To Walk or Not To Walk?

The Happy Medic (THM) recently posted a fantastic topic on his blog. I love diving into controversial decisions that we have to make every shift. Here’s one of those questions that we need to answer on just about every call. Should we walk the patient to the pram or carry them?

This is one of those things that we have no choice but to address in every system on just about every call. How to we get the patient to the pram? When is it OK to walk them?

It seems like this subject got rolling on Justin’s (THM) blog when EMS types from around the country started sending him feedback about his role in the documentary film, The Chronicles of EMS. He was surprised by the volume of comments about him choosing to walk patients to the ambulance.

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Responding to Hypothermia

Part 2 of a 2 part series. (Part one is here.)

In our last post we looked at some of the causes of hypothermia, both typical and atypical. Then we talked a bit about the recognition of the hypothermia progression and what patients might look, feel and act like as they progress through their hypothermic condition.

Now let’s look at some of the guidelines for treating our hypothermia victims.

On the surface, treating hypothermia might seem deceptively simple. The treatment of mild hypothermia often is simple. Bring them in, stop the cooling and rewarm them. But as we progress into moderate and severe hypothermia, things get more complicated. Here are 12 guidelines to consider when the patient is more than just a little chilled.

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Mastering The Head-To-Toe Assessment

You probably practiced your head-to-toe assessment a bunch in your EMT class. Maybe more than any other skill in the EMT curriculum. If your class was or is anything like mine (as a student or a teacher) you performed the head-to-toe assessment again and again.

As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.

That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.

I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.

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Medicine Between The Frames

One of my favorite bloggers, Seth Godin, recently introduced me to the work of Scott McCloud, an author who’s written several classic books on understanding comic books. Scott dissects the comic medium and explains the ongoing allure of the comic book to the uninitiated.

One of Scott’s observations is that comic books require imagination on the part of the reader because, in all great comic books, the action occurs between the frames. The artist only shows you snapshots of action and dialogue. Most of the story takes place in our heads. The real story is the stuff that we invent that happened in-between the frames.

Medicine works in much the same way. We assess, we ask our questions, we do our head-to-toe and we make a guess (educated) about what’s going on. Then we make a change, and the medicine begins, after we make the change, not before.

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The Art of The Pulse Check

   Fast or Slow, Strong or Weak, Regular or Irregular

I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.

I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.

In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.

The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.

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Test For Unconsciousness: The Sternal Rub

Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.

In other words … it’s a great subject for The Spot.

Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.

Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.

If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.

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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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Understanding OPQRST

After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.

For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.

This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.

Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.

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Lessons I Learned From My First Cardiac Arrest

It strange to think that it’s been almost 20 years since the first time I did CPR. I still remember it so vividly. How the time flies.

I was fortunate to have good mentors and teachers in my early days in EMS. One of them was Phil Rigardo. As an EMT student, Phil had invited me to come do a few ride-along’s with him. I owe a lot to Phil. He was one of the first major influences I had in EMS and he framed the job in a fun and exciting way. I’ve managed to carry that initial frame (EMS is fun) for most of my career.

I had been riding with Phil for a few shifts when we got dispatched to a cardiac arrest. This was the first really sick person I had ever seen Phil treat. My first chance to see him in action. That was a big deal to me.

The engine crew arrived before us and the three man crew had been working for a few minutes prior to our arrival. I remember the narrow staircase that lead up to the crowded upstairs apartment. Clothes and furniture and bags and the stuff of crowded people living crowded lives filled the place. Three firefighters were crammed in to a bedroom made for one doing CPR on the bed. The Captain was speaking in a raised voice and stress was evident across his forehead. Our patient filled the bed and bounced with each compression.

Phil walked in and did something I never expected.

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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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