On the Way to Paramedic in Northern VA
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Thursday, June 23 2005
Muh muh muh My, My Medic

I don't know how much more good news this old carcass can stand.

It's all these cigars. DTs gave up smoking over a year ago, April methinks, yet here he is once again with a ten dollar cigar dangling from his smirking yap, dropping ash into a tumbler of single malt as he celebrates yet again, the second time in three or so weeks.

Cigars and Bushmill's is just something we medics do, on occasion, you see.

Yes, tremble, Northern Virginia - DTs is a medic. Not a paramedic, mind you - although the classes and clinicals and requirements are met for that lofty post, the street time has not yet been concluded. The test taken (and passed, yes, thank you, thank you) was for Intermediate level, or what some disdainfully term "paramediate". Philistines. I refuse to speak with them.

For is it not Written, in Protocols 1:15, "Verily, the Intermediate shalt do all that a Paramedic may do, yea even unto twelve leads and rapid sequence intubations, and all that may be done unto every manner of creature that dials 911, even the porcupine."

The Book of Protocols has some strange stuff. Nevertheless, it is a Good Book.

In this Age of the Internet we were fortunate to find advance information concerning our test status from the NREMT web site. Otherwise, it'd be another week or three before the mail brought my rocker patch. As it is, my frazzled nerves are sooner on the mend.

Could that be it? Have studies been done? Is the "celebratory" drink nothing more than what was claimed in the 20's advertising, a "nerve tonic"? I refuse to condone excuses for excessive drinking, but think (if that be the word, at this time) that a Saint Bernard be-necklaced with a small keg is perhaps a fine mascot for EMS folk everywhere.

As for me, I shall now gently stew. Fear not, there be many steps left until DTs roams the streets with IV needle in hand and paddles at the ready.

Paramedic be in me sights now, however, me hearties.


Saturday, June 18 2005
Clever Ploy or Biting Criticism?

"Que pasa?" asks DTs as he identifies the patient in the group. "What's going on?"

The patient glances around for support. "No hablo Ingles," says the patient to DTs.

"Que molestias tiene?" asked DTs. "What's bothering you?"

"No hablo Ingles," came the reply. Various nods in the silent group. It is true.

"Ooookay. Um, donde le dolor?" "Where is the pain?"

"No hablo Ingles," again.

"Habla Ingles algien aqui?" "Does anyone here speak English?" asks DTs plaintively.

Quoth the patient, "No hablo Ingles".

Sigh. Is my pronunciation that bad? Must look up "I don't care about immigration status" and keep that handy.


Thursday, June 16 2005
Farmology

Maddog Medic posted recently about a patient taking Peanutbutterballs, when actually the patient meant Phenobarbital. This got me to thinking about all the other ingenious pharmaceuticals which patients are taking, and the conditions they treat.

In Pharmacology one is taught that drugs have chemical names, such as H2O; generic names such as "water", and trade names such as "Evian". And now add to that patient names.

Now, before anyone accuses me of sneering at others, know that everyone does this. Kleenex and Xerox used to be specific brands of nosewipes and photocopiers, but nowadays have passed into the "hand me a kleenex" and "hey, xerox this will ya?" lexicography. We're all guilty of making up our own terminologies for things, then, or at least using the terms thought up by others. Which makes sense. If someone hands you a document and asks you to Xerox it, off you go to photocopy it. If on the other hand they're being all proper and righteous about their particular copier brand and ask you to Canon the document, what're you gonna do? Shoot it out of something, which is not at all what they wanted. "Canon'd your document, went fifty feet!"

So everyone to some degree uses the wrong term, but the important thing is that everyone understands what is meant. It isn't communication until everyone understands what's being said. Rarely have I come up to someone and said, "Dude, you been doin' 3-benzoyloxy-8-methyl-8-azabicyclo [3.2.1]octane-4-carboxylic acid methyl ester?" Very rarely. If they answer yes, they're probably high. Usually, I say "cocaine".

A patient taking "water pills" usually means some diuretic, generally lasix. Lord only knows when they tell you they have "lots of vitamins from the doctor". Thankfully there is some underlying human need to lump this stuff together, on the nightstand, in the bathroom or kitchen where it can be swept into a bag and brought along. People whose homes otherwise show no underlying sense of order will have their medications together in one spot.

Patients name not only their medications but will also name their conditions. The variations are many, and strongly influenced by patient demographics. Just remember, "I have sugar" means the patient is a diabetic. "Gimme some sugar" means the patient wants a kiss - not recommended.


Friday, June 10 2005
A Shot Across The Bow

Our call was in the wee hours to a retirement community for a "difficulty breathing". This is Bad Juju - ya gotta breathe - so we went loud, fast and flashy. Our closest medic was on another call, so I noted that the next available medic coming in was from two dues over.

Arrive on scene, whip out the cot, toss a Lifepak, airway and aid bags onto it and begin rolling inside. The security guy let us in and told us the floor. No sign of the medic yet, so let the elevator doors slide closed and get there.

Navigating a maze of silent corridors, second-guessing ourselves at each intersection. We finally run into someone who led us the rest of the way to the room.

A nurse stood between our patient's bed and an oxygen concentrator - a machine that drags O2 out of room air and concentrates it into a mask or nasal cannula.

