient....

How is A. fib with inconsistent aberrancy sound?

Go figure that it couldn't be sinus, or STEMI, or ANYTHING straight forward. No, it has to be a pt. with some narrow QRS once and a while, then wide RBBB-like QRS for a little while.

It wasn't runs of V-Tach, because it stated in a rate of the 60-70 bpm.

Luckily, when we got to the ED, the Tech already had an old copy of the Patient's EKG, and it looked the exact same.

Update (8/24/1): More information(or guessing and conjecture!) on Chest Pain patient here

Patient Assessment - Trauma

Someone once told me that the most failed station by ALS test takers was the Trauma Patient Assessment (PA).

Then again, I have also heard the same about the Oral Station, KED, Dynamic, Static, IV, and Airway Management.

The trick to surviving the trauma PA station is this....

"BSI, Is the scene safe? What is my mechanism of injury? How many patients to I have? Do I foresee needing addition resources? My general impression is that this is a critical patient that will need rapid transport. I will have my partner maintain C-spine immobilization while I assess the patient's responsiveness and ABCs. Do I see any major bleeding as a approach the patient?"

If you don't know what any of that means, please go back and learn. Saying all of this stuff sets you up as a test-taker who knows what they are doing so the examiner is probably less apt to pay attention at this point.

Whenever I have an unresponsive trauma patient scenario (they ALWAYS seem to be unresponsive, or painfully responsive) I place an appropriately sized OPA and ventilate the patient on high flow oxygen with a BVM at a rate of 10-12 per minute, to chest rise.

I'm not sure how many folks fail this station on critical criteria or just fail because points. I'm guessing it has more to do with points than anything.

Lastly, make sure you know what you are going to do when you walk into the station and the patient is lying prone.

Please leave comments saying I'm full of bologna or whatever.

Oral Station NR practical Exam

Part of the National Registry Practical exam is two Oral Stations, I have discussed it previously here.

 I'm not sure but I have heard that the addition of these Oral Stations is a relatively new addition to the test.

Obviously checklist station scenarios do a poor job of assessing higher brain function in the paramedic student.

You can teach a monkey to pass Dynamic. What really separates a Paramedic from other level providers is their critical thinking skills and ability to control a scene.

The Oral station is suppose to test that.

I don't think I am suppose to discuss the specifics of my scenarios that were presented but I can say that they weren't that difficult to deal with.

 And that is what really screwed folks up.

 I am guessing that the reason so many folks failed the station was that they didn't ask all the SAMPLE questions and take a complete set of vitals.

Honestly, I only did it because during practice one of my instructors told me I should (when testing the Oral Stations).

Also, when I say a "complete set of vitals" I am talking HR, RR, BP, SP02, pupils, lung sounds, temperature, FSBG, skin color, temperature, and moisture.

I can tell you that one of the patients I flat out would not have taken FSBG or temperature if faced with that exact situation in the field, because I honestly don't think there would be enough time(it was an 8 minute transport time to trauma center)

I may very well may have not asked about allergies either, because in this case the patient really didn't "need" any medications.

But I did ask, and I passed. Folks I know didn't ask, and didn't pass.

This whole situation kind of goes against what Paramedic instruction presses.

Paramedics are taught to form a differential diagnosis, and ask pertinent questions regarding patient presentation and that underlying differential.

If it doesn't matter what the patient's temperature is, I really don't think that someone should be penalized for not asking about it.


 So future paramedic student test-takers keep that in mind....

 

Practicals

So I am done testing....I passed my practical.

I had to retest KED.

I just wanted to carry on the proud tradition of ALS test-takers failing the BLS station.


Parts of it were easier than I thought they would be...other parts were harder.

Now I'm just waiting for my cards to show up.

National Registry CBT

All I can say is that the most important thing to remember is to be the BEST answer...as the instructions at the beginning on the computer based test state. I have found that if this statement is phrased another way, it makes taking the test a whole lot easier....

Always pick the least wrong answer

Often, I found myself reading a question, and finding that the answer that I had formulated in my mind was not listed, not even a little bit, so I was forced to pick things like "don an air-purifying mask" before started triage at an hazardous chemical spill MCI, where the appropriate answer was "GET THE HELL OUT OF THERE!!"

But anyway, I passed. The test cut me off after 80 questions, so I guess I did pretty good.

