Busy Christmas Time

Turned grades in Monday. The Fall semester of 2004 is officially over for me.

Some family in town for Christmas, then out the door, and then more to replace them. Rapid house cleaning and restocking as we had just a few hours between overnight visitors.

Busy EMS time as well. From Friday to Today I went of every call we had...

Two more MVAs. One involved no significant injuries. The other one, a one car rollover, was much more serious. Patient was trapped in her car and had obvious head injuries and was talking but clearly amnesic (she had a endless cycle of “where am I”, “what happened”, “Who are you?”, “where am I”…). The helicopter landed just as we got her out of the car. Into the back of the rig where I finished packaging her as the flight paramedic and flight nurse did some INTERESTING stuff (I/O line using a new-fangled drill; facilitated intubation, etc.). This was the first time I got to see a positive “halo test” (when you see a ring of cerebral-spinal fluid around a spot of blood). She had an open head injury in the occipital area, and maybe in the R temporal as well. I got to help load her onto the helicopter, which was a great experience, though I couldn’t help but think of that doc on the show “ER” who looses an arm to a copter blade.

Other calls:

Numbness of the Hands – Panic attack, I think.

Stroke: a REAL one. Bad. Patient had a GCS of 12 and showed no improvement while we were with her.

Fire Standby: helped re-hab firefighters and helped calm down a distraught resident who lost everything in the fire. Two hours on scene in the middle of the night…

Difficulty breathing: BLS only (due to personnel – we could have used ALS) – Good chance to hear crackles associated with an upper-respiratory infection.

Injuries from a fall: Went out with a crew of two (a driver with no medical training and me). I missed having the students around as I had to collar and backboard this patient with citizen help.

General Illness: She was indeed generally ill.

The chief asked me today if I wanted to keep a jump kit in my car complete with O2, etc., as well as a mobile radio in addition to my portable. Corps treat, of course. I guess he thinks I can be of some use around here…

Sleep Walking

Wednesday we had two calls…

“WALK, people!”
Around 1030 or so freezing rain came out of no where. A campus safety officer stops by my office to tell me to be careful if I go outside as it is SLICK. Ten minutes later my wife calls to tell me the roads are horrific and that I should be careful as we will likely get a call and it is nasty out. She’s got the power…

At around 1300 tones drop for one-car MVA with entrapment. As I have mentioned, our ambulance district covers multiple fire districts. Let’s say this accident happened in district “B”. Because “B” doesn’t have “heavy rescue” capabilities (cutting cars apart, etc.), district “A” is their automatic mutual aid for entrapments. So at first, tones go out for B (their district), A (automatic mutual aid) and us (ambulance). Because “B” didn’t answer up quickly (small department, people have jobs, etc.), district “C” was also called, because they are “B”s automatic mutual aid for OTHER types of fire calls (including “light” rescue). Four agencies responding to one car crash. Confused? I was.

[note: it is OK to laugh about the following, but I still can’t as I strained some muscles in my abdomen in the process…]

As I had just finished lunch out I was driving in my car when my pager went off. I was first to the station (I am rarely first as I live out a bit) and very excited by this fact. We have a general rule, which is to WALK when responding to a call. I ignored this rule and was running up to the station from my car. As I approached the door to the station I went to slow down and seemingly instantaneously I was in a Wile E. Coyote-like mid-air suspension. What looked like wet blacktop beneath my feet had been clear ice with water on it. Nothing slicker. I stuck my arm out reflexively and managed to avoid slamming my head into the ground, but I landed pretty much flat on my back. Did I mention our ambulance station is across the street from Fire Department A? Which has people flying to it to get out on their heavy rescue (those folks LIKE entrapments. Really, they do)? I am SO embarrassed by my fall that all I can think of is getting up quickly, which as you can imagine is less than graceful when you are on a frictionless plane. I am certain a video of this performance would be worth money, but I don’t think anyone saw me.

We get out of service BLS with two EMTs and a driver and I run the call. In the twelve minutes it takes us to get to the scene Control AND the rescue guys radio us and tell us to be careful, as the roads are horrendous. My throbbing hand is my memory of how quickly the ice will claim you and that, combined with incident the night before (see recent post), leads me to be a bit more assertive with the driver when it comes to explaining that speed is not our number-one priority given the number of rescue personel already on scene.

