What’s Your Potential?

The internet is an amazing place! The mass of the world’s knowledge is shared freely for everyone. Unfortunately, the mass of the world’s lunacy is also open to continuing misinformation. For the Record, Dr. Wiki or Nurse Google have never attended medical school. Social Worker FaceBook has little actual experience.

When we find articles online, it’s best to take them with a grain of skepticism. Even the M & M adviser Snopes is nothing more than a husband and wife searching google to create their own digital form of Mythbusters.

Recently, my mother came across an interesting video and asked that I review it for accuracy. Now, I will admit, I am not the authority on everything. . . Don’t tell my kids.

It drives me crazy to see misinformation propagated because it may be right. I have seen many times that “The new F.A.S.T” mnemonic for stroke involves tongue deviation. The mnemonic actually stands for Facial droop, Arm drift, Slurred speech and Time of onset. Tongue deviation is too subjective and controllable to be a valid diagnostic test for stroke. The American Heart Association Stroke Advisory Board nor any other stroke research agency recognizes tongue deviation as a diagnostic sign of stroke.  I’ve published this before and had been admonished by “stroke” nurses that I am part of the misinformation machine that I’m currently writing against. The tongue is evaluated as part of intake, not to diagnose, but to determine the extent of an infarct. I challenge each of you to comment what is actually being assessed and why. If I get some responses, I’ll explain why they check tongue deviation on initial assessment.

miley-stroke-association-snl
(okay, in this case, she is definitely having a stroke)

The video that I was asked to review this time while sensationalized a bit, is pretty accurate. It discusses the ground potential of downed power lines. I suggest that everyone take the time to review the video, not only to learn what to do if involved in a crash with power lines but for your safety in approaching the scene to render aid.

The first lesson that we learn in prehospital medicine is “Scene Safety.” Please be sure to always check for downed power lines to ensure that you will continue to live up to your potential.

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Posted in Education, Patient Care, Safety | Leave a comment

What’s that For?

Over the years, pre-hospital care has grown. We’ve moved away from some equipment, and have relegated other to dark corners of cabinets. Patient care is constantly changing. Some of this equipment has been shown to be ineffective, while other inventions have shifted us toward their use. If we still have it, we should know how to use the equipment. There may be times that the newer innovations won’t quite do the job.

We must always strive to be proficient in our craft, and consider non traditional benefits of some of the equipment.

Kendrick Extrication Devices (KED) have been used for many years as a means of immobilizing a patient. Recently it has lost favor because of the amount of time needed to properly fit it to a patient and execute its intended function. But it can still be used to provide stabilization as we try to move our patient from a difficult situation. A KED can also be used as a quick leg splint (secured securely with tape or kling) or as an immobilization device for a small child.

Traction splints have very limited usage, indicated for a midshaft femur fracture only. While I have, in a previous article, rallied against their use, the fact is they are still considered the standard of care. We need to be proficient, whether we use a Sager, Kendrick or Hare device time should be taken to ensure that you know how to properly secure it to a patient. Practice should also be done in less than optimal conditions and determine how to best use your device. In my career, I’ve needed it for only 1 patient. Lack of practice made this one application a thought experiment to remember skills taught many years ago, and only refreshed occasionally.

Some services use Scoop Stretchers routinely, while other’s have probably not removed it from their ambulance for years. If you fall into the later group, are you still familiar with how to adjust the unit? How to open it? Can it in fact be opened. We relegate this device to a cabinet that can collect a lot of dirt that may get into the joints and locks. Does it still work? There are some exciting studies that are using a scoop stretcher in head inclined CPR, while others are showing better spinal safety for immobilization. The Scoop Stretcher should be considered more frequently.

Beyond these large pieces of equipment, there’s far more that we may not be familiar. Many patrollers and medics have begun using automatic blood pressure cuffs exclusively. Do we still know how to take a blood pressure? Can you utilize a BP cuff as a tourniquet if needed? Complacency is one of our greatest enemies.

There are a number of small good items that we need to review far more frequently. When was the last time that you looked at the contents of an OB kit? When was the last time that you looked at some of your more advanced equipment? We should be spending some of our downtime from each shift reviewing some of our less used equipment and practicing for the infrequent need.

I am still looking for ideas that you’d like to see covered in these articles. If you have any suggestions, please email me at jay (at) pinemountainskipatrol.com

 

 

Posted in Assessment, Education, Orthopedics, Spine | Leave a comment

What’s That Sound?