There was a ton of scenario based questions for sure, so I would suggest getting very comfortable with those.

Only a few times (probably about 4) did I have to straight up just guess an answer.

Now, on to the Practical!!!

Taking Responsiblity

As Paramedic school was coming to a close, it became apparent which students were "getting it" and which really weren't. There is something that I can say that I observed about those that seemed to have more trouble than the rest.


They always had an excuse.

I never heard someone who was really having trouble with rhythm recognition say "I will take responsibility for my own learning"

Of course, that is a really strange thing for someone to say...but there always seemed to be extrinsic factors regarding learning, with the course, the teacher, the book, the tests, or the rhythms themselves.

To future paramedic students, my advice in regards to this is that when you crash and burn (you will). Learn from that experience and find ways for you to improve, don't just blame it on factors outside of your control.

Also, if banging your head against the wall doesn't help you retain material, stop banging your head against the wall.

Flash cards were the suggestion for learning pharmacology.

Flash cards didn't work for me.

I stopped using flash cards.

I didn't blame the flash cards, or the people who told me to use flash cards, I didn't blame the fact that we spent slim to nil amount of time on the material in class.

I found something else that worked for me.

What I learned about Hospital Clinicals (Part II)

Pay Attention to the Nurses that enjoy the help

There are going to be some nurses that for one reason or another will have no problem having a paramedic student start every single IV for them and push any medications that they need to.

These nurses are the best, but don't mess things up.

Keep your ears open to how you can help these nurses more. Changing sheets, taking vitals, whatever. That brings us to the next point...

Make sure the nurses that don't give you opportunities see how much (more) you are helping the nurses that are

Don't be obvious, blunt, verbal, or a jerk about it. But if the stick-in-the-mud nurses see how much easier you can make their job, they might open up more.

Graduated

Yesterday I took my finals (practical and written), and I passed.

I am officially graduated from Paramedic School.

My NR Practical Exam is scheduled July 8th, and I will be scheduling the Written Exam as soon as my Program gets the ducks in a row.


I will probably find some time to put some more posts up with my copious amounts of free time.

Ride time

The Harley is still shiny, there isn't any major damage, there is a small pool of blood approximately 6 feet from where the patient is lying supine, C-spine being held by a passerby that happened to be from a local squad. First Response Squad members are surrounding the patient....

"Hi, Whats your name"

"Cindy"

"Cindy, What happened?"

"I don't know"

Judging by her facial expressions she knowns that something is out of the ordinary and she isn't in any pain, there is a small laceration that appears to be bleeding from her chin, she bit her lips, all her teeth are intact and her airway is clear, she has a helmet on, no visible deformities and major bleeds evident. Pressure is being held on a wound below her knee by a first responder. A rapid trauma assessment confirms what I already figured. The lac on her knee must be from something on the bike and the bones underneath appear to be intact.
She says her neck hurts, but its probably not neck-neck pain.

No allergies, takes an ACE inhibitor and birth control.

She goes on a board, and into the truck, off to the hospital. 

Her pressure is slightly elevated, no signs or symptoms of cerebral hemorrhage.

I ask her numerous times if she is feeling nauseous.

18 gauge in her left AC.

Equal chest rise bilaterally, denies SOB, saturation at 100% on room air.

It was her first day riding, she had taken a safety course the previous weekend.

"If at first you don't succeed, don't try skydiving" goes through my head.

What I learned about Hospital Clinicals (Part I...A)

I totally forgot about the main thing I really wanted to touch on...

Schedule all of your clinical time early

My program doesn't allow students to begin ride time before hospital clinicals are completely finished. I am way behind where I wanted to be, mostly because it took more time than I was expecting to talk to the people I needed to and schedule time in the departments that I needed too as well.

I just assumed it was going to be as smooth for me to schedule time in the Cath Lab, L and D, ICU, and Pysch as it was for me to schedule time in the ED.

I was very wrong. It sometimes took me weeks to get in touch with those I needed to speak with, so ultimately I had weeks that were lost. Had I begun to schedule my time back in July, then I'm sure things would've been sorted out early. But it took me a 6 weeks to finally get into the ICU, and I ended up having to schedule my L and D time at another hospital.

Plan ahead....like...way ahead.

What I learned about Hospital Clinicals (Part I)

Next week I have my 8 hour Psych clinical shift, then I will have completely my hospital clinical time.

