Is it bad to over-react in Emergency Medicine?
I came on the scene, the patient was lying prone in firm snow, on a fairly steep bank on the uphill side of a trail. His right ski was still on his foot, and his left boot was externally rotated to what appeared to be opposite of the bend in the knee. Neither of his ski boots were buckled correctly, and consequence of such, were very loose. He was relatively calm, probably about 10 years old. I asked him what happened...
He said that he had fallen and twisted his ankle, and now it felt "weird". He said he couldn't walk on it. He used words like tingling, burning, electricity, numbness. The patient denied other injuries and there was no spinal point tenderness on palpation. The position he was in, plus the possibility of an in-boot spiral tib/fib were my main concerns. I tried to palpate for deformity/open wounds in his boot. After a slight scare that turned into melted snow, I ruled out any bleeding, but I couldn't tell on deformities one way or the other.
I called for a backboard and a set of hands because the patient was in relative comfort in the position found, and I didn't want to have to flip him, and end up have him screaming as his leg flopped around, or both of us go sliding down the hill and cause more significant injury to his leg.
When help arrived, we managed to log roll the patient onto the backboard, which caused no discomfort at all, the patients injured foot was stable, and didn't rotate to either direction. After more assessment I finally asked the right question...
"Have you ever hurt yourself before?"
"Yeah, but I've never broken anything, just bruises"
"How much does your ankle hurt compared to that?"
"Less..."
We took him off the board, he sat up, and we got him down, he walked just fine.
If I just went on the level of discomfort this patient was in, I could have figured he just twisted his ankle. But I had been in a similar situation; the EMTs were certain I didn't break my femur because I wasn't screaming enough. I'm sure they had learned in the back room of some fire house that femur injuries hurt like hell and the patient will be screaming their bloody cords out. There are so many subjective measures in what we do, the only thing that we can do is what we think is best for the patient at the time.
On scene, for a moment, I was slightly worried about overreacting, for a split second I was concerned what folks would say for me calling for a backboard for a patient with a twisted ankle, but I am glad that I immediately thought about what would happen to this patient did have a fracture, and if I did try to flip them on my own and take care of the situation without help. There would be a chance that we would have slipped a few dozen feet down the slope.
As I read over this post, and think about this situation I guess if I had asked the patient if they could flip on to their back or sit up, he would have, and been fine, but I assumed that no one would lie face down in the snow unless that WAS the most comfortable position, but I guess the way his leg was presenting put that out of my mind right away. I guess you can call that defensive assumptions.
One thing I know for certain is that I can only do what I think is best for the patient at that moment in time. It is easier to justify our actions for the worst case scenario than to say "I didn't think it was that bad"
As I read over this post, and think about this situation I guess if I had asked the patient if they could flip on to their back or sit up, he would have, and been fine, but I assumed that no one would lie face down in the snow unless that WAS the most comfortable position, but I guess the way his leg was presenting put that out of my mind right away
Showing posts with label EMS. Show all posts
Showing posts with label EMS. Show all posts
Saturday, January 1, 2011
Friday, December 17, 2010
Establishing a Baseline
I found out at work recently how important establishing a baseline mental status for a patient is, and as well as how much of our assessment of a patient's status relies on nothing that can be said or measured, and when at times, maybe those things should be said, just to make sure.
We received a call to a patients home for a severe headache, and for some reason, my partner had first contact with the patient and pt. family. When I had entered the primary caregiver was giving a report to my partner, and the patient was on a hospital bed in the living room. The patient was completely unresponsive, eyes shut, and appeared to be breathing only after prolonged observation for chest rise.
This patient appeared dead.
The rest of the family was quite unconcerned with the situation, and after ascertaining that this patient was, in fact, breathing, we continued to listen to the patient's daughter describe the situation.
The Patient was a 82 year old female on Hospice care, I thought that my partner had asked what for.
She hadn't. I didn't want to trouble the patient's family with asking questions that had already been asked, I should have, I need to get over that. I was going to be teching the call.
My partner asked the patient's daughter if this was the patient's baseline.
"Oh, yes"
Maybe I didn't want to ask more questions, because the whole situation seemed very casual to the family in the room, it was just a simple issue that the doctor said should get checked out, and they didn't want to wait until Monday, so I knew THEY weren't too worried. but if I'm not asking questions when its casual, will I ask them when things get a little more on edge?