Before we get to the scene heavy rescue is cancelled. The patient was out upon the first-responder's arrival. We arrive to see a newish SUV down a 20 foot embankment. There is a county snowplow on the side of the road right across from the SUV, and my first thought is whether this was really a one-car MVA. Turns out the plow operator saw the car off the road, called 911, and then helped the patient (neck and back pain included) out of her SUV and into the passenger seat of his plow. These plows are BIG, so that when you open the door you are looking at the feet of the person sitting in the cab. Patient got collared and a KED in the cab and then onto the board. I was VERY pleased with how smoothly this all went as none of it was as you would practice in a passenger vehicle. The rescue guys did a great job and we worked together seamlessly.

Patient had some bumps and pain but no major issues and we took her to the local ED without further incident.


You’re Sleepy, I’m Sleepy

Our second call came in at about 2200 and I was sleeping HARD: “… request for your equipment at #### route ##, lot #, the ***** residence for a bipolar patient with an overdose, police enroute”. First of all, it cracks me up when we get a page requesting our equipment (this is common terminology around here). What do they want, the ambulance with no personnel?

Our patient took six Ambien (10 mg each) by accident and was sleepy. Off to the ED with a sleepy but otherwise OK patient.



I’m off the board tonight and then on again on Christmas Eve and all of Christmas day.

Happy Holidays Everyone!

DJ

Minor Trauma, Near Heart Attack for the Prof.

Call came in yesterday evening: MVA rollover, state police on the scene asking for an evaluation.

The scene is in the middle of nowhere. The secondary roads, which are all we’ll be on for the whole call, are covered with a mix of packed snow, ice, and slush (you can’t see pavement). On the way to the scene I felt like we were going a bit fast, and the medic even said “slow down, rescue is already there and it is just an evaluation”. This is very non-subtle foreshadowing…

On scene: Our patient is a 17 y/o female sitting in a police car shaking. She was the restrained driver of a pickup that rolled over and is in fairly good shape, but due to the mechanism of injury (the car + her report she hit her head) we took full spinal immobilization precautions. As we leave the scene I say to the driver: “[blank] we can get going, nice and easy please”. I am focusing on the patient, doing further assessment, taking vitals, etc. About 8 minutes into the ride back, the rig swerves one way, then we are sliding, then we swerve the other way, and SLIDE.... and then we stop.

For the 10 seconds or so I was convinced we were going to rollover, I had about thousand thoughts go through my head. Am I going to die taking care of someone else while my family at home needs me? How smart am I to let volunteer drivers who are over the age of 55 control my safety? Do we have enough people around to staff a second rig to come take care of us? What agency would come as mutual aid? I was scared…

“I think I hit it!” comes from the front. My heart rate is right up near 120 when I assess what happened. OK, we are upright, I heard no crunching, and everyone is fine. Hit what? Deer, I’m thinking. “I should go out and see if the car is ok”. Car? We hit a car? How many people? How badly hurt?

Turns out we hit a parked car. We did a bit of damage to the car. The rig has a ding and three-foot scrape, but is otherwise fine.

The whole experience did remind me how vulnerable we are in the back of an ambulance. In my agency people do not wear seat belts in the back. I wonder if we should?

DJ

What we can and cannot do...

Yo,

Still grading stats exams. Yech. It has been FREEZING cold here the last few days (as in below zero F). No ambulance calls for my agency in almost a week! Cold must be keeping people inside.

Last week MacMedic and aoblog (see blog links at right) gave a rundown of provider levels and allowed drugs/procedures for their regions. I find it interesting to read what prehospital care providers can and can’t do in other areas and thought I’d contribute. Please note that this will be boring as H&LL if you are not involved in the field …

OK, in my region there are the following levels:

CFR: Certified First Responders. Frankly, I don’t know what they can do and don’t see it listed anywhere. Mostly controlling immediate threats to airway, breathing and circulation until a higher level provider arrives.

Basic EMTs: Nasal and Oral Airways; PASG pants; Semi-Automatic defibrillators; Oxygen; Activated Charcoal (with medical control); Albuterol; Epinephrine with an “Autoinjector”; oral glucose; assist patient with their own inhaler/nebulizer; assist patient with their own nitroglycerine.

