Saturday, December 6, 2014

Cranial nerves and hard ons, oh my...

"Ooh, Ooh, Ooh, to touch a female vagina, gives Victor a hardon."

Patrick J. Lynch, medical illustrator
See, I said it. Vagina, hard on, and I'll just go ahead and add penis to this sentence. However, It worked for it's purpose. Remembering the 12 Cranial nerves.

I – Olfactory
II – Optic
III – Oculomotor
IV – Trochlear
V (1,2,3) – Trigeminal
VI – Abducens
VII – Facial
VIII – Vestibulocochlear
IX – Glossopharyngeal
X – Vagus
XI – Accessory
XII – Hypoglossal  - (Via Wikipedia)

(Yes, I'm using Wikipedia as a source. No this isn't a scholarly or even very intelligent post, it's okay.)

Sooo, I was suppose to memorize the 12 cranial nerves and their function (sensory, motor, or both) for a test this semester. I didn't, the test didn't go well. this is the point of test (or is how I use them at least). They are to show you what you need to learn! Within hours of that class ending, the tale of Victors sexual adventure was being repeated in my head over, and over, and over. The names of each nerve sticking out to me as much as the same nerves in my head. With the names cemented I needed a way to remember the function, and in came Victors brother.

"Some say marry money but my brother says big brains(and/or boobs) matter more" ~Dr Tim Luijkx and Dr Frank Gaillard et al


Sensory, Motor, or Both? That is the question... So we take our list of cranial nerves and line them up like so.
Some – Olfactory
Say– Optic
Marry – Oculomotor
Money– Trochlear
But – (1,2,3) – Trigeminal
My– Abducens
Brother– Facial
Says– Vestibulocochlear
Big– Glossopharyngeal
Brains/Boobs– Vagus
Matter– Accessory
More– Hypoglossal

That gives us the basic breakdown. Which is all I need for now. I hope someone finds this as helpful as I did! I wonder if anyone has done a study to see if the more inappropriate the mnemonic is the more effective it is to help people remember. Or maybe I'm just a little extra goofy and dirty minded... uh oh...

Friday, November 14, 2014

Medic school paper - Appropriate Utilization of Helicopter EMS - Draft

(Please comment! If you want to comment on the paper in Google docs then I will happily share the link! Thank you!)