Before I start this week, I want to apologize. As much as I want to produce a weekly article for Medical Monday, life sometimes gets in the way. I have been working on my Senior status for the Ski Patrol while simultaneously managing the patrol and updating my classes to incorporate the new AHA standards.

Truth be told, I’m also running out of ideas of topics to cover. I’m VERY open to suggestion of any topic in medicine that you find difficult to understand or are looking to learn. Please send the comments and help me help you.

We all carry stethoscopes to use for assessing patients, but how many of us really know the sounds that we’re hearing. For most pre-hospital care simply knowing that there’s air moving into the lobes of the lungs is sufficient. But are we listening in the right place to assess all 5 lobes?  I had found this photo series to show the proper place to assess lung sounds in each lobe. (I’m sorry I don’t know the proper photo credit, I found it uncredited. If someone know the proper source, I’ll be happy to update).

It’s also important to remove anything that may impede a clear sound. We have to place our stethoscope diaphragm (or bell) directly to the skin. Movement of clothing can greatly affect our ability to hear the subtle sounds of the lungs. In addition a good quality stethoscope can help you better hear the sounds. I personally do not find sprague-rapport stethoscopes useful at all because of the sounds of the tubes interacting. I also wouldn’t even consider one of the cheaper stethoscopes useful even as a toy.

So what are the sounds created by the lungs? You will only learn them by listening to a lot of lungs (in a quiet space). Please listen to the following video to begin to learn the sounds and then listen to as many lungs as possible.  Just as all other things in the human body, everyone is individual and will sound slightly different. It’s only through a very large sample that we begin to become proficient.

Heart sounds are an entirely different matter. Just as lungs the sounds very subtle, but with practice you can diagnose various abnormalities in the heart. Things like murmurs, rubs and valves can all be assesses by a trained ear. This is a very informative video for assessing heart sounds.

The stethoscope is a very important tool to any pre-hospital provider, but without practice becomes inefficient to our patient’s care. Take the time to really learn the sounds and put add more sense (hearing) to your care.

 

Posted in Airway, Assessment, Cardiac | Leave a comment

Bigger than a Breadbox

As a side note, I recently had the pleasure of having Greg Friese, the Editor of EMS1.com in a class. I would ask everyone to please check out this website for information, updates, news and innovations in EMS. EMS1.com

Many years ago, I noticed that when my mother brought bread home from the store, she took the heels and threw them away. When I asked her why, she said that’s what her mom always did. When I asked Grandma, she gave the same statement. I was lucky enough to know my great-grandmother and asked her. She said “Because my breadbox was too small.”

How many things do we do in EMS, or in life, because it was always done this way?

Red Lights & Sirens – How many times do we drive to scenes with out hair on fire to find out that minutes really do not count. As well trained responders, we can provide care to our patients immediately upon our arrival. In reality, how many of those illnesses or injuries would be adversely affected with a minute or two delay in response. Many times we find that they’ve been ill for hours, or not really an emergency. We drive to our scenes hot because of the anecdotal cases of something being far worse than described by the dispatcher. Racing to the “Help I’ve Fallen” cases puts us and everyone around us at risk as we rush to help. Our very first lesson in first aid was “Keep yourself safe.” Have we?

Stand them on their head – For many years, we placed shock patients with their feet elevated. When I’ve discussed Shock in detail a few months ago, I covered that our problem can be found in the lungs, pump, fluid and pipes. We have to fix the underlying problem to cure the shock, and many times this takes a surgeon. In reality, they are already compromised and placing them upside down will only make things more difficult. Simply laying them down will help alleviate the forces of gravity on their circulation without putting undue pressure on the head or central organs.

Realign the bones – For years we’ve been using traction splints to move fractured femurs back in alignment. We’ve been taught that the movement of bones can cause internal bleeding, and it is possible. Moving the jagged edges of one of the largest bones in the body, near one of the most important arteries can only lead to problems. Splinting the bone to prevent it from moving and rapidly transporting is our best option. If the alignment does cut the artery, the patient will exsanguinate before we can get further help.

KED immobilization – If we wish to immobilize our patient prior to extrication, the KED board only gives a false sense of security. We are further to save the time needed to properly attach the short immobilization device and use manual methods to ensure alignment as we move them to a full body stabilization method. When we use the KED, the hips can still rotate, and these rotational forces can be transmitted throughout the back to the point of suspected injury. If we avoid the KED, we will likely be more careful and thus can ensure that the rotation occurs as a whole unit.

There are many things that we have done because of the generations before. If you have practices that you know are outdated, please comment below.

 

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But We’ve Always Done It . . .