AEMT-I: Start an IV of normal saline on patients 16 years and older when they have responded and ALS intercept (AEMT-CC or AEMT-P; see below) has been called. Intubate patient with agonal respirations or in respiratory arrest if pt is 16 y/o or older. NO DRUGS except those listed above for basics.

AEMT-CC (“medics”): This is the level I am currently in training for… IV on patients 5 and older. Tube patients 5 and older. See drugs below. Routes allowed: PO, SQ, IM, PR, IV, ETT. Also: Glucose monitoring, pulse ox.

AEMT-P (“paramedics”): Add: Needle Decompression; Needle Cricothyroidotomy; Dopamine drips; IV & ETT all ages (including I/O; no facilitated intubation…); more latitude to use “standing orders” vs needing online med control orders. Routes allowed: PO, SQ, IM, PR, IV, ETT, IO.

Drugs used by medics and paramedics in my region:

Activated Charcoal with Sorbitol; Andenosine; Albuterol; Atropine; Baby Asprin; Bretylium; Dextrose 50%; Diazepam; Diphenhyramine; Epinephrine (Sub Q, IV and ETT); Furosemide; Blucagon; Lidocaine; Magnesium Sulfate; Morphine; Nalbuphine; Naloxone; Nitroglycerine; Procainaminde; Solumedrol; Thiamine; Verapamil.

Let me know if you have questions.

DJ

More Cheating Spines

Thanks for all the comments.

Regarding the “Car-Deer” woman: The hospital gave me no grief for bringing her in like I did. We do not have a field spinal clearance protocol, though I have read many and go through them in checking out any patient who may have this type of injury.

Regarding the plagiarism cases: Several years ago “intent” was removed from the definition of plagiarism. If you turn in work that improperly cites where information came from, you have plagiarized. Professors have the option to decide that something is sloppy scholarship and to handle things without the Conduct Board. And the disciplinary officer (who has a Ph.D. in the humanities from Harvard, so she knows a thing or too about writing) is good about communicating with faculty and getting them to see something isn’t “plagiarism” as much as bad scholarship. But, in the end, if the faculty member wants to charge someone with plagiarism, the board will hear the case. While not official, there are several factors that the board seems to take into consideration when determining sanctions:

1) What year is the student? Citing the correct sources but not putting something in quotes that should be is not acceptable, but it is certainly easier to understand how it can happen with a first year than a senior.

2) How egregious is the act? One sentence in a 25 page paper is a bit different than 20+ pages in a 30 page paper (yep, I’ve seen it).

3) Does the person seem to know what they did wrong and do they have a plan to keep it from happening again?

I should have mentioned in my last post that the standard by which a decision is reached is “more likely than not” by a simple majority of the board.


I leave the conduct board meetings stressed. It is very important work, but it is HARD to deal with these issues on a case-by-case basis. It really is the ugly underside of academia (or at least one of them...).


I was on call for 30 hours from Friday through Saturday without a single call. I thought this was supposed to be trauma season…

DJ

I'm Back

Whew! While still in the process of grading finals, things are slowing down to a tolerable pace. The last week or so has seen the normal flurry of activity that surrounds the end of the semester (extended office hours, writing final exams, etc.) along with a test in my medic class, meetings galore (a job search, Student Conduct Board, the group that oversees the core curriculum, yada, yada, yada), etc.

EMS Stuff First

I last wrote about a call were there was a woman down at a group home. As background, this place isn’t quite a nursing home, but the people there are not in good health and there are LPNs around most of the time. The home is state funded, and it is depressing to walk into the place (the sights, sounds, and smells are not out of a vacation brochure, that’s for sure). The call came in as injuries from a fall. This home is a good 11 minutes from our station going lights and siren and there is a small fire department with a rescue squad less than two minutes away from the home. Rescue was on the scene when we got there taking a set of vitals. The patient was on the floor, lying on her right side (right lateral recumbent), and grimacing. No head stabilization. No collar. No board. “What do we have?” Seems the patient needed to go potty and while a staff member was helping the patient head towards the bathroom the patient became too heavy to handle. Down went patient. As I began to interview the staff member, she got real defensive. I just wanted to know if the patient fell or if she was eased down to the ground, but for some reason the staff member thought I was blaming her. In any event, I was convinced the patient’s C-Spine was not compromised, and got to work. “My leg hurts” was her chief complaint. She had a knee brace on her right leg. When I loosened the Velcro around her brace to evaluate her leg, she said “Ah! You fixed it! It feels great now”. Turns out the patient had fallen the night before due to her knee giving out. She had been placed in a brace and no one had checked its fit… I work miracles I tell you!

