The Non-Conformists’ Guide is Here!

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

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The E-Book is Coming!

OK, I can’t keep this to myself any longer. It’s time for the big announcement. With the final draft still in the mail from my editorial team and the final design still lacking a few details, it would probably be best to just keep this under wraps for a few more weeks, but I can’t wait.

My first E-book is scheduled for release on January 21st, one week from today. The e-book will be free and it will be available right here at The Spot.

The Book is called The Non-Conformists Guide to EMS Success. This book is the culmination of two decades of EMS experiences, mistakes, failures, trials, and errors that lead to my ultimate success. My goal was to write something that would be useful to EMTs at any stage in their career. And I didn’t hold anything back. This is my road map to finding true success and fulfilment in EMS work.

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What Is Ketosis Anyway?

The carb craze may be responsible for thrusting the term ketosis into the mainstream vernacular. Before that, it was a word you rarely heard outside of medicine. Before Dr. Atikins and the low carb evangelists came along, you could relegate ketosis to a power point slide in an occasional diabetes lecture and be done with it.

Now it seems like ketosis is the in-word with soccer moms and zone dieters alike. And, while its conceptual popularity has grown, there’s still a lot of misunderstanding floating around about what ketosis is and what it means for your body. Much like belly button lint and the popularity of boy-bands, the ketosis phenomenon is well known yet somewhat mysterious and difficult to explain. So let’s review.

If you don’t have time for the long answer, here’s the short and sweet version:

• Ketosis is the term for abnormally high levels of ketone bodies in the blood.
• Ketones are created when the body breaks down fat for energy.

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Don’t Forget To Ask The Patient

Let the young know they will never find a more interesting, more instructive book than the patient himself. ~Giorgio Baglivi

It was nearly two decades ago that I knelt on the floor before Sammy in the Santa Clara County Sheriffs booking facility. I remember him so vividly that it’s hard to believe so much time has passed. There was nothing exceptional about him. Handcuffed to the waiting area bench, he looked very much like you might expect a man high on drugs, being booked for petty larceny, might look.

Sammy felt like his heart was racing and, given his drug history, the officer thought that he needed a once-over before heading off to the county lock-up. I, the young, scared, mostly clueless paramedic intern was doing my best to evaluate him. Growing up in a quaint California suburb I hadn’t crossed paths with to many folks like Sammy. He, quite frankly, terrified me. My preceptors stood back and observed.

“Sammy did you do any drugs tonight?” I asked.

“Yeah, I did a speedball about an hour ago.” He casually offered.

I looked over at my preceptor Mark hoping for clarification. I got nothing. I looked back at Sammy and then again at Mark who smiled demurely. “What’s a speedball I asked?” Mark knew the answer but he had other ideas. He gestured toward Sammy. “Ask him. He’s the one who took it.”

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Atypical Cardiac Chest Pain

We taught you what cardiac chest pain looked like, right? You remember.

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

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What Is A Pandemic Anyway?

This pandemic word has been getting tossed around a bunch in the media lately. Ever since the World Health Organiztion started raising the pandemic alert level back in April of 2009 the media started tossing the P word out there like it was a bad cliche or a Geiko commercial. But what is a pandemic anyway? What makes one disease a pandemic and another one a run of the mill epidemic?

To answer that question lets start with that other, over-used media phrase “epidemic“.

Epidemics are all about predictability. (Not rate of spread or numbers of individuals effected.) So lets say you’re a run of the mill influenza virus and you’re off doing your seasonal influenza thing. The Centers for Disease Control may predict that you’ll infect 8.2-12.9% of the population this year.

To become an epidemic you need to beat your numbers. You need to outperform your statistical curve. Step up big time and infect 14% of the population and you too may be granted the status of “flu epidemic”.

Pandemics are a bit different. Pandemics need to meet a few more criteria before they get dubbed pandemic.

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What Is Muscular Dystrophy Anyway?

Since we’ve been talking about the fill the boot campaign the annual MDA telethon, why not use our “what is” series to take a closer look at the group of diseases we commonly refer to as muscular dystrophy.

While most EMS caregivers have a general idea of what to expect in a muscular dystrophy presentation, few of us are as knowledgeable as we should be about what muscular dystrophy is and what it does to the body. Let’s take a closer look.

While we tead to refer to muscular dystrophy as a single defined disease process, it is actually a group of disease that share some common characteristics. Add to that the fact that all of these diseases are degenerative in nature and you can imagine how remarkably different these patients can be.