Helicopter based emergency medical services (HEMS) are an essential part to any EMS system.  The first benefit noted with HEMS is that it gives prehospital providers access to rapid transport without the difficulties of traffic or terrain. HEMS utilizes staff ranging from a critical care paramedic to a physician led team. Working under an expanded scope of practice compared to the traditional ground ambulance. However, HEMS can be misused and abused like the rest of the EMS and emergency response system. According to Taylor, C. B. (2010) annual cost range from $115,777 to $5,571,578.  The LifeFlight Foundation annual report states that in 2013 alone Maine’s very own “Green Angels” had expenses equalling $9,109,732 (2013, p. 22). That cost can be placed with the patients and insurance or absorbed by the government and citizens. No matter where the funding comes from, it is associated with significant cost. The question is are we, as ground based field providers, properly utilizing HEMS as the valuable and equally expensive resource it is? To decide that we are going to look at HEMS response, skills provided by HEMS, and issues or risks associated with HEMS.
The first decision we need to make is when the proper time is to activate HEMS, and when is air transport beneficial over ground transport. The first thought is almost always trauma. From my first day learning the management of trauma as an EMT, I was taught that “bright lights, cold steel” are what save the lives of trauma patients, and that getting them to a trauma center as quickly as possible is the best way to help that patient. It’s easy to assume that calling a helicopter will decrease that time. Helicopters fly faster than we can drive and don’t deal with rush hour traffic; unfortunately life is never that simple. Shepherd, Trethewy, Kennedy, and Davis performed a retrospective study. “To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer.” (2008, p. 1). While Maine may not be as interesting as Australia it does have many places that fit into the rural category.
When comparing air transport to the computer calculated ground transport by local ems, Shepard, Trethewy, Kennedy and Davis found that in transports under 50Km (31 Miles) road transport calculated to a mean of 29.44 minutes, while air transport had a mean of 48.11 minutes. This is due partially to pre-flight preparation and increased response distance compared to local ground EMS. It was noted between 50 Km and 100 Km that times were very close with a mean time of 56.34 minutes for ground and 62.63 minutes for air. When looking beyond 100 Km (62 Miles) a significant difference is found; the mean transport time of the helicopter being 93 minutes while ground transport reached a mean of 141 minutes (2008, p. 496-497). Shepherd, Trethewy, Kennedy, and Davis concluded, “we believe that in comparable environments and in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care” (2008, p. 498).
Take a map of Maine, and draw circles of a 30 mile radius of every trauma center. If your service falls in this circle, than even in trauma without special circumstances (e.g. patient entrapment or airway interventions beyond paramedic scope of practice) strongly consider transporting directly to the trauma center. On the other side of the equation, if your service covers an area 60 plus miles from a trauma center or the call requires prolonged extrications, or advance airway interventions outside of the paramedic scope of practice, then strongly consider HEMS in severe trauma.
LifeFlight has access to multiple tools that are either prohibited by cost or law to ground transport. Tools like rapid sequence intubation protocols, mechanical ventilators, portable lab equipment, invasive blood pressure monitoring, and blood products. Utilizing a paramedic and nurse team gives them the ability to provide the appropriate care to the most critical patients quickly and rapidly transport to the appropriate facility. While HEMS can use more tools than most ground based EMS and possibly use them better due to higher frequency skill use and proficiency.
“...prehospital intubation in patients with severe head injury was associated with worse survival and functional outcome in their overall population, but was associated with improved outcomes when performed by helicopter crews”. (Brown, 2013, p. 282)
It was noted in the article that in a separate study, HEMS crews had a much higher intubation frequency (80%) as compared to their grounded EMS counterparts (10%), and had a lower mortality rate in head trauma patients of 34% (Brown, 2013, p. 282). we have evidence that attributes lower mortality to a specific injury process and we should strongly consider it.
Currently, LifeFlight uses two helicopters. One is located at Central Maine Medical Center in Lewiston and the other is, located at Eastern Maine Medical Center in Bangor. These two HEMS units cover the entire state of Maine which leaves some obvious access limitations. I personally have called for LifeFlight for a severe trauma and was told that the closest unit was over an hour away in New Hampshire. The reason? Both helicopters were transporting critically ill patients from smaller, community hospitals to large, tertiary hospitals. LifeFlight provides critical care interfacility transport to all the hospitals of Maine, taking an already limited resource and stretching it further. However, this is an essential task to providing good care to the population of Maine. Unfortunately, HEMS units may be available but unable to fly as well.
In EMS we have the difficult job of actually finding and retrieving the patient, no matter where they are. When the EMS system is activated we are obligated to respond in worse conditions than the Mailman. Rain, snow, and ice are all too frequent response conditions in Maine. I do not have the option of saying no to a 911 call. When winter comes and I have to respond to one of the many crashes, caused by snow and poor decisions, I will slowly and safely respond.
Most HEMS on the other hand can refuse a call for any reason, due to the increased dangers of flight and helicopters. The most common one being weather. With the dangers of operating a helicopter in inclement weather it is reasonable for a crew of three people to refuse a dangerous mission. They are not only responsible for their own safety like every EMS provider on the ground, but they also have to think of the patient and the risk over benefits of air transport in poor flight conditions.
It is not only the HEMS medical team that has to consider risk and benefits to the patient, the ground system requesting HEMS also has to consider it. Cost should never be a major factor in directing patient care, but we should always advocate for our patients. With air transport cost being substantially higher than ground, we have to use good critical thinking and medical decision making in deciding “should this patients be flown”? Does the benefit outweigh the cost and risk? Is it reasonable to saddle the patient with transport bill in the tens of thousands of dollars range for injuries or illness that is affecting them? As an EMS provider it is very easy to be afraid for your patient and want to give them the best possible chance by flying them. With any high index of suspicion due to apparent injury, clinical presentation, or mechanism of injury it is reasonable to activate HEMS. It is a different story if do not want to sit with the patient. If you are afraid of treating a patient for the time it will take to get to a trauma center then consider additional help in the back the ambulance instead of having HEMS transport. If for some reason a provider did not feel like giving the effort or the time to treat and transport a sick or injured patient this would be an obvious misuse of resources. It would be unethical for a provider to hand off a patient to a valuable resource as HEMS for personal convenience.
As much as I wish we had a scanner like “The Doctor” has in Star Trek: Voyager, we do not. We have to rely on a solid clinical assessment and factors like the mechanism of injury when it comes to requesting HEMS transport. The choice should never be made lightly, but if a provider has a strong feeling that the patient would benefit from HEMS for any of the reasons that have been discussed, like trauma with distances over 100Km, prolonged extrication, head injury with or without need of airway management. Patients who would benefit from medication assisted intubation, blood products, or invasive monitoring. It is important to recognize however, that HEMS is not always available or could have a significant response time. HEMS crews can refuse to respond for their own and the patients safety. In the critically injured or ill patient we as prehospital providers should always advocate for our patients and consider the risk and benefits of all of our interventions, that includes “calling the bird”.