Two nights ago I had a “Car vs deer” (they really dispatch this way – “Car vs Deer” or “Car vs Tree”. In this case, the deer lost in the first round). The state cop on the scene said they had put seven (7!) deer out of their misery that day/night due to car-deer collisions. The original call came in as a car fire secondary to the colission. The fire department got there, saw the car, and decided we should come to check out the driver. By the time we got there, my patient had been out of the car for 30 minutes. As we rolled up she had Christmas presents in both arms, was walking and talking with a police officer, and her head was nodding up-and-down and side-to-side like a bobble head doll. She did not SEEM to be having issues with her cervical spine. The patient did report pain in her shoulder area (near the mid-clavicular line). She did not want to go to the hospital and was certain she didn’t want a board & collar job. I would have let her walk but both airbags went off in her car, and I am still a newbie enough that I decided to err on the side of caution and encourage her to go for a ride with us. She went along and we had a pleasant ride, though I was a bit nervous bringing in a non-collared and boarded patient. She had full movement and sensation in all four extremities, no paresthesia, and no palpaple deformities or tenderness in her neck or back. Head, eyes, ears, nose and throat were clear, GCS = 15, A&Ox3. The car itself had maybe four inches of deformity. For those of you playing along at home - Would you have pushed for her to be boarded and collared?

Medic Class
We are on a break until the new year, and ride time will start in early January as well. We had our Module 3 exam Monday. Module 3 included bleeding and shock plus trauma. I went into the exam a hair bit under-studied for the exam itself, but I had done all of the reading when it was due. I got a 95 out of 100 (they score your test right there) and feel pretty good about how I did. We move into respiratory and cardiac for Module 4, and I am really looking forward to this section as it covers what the majority of our ALS calls are in my region.


Student Conduct Board

I mentioned that I am on the student conduct board. Given how sensitive these cases are, and how at least some of you know what institution I am at, I am going to write about the board in general and I want to make clear I am not referring specifically to any case that I have had recently.

The student conduct board hears cases in one these situations:
1) Plagiarism or academic dishonesty – MUST go in front of the board.
2) Other “minor” charge where the student does not accept responsibility for their actions (if they do, they can be sanctioned by the disciplinary officer without a hearing, and this sanctioning is usually MUCH milder than they would get from the board).
3) The student is at risk of being suspended or expelled from school. This requires a hearing.
4) A student group is accused of violating university policy and risks institutional sanctioning (e.g., a singing group is accused of having new members be locked in a closet and “asked” to drink a certain amount before they can be let out).

Most of what the board hears is either plagiarism or violations of university policy that are made by someone who is already on probation. For example, the first time you are caught smoking pot, if you admit to it, you might get a “warning”. The second time you might get “probation”. Both of these would come from the disciplinary officer. Since violating probation carries the risk of suspension or expulsion, your third run-in with the system will bring you to us for a full hearing. It does happen, of course, that someone does something for the first time but ends up in front of us (arson, assault, driving while intoxicated, steeling, etc.).

Here a few examples of plagiarism that I have seen over the last X years:
1) Student has one sentence in a paper that is attributed to a source but is not in quotes even though it is verbatim from the text.
2) Student has an idea in a paper that comes straight from another source but is not attributed to that source.
3) Student has a purchased paper from an online paper mill.
4) Student used a “recycled” paper from someone who took the course in a previous year.
5) Two students (roommates) come before the board, having turned in identical papers for different sections of the same course. Turns out one stole it from the other without his/her knowledge.

The minimum penalty we can give in cases like the above is failure in the course (this is legislated). Realistically, the minimum we give is failure of the course + a warning. More common is failure and probation (which, in effect, keeps them out of law school for the next decade). Egregious cases get failure of the course and suspension, though if you try hard enough you can get expelled.

