It’s not always hypoglycemia…

Call: "Unresponsive female at [store]".

Scene:
Our ambulance rolls to a stop in front of a store, and as we go into the entryway we see a crowd around a bench. On the bench is a mid-50’s female lying supine, legs elevated and head on a coat. A person approaches us with a tube of glucose in her hand. She identifies herself as a bystander, and has taken a brief history (she asked the patient her age and whether she has diabetes). The bystander tells us our patient is a diabetic, has lost consciousness twice in the last hour, and currently has a pulse of 77. She was about to give the patient glucose when we arrived. She hands the tube to me expectantly, and when I go to get more information from the patient the bystander states “this patient needs glucose NOW”. She practically puts her hands on her hips and taps her foot as I go about assessing the patient.

Patient:
Alert and oriented to time, place and self. Strong sense of humor evident from the start, and no signs that she’s feeling anxious, confused or like she’s about to buy the big farm in the sky. She is, however, pale. VERY pale. She is a diabetic, but she is not insulin dependent, is current on her meds, and did eat her normal breakfast and lunch. Her vitals are not scary (I’m not sure the state recognizes “scary” as a category for vital signs, but I now do…). Patient and her daughter report that both episodes of syncope were for about 15 seconds each and that the pt returned to normal mental status within a minute.

Blood glucose level? High normal. The opened tube of glucose goes in the trash and we get the patient in the rig.

The cardiac monitor is showing a first-degree heart block, which the patient claims is new onset and may well explain the syncope. I start a line, and we start rolling to the hospital. The patient is hemodynamically stable the whole trip.

Lesson learned: Diabetics with altered mental status are not necessarily having a hypoglycemic episode, and asking someone if they are a diabetic is not enough history taking.

Sour Stomach and Too Close to Home

For the last few days, when I am awake, I have a slightly sour stomach and mild tachycardia most of the time. Rational or not, I am tweaked at the idea that at any second the tones could go off and I’ll arrive on a scene with people looking at me to quickly and accurately know how to help very sick people. When I’m actually on a call, things are going fine (though I still have a lot to learn). However, when I’m not on a call, the protocols begin to swim in my head, I start to wonder if you select the “paddles lead” for pacing or cardioversion, and I become convinced I am going to freeze when it matters most. I think I just need to run more calls and, sadly, handle a “big one” by myself. I don’t like this feeling, however, and hope it stops soon (hopefully without my hurting someone).

The other night my wife woke me up asking me to listen to our 3 year-old daughter’s breathing. It didn’t take a stethoscope to make me nervous. From outside her door I could hear loud stridor with each inspiration, and her respiratory rate was a bit high for her age. When I got into the room, she was supine, awake, looking semi-agitated, and had mild retractions. I briefly considered calling the ambulance, but given I was the medic on call, and knowing how long it would take the rig to get to our house, the wife and I headed to the hospital ED in our vehicle while my parents (who were visiting) and son slept in peace. I was, of course, thinking though the whole croup vs. epiglottis differential diagnosis. I new better than to try and get a look at my daughter’s throat, she wasn’t drooling, and I was relieved a bit when her stridor calmed as we got out into the cool night air. It was bad enough that at the ED that they gave her a dose of steroids before sending us home. Her pediatrician, who saw her a few days later, started another course of steroids and has her taking albuterol for a week or so. Nasty case of croup, to be sure, and I’ll be OK if I never see another.

My office is a mess and needs to be overhauled, but I am admittedly having a post-semester and post-medic class break / letdown. I’ll get off my a$$ soon, but it is nice to have my evenings with my family and a little less structure during the day (this will crash soon enough, as I have a research student and summer class to teach this summer). Mark my words – I’m going to start working out on a regular basis or I’ll shave my head. Really. Hold me to this, will ya? Thanks.

DJ

I Did it!

State written exam was Thursday. I drove two hours to take it at a site where they could score my exam right away. The exam was broken into BLS and ALS sections. The BLS seemed easy and the ALS seemed REALLY hard. I wasn’t alone in this assessment as everyone I spoke to about it agreed that the ALS was a nightmare. In any event, I passed (97% for the BLS part and 88% for the ALS part). Friday I took a protocol test for my region and as of about 11 am I was a certified ALS provider online with my local medical control. I'm finally finished and it feels good.

Friday night I was hanging around with my family (including my parents who are visiting) when I heard my ambulance’s siren on our street. Odd, given my pager didn’t go off. My wife had arranged for a bunch of people to come over for a surprise party, including the on call crew. We had a lot of fun, grilling burgers and dogs and chatting. Perfect weather and great company. Very thoughtful of everyone, including my wife.