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Wrong Medicine

Some of the stacks of trip reports were nearing four feet high and they filled the musty closet. Dividing them up, we started sorting through them in earnest. The dates indicated that the calls had been run between 1972 and 1978. Most of the narratives were as brief as the treatment lists.

Hall Ambulance’s station one was an older house in an early residential area of Bakersfield, California. It had been, at one time, the residence of the company’s owner, Harvey Hall. In the early days of the ambulance service, Harvey had both lived in the home and run his fledgling ambulance service out of it. 

One of the crews stationed at the home had gone digging in the dusty storage closets and struck EMS history gold. Stacks and stacks of old trip reports from the Mother, Jugs and Speed days of EMS. That’s where we found it. A call run by our medical director back in his days as a paramedic for the service. A cardiac arrest, no less. The total list of treatments given; CPR, BVM, Epinephrine 1mg, Sodium Bicarbonate 2 amps.

The year was 1991. We found this hilarious. We were still in our ACLS infancy. There was no CPR first or AEDs or Amiodarone. Nobody had heard of capnography and there was nothing therapeutic about hypothermia. Yet we felt very advanced looking at our medical directors run report. The massive Sodium Bicarbonate doses of the seventies had long since gone away. 

More than happy to reminisce about the call, our doc read the report with a bemused sort of faraway look and announced, “I remember this guy.” He told us the story of the overweight, mid-sixties male who had collapsed in the parking lot across from the hospital. And then he made an observation that has stuck with me my whole career.

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Beyond The 1-10 Pain Scale

How bad does it hurt? I’m willing to go out on a limb and say that this is, quite possibly, the most common question we ask in EMS. And it can be a difficult question to answer. How bad compared to what? How do we reconcile the patient with significant pain who winces and says it only hurts a little. Or what about the patient who is relaxed and seemingly comfortable while reporting the worst pain they have ever felt?

Not everyone feels pain the same way. Some patients feel pain more than others. And, perhaps even more significant, some patients fear pain more than others. What’s a clinician to do?

You and I aren’t the first ones to wrestle with this question. Medicine has devised a multitude of way to ask patients how much pain they are experiencing. We’ve even gone lengths to try to assess which ones are comparatively more accurate. From numeric rating scales to verbal rating scales to visual analogue scales. (No, I didn’t make that up.)

If you prefer to know who’s scale you’re using you can try the Wong-Baker faces scale, the McGill scale or even the Walid-Robinson pain index. (The patient needs to be taking opiates to use that last one.)

The truth is, we may just be wasting or time trying to develop more sophisticated and accurate ways of asking this question. With rare exceptions, prehospital folk tend to use the standard numeric rating scale, A.K.A. the 1-10 scale. It’s simple, it’s relatively fast and it doesn’t require us to carry around cards with faces on them or lists of questions.

I’ve always used the numeric scale and I’ve found it to be simple and useful but it has its pitfalls. You need to be careful how you ask the question. You also need to have a few back-up questions ready to help clarify the answer. Here are some of the questions I ask when I’m assessing pain severity.

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What Is GHB Anyway?

Let’s face it, there are a whole bunch of street drugs out there that we as EMS caregivers should understand. While we can’t always be expected to identify the exact drug a patient has ingested. We do need to be able to predict a given drugs effect on the body. We should also be able to take a fair guess at the identity of an ingested drug based on our evaluation of the patient’s physical presentation. GHB is one of those drugs that can be hard to nail down based on the physical signs. But it does leave some clues – if you know what your look for.

What Is It? : A Multi-Receptor Stimulant

GHB is short for gamma-Hydroxybutyric Acid, a naturally occurring substance produced by the central nervous system and found in small quantities in beef, wine and citrus fruits. It was first synthesized in a laboratory in 1874 but it wasn’t used in humans until 1960 when it was used in GABA receptor research and found to have a wide range of effects. In that year, scientists began testing GHB as an anesthetic and in the treatment of insomnia and depression.

The drug acts on both GABA and GHB receptors in the brain. Stimulation of GABA receptors has a sedative and analgesic effect. Stimulation of GHB receptors is primarily stimulatory. GHB also produces a biphasic release of Dopamine which produces euphoria. Understanding this multi-function aspect of GHB is key to recognizing the wide range of physical symptoms that are produced from a single GHB ingestion.

 The Hallmark of GHB Overdose: Wave-like Altered Mentation

A patient experiencing a GHB high will have many symptoms similar to other drugs. But they’ll also have a unique progression of symptoms unlike any other single street drug. This becomes confusing for the emergency caregiver. GHB overdoses don’t follow a linear progression of symptoms They ride waves of symptoms. … Let me explain.

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