As we began to move the patient, she opened her eyes, and starting making vocalizations that were unintelligible, as well as strange kissy noises. The family seemed unconcerned with this, so we just went with it, but right away I wasn't sure how I was going to present this to the emergency department at the hospital.
But just to make sure, when we finally got in the ambulance, and I asked her:
"Hey, My name is Devin, what is your name?"
....and she answered the question completely appropriate.
"Is this her baseline?"
"This"....what exactly does "this" mean? The patient could have been yabbering up a storm and answering all on Alex Trebek's questions correctly minutes before we walked in the door.
Internal observations and judgements don't translate well as "this", especially when talking to a cargiver, who may or may not know exactly what you are asking.
The patient's daughter spoke with us, right in front of the patient, for a few minutes at least and the patient didn't let out so much as a stir, murmur, or blink.
I know now that when I am ascertaining history from a family member/bystander/layperson, I better be specific.
The situation resolved itself uneventfully, but not without me looking like a moron to the Emergency Department, as well as learning a thing or two, which is always good.
The patient ended up having shingles...
No stoke, no vascular issues, nothing.
Good learning experience if you ask me.
On a side note, this family wasn't really ready for this woman to be DNR, it was easy to see, and maybe a discussion for a later time.
We received a call to a patients home for a severe headache, and for some reason, my partner had first contact with the patient and pt. family. When I had entered the primary caregiver was giving a report to my partner, and the patient was on a hospital bed in the living room. The patient was completely unresponsive, eyes shut, and appeared to be breathing only after prolonged observation for chest rise.
This patient appeared dead.
The rest of the family was quite unconcerned with the situation, and after ascertaining that this patient was, in fact, breathing, we continued to listen to the patient's daughter describe the situation.
The Patient was a 82 year old female on Hospice care, I thought that my partner had asked what for.
She hadn't. I didn't want to trouble the patient's family with asking questions that had already been asked, I should have, I need to get over that. I was going to be teching the call.
My partner asked the patient's daughter if this was the patient's baseline.
"Oh, yes"
Maybe I didn't want to ask more questions, because the whole situation seemed very casual to the family in the room, it was just a simple issue that the doctor said should get checked out, and they didn't want to wait until Monday, so I knew THEY weren't too worried. but if I'm not asking questions when its casual, will I ask them when things get a little more on edge?
As we began to move the patient, she opened her eyes, and starting making vocalizations that were unintelligible, as well as strange kissy noises. The family seemed unconcerned with this, so we just went with it, but right away I wasn't sure how I was going to present this to the emergency department at the hospital.
But just to make sure, when we finally got in the ambulance, and I asked her:
"Hey, My name is Devin, what is your name?"
....and she answered the question completely appropriate.
"Is this her baseline?"
"This"....what exactly does "this" mean? The patient could have been yabbering up a storm and answering all on Alex Trebek's questions correctly minutes before we walked in the door.
Internal observations and judgements don't translate well as "this", especially when talking to a cargiver, who may or may not know exactly what you are asking.
The patient's daughter spoke with us, right in front of the patient, for a few minutes at least and the patient didn't let out so much as a stir, murmur, or blink.
I know now that when I am ascertaining history from a family member/bystander/layperson, I better be specific.
The situation resolved itself uneventfully, but not without me looking like a moron to the Emergency Department, as well as learning a thing or two, which is always good.
The patient ended up having shingles...
No stoke, no vascular issues, nothing.
Good learning experience if you ask me.
On a side note, this family wasn't really ready for this woman to be DNR, it was easy to see, and maybe a discussion for a later time.
Saturday, December 4, 2010
Why do I need an expensive stethoscope?
In my experience, EMS professionals are fiercely loyal to the Littman brand of stethoscopes. I feel like some of that loyalty is mis-guided. I have heard from some folks that the quality has decreased from Littmans since they were bought by 3M, which I can totally believe. How good a specific scope is can be very difficulty to quantify, and working in the environments we do, I think that its important for our equipment to be mildly expendable. I mean, one can never be sure when they are going to have to restrain a patient with a combative head injury with nothing but a nasal cannula and their stethoscope tubing.
Maybe not, but its easy to see where I'm going. Its my opinion that a $100+ cardiology grade scope is a waste of money for your everyday EMT, and anyone who says otherwise is just repeating what they have heard. My scope is for blood pressures and lung sounds, and I don't have a problem hearing those things in the back of an ambulance with the cheap scope, so I can't justify paying a quarter of my monthly rent on something I don't really need.
