On the Way to Paramedic in Northern VA
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Wednesday, May 24 2006
Through a Glass, EMSly - Vaulting

Several weeks back an opportunity was brought to my attention by Maddog. A medic was needed at the Great Falls Vaulters & Topaz Vaulters Spring Fest. All I knew about this event was that it involved people doing things on horses. Sounds like fun, and I've never done a standby on my lonesome. Be the Medic.

And so here it is - having never before attended any sort of horsey-thingy as a rider or spectator, with brow-creasing visions of Christopher Reeve flitting through the background.

Cue Sam Beckett: "Oh boy."

Observations from the perspective of EMS, and some things I learned. "Note to EMS:" notes were taken on scene, addressed to meself, but may be of interest.

First, I contacted via email the fellow who normally did this (obligations precluded him from doing so this year). He advised that the injuries, if any, would consist of a sprained ankle or two. No OMD was associated with the event - the level of care provided would be BLS, almost First Responder - minor first aid, call in the cavalry if required. The most useful item I could bring would be a good book to read. All very matter-of-fact, and low-key, BUT:

Normally one works a scene with a well-stocked ambulance, and a partner. A way to Load, and a way to Go, if required. It is very different indeed to walk into a situation knowing that your ambulance equipment is what you bring with you, and you have no partner trained to any level of EMS.

Alone, all alone...

 

The Jump Bag, at a Best Guess

For several nights prior to the event some time was spent considering how best to pack the jump bag. Limited space and all that. What could I expect at this event? I had no indicators except a) horses, and b) people. Yes, yes, anything at all could happen - a tornado could hit and smash the arena down, necessitating a collapse truck and extrication equipment. But recall basic EMS training: Scene size up, call for additional resources, THEN triage and treat. Anything major would be preceded by a call to 911, then me to treat while waiting for the responding units.

Breakdown of expected problems therefore fell into a few categories:

Trauma from Horse-related activities: Injuries from a fall from horseback; trauma from getting kicked or bitten (yeah, they bite, my grandfather's horse bit me once), trauma from getting stepped on. Human lawn-darts as the horse comes to a sudden stop - albeit this may happen only in cartoons.

Farm Equipment and Machinery Mishaps.

General Crowd Stuff: AMI, stroke, heat-related emergencies, OB (always a possibility), maybe an allergic reaction or two.

Most things in the jump bag were left there - abdominal pads, ammonia inhalants, bulb suction and mini-kit for field deliveries, OPA assortment and pocket mask, 4x4s, etc. Stethoscope, BP cuffs, pens and pads for patient info.

Some supplies were beefed up by about 300% - kling rolls, cloth tape in various widths, a couple of rolls of ACE bandages, cold packs and hot packs. Separate carry-bag for adult BVM, adult C-Collar, large adult sized BP cuff.

Around the handles of the jump-bag wrap a SAM splint, ready to go.

Level of care BLS, leave the IV start kit and fluid resuscitation stuff. Come to think of it, I probably shouldn't even have such a thing since the needles and tubing and all could be considered "paraphernalia". Eh.

No colors. A newly-purchased shirt says "EMT" on the back, but that's it. It is important, to my way of thinking, to not show colors unless you are truly representing - by which I mean, no rescue-squad uniform or private ambulance service uniform, unless your rescue squad or service is actually involved in providing EMS support at the event.

Note to EMS: Check with the organizers and see if there is an official code - all event honchoes wear a white shirt, or whatever. Be identifiable to the crowd as someone "with it" so they can find you, if needed.

 

At the Arena

Very different from television depictions of a rodeo. There is a decided lack of tobacco-chewing going on, and nobody is dressed like a cowboy. This is upscale horse stuff, not wild-west horse stuff. No Marlboro men.

The arena is indoors. The surface of the ring is deep sand, turned and graded by a tractor, rather than hard-packed earth.

Once in a while the action stops and the tractor rolls in to re-grade.

Horses don't sniff each others' butts, which makes them quite the noble beasts.

 

Vaulting

So, what is vaulting? Basically, at this facility at any rate, there are three arenas or "rings". One ring is devoted to the "barrels", large steel drums on four sturdy legs, covered with carpet or a thick wooly padding, having on the top two hoops like two halves of a car steering wheel mounted off-center at the apex. Performers climb aboard these barrels and perform handstands and other balance-beam gymnastics, about four feet off the ground.

Center ring is devoted to warm-up exercises on the horses, while the third ring is for the competition proper.

