brams-medical-tutorials

[brams-medical-tutorials]

Could you tell us about some different gunshot wounds? Complications involved, estimated survival time without treatment, how they'd be treated by paramedics and at the hospital, that kind of thing? I'm trying to decide where a RP character of mine is gonna get shot where it's definitely life-threatening and a touch-and-go situation for a few days, but it won't kill him before he can get to the hospital.

Oooh, gunshot wounds are HARD. I'll warn you first that as an Australian, I don't know anything about guns, and I've never treated a gunshot wound. If I were called to one, we'd never try and fish the bullet out, and we'd try to work out what the weapon was or calibre of it to tell the hospital, but mostly we'd just plug the bleeding and GTFO.

The only thing that can save a serious gunshot wound is theater. Options that we have for plugging bleeding, combine and bandage, Israeli bandage, or a tourniquet if neither of those work.But if I saw an artery spurting away and thought I could clamp it with my fingers or a maternity clip, I very much would, though its not in my scope of practice. 

Other things we can do if its not too serious include pain relief, anti emetics (losing a lot of blood can make a person very dizzy and nauseous), and ofcourse, fluid replacement. We carry sodium chloride 0.9% solution, but there are some ambulance services that might carry plasma (maybe?), we can't really carry blood products because we rarely know what the patient's blood type is. 

The main immediate complication of a gunshot wound is blood loss through direct tissue damage. 

Obviously you will also have the entry (and maybe exit) wounds, these are at risk of infection, you are going to stay in hospital A LOT longer if you get an infection. You might also have burns from the bullet or gun. 

The neat thing about these wounds is that the bullets tumble inside you (you can also get special bullets that tumble a lot more which I think are illegal or only used for shooting game), because of this, you will have the entry wound, which will be very small, because it sucks in on itself unless its from a shotgun or something quite close, and then you have a comparatively HUGE cavity of tissue damage from the bullet bouncing around on whatever it hits. You can also get bullets that splinter and just nasty bullets for nasty wounds. 

I would steer clear of the lungs if you want your sequence to be easier (but you might damage the lowest ribs with abdominal trauma) and steer clear of hitting someone in the head or the aorta. 

Arms and legs are easy, the greatest risk is the thigh, biggest complications would be if you hit the femur (with a big enough bullet to break it) or the femoral artery. This is bleeding we can easily control, but another thing to try and note is how well the rest of the limb is perfusing (receiving blood), if the whole arm or leg lower to the site of injury is white, with no pulses, unfeeling and immovable, you might lose an arm, you might even get what's known as compartment syndrome (which I might go into later but probably not right now). If your wound is very serious, your patient might be unconscious, or have an altered level of consciousness (ie: drowsiness, confusion, agitation, not quite alert). This is to do with a lack of perfusion (blood flow) to the brain). They might also be pale and sweaty (diaphoretic), both signs that there is not enough blood flow in their peripheries. As for which organ you'd like to hit, there are a couple that are worse, the pancreas and stomach are bad because if they rupture they release digestive enzymes into your body cavity, which digest meat. You are meat. 

The liver is probably your best bet because it is so big and is on the front. You are very at risk of haemorrhagic shock (a lot of blood loss), with this because it has a huge blood supply. The spleen also bleeds a lot. With both the liver and spleen, the patient might get referred pain to their right shoulder, caused by blood pooling under the diaphragm. Neato, body!

Other things that you will see when there is a lot of bleeding in the abdominal cavity are tenderness and even rigidity.

If you hit the lower stomach, there's a lot of bowel and intestines there so expect it to smell. You might even get some intestine herniating outside of your body. Don't try to push this back in, just cover it with a moist dressing and carry on.

Basically though, my job is to find it fix it. Airway, breathing and circulation. If one of these is off, I fix it. Mostly, I would expect circulation to be off, because of the blood loss. So in my case, I will probably never know what organ is injured, because I can't see inside of people. So I apply pressure to control the bleeding, try to prevent infection, replace fluid volume (i'd give these people two 14 or 16 gauge cannulas if i could, one in each arm, and a bag of fluid open for each), but putting needles in people who are in shock is hard because their body will shut of perfusion to their arms and legs in order to keep blood for the brain and heart. And I would also make sure I know what I am treating, so expose the person completely and check for any other bullet wounds so I know how many I'm dealing with. I'd roll them over to plug the exit wound if there is one. 

I'm just heading out now to finish my Christmas shopping, but if you think there's something up there that you'd like to explore further, then let me know and I'll elaborate for you with some more specificity. It's just a lot of words if I were to detail all kinds of penetrating trauma. Anyway, until then, Merry Christmas!Love Bram. 

[brams-medical-tutorials]

Graded potential anyone?

My friend is doing a uni lecture; the last time he tried to draw a diagram it ended up being quite the phallic icebreaker for his first years.  Time to help a fellow scientist out.  Label it if you want : )

[brams-medical-tutorials]

Quick question. In some cases of a simple or tension pneumothorax, don't some pts cough up pink foamy sputum?