But anyway, I recently purchased an American Diagnostic Corp. stainless steel stethoscope, it was $30, and I picked it up so I wouldn't have to pay shipping on an order I made at Galls.
ADC ADSCOPE 603 Stainless Stethoscope, Royal Blue
The clarity of sound is much better, and the soft-rubber ear plugs are very good at sealing out sound, and I am happy with my purchase so far. If I can hang on to this scope for a year without losing it, then maybe I might start to consider something more expensive if my opinion changes, or if I start listening for abnormal heart sounds on regular basis.
But in the end, in my limited experience, I have found that proper cuff sizing, proper cuff and scope placements, and making sure all your various tubes aren't knocking into each other and creating artifacts goes a long way towards getting good blood pressures.
But I'd like to hear other opinions.
Lastly, my mother is an RN, I asked her opinion:
"Just get a cheap one, expensive scopes just get stolen..."
UPDATE 8/16/11: Read my attitude shift towards different stethoscopes
Maybe not, but its easy to see where I'm going. Its my opinion that a $100+ cardiology grade scope is a waste of money for your everyday EMT, and anyone who says otherwise is just repeating what they have heard. My scope is for blood pressures and lung sounds, and I don't have a problem hearing those things in the back of an ambulance with the cheap scope, so I can't justify paying a quarter of my monthly rent on something I don't really need.
But anyway, I recently purchased an American Diagnostic Corp. stainless steel stethoscope, it was $30, and I picked it up so I wouldn't have to pay shipping on an order I made at Galls.
ADC ADSCOPE 603 Stainless Stethoscope, Royal BlueThe clarity of sound is much better, and the soft-rubber ear plugs are very good at sealing out sound, and I am happy with my purchase so far. If I can hang on to this scope for a year without losing it, then maybe I might start to consider something more expensive if my opinion changes, or if I start listening for abnormal heart sounds on regular basis.
But in the end, in my limited experience, I have found that proper cuff sizing, proper cuff and scope placements, and making sure all your various tubes aren't knocking into each other and creating artifacts goes a long way towards getting good blood pressures.
But I'd like to hear other opinions.
Lastly, my mother is an RN, I asked her opinion:
"Just get a cheap one, expensive scopes just get stolen..."
UPDATE 8/16/11: Read my attitude shift towards different stethoscopes
Paramedic School
My name is Devin, and I am an Nationally Registered EMT Basic, working for a for-profit Ambulance company in a New England State.
A few years ago, in my attempt to forestall responsibility, I stumbled onto Emergency Medicine through Alpine Ski Patrolling.
In about a month, I will begin the 18 month journey of becoming a paramedic in New England. I will be attending an accredited Hospital Sponsored Paramedic Program . I decided that this would be the best course of action. I think that I will get a better education from a school that is specifically designed for Paramedic Education, and not some mixed bag of who knows what from a for-profit or community college. A long time ago, I took an EMT-B course from a community college, I never took the test, and the experience left a bad taste in my mouth.
When I started to look into becoming a Paramedic, I looked for other's experiences with various programs, and I thought that the experience would make a good blog, I named the works Surviving Paramedic School because when I get through the works, hopefully I will have some pointers for those that come after me.
Once things are over, I will continue to put entries about things I found, in a half-hearted attempt to keep the newly undead-zombie-blog-that-has-outlived-it-natural-life relevant.
A few years ago, in my attempt to forestall responsibility, I stumbled onto Emergency Medicine through Alpine Ski Patrolling.
In about a month, I will begin the 18 month journey of becoming a paramedic in New England. I will be attending an accredited Hospital Sponsored Paramedic Program . I decided that this would be the best course of action. I think that I will get a better education from a school that is specifically designed for Paramedic Education, and not some mixed bag of who knows what from a for-profit or community college. A long time ago, I took an EMT-B course from a community college, I never took the test, and the experience left a bad taste in my mouth.
When I started to look into becoming a Paramedic, I looked for other's experiences with various programs, and I thought that the experience would make a good blog, I named the works Surviving Paramedic School because when I get through the works, hopefully I will have some pointers for those that come after me.
Once things are over, I will continue to put entries about things I found, in a half-hearted attempt to keep the newly undead-zombie-blog-that-has-outlived-it-natural-life relevant.
Subscribe to:
Posts (Atom)