The horses used in these events are generally from draft-horse stock, giving them slower gaits, broader backs for the performer's use, and generally good dispositions. Most of the horses stand about five feet tall at the shoulder, although there are individual variations. There were a few ponies, mostly for the use of the younger vaulters.

First thing noticed - all these teeny, tiny little competitors. Few were over sixteen years of age, 90%+ were female, thin, and agile. The vaulters wear slippers, not shoes - no ankle support. There's not a steel-toe in a barnful, and I was told that a horse accidentally stepping on a foot sometimes accounts for an injury. They wear no helmets.

Note to EMS: Yes, an adult could fall backwards off the bleachers or have an AMI, but adult C-collars and BVMs are just about worthless. You didn't pack enough pediatric supplies.

The horses have a saddle duplicating the barrel arrangement - two hoops at the horse's shoulders instead of a central pommel or saddle-horn. There is no saddle per se, but a blanket or pad on the horse's back. There are strap-like stirrups which are used to allow the performers to stand on one leg and strike a pose while riding.

The horses canter or trot - never a gallop - in a circle, usually counter-clockwise. Vaulters always approach the animal from the center, so counter-clockwise means mounting on the horse's LEFT side, the "normal" way.

Note to EMS: Pay closer attention when the horse is moving CLOCKWISE, as the vaulter is mounting on the animal's RIGHT. This is unusual both for the vaulter and the horse, and mishaps (I should think) would be more common, accordingly.

At the center of the circle is the longeur or lunger (pron. lunjer, not lung-er). This individual holds a strap connected to the horse's bit and rotates in the center of the ring, keeping the horse moving in a circular fashion.

The lunger also controls the horse's speed with voice commands, and a whip, an eight-foot long stick with a 12-foot or so length of cord. Most lungers used this as both an aural and visual cue for the horse, although there was one trainer with anger-management issues, probably a fine fellow, but...

 

The Day Begins

Note to EMS: Think "lifeguard at a busy pool"

Everywhere, kids are climbing on barrels and fences, jumping around. No different, really, from a playground scene where thirty to sixty kids are playing around except that here the ground is soft turned sand and the kids are used to this kind of playground equipment.

Note to EMS: Usually, there will be a parent or older adolescent spotting the kids on the barrels. But not always, and the kids will sometimes try something they see being done by older more experienced vaulters.

Eagle eyed for three hours, trying to keep an eye on all three rings. Someone engages me in conversation for the first time, and not sixty seconds elapse before the call for "Medic!" comes from the performer's ring.

"Ah," thinks he to himself. "It begins."

After doing her routine, a young lady leapt lightly from the horse and landed, per plan, on both feet. One foot entered a divot left by horse's hooves and the knee on that leg went "Pop!".

The patient was laying supine in the arena, both legs in the air, in a good deal of pain. The lunger had controlled the horse and led him/her out of the arena, so that wasn't a concern. Palpation of the knee joint showed that the patella had popped back into place - a bad sprain, then, rather than an ongoing dislocation. Patient denies neck or back pain, denies LOC, moving air well with equal chest rise/fall - no spinal or rib injuries. complete assessment from head to toe anyway because the knee pain might be masking other injuries. Splint the leg in a position of comfort and move the performer out of the ring. Vital signs, PMH, allergies and all that jazz. Ice pack for the knee. The adult in loco parentis confers with me and decides to go POV to the ER at a later time, if the injury doesn't worsen. I'll check on her periodically through the day, changing ice packs.

Note to EMS: The arena(s) shrink down incredibly after the first call.

Competitions continued. Not knowing, of course, if the "injury trifecta" was in play, eyes are peeled even further for the next mishap. However, that first injury works both ways: the performers themselves are, it seems, even more careful, which is a good thing.

Note to EMS: The lungers control the horse's speed, but the horse will (perhaps uncontrollably) change his gait while dropping a load. Closer attention to the performer during "cleanup in aisle 3" events.

As we all know, one way to ensure that the tones don't drop is to sit in the unit sipping coffee and studying. It's no fun for the Gods of EMS because you're ready. Tones drop when you're on the can, or in the shower. Predictably, DTs being the conscientious fellow he is, no further medical mishaps occur.

 

Spring Fest Day 2, The Jump Bag Revisited.

Some rethinking went on overnight. Dump the adult BVM, keep the pocket mask - one size can fit all. Drop the adult C-collar for two reasons: one, it is improperly sized for the performers; a SAM splint can be fashioned into a workable pediatric c-collar (you knew that, of course), and two, with no other trained medic available on scene, DTs is committed to holding c-spine anyway, collar or no, until the cavalry arrives.