Our patient was very elderly but looked surprisingly well. The patient's skin was pink and dry - good circulation and oxygenation may be implied there. The patient was laying flat in bed - not sitting up gasping for breath, nor propped up with pillows. I greeted the patient and she replied in full sentences, no wheezing, and her replies were oriented and proper. Eyes PERL, smile and grips equal bilaterally, good distal PMS. Hmm.

Despite the presence of the concentrator (which was turned off) the patient had no mask or cannula on. Oxygen saturation levels confirmed the patient's apparent O2 levels - 95+%. Lung sounds clear all fields, good tidal volumes, patient is calm and seems fine.

The patient did not want to go with us to the hospital because she had all kinds of things planned for the day. Thinking of giving the medic a break, DTs raises his radio and cancels the medic, then begins talking the patient into getting checked out. The medic, we hear over the radio, acknowledges and tells the dispatcher that they're out of service for a while, restocking or some such. (Old hands can see exactly what's coming.)

Finally, the patient agrees to come with us to the hospital for a checkout. DTs asks the nurse, "Say, by the way, who called 911? Was it you or the patient?" "Oh, I did," says the nurse, "When I found her slumped on the toilet."

"The you what okay start over" stutters DTs.

"I was making rounds, and the patient was slumped on the toilet. Her pulse ox was 64%. I put her on oxygen and got her to bed."

"Well well." says DTs. "And you took the patient off the oxygen...?"

"Just a second before you came through the door."

Okay, well, that explains the lovely high O2 sat we got, and the patient's color. Straining on the toilet is a classic path to heart attack ("grunting" activates the vagal nerve, which slows the heart rate.) And when your heart stops, well, you might just stop breathing too.

Oh shit oh dear. And Yankees in the cellar.

The patient is on our cot, we're ready to go. Patient still looks and sounds great, strong regular pulses, good sats, clear lung fields... DTs is torn. We can be at the ER by the time any medic can get to us, so that decides the path.

We'll go ahead and take her, but damn! I wish I could start a line, and put her on the cardiac monitor. I want that O2 sat level up to 100%, so I bump the liters per minute twice en route. Hold hands the whole way - DTs has a less scientific but equally accurate pulse monitor built into his fingertips. Strong and regular. Keep the chitchat flowing - note to field providers, hearing about your patient's grandchildren is a cheap and easy airway monitor.

Transport was uneventful (thankfully) and the ER cardiologist found no problems. Still, scary stuff.

Lessons learned: 1) Never send the medic home unless you are one; 2) Never assume anything re the patient, disposition, etc. 3) Patients who might require CPR are far scarier than patients on whom one is performing CPR already.


Sunday, June 05 2005
A Fine Excuse for Scotch and Cigars

Testing is complete. Now we play the waiting game (but as Homer Simpson says, "The waiting game sucks! Let's play Hungry Hungry Hippos".)

Ah, the National Registry tests. For those unfamiliar with it, a brief outline:

EMS Providers, at the Basic, Intermediate, and Paramedic levels, do lots of "doctor stuff" for people we literally just met. We are of course not doctors, and so a minor legal problem is created, to whit: "That feller done said he an EMT and pulldied-off mah armbone! Who do I sue?"

That problem divides into two or more parts, the more salient being, 1) How much care can we provide? and 2) Who says so? The parts are interlinked.

Nah, even briefer than that, come to think of it.

It all boils down to, "How much do you think you know, how much can you prove you know, and who's going to take the blame if you-god-forbid-f-someone-up?"

Different states allow different provider levels to do different things. Within that allowance, each county or region has an OMD who is the "doctor's license" behind all we do. Some OMDs want you to put 'em in the bambulance and bring 'em to the ER - that's it, no matter your training. Other (need I add, cooler) OMDs allow field RSI - rapid sequence intubation - where we chemically paralyze the patient to allow us to secure his airway. It all depends.

And so, the National Registry. Their written test is carefully crafted to obscure the answers. You know, you can sometimes take a test and walk out knowing you aced it? Well, not the NREMT tests you don't, baby. It is Obfuscation, raised to the highest form of art - and it's multiple-choice. Some keen minds at work behind that biatch.

The practical tests are nightmarish as well, especially for those of us who run calls. We have a certain way of doing things in the field. This is not the NREMT Way. Boo hoo - you fail.

And, do we miss the written or practical tests, we are never told why. "The NREMT is a testing and certification agency, not a training agency. If you fail a test, go see the folks who trained you, we won't tell you why."

So: The practicals I did pass, 'cuz they let you know that on the day you take them. From 07:30 to 17:00, but take them and pass them I did. Had to retake Static Cardiology and Trauma Assessment - I may have got a rhythm wrong on the cardiology but I'll be damned if I know where I screwed up a trauma assessment - but a single "redo" is allowed on test day and both my redos went well. Or the fact that DTs can look like a Margaret Keane painting and reveal the Pathetic Woeful Creature Within. And I told each of my testers that I wasn't allowed home until I passed. Just kidding - the folks aren't heartless but they are very professional, local Paramedics who were moonlighting as NREMT testers that day.

It remains to be seen about the written. Three weeks or thereabouts before anyone hears about that.

If all goes well, a fat packet including a rocker for DTs EMS patch, indicating "I" status, will arrive. After which time does begin precepting for an "I" position - in some counties this can be 12-18 months under field supervision. Good times.


Thursday, June 02 2005
Crescat scientia.

Testing time.

 



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