I had my first ALS call this morning. Call came in as “child with unknown medical emergency”. I walked (very FAST walk) into a hotel room to find a VERY groggy, nearly unresponsive 4 year old with a history of asthma. She didn’t seem to be moving much air – YIKES. Given our proximity to the hospital (less than 2 min), I did not mess around on scene. We loaded and drove lights and siren to the ED. From my arrival on scene to arival at the hospital was about 3 minutes. Certainly got my heart rate up, but I think the call went OK (I think the child was actually post-ictial when we got there, but didn’t figure that out until the call was over). My chief and another medic who showed up on scene both claimed I did a good job, so that helped. I really didn’t do much, (made sure her airway was open and gave her O2) but I really didn’t see the point in sticking around on scene when the hospital was so close, and I was just finished with the ABC’s when we got to the hospital, so no meds).

Lost Paramedic and Vodka (no, they don't actually go together)

Well, until today our Ambulance Corps has had two advanced life support providers who take 95% of the calls (one a paramedic and the other what New York calls an AEMT-CC, sort of in between the national registry intermediate and the national registry paramedic). Our paramedic graduated yesterday and drove off today after giving me his corps issued medic jacket and some last minute instructions and best wishes. He took a LOT of calls for our agency, and will be sorely missed. The remaining medic is VERY ready for me to jump on board, and he still has a few days of taking things alone yet.

So, that’s the medic part. Here’s the vodka part. One of the students I’ve worked closely with over the last four years has a father who does a lot of work for the department of defense. Her dad was born in Canada, and travels a lot internationally. A running joke I have with the student is that her father is a double agent for the “commies” (note: yes, I know, I know…). I thought this joke was between the two of us, as it is beyond sophomoric. I was wrong. Her father wanted to thank me for all I’ve done for his daughter, said some very nice things to me, and then handed me a bottle in a bag, winked, and said “you are the only one to have guessed the truth!” Inside the bag was a bottle of Stolichnaya Vodka (a very good [imho] Russian Vodka). Very nice gift and fun way to let me know he was in on the joke. That or the dude is taking money from the reds...

As I sign off, a local fire department is being dispatched to an “outhouse fire”. At first I figured there was some confusion and the building on fire must be an outbuilding of some sort, but it sounds like it really is an outhouse that is on fire.

Questions:
1) Who still uses an outhouse?
2) How does it catch of fire (I assume it isn’t faulty wiring)?
3) Do you really need the fire department for this?
4) Do people have outhouse insurance? “I lost all my $#!^ in a fire” takes on a whole new meaning…

Practical Skills Exam Done!

Marched in graduation today and went with the family to a graduation party at the ambulance station. I'm tired and going to bed, but wanted write an update on the state practical skills exam I took Saturday.

For my state practical skills exam we had to do 18 “skill stations”, not finding out which they would be until the morning of the test (there are over 30 to know). Each station has some maximum number of points and “critical fail” criteria. To pass the station, you need some number of points out of the total possible (it varies from station to station) AND you need to have no critical failures (doing something you shouldn’t or not doing something you should). The stations I was tested on were:

1. Patient Assessment – Medical (Difficulty Breathing with a history of emphysema). In this station we need to go over an entire medical call, from scene size-up to handing the patient over to the hospital. Each assessment or treatment is “voiced” and information is given to you as you discover it.

2. Nebulized Medicine Administration (albuterol 2.5 mg in 3ml NS via small volume nebulizer). Hardest part to this is verbalizing that you would dispose of the equipment in a “red bag” container. Forget to say this and you fail the station (there isn’t a red bag there, which makes it hard for me).

3. Patient Assessment - Trauma (ejected from car – flail chest, deformed shoulder and broken femur). Same idea as medical but with a trauma victum.

4. Immobilization of a joint injury – Sling and swath for a shoulder.

5. ET Tube – Adult + secondary verification and suctioning – lots of chances to mess this up. Open the patient's airway manually, insert an adjunct, bag the patient, bag the patient with 02, tube them, make sure the tube is in the right place, suction the tube. Lots of fun.

6. ET Tube – Child. Similar to above but an added issue was that child mannequin had three holes – esophagus, trachea, and a torn hole near the velecula. Time for a new mannequin!

7. ET Tube Medication Administration (Epi 1:10,000).

8. Intravenous Line – appropriate gauge needle for the scenario and the right fluid, start the line, etc.

9. IV Bolus Admin (1 mg/kg Lidocaine – my patient weighed 100KG – convenient, eh?)

10. IV Drip (Lidocane at 2mg/min)

11. Sub-Q Drug Administration (0.3 mg of Epi 1:1000)

12. Static Cardiology where you look at four strips, one at a time. For each strip, you voice treatment per protocol (mine were 2nd degree type II heart block – Bradycardic; underlying sinus rhythm with malignant multi-focal PVCs; asystole; course v-fib).

13. Dynamic Cardiology – similar to static, but as you are treating your patient the rhythm changes and you need to change your treatment accordingly (my patient: sinus brady; v-fib; asystole; sinus)

14. Cardiac“Pacing”- Give some electricity to your favorite bradycardic patient.

15. Imobilizing an infant in a car seat. Lots of towels and lots of tape.

16. Imobilizing an adult from a sitting position (using a “KED”)

17. Simple airway adjuncts and suctioning - same BLS station from our EMT-Basic test. Easy as pie.

18. Bleeding and Shock Management


This whole process is made more difficult, in my mind, by their not telling you how you've done until you finish all 18 stations. Fail 5 or fewer and you can re-test them. Fail 6 or more and you have to re-take the whole class!