Arriving home last evening DTs filled some good-quality (no leaks) Ziploc bags half with water, then chucked them into the freezer to make a dozen or so ice-packs. These will go in a cooler.

Two rings this day, rather than three. The first ring, kids on barrels, has been finished and dispensed with. Barrels are still in evidence, and youngsters still fooling around on them, but both are fewer.

Today the "compulsory" gymnastics are over; the performers now get to do freestyle gymnastics on horseback, sometimes in groups of two or three kids at a time.

Impressive!

And, thankfully, without injury.


Tuesday, May 16 2006
Just Big-Boned

For the longest time, there was a scale in the bathroom. It was a congenital liar, and the only purpose it served was to collect an impassable moat of dust-bunnies at its perimeter. As a Scientific Instrument of Measure, it lacked certain features - such as consistency. For instance, one would find he weighed more, or less, depending on whether he stood on two legs or only one. It also seemed that, when clouds appeared on the horizon, one's weight changed as well. By many pounds.

Whilst shopping for exercise equipment, DTs (who likes Neat Things) came across a bathroom scale which was a Neat Thing indeed. It not only measured one's weight, but also would tell one his body fat percentage, and made no claim to being a barometer. Money changed hands.

Arriving home, DTs found through this Neat Thing that he weighed 206.0 pounds and had a whopping 19% body fat percentage. Simple math dictated that on his 6 foot four inch frame, fully 39+ pounds was fat. Eeeewww.

Not a problem. Charles Atlas says he can make me the Hero of the Beach in only fifteen minutes a day. I'll gamble the stamp and send for his system today!.

As time went by, exercise continued, and weighing occurred when and if. Both weight and fat percentage fluctuated, of course, with hard numbers - but there were no hard numbers for muscle mass, which was the object of it all. It would have been really neat if the scale flashed, "Muscle: 90%" or whatever. Well, yeah, okay, not 90%, but you know...

Subtraction, of course. Body weight - Fat % = "not fat" weight. But that weight includes things like bone (exercise wasn't going to make me any taller), internal organs (hopefully not going anywhere) and blood (rushing around a bit more, but weight unaffected.) Deduct the weights of these items, and one is left with the muscle, right?

This is the sort of button-sorting and bean-counting that wins Nobel Prizes, folks.

How much do organs weigh? Not so easy to find out, but find out I did, by combing through many an autopsy report. Data had to come from adult males, of course. Abnormal data from sufferers of certain diseases, e.g. hepatomegaly (enlarged liver) were discarded.

Cue Marty Feldman: "Abby-someone."

OrganLow GramsHigh GramsAvg GramsAvg Lbs
Brain1080164013603.00
Right Lung210835522.51.15
Left Lung205810507.51.12
Heart180465322.50.71
Spleen89316202.50.45
Liver90318901396.53.08
Thyroid1050300.07
Kidneys153560356.50.79
Blood453.59453.59453.5912.00
L&R Suprarenals173827.50.06
Testes389767.50.15
Prostate358057.50.13
Pancreas1121901510.33
Organ Weight3485.597424.595455.0923.03

Okay - taking the averages, then, from his 206.0 pounds DTs may subtract 23.03 right off the bat for internal organs.

Does this mean the remainder, Body Weight - Fat % - Organs = Rippling Mountain of Muscle? No indeed, for our handy little chart is missing stuff. Bones. Skin. Intestines. Oogy things. Hey, if I find that data, in it goes, but until then, what to do?

One would expect an easy time to find these weights. One would be wrong. Bones are not weighed at autopsy, and cadaver bones are dry, useless things without marrow. What was needed was the weight of a skeleton which is functional. Oddly enough, one walked across the TV screen just then for Calvin Klein or some such.

Aha! If we had someone who was nothing but skin and bones, no fat or muscle to speak of, and subtracted the organ weight, we would know how much... well, how much skin and bones weighed. We'd need height data, because obviously a tall skinny person will weigh more than a short skinny person. Calvin Klein models would not do - male and female were bound to be somewhat different. I found my data in contemporary cases of severe anorexia nervosa, and from liberated Axis POWs:

height in.weight lbslbs per in
721201.67
64801.25
601011.68
74811.09
72881.22
63681.08
721361.89
76951.25
731121.53
72961.33
72901.25
72981.36
63801.27
62801.29
64470.73
671121.67
691001.45
63951.51
66911.38
Averages:
68.7391.471.36

Now, these folks had all their organs in, of course. For the most part, organs don't really change much due to height, so let's remove their weight. 91.47 minus 23.03 gives 68.44, and here we have a neat generalization. Notice the average height.