Over the years we all come upon our own method of doing things. Whether it be our particular order of Primary survey to methods of writing a report. We’ve developed these based on what we feel is the best for our patients. So embroiled are we in our habits that we pass them on to new medical care candidates.  But some of these practices are not based upon science and have no real benefit to our patients.

As more of us teach, more opinions are passed onto the next generation. We are a field based upon research and science and therefore should return to what is proven when educating.

I had explained to a class once that as I teach I can only teach certain ways of doing things, similar to when we learned the alphabet. We learned that the order was ABC . . . and that B always comes before C. But after understanding this alphabet someone can rearrange the order to create something beautiful like “I have a dream!” While there are many alphabets out there, we cannot add letters on a whim and expect that others must use these letters in the future.

Let’s cover some misconceptions.

Long boarding based solely on the mechanism of action. Many years ago, we would immobilize people based upon sound clinical judgement that included assessment AND MOI. Later we started to think that the next generations were not smart enough to use judgement and taught that we should immobilize patients regardless of their presentation.  I have written an article a few months ago To Board or Not to Board regarding LSB’s and the fact that there has never been a study to show their efficacy.

Oxygen is needed by everyone. We teach that a little oxygen is good, a lot is better. It’s suggested that apply oxygen again based on the Nature of Illness, not sound clinical judgement. We have tools that allow us to determine just how well the patient is breathing. Pulse Oxymetry and End Tital CO2 can help us determine if the patient’s respiratory rate is sufficient and that there is perfusion happening at the cells. The patient has similar tools within the body and will increase or decrease ventilations to ensure proper cellular respiration. If the patient is maintaining an alert LOC and not guppy breathing, they likely don’t need oxygen. When they do, 2-4 liters is generally sufficient.

In cardiac arrest, it’s the drugs that save people. The truth is that all of the advanced care that we provide is simply there to support or benefit GREAT basic life support. Great compressions will circulate the blood and benefit the patient more than the drugs. Don’t get me wrong, the drugs are beneficial, but should not replace great mechanical skills.

An arrested patient needs oxygen to the cells, ventilate more. We have plenty of oxygen bound to our hemoglobin, we simply need to circulate it to cells that need it. Over bagging simply increases intrathoracic pressure, reducing blood flow (in an already compromised system).

Stopping compressions to breathe. Many of us have been to a campground with a water pump. During the first few pumps, nothing happens as we need to prime the pump. When we stop, we need to start over by priming. The heart works the same way, studies show it takes approximately 10 compressions to prime the pump. If we stop to breathe, we have to re-prime the heart, losing a full 1/3 of our compressions. Until we can secure the airway, compressions only will benefit the patient more(see above). We should try for an advanced airway soon so that we can continue to provide compressions without interruption.

A trained medic can replace a doctor. Many times we have family members or neighbors that ask our opinion on medical care or the need for more. They assume that we provide definitive care. A good medic realizes that the best outcome from every situation involves us bringing our patient to the doctor. We cannot diagnose over the telephone and do not have the tools (or sometimes experience) to be able to make a good judgement. Point these people to their doctor.

We don’t need to know that. Many are so stuck on their scope of practice that they feel that anything outside what they learned in a book, or in our class years ago should be ignored. Sticking our head in the sand will not benefit our patients. We should ALWAYS be learning. Using the same alphabet demonstration from before, we should always be looking for new words to spell using the same alphabet.

Next week, I’d like to cover some more. We should be based on sound clinical experimentation and judgement, not because we’ve always done it that way. We can do better than simply rehashing misconceptions.

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Ring Your Bell?

Recently there has been a much greater awareness of concussions in sports. More recent studies link concussions, particularly repetitive concussions with long term maladies. In the United States, there’s been a movie released that is quite critical of the NFL and their treatments of concussion. Yes, they were a bit slow to the uptake, but the NFL and other sports giants have been enacting standards for assessment and protocols to follow for the concussed athlete. While these protocols don’t do too much toward prevention, they do their best to mitigate the effects.

A Concussion happens when someone hits their head. The brain, which is not attached to the skull but rather encased by the skull and floating in synovial fluid, shifts rapidly and “jolts” or sometimes shifts temporarily within the skull. Make no excuse, this is a Traumatic Brain Injury. If there is a loss of consciousness, it is most certainly a concussion.

Helmets are a wonderful thing, but do not really prevent concussion. They are much better at preventing skull fracture. In fact, some have said that a helmet may worsen the potential for concussion as they give a false sense of security. Imagine how much less leading by the head would be in sports if it actually hurt.