References
Mommsen, P., Bradt, N., Zeckey, C., Andruszkow, H., Petri, M., Frink, M., & ... Probst, C. (2012). Comparison of helicopter and ground Emergency Medical Service: A retrospective analysis of a German rescue helicopter base. Technology & Health Care, 20(1), 49-56.


Shepherd, M., Trethewy, C., Kennedy, J., & Davis, L. (2008). Helicopter use in rural trauma. Emergency Medicine Australasia, 20(6), 494-499. doi:10.1111/j.1742-6723.2008.01135.x


Brown, J., & Gestring, M. (2013). Does helicopter transport impact outcome following trauma?. Trauma, 15(4), 279-288. doi:10.1177/1460408613497153


Taylor, C. B., Stevenson, M., Jan, S., Middleton, P. M., Fitzharris, M., & Myburgh, J. A. (2010). A systematic review of the costs and benefits of helicopter emergency medical services. Injury, 41(1), 10-20. doi:10.1016/j.injury.2009.09.030

LifeFlight Foundation. (2013). Annual reports [PDF]. Retrieved from   http://www.lifeflightmaine.org/getattachment/About-Us/Publications/ Annual-Reports/Annual-Report-FY13-FINAL.pdf.aspx

Wednesday, October 8, 2014

Medic School Presentations: Tetanus, Infectious disease process



  • What type of organism is involved in spreading this pathogen (bacteria, virus, etc.)?  Identify the name of the organism (if any).  If you have been provided with an organism/pathogen what disease does it cause?
    • Clostridium tetani spores
      • Anaerobic gram-positive, spore-forming bacteria
      • Spores found in soil, animal feces; may persist for months to years
      • They can survive autoclaving at 249.8°F (121°C) for 10–15 minutes.
      • The spores are also relatively resistant to phenol and other chemical agents.
      • Tetanospasmin estimated human lethal dose = 2.5 ng/kg
      • Causes Tetanus (Centers for Disease Control and Prevention, 2012, p. 291).
  • What is the common route of infection (air, blood, etc.)?  Identify what would be the most likely way a paramedic would be exposed.
    • Spores usually enters the body through a wound or breach in the skin. Toxins are produced and disseminated via bloodstream and lymphatic system (Centers for Disease Control and Prevention, 2012, p. 292).
    • Paramedic could be susceptible in any environment that could cause a minor or major penetration injury.
      • During vehicle extrication. IE: Cutting hand or arm on severed vehicle post.
      • Removal of Pt from environment to Ambulance. IE: removal via stairchair and getting cut on rusty nail or removal from woods and getting cut from the undergrowth.
  • What personal protective equipment will limit the exposure of healthcare providers to the pathogen?
    • wear full length heavy pants, ankle covering leather boots, slash resistant work/turn out gloves, full sleeve shirt/forearm guards, and most importantly, get and maintain vaccination!
  • What is the incubation time for the infection?
    • The incubation period ranges from 3 to 21 days, usually about 10 days.
      • In general, the further the injury site is from the central nervous system, the longer the incubation period.
      • A shorter incubation period is associated with more severe disease, complications, and a higher chance of death.
      • In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days (Centers for Disease Control and Prevention, 2012, p. 292).
  • What are common signs and symptoms seen in a patient with an active infection?  What will occur (signs/symptoms) if the disease is untreated?  Provide stages if applicable.
    • The first sign is trismus or lockjaw.  followed by stiffness of the neck
      • difficulty in swallowing
      • and rigidity of abdominal muscles.
      • Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate.
      • Spasms may occur frequently and last for several minutes. Spasms continue for 3–4 weeks.
      • Complete recovery may take months.
      • Tetanus is often fatal if left untreated.- (Centers for Disease Control and Prevention, 2012, p. 292).