Due to how small my campus is, and how public the other types of cases we see are, I just can’t even begin to write about them. I will note that being on this board has really opened my eyes to the range of behavior college students engage in, and has taught me that people WILL look you in the eye, seem as sincere as you can imagine, and LIE, LIE, LIE.

Back to grading exams. I’ll be taking a lot of call between now and the new year, so I’ll check in a bit more often than I did this last week.

DJ

I'll catch up soon

I'll be back in service by thursday. I have not forgotten the blog - just so swamped I can't do it justice. Sorry for the down time.

MadDog and MacMedic - I'll fill in some of the details then...

DJ

My 12/08/04 was fine, how was yours?

Wednesday was busy. At work from 8:00 to 4:45. Home from 4:45 to 5:30. Left home for medic class and learned about abdominal trauma from 6:30 to about 9 (our test got moved to Monday). After medic class I stopped back by the office and worked again until right before midnight (finishing up some nominations for NCAA postgraduate fellowship awards). Had to get home by 0000 because I was on the board from 0000-0600 this morning. Fell asleep sometime before one in the morning.

Tones dropped about 0315: “89 y/o female, injuries from a fall”. I’ll spare you the details, but there was a fall, there was an injury. It is just that the injury was unrelated to THIS fall, but the fall that happened last night that took the same patient to the hospital. Everyone on the crew looked zonked. I don’t know how we’ll deal with no students around from now until mid Jan.

12/09/04: Three plagiarism cases for the Student Conduct Board to hear today starting at 4pm. I hope we finish in time for me to eat with my family… (I am on the student conduct board, a board that hears any student conduct case that can result in a suspend or explusion).

End of year banquet

I just got back from my agencies annual awards banquet.

I got two “awards”:

A toy ambulance “stuck” in the mud (real mud in a Tupperware container). I got the rig stuck after a football game last year and you’d think they would have forgotten, but NO.

The medics and medic to be (me, I hope) were awarded a new training aid (the game Operation). Since I am still in training the medics decided I should have it.

They also gave my wife a nice centerpiece for putting up with me being in the medic class. VERY thoughtful as she really is paying a huge price with me being gone so much.

Best awards went to the chief and deputy chief, both of whom had a situation this year where they could not find a call on the street our station is on. They got framed maps of the town and a compass.

While it ran longer than it should have, I think a good time was had by all.

DJ

5th time a charm?

A local EMT Basic class had their state practical skills exam yesterday (Sat.). In these exams you go to "stations" where you perform a skill or treat a patient. Some of the stations, like airway, have NO variation in them. That is, you know exactly what will happen in the station months in advance (some, like trauma and medical, follow a prescribed order, but you won't know what is wrong with your patient until you evaluate them). A student of mine was a proctor for the exam and sent me this e-mail:

"AHHHH!! You'll find this amusing in a bad way. There was one guy and this was his 4th, yes 4th, time taking the class and he failed at least two stations including mine. Mine was airway adjuncts!!! HOW????"

I can see failing a station or two, but the airway station is as easy as it gets. And this was this guy's fourth time through an EMT class. What agency signs off on this guy to take the class four times? Do YOU want someone treating you who couldn't pass the class three times in a row (and, based on the looks of things, four times in a row)?

Maybe the 5th time will do it for him and he'll be the best EMT in the area. It's possible, right?

I tried, I really did try...

Exam 2 in my stats class was way too hard. I tried to make it up by making Exam 3 easier. If you look at the median and mode, it clearly was EASY, right?

Exam 3: Median=90.00; Mode=92.00


However, look at the grade breakdown:

Exam 3
Frequency
35.00 1
37.00 1
49.00 1
50.00 1
58.00 1
62.00 1
64.00 1
73.00 1
75.00 1
82.00 1
84.00 1
85.00 1
87.00 1
89.00 2
91.00 2
92.00 4
93.00 3
94.00 1
95.00 2
96.00 3

How do you score in the 30's and 40's when half, HALF! of the class scores at 90 or above? Those are the students who are going to ask "if we pull our grades up on the final will we be OK?" DO YOU SEE WHAT YOU ARE TELLING ME WHEN YOU SCORE LESS THAN 60 WHEN 1/2 OF YOUR PEERS SCORED ABOVE 90? I can not ignore it. I really can't.

Can you tell the end of the semester is coming and I'm getting cranky?