We place too much emphasis in getting our children involved in contact sports when they’re young, but their bodies and brains are still developing. A minor concussion during development may have life long effects. I’ve seen many parents coaches in pee-wee sports that promote unsportsmanlike conduct by encouraging “leading with the head” (“spearing” when I was young). My personal opinion is that heading the ball in soccer should be prohibited until after high school. I’ve witnessed many concussion and occasional neck injuries by young players that just had to make the play.

Concussions can be recognized by a myriad of symptoms, including confusion or being dazed, clumsiness, slurred speech, nausea or vomiting, headache, blurred vision, sensitivity to light or noise, sluggishness, tinnitus, changes in behavior or personality, difficulty concentrating or amnesia. If any of these are recognized after a hit to the head, please do not just “blow it off.”

Please remember that concussion can occur from MANY sports activities. They can also occur as the result of a motor vehicle crash, a slip on the sidewalk or a hard hit to the head at work. Men out there, concussions can also occur in a physical fight.

Because everyone is taking their own path, and nobody coordinates efforts, skiing has sustained many concussions or worse traumatic brain injuries. Some high profile accidents (Sonny Bono, Natasha Richardson, & Michael Kennedy) have even resulted in death.

Prevention is by far the best plan, for some of the more extreme athletes out there, stop doing stupid things. A helmet will may prevent a concussion but should still be worn in any activities were a potential exists. A helmet is designed to pad, or slow the movement of the head in relation to the blow, but is still not a panacea; as mentioned earlier it may give only a false sense of security.

There is a very nice assessment tool that should be done to any athlete with a potential for injury before the season, immediately after the injury and as follow up. The SCAT-3 (Sports Concussion Assessment Tool) can provide a baseline, as well as monitor the progression through the healing from the injury.

Adult – SCAT 3 Assessment
Child –  SCAT 3 Assessment for Children 5-12

If you have a patient who has sustained a concussion the brain must be allowed to heal. Stop the activity immediately, sit out the rest of the game or day. Continued contact, stimulation or conversation must be avoided as it increases the neurological stimulus to the brain. A physician should be consulted, and may order tests to ensure that there’s not bleeding in the brain (a type of stroke). If they do not require hospitalization, rest will be recommended with non-aspirin or NSAID treatment of pain. A victim should avoid TV, Reading, Electronic Games and should spend 24 hours in a dark room to avoid stimulus. If symptoms worsen, IMMEDIATE medical consult is recommended.

The American Academy of Neurology has released guidelines that should be used to determine return to activity. Children should be treated with a much more conservative view for the return to activity as their development may affect their healing. In addition, there is no set time period, each athlete must be considered unique.

American Academy of Neurology – Concussion guidelines

When you do return to your activity, extra care should be used to avoid repetitive injuries as multiple concussions may have a greater than cumulative effect.

Sports that potentiate injuries to the head are fun, do doubt. But care must be taken to avoid injuries and treatment should be regarded as paramount, not disregarded to continue the activity.

Years ago, Saturday morning cartoons would show hits to the head concurring with a sound that resembled a broken cowbell. When someone sustains an injury to the head, many report a similar sound. Take care to avoid “Having Your Bell Rung.”

Posted in Altered Mental Status, Neurological, Trauma | Leave a comment

What’s Your Resolution?

Happy 2016 to everyone. I hope that you have a wonderful year and are able to continue to help others through your medical calling.

Every year as we begin anew, we make resolutions to be better; to lose weight, stop drinking, exercise. Have you every considered a professional resolution?

As we continue to do our job with the same people, the same policies and same preconceived notions of best practices we are potentially missing some great ways to treat patients. Have you ever considered taking a day and volunteer at another hill or ride along with another service? Every medic or patroller has a different idea of ideal and you just might learn something that has you rethinking your practice for the better. If you happen to be a service director, make arrangements with another service to trade people on a regular basis to help both companies grow.

Have you always been content with the refresher’s topics or have you wanted to learn more? There are many research studies that are ongoing. Read some of the published results and how they may benefit your practice. Read research, work with your medical director to begin gathering data for these experiments and help move pre-hospital care forward.

Look for ways to better serve our customers; the injured and their families. I’m not talking about medical skills but rather people skills. We must remember that these are people, someone else’s loved one. We can have the best medical skills but if we refuse to care, our care will be minimized.

Lastly, but most important. Spend some time now and plan date nights with your spouse. Divorce rates skyrocket in EMS. Our schedules are weird and we put complete strangers in front of our own health and relationships. Spend some time with a calendar and book date nights now. They don’t have to be special, just time together. My folks spend many major events together at Taco Bell. These little “Burrito” meetings help them wrap up items together for the betterment of their relationship.