  • How is this disease treated once a host has become infected?  What medications/treatments are utilized?
    • Treatment for Tetanus consist of:
      • Antibiotics (primarily Metronidazole or Penicillin G) to eliminate the bacteria
      • Tetanus immune globulin (TIG) to neutralize the unbound Toxins.
      • This should be immediately followed by a Tetanus Toxoid containing vaccine (Hinfey, 2014).
  • Is there a vaccination for this disease?  What is the vaccination (provide the name (s) of the vaccination(s))?  How is the vaccine administered?  How long does it last?
    • Tetanus vaccination comes in a couple different forms based on the age you receive it. -(Centers for Disease Control and Prevention, 2012, p. 297-298).
      • DTaP (diphtheria and tetanus toxoids and acellular pertussis vaccine) is the vaccine of choice for children 6 weeks through 6 years of age.
      • If a child has a valid contraindication to pertussis vaccine, pediatric DT should be used to complete the vaccination series.
      • Td is the vaccine of choice for children 7 years and older and for adults.
      • A booster dose of Td should be given every 10 years.
      • Contracting the illness WILL NOT provide immunity due to the incredibly small amount of the toxin required to cause illness.






references


Centers for Disease Control and Prevention. (2012). Tetanus. In W. Atkinson, C.
    Wolfe, & J. Hamborsky (Eds.), Epidemiology and prevention of
    vaccine-preventable diseases (12th ed., pp. 291-300). Aurthor.


Hinfey, P. B. (2014, March 26). Tetanus medication. Retrieved October 2, 2014,
    from Medscape website: http://emedicine.medscape.com/article/
    229594-medication#8

Friday, September 26, 2014

Medic school Response: Into the water


Into the Water — The Clinical Clerkships — NEJM

Something that I have a hard time with and work equally hard at is understanding that I think, I make the world around me. I get so focused on trying to be "the best I can be" and all the silly ideas that come with that. I focus on the best I can be, which turns into just focusing on me, which turns into not thinking outside my own head. So it's good to hear I'm not alone in that thought. It's better to know that I can change it. I hope that as my education and understanding of the world around me gets better I'll remember to think more. Now I've been in EMS for 2 years, which is a small chunk of time in the scheme of things but I do understand how the clinical clerkship can affect providers. Tuesday night I had an elderly lady with chest pain. A man in his 50s who was having a STEMI.  98% occlusions of the circumflex was the cath lab report when we got back. A post arrest, vented Pt who was bucking the tube but the receiving facility denied the request for sedation. A young girl who had a concussion from a car crash and was like a record repeating the same loop of confusion, tears, and questions. I gave each of them the compassionate, empathetic voice they all needed when they were sick but I could help but think when I was going to get my next coffee. Six months ago even i would have been overwhelmed to deal with just talking to these people in a single night. Now it's much easier to just smile, answer what questions I can, and try to treat them the best I know how. Now I'm not totally heartless or disconnected ether. "Occasionally, however, there were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time." - Neal Chatterjee. I don't think I'll ever forget the screams of anguish from the father of the 16 year old boy I did compression on for far longer than we should have. I have aspirations of being a paramedic, I have aspirations of getting to that third year. I want to be a paramedic to try and get use to the water. I'm hoping by learning what water is and how to tread in it I will be more equipped to take the dive when the time comes.