Throughout my journey there are a few things that I learned that I would love to pass along. I figure that these learnings are worth at least a few blog entries, so for this first one I will start with overall things that will help future paramedic students along no matter what department they are in.

Seize every opportunity to learn...even if it has nothing to do with your program.

I watched a plastic surgeon stitch up the face of a guy who got kicked (in the face) by a horse, I watched epidurals get administered, I assisted nurses with placing catheters, I helped clean and dress pressure ulcers, I watched ED docs drain infected cysts, I watched cardiologists start cardiac caths in the femoral and radial arteries, I assisted in reducing dislocated shoulders and ankles.

My clinical time in the hospital was a unique opportunity to see some really awesome medicine that I was paying for in dollars and time. I didn't want to miss any of it.

Smile, be courteous, helpful, thankful, and pay attention to staying out of the way.

I tried to make sure everyone I worked with knew that I was happy that they had given me the opportunity to be there. A lot of the time, having a Paramedic student following you around ends up being more work than not. It is important to realize those moments you can make the Nurses and Doctors life easier and jump on those opportunities.

Don't be afraid to ask about getting it done.

I missed opportunities for skills because I didn't want to bother people. Depending on your disposition and the people that you are working with, this might be more of a problem or less. There are specific things that you need to get done while you are there, and no one will fault you for attempting to get done what you need. There is definitely a balancing act though, and a student might be perceived as pushy, or apathetic.

Don't expect to get any skills or assessments in during your non-ED rotations.

This obviously doesn't include OB/GYN births and OR tubes. But the time I spent in Pediatrics, NICU, ICU, and the Cardiac Cath Lab, I don't think I was able to get much done (in terms of skills). I expected to get 20 pediatric assessments in the 32 hours I spent in Peds and the NICU, and I ended up with 6. There were nurses that didn't want anything to do with me in both departments, and I stacked my hours between a Saturday and a Sunday, so I ended up seeing all the same patients, which I could've probably "re-assessed" but I decided against it. A students best opportunity to "get-er-done" is definitely in the ED, and the ED expects that.

Be extra helpful and courteous to the nurses that don't want anything to do with you.

A paramedic student is definitely going to come up against some adversity. Negativity never helped anyone. The "if you give me crap, I will give it right back" attitude isn't going to help you, or the paramedic students who come along after you are gone. Early in my time at the ED, one nurse flat out ignored me and never asked if I wanted to assist them in any way. I just decided to start helping them any way I could, I would assist them with moving patients, taking vitals, and checking call lights. It only took a few instances of me just going out of my way to help them, and from that point on, this nurse asked me every time if I wanted to start their IVs. There also was a CRNA that didn't seem to keen on me. I was never asked to start any other their tubes, and everyone else in the anaesthesia department seemed to steer me clear of them,  but I had few good conversations regarding patient care and the stock market with them, so I hope that helped whoever came along after me.


I reckon thats enough for now.
 

Pharmacology and Med Math

A big chuck of Paramedic school consists of Pharmacology. My program is designed that every week we have a cumulative drug quiz that consists of the new drug of the week and possible dosages and information on every previous drug that we have studied up until that point.

I don't know how this stacks up against how other paramedic programs do pharmacology. But this path seems (to me) to lend itself to a lot of rote memorization. Which is funny, because medicine is one big interlocking web and understanding how the whole system works makes it easier to understand how the whole system works.

So, there are a few tips that I have picked up along the way that have helped me.

Understanding Functional Classes

Its not only important to know that Epi is a sympathomimetic, but it is very important to understand what a sympathomimetic is. If you understand what actually the underlying functional class of the drug is, then it is a lot easier to understand what the drug does, and you know what a selective beta-2 agonist is. If you have an understanding of the sympathetic nervous system to begin with.

Does that answer make sense?

Our med quizzes also have at least 1 or 2 questions about med math, and luckily enough, the math is usually based on actual drugs and actual dosages, so I never have had to worry about whether the answer of 950 gtts/min is the right answer.
But I have found that if I can get the per ml concentration, I can get to the answer or back to the start without relying on "the formula" too much.


I will post some more ideas when I think of them I guess...

Review of MedicTests.com

[rant]

So I listen to Confessions of An EMS Newbie...