I had seen a book titled “If it’s not broken, break it” and there were some great points to be learned. Just because it’s working doesn’t mean it cannot be working better. Spend 2016 mixing things up to look for the best practices from many services or patrols to help your care and your patient’s outcome.

Happy New Year!

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Happy Holiday’s & Thank YOU!

I am trying to spend some time skiing this week and therefore will be keeping this very short.

First, Happy Holiday’s to everyone who reads these articles. I hope that you were able to spend some time with loved ones and have had a blessed season.

Second, I ask that we all remember all of our brothers and sisters that have spent their holiday in the service of others. Working on an ambulance, or in a hospital, to ensure that complete strangers can be eased through their issues and hopefully heal.

Thank you to all of you for the sacrifices that you make to help others. We are often overlooked,  but please remember you all make a difference.

Please have a safe New Year’s eve and a prosperous new year of 2016.

Jay

Posted in Customer Service, Well Being | Leave a comment

When is Enough Too Much

Over the years pre-hospital education has taken many turns and has dramatically increased in both educational requirements and scope of practice.

During it’s inception, pre-hospital medicine involved only quick transport, sometimes proving only the most rudimentary knowledge of medical care. Many early ambulance vehicles were owned by funeral homes. The attendant would pick up the patient and drive fast toward the hospital, if they should happen to die, the “ambulance” would simply turn off it’s red lights and proceed to the funeral home.

But have we gone too far. We include in training a few topics that while they sound good on paper have no basis in scientific care… There have never been studies that show the efficacy of Long Spine Board immobilization, yet many hours of EMS or OEC training are dedicated to their use. Recent information actually points more toward the practice being detrimental to the patient.

Every area of pre-hospital care has issues with recruiting and retaining providers. Many hours of training are dedicated to perhaps low or no paying careers. Many hours training equipment that is seldom to never used. There have been many hours dedicated to practices that will not be used in practice.

Currently there’s some that are pushing back. The National Ski Patrol, as a certifying agency for Outdoor Emergency Care, has received push-back from many resort owners. The owners are saying that the program is requiring proficiency in areas that will never be provided as ski patrollers. . .  Poisonous plants, Childbirth, Poisonous spiders & Reptiles.

Ski patrollers provide care in very specific conditions, Winter skiing activities. The rub exists in the NSP wishing to expand their product. The wish to be the certifying agency for all forms of extreme outdoor activities, including specialties that have no similarity to our core. . . Skiing. The program is now designed to exceed national requirements for Emergency Medical Responders (EMR); a level of training just below EMT.

The resort owners are contending that they don’t need the patrollers trained to handle all of these unrelated activities and the insistence of the NSP to train everyone for every activity makes it far to difficult to bring in new patrollers. These requests have fallen, until now (hopefully) upon deaf ears. The resort owners have felt so jilted that they have recently actively promoted their resorts to seek out alternatives to NSP patrollers.

All pre-hospital certifying agencies in the US are bound by USDOT standards that themselves have flaws. The standards have removed the critical thinking of the providers. The standards require training in equipment but have removed the component to true understanding of the benefits that they provide, or worse yet the damage that they may cause.

If we want EMS or OEC to continue, we cannot continue with the Pondzi model of train enough people to make up for the abysmal retention. We cannot continue to increase the hurdles for entry level positions. We must provide education that is relevant to the care and cases that will be experienced, and we need to educate the providers to understand the body well enough to improvise.

All areas of pre-hosptial care have difficulty acquiring new providers, but until we make some changes this trend will continue.

Posted in Education, Uncategorized | Leave a comment

Let’s Have Some Fun!

Here in the Midwest we are experiencing a wonderful spring. The weather yesterday was a balmy 58* with lots of rain. Unfortunately it’s December and we should be experiencing snow and winter. Most of the ski resorts are having great difficulty finding days to make snow and some are even thinking of creating a new sport for their hill, called Standing!

IMG_8307

We always need to be working on our skills, whether medical or transport. Who says that this must be boring. Throughout the country this season many patrols will challenge themselves to silly competitions and challenges that on the surface seem like just fun. But through these fun games a lot is learned.  Switching personnel, moving through obstacles, speedy yet safe transport. Patient stability. We can discover new techniques and strengthen our current skills through play.

Plan to spend some time playing this season.

Posted in Downhill Skiing, National Ski Patrol, Well Being | Leave a comment