Thursday, September 18, 2014

Medic school discussions: VARK and JUNG

Vark Learning tool

Visual: 4
Aural: 12
Read/Write: 4
Kinesthetic: 14

The VARK very accurately describes my personal learning style. I have always learned best by doing. I have to actually manipulate and try things to do them to the best of my abilities. I also enjoy and do well with lecturing. I enjoy listening and talking to people. I am indifferent to visual aid and power points, I see them more as a reminder of what a good lecturer should be talking about. I also dislike just reading text. I understand it’s importance and do it willingly, but it’s a slow process for me and I often get distracted multiple times a page.

With lecturing I am going to use my visual, aural, and more than likely reading/writing. Luckily my Aural skills are better and that makes me a good student for listening to lecture.

Hands on learning happens to be my forte. I do very well working with people and practicing skills, I learn by doing very quickly and have a much higher retention rate.


Jung Typology test

  • Please post your answers to the following questions: ENFJ - Extravert(67%) iNtuitive(38%) Feeling(12%) Judging(33%)
    • Do you feel that the Jung Typology Test is an accurate description of you?  Why or Why not, please be specific.
I think this is a very good example of my personality. I've always been drawn to helping people. People find me likable, passionate, and charismatic. I feel like I could be a good leader. I always have been among friends and in social groups. I’m always a “glass half full” type of person and I think people like that about me and let me speak my mind because of it.
  • Do you think your personality type will make you a better paramedic?  Why or Why not, please be specific.
I think it will help my career as a paramedic, EMS is a team sport but at the same time every team needs a leader. The most important thing that will help me lead an EMS team would be my faith in my team. ENFJ has a strong desire to believe and expect the best out of other people. We also are excellent communicators which is essential in any good medical care, much more EMS.

  • Do you think your personality type will make you a better educator?  Why or Why not, please be specific.
I think I could be a good educator. I enjoy helping people figure out problems. At work I’m often asked questions about using the computers, mainly because I’m a geek, but also because I’m more then willing to sit down and explain things to people. I think anyone can learn anything given the time and good, quality direction.

Monday, September 15, 2014

Medic School Discussions: Roles & Responsibilities of the paramedic

**Please comment and let me know your thoughts, if I'm wrong I want to learn why and how to be better**

Roles & Responsibilities



My three good qualities are preparation, response, and return to service. The only one I would say I’m strong in is Preparation. My thought process is that every call is critical until proven otherwise. I know this isn’t entirely true, but It’s much easier to motivate myself to check every nook and cranny of the truck and house bag if I think I’m going to work a code. I always find question to ask the medics I work with about calls I’ve done or stories I’ve heard. I read and listen to people like EMCrit to try and learn more about medicine and hope I get something I can use in my daily assessments and treatments of my patients. I feel my response is good, I’m almost always in the truck first. I drive to every call as quickly as I safely can with regard to traffic, road conditions, and weather. At the end of every call I work hard to get my truck to a better condition than it was before the call. I restock a little more than I used. I clean a little more than got dirty. I always want the truck to be in better condition when I leave then when I got there.