I'm not sure when but recently they started advertising MedicTests.com

They are actually pretty heavily promoting it "on air"

Being 3-6 months away from taking the National Registry Test, I decided to buy a 3 month membership. For the fee of $59.

My membership when through, and my paypal account was debited.

When I signed in....I couldn't acccess the tests.

I checked to make sure all the tech stuff on my side was good...and it was.

I sent in a support request and 5 hours later the admin was able to manually approve something and I was able to get to the tests. So that went okay.


But, overall the whole site just seemed....unfinished.

I don't know how many questions the bank has, but I've been through the 50 question practice test about 3 times and the National Registry practice exam once, and there has been I'd say about 10% overlap in that I have seen repeat questions.

The thing that really got me was that there were spelling errors in some questions.

There was at least one question that I think the correct answer was programmed completely wrong. This is of particular concern because this site may be inhibiting a paramedic student's chances of success by providing the wrong information. I remember this question particularly because it wasn't a case of NR "least wrong" answer being the right answer, it was a flat out straight forward question that had the wrong answer marked as correct.

As well as some questions that appear dated in terms of Standard of Care.

I think the National Registry Test Simulator is somewhat Bloat-ware as well.

According to National Registry Web Site the cognitive exam is between 80-150 questions that 2 hours and 30 minutes are allotted.

I know from my own experience (at least with the EMT-B test) is that once you answer a question and move on, you cannot return to a previous question. I also noticed that if you got a question wrong in the computer based test, the test asked you the same question worded somewhat differently.

The simulator on the site gives you 100 questions in 2 hours, which you can scroll back and forth through all the questions. I'm not sure but the test doesn't seem to adjust (or adapt) depending on your answers. And it doesn't let you review the questions at the end.

So in my estimation, its doesn't seem to simulate the NR test well, and it doesn't let you see the questions you made mistakes on. So I don't find it particularly useful.

So really the only similarity between it and the actual computer based test is that it doesn't let you review the test and see what you got wrong. Which I don't think there is any value.

There was a little icon that allowed a test-taker to "flag" a question, which I did, but I am apprehensive that that might actually do anything, because of my next point.

Something that was very frustrating was the "review" option, for questions that you got wrong. When I was going over the questions I got wrong..there is a "review" button that I was figuring would go over the correct answer and maybe some background information. That would be VERY helpful right? Press that button and all you get is a confirmation that the answer you gave was right or wrong. Awesome.

This leads me to believe that MedicTests.com purchased some out-of-the-box Adobe Flash test creation program...and didn't bother to disable the Review button, or fill out the information to make the Review Button actually useful. This just leads me to my feeling of the website being unfinished.

Which brings us to the study materials portion. I was surprised to see the vast majority of the additional resources behind the pay-wall were free to any internet user links to other web pages.

That lead me to feel like I had just been duped. I had paid for information that was freely available on the internet, of which MedicTests.com appears to have no control over.

MedicTests.com appears to be charging for access to web hyperlinks to information that isn't under their domain name, and is freely available by other means.

MedicTests.com has a guarantee that if you use their program for 3 months 3 days a week and don't pass the NR cognitive exam, they will refund you your membership fees. But you still would be out the $110 it costs to take the test.

Overall, I guess you can say that the experience had not met my expectations.

I set those expectations by Ron and Kelly's hardy recommendation of this product.

I hate being negative, and I really didn't want this blog to become a bitch session regarding all the ills that surround EMS in general and Paramedic Education in particular.

But like I said, MedicTests.com feels unfinished, it definitely has potential. I'm not sure how adaptive the test is, but it could definitely be an outstanding product that assists all us paramedic-lings to success.


[/rant]

Bigeminy vs. Couplets

Bigeminy is when a sinus beat is followed by an aberrant conduction pattern. Trigeminy is 2 sinus beats followed by ann aberrant conduction pattern.

Couplets are 2 aberrant conduction patterns in a row.
Triplets are 3 aberrant conduction patterns in a row.


I seem to have wired these two things in my brain wrong and I am trying to get them sorted out.

Aberrant Conduction is caused by something, treat the underlying cause and don't abolish perfusing rhythms.

NTG, NTG, NTG....

We had a practical lab day this past week and these are the things I have to work on.

Update(8/23/2012): This seems to be the most popular post I have on this blog, a lot of folks navigate here from googling "Bigeminy Couplets". Does this help explain things a bit? Please comment...