Thankfully, I passed them all first time through. In fact, I only missed one point on the whole exam. I am very pleased and am left just needing to get ready for the state written on Thursday. Unless something strange happens, I’ll be a medic on Friday of this week.

DJ

School's Out For Summer - Almost

Classes are done (both at work and EMS). Graduation is this weekend, as is my state practical skills exam. Senior grades are turned in, and I'm close on everyone else. I'm swamped, and starting to get nervous (needlessly, I hope) about the practical skills exam on Sat. 18 stations (drawn from thirty-something we need to know).

Off to a d-board - if found responsible for plagerism some of the people I see today won't get to walk this weekend.

I'll write Sunday with the ugly details of the PSE.

DJ

370 –or- It’s Called Sampling!

Yesterday was totally consumed by honors defenses at work and the cumulative written final for my medic class. The entire department was locked into a room together from 8 AM to 5 PM, with a steady stream of VERY nervous but talented students. My student went at 8 and it was nice to get the most stressful one (for me) over early so I could enjoy the others. She did a GREAT job, and I am very proud of her. In fact, as a package, yesterday’s presentations were the best I’ve seen in my 9 something years here. Either the students are getting better or we are doing a better job preparing them (I predict the former).

Ah, the cumulative written exam for medic class. Three hundred and seventy questions of fun. 370. Thirty shy of 400. I was joking with the instructor that maybe they should ask us a sample of the infinite number of questions they could ask. He didn’t think it was funny, mostly because his brother put the exam together, but the guy I was joking with had to grade it and hear the class bitch about it (the brothers team teach the course). It was LONG. Most people came early to make sure they had plenty of time. I just couldn’t start early, and this cost me as I finished late in the pack and the exams were graded in the order in which they were completed. I was there from 1830 to 2230, and was plenty tired after thinking all day (I know, sounds like it should not be tiring to sit on your [blank] and think, but for some reason it is for me].

It was a tough exam, a mix of questions we had seen before and many we hadn’t. The new ones, as far as I can tell, came from a test bank (I see a lot of test bank questions in my line of work, and I know how our instructors write, hence this prediction). Worse, a reasonable subset of the questions was NOT covered in class or the book. Thus I think the test bank was for a paramedic text we didn’t use. Certainly added to the challenge.

Those waiting for grades were in a different room than the testing room, so there was a fair amount of chatter and banter. Before I got there a system was set up where people reported their score to the group along with how far below their class average they scored. It turned into a sport, with the goal being to make the best face/noise when seeing your score. EVERYONE before me scored below their average, most by 5 to 10 points. This did cause me pause a bit, because I effectively did not study for the exam. I spent a couple of hours Tuesday looking over all of our old quizzes and tests, but did not turn a page of the text or our notes. I just didn’t have time. I reached a Zen like calm, reassuring myself that I learned the material as I went along and would be fine. I did miss 36 questions, but of course that kept me in the 90’s so I was very pleased.

Three more class meetings left: Two practice practical exams and then a review before the state exam. No new material, no written quizzes or tests. SWEET!

DJ

PALS Over, Everyone Lived

We finished up PALS (pediatric advanced life-support) yesterday with a review, written exam and some “Mega Codes” to test our practical skills.

The review really helped pull things together and solidified some concepts for me. The written exam was a 33 question multiple choice test, and most of the questions were straightforward (there was only one I didn’t know for sure, and I guessed right). Effectively our grades were public, as the scored answer sheets were sitting on a table. My classmates took some pleasure in giving me crap for the perfect score, and I took some pleasure in getting it (the crap and the score).

The “Mega Code” was different than our class-based codes as it involved doing a lot of things on dummies as well as verbalization. I know “fun” shouldn’t really come into play with critically ill children, but given the kids were plastic the process really was interesting and enjoyable.

With yesterday down, I’ll have a PALS card to add to my PHTLS (pre-hospital trauma life support) and ACLS (advanced cardiac life support) cards. What is odd about having the PALS card is that given my level of training (what New York State calls a Critical Care tech [AEMT-CC]), I can’t work an ALS code on anyone under 5 years of age. Before I took PALS I thought I wouldn’t want to be a paramedic as I did not want the responsibility of dealing with young kids. Yesterday it hit me that I could well be on a call with a 7 month old who needs ALS interventions, sitting 20 minutes away from the hospital and with no paramedic around. While I know I don’t want that to happen, I now wonder just how shitty it will feel if it does and I know that if I had taken the paramedic class I could do something besides BLS care and driving fast. Practially speaking, I couldn’t take the paramedic class as it conflicted with a work commitment, and the additional clinical hours and ride time would have killed me. My state has “bridge” classes for experienced AEMT-CC techs, and maybe I’ll try one of those in a couple of years.

Right now I’m ready to finish things up, run some calls, and be home more. My family is ready as well.