My weaknesses I would label as Scene management, Patient assessment and care, and Patient transfer and report. I think all of my weaknesses are experience or confidence related. I’m a lot better at helping to manage the scene, I think about how to best get to the patient and how to best and safely get them to the truck. I’m constantly looking for potential hazard in homes, especially in elderly population and with fall victims. I know I still need to work on it a lot more though. I always think of and utilize gloves as PPE but I rarely even consider the need for goggles, gowns, or mask. I believe my assessments are too disorganized, I try to figure out what is going on before I’ve established a solid baseline for my patient. That leads to the issues with Patient transfer. I don’t always have some of the information the ED wants to know because I focused my exam and assessment on what I thought the issue was from talking to the patient. Then I feel like I’ve done something in error and it throws off the rest of my report because I’m desperately trying to figure out what I missed.


My plan to resolve my weak areas should be mostly resolved as I move through this course. As I learn more about scene management from the medics prospective I’ll be able to assist better as a BLS provider and know what information is pertinent to tell my partner when I’m a medic. I fully plan on utilizing everything I learn, as I learn it to my nightly work. As for my patient assessment I will have an excellent opportunity to learn and refine my technique into an orderly, concise, and accurate assessment with this class and paramedic procedures I. As I strengthen my assessment abilities I will be able to confidently give a quality, concise report to any ER nurse because I will have done a broad spectrum assessment and a focus exam of the issues.

Friday, September 12, 2014

Medic School Discussions: What Does Professional Mean to you?

**Please comment and let me know your thoughts, if I'm wrong I want to learn why and how to be better**

What Does Professional Mean to you?



professionalism: Possessing the required abilities, knowledge, and self-discipline to effectively perform a specialized action or work. As a paramedic I have to be able to quickly and accurately assess and treat a Patient. Not only do I need the knowledge and physical ability to do the work, but I need to have the self-discipline to do it appropriately, effectively, and compassionately. Because our work is so publicly available it is essential that we show ourselves in a confident, competent manner. If my patient doesn't think I’m competent because I lacked the self-discipline to tuck my shirt in and fix my hair at O’dark thirty they won’t be as receptive to my assessment or treatments.

As someone who doesn't have a lot of volunteer experience I have mixed thoughts of “professional” volunteers. On the first day of orientation at a 24/7 paramedic license service i was told never to laugh at the volunteers. No matter what they do wrong. That’s been extremely hard for me at some points. I am always extremely thankful we have volunteer EMTs that first respond in our communities. However, I think it is very hard for anyone to keep up a “professional” level of competency doing this on their off time. I have also been on scene where at O’dark thirty a volunteer jumped out of bed to meet us at a call but looks terrible. I’ve seen patients and family visibly settle when the “real” Paramedic/EMTs show up in uniform and looking semi-awake. I think a volunteer could be an EMS professional, but the majority simply can not afford the time, energy, and experience it takes to be an EMS professional.

As a full time, paid, employee of an ambulance company this is how I put food on my table. This is all I have to know how to do. I spend a minimum of 36 hours a week on a truck. During those hours I am getting paid to provide professional quality emergency medical care. I don’t have any other jobs other than being a student. Then I’m learning how to be a better, more professional EMS provider. Is every paid EMS provider a professional? I don’t believe so. Should they be? absolutely. We are the one who must take the call when a volunteer doesn’t want to. Our time is focused on keeping competent, and maintaining the abilities, knowledge, and self-discipline required to be EMS professionals.

Personally, I am always looking for means of improving myself. I am young, and still fairly inexperienced. So for me I feel my major weak spots in my professionalism are confidence, self-motivation, and time management. I am still a young provider. When I first started I was terrified to be left in the back or perform skills on a patient for fear of messing up or possibly harming a patient. Now that I’ve been doing it for a couple years I still doubt myself and my abilities at times; I know I can manage some sick and injured to my license level. Motivating myself and managing my time will be a critical skill I’m going to learn quickly from this class. I’m very motivated to do very well in this class, My only weakness is my squirrel quality attention span. my main effort will be to overcoming those and sitting down and fully completing assignments in a high quality, timely fashion.