It would seem, empirically at least, that each inch of height is 0.9957 pounds of weight in bones, skin, and viscera. Obviously this is an average - one has no viscera in one's legs, for instance.

In general, then, one could conceivably multiply his height by 0.996 (or 1) and then add 23.03, and call this number "everything BUT muscle". Subtract that from total weight, and there you have it. Muscles.

Wait a minute... I missed lymph. I'll be right back...


Friday, May 12 2006
Eats Many Snackfoods

There is a conundrum particular to EMS concerning Bodies. Not dead ones, O Ye Morbid, nor those of the patients whom it is our duty and privilege to gruntingly lift to cot.

The challenge is with our own.

EMS Man, him good, him strong, and it is well that this is so because, as you may imagine, the less care someone takes of his body, the more likely it is that we in EMS are going to need to lift it.

Morbid obesity, to name just one state a patient may attain, carries with it all sorts of related complications including heart disease, dyspneas of various forms, blood-sugar irregularities, stroke, etc, any of which may precipitate a call to EMS. Indeed, obesity itself may be a side-effect of a serious condition, but there it is. When the patient gotta go, the patient gotta go, and EMS gotta get 'em there.

Some EMS systems, therefore, implement PT or Physical Training into their daily routines. An ambulance crew (and of course the fire guys) show up at work, change into shorts and those famous gray T-shirts and run around a bit, do some weight lifting, stretching, and all that good-for-you jazz. Hoo-ah. Shower, change, and the crew is ready for the day, having increased both strength and stamina on the clock. PT done, crew clean, the previous shift stands down. The ambulance has been staffed while the incoming exercisers finished up.

Some systems, however, do not explicitly provide for that sort of warm-up. Arrive at work, punch in, and you may at any moment be toned out to a call, at any time.

The Unthinkable Scenario: The tones drop. "Respond to Chest Pain at 123 Wombat Avenue".

1) Our Hero sets the barbell in its cradle and wipes face with towel, then

2) Strips hurriedly while running to the shower, then

3) Washes and dries quickly, then

4) Dresses, remembering trauma sheers, radio, stethoscope, Bat-Carousel Reversing Spray, then

5) Responds, somewhat out of breath but feeling Mean and Clean

There are individuals of both Experience and Speed, who can actually pull off that or a similar process and still beat you to the unit, but those of us who are Too New to go from Exercise to 60 in 3.2 seconds generally exempt ourselves from Physical Betterment, at least at the station. The alternative is to exercise in your BDUs, then subject the poor patient to your odiferous presence on the ride to the hospital.

"What's this patient's chief complaint," asks the kindly Doc.

"Well," you stammer, "It was Chest Pain, but now it is Shortness of Breath."

"And Nausea," pipes up the patient.

Alas.

"Ah, DTs," you shake your head sadly. "You are indeed shortsighted, and only Strong Drink can excuse your inability to grasp that exercise may be done AFTER one's shift."

Indeed. However, human nature being what it is, let us choose the likelier of two possibilities for a middle-aged Medic after a busy 24-hour shift:

a) Turn over the truck to the incoming crew, then change, and exercise for an hour;

b) Turn over the truck to the incoming crew, go home to family, get sleep.

Hmmmm. Tricky. The same applies to exercise prior to showing up to work. Does one get up and exercise, or hit the snooze button one more time, prior to running for 24 hours straight? The Strong of Will will be pounding the sidewalk, jogging past the draperies shielding DTs' slumbering form, but there it is.

Certainly exercise is but one facet of good health. An EMT's gotta eat.

We live in the fast lane. Fast cars, fast women, and fast food. Eating is personal time, done at the whim of Dispatch, who themselves operate at the Whims of the 911 System. So, if one wishes to eat, it must be done quickly.

While the alternatives in nutrition falling into that category are myriad, they are mostly not good for the Long Haul. There is Someone monitoring us, and ordering a meal which takes more than three minutes to prepare is a sure-fire way to generate a stat call.

Paying more than $5 for a meal will guarantee it will never be eaten - your calls will come continuously until what was a gourmet delight is now a decayed mulch in a Styrofoam take-out box. And don't even try to get all the crews together for a sit-down meal.

So, what does all this mean? Due to our eating habits, impressed upon us by circumstance, exercise is almost de rigeur. And Exercise, for some including DTs, consists of what we can get while off-duty.

As such, exercise itself has been accompanied by enough free time surrounding it that the Computer Geek in DTs has reared his also-ugly head and compiled many a statistic and measurement, which I am sure are universally applicable and with which I shall bore you next post.



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