The classic pink frothy sputum is more a characteristic sign of something like pulmonary oedema, where there is an imbalanced pressure gradient in the pulmonary vessels (too high, usually as a response to the heart not moving blood properly causing it to pool in the pulmonary circuit) , which forces fluid back into the alveoli. This gives a lovely crackle sound on auscultation from the alveoli being forced open and then closing again. The presence of fluid means that they cannot stay open like they would in healthy humans. If the pneumothorax is secondary to some existing lung pathology (spontaneous secondary pneumothorax), then absolutely you could have pink frothy sputum, but its more of an acute thing that happens in response to a chronic lung condition.A pneumothorax is really only a description of that specific aspect of an injury. Every body and every injury or illness is going to be specific to the person who has it. If someone were coughing up blood from a traumatic pneumothorax (first, I wouldn't expect their coughing to be particularly effective enough to bring anything up), secondly, if they did I would expect it to be in larger quantities. But it depends on the nature of the bleed and the lung damage, I suppose.The kind of pink frothy sputum is specifically described as something that happens in the smallest parts of the lungs, from minute tissue damage over time. This is my understanding anyway. If anyone can add anything that would be much appreciated. Unfortunately we don't get a lot of practical exposure to trauma on road anymore. Hope this helps : )

[brams-medical-tutorials]

How do I coax a big burly "bearish" man into not hitting on me while I treat him?

Okay while this is funny in theory, and would be absolutely perfect for a story (honestly, it'd be great). In practice it is kind of disgusting when patient's hit on you. And as a (tuesday turned 21YOF), it is kindof a personal sore spot for me. The only way that I can see a paramedic/health care practitioner finding a patient attractive enough to encourage that kind of thing is if the patient is age-appropriate/alive/not ALOC/intoxicated and has no disgusting medical conditions. And also, because clearly they're not going to be sick enough/drunk enough to call an ambulance if none of those factors are in play, they must also be embarrassed and apologetic that someone called an ambulance on their behalf. I'm not even kidding though. I've had some absolutely foul things said and done to me by patients.It's actually a minefield, because you can't be too rude and you can't physically injure your patients because you are supposed to care for them and you don't want complaints, and you can't swear or threaten them no matter how drunk they are because there are ALWAYS bystanders with camera phones, but if they are trying to touch you up or making sexual remarks while you try to do your job, then that is bullshit and you have the right to feel safe in my own workplace, and you have the right to refuse to treat them if you do not feel safe. And if your ambulance service is not 100% behind you on this, then they are wrong. But also you'd totally be made fun of by your colleagues for not being tough enough.BUT! For the sake of fiction. Perhaps you might just talk about the previous patient that you had with explosive diarrhea and how you forgot to wash your hands. Or maybe you could threaten to sedate them, or you could threaten to use an unnecessarily large needle, or threaten to shave off his beard. There is the standard bar excuse "I'm married" or, "I have a boyfriend". Or you could roll them up in a blanket and seatbelt their arms down (not really allowed but it doesn't hurt drunk patients who are behaving disgustingly), you could sit in the front seat and leave the patient alone and put "unable to obtain" in your paperwork for vital signs. You could call the police for your safety, you could beg your partner to take that job in exchange for all the transfers. If you are writing a fictional health professional who is interested in a patient, and I want to make clear that I've never done these things, nor would I ever, though it is oft joked about in the write up room, you could do a 12 lead on them unnecessarily (requires you to touch the chest/shave the chest if you into that), or doing a really thorough abdominal palpation for the abs BDMaybe just me because of the asexual thing but honestly, the majority of patients are old enough to be my parent/grandparent so even if any of anything were reciprocated I am at work and deserve to be treated like the professional that I am.Sorry about the post derail. I am a butt.

[brams-medical-tutorials]

What can you tell us about albinism in humans? What're some complications they deal with?

I'm sorry to be of little help but I'm not usually very helpful on things that are not emergency medical issues. However, I will tell you what I do know. Most of us already know that albinism is a condition in which a person who produces little to no pigmentation in their body. The pigment is called melanin and people with albinism with have little to no colour in their hair, skin and eyes. It can affect any race but is more common with incest. Here is a picture of a pretty lady who is albino. I got her from google images. Having the stereotypical red eyes is a bit rare, actually.

So an obvious one is they have an increased susceptibility to skin cancer. And another obvious one is that they often have very poor eyesight, but interestingly, with some forms of albinism, their vision may improve with age and with increased pigmentation in childhood. They might also have nystagmus (involuntary movement of the eyes) present at birth and sometimes later in life. Some forms of albinism are linked with immunodeficiency, so a child with albinism may have frequent infections, which might lead to them being smaller and underdeveloped as adults. Albinism is also sometimes associated with different forms of mental retardation. Sorry I couldn't find anything else. I've been a bit of a neglecting mother to this blog at the moment because I have had my own student that I've been mentoring for a few weeks. Let me know if I can help with anything else : )

[brams-medical-tutorials]

Oops, sorry guys. My phone gets confused between medical blog and personal blog. Won't happen again, sorry.

[brams-medical-tutorials]

Hey Bram, this doesn't sound too professional, but don't you just love a man with a good chest? ;D

Trust me when I say that I do my best to keep my professional contacts away from this blog. I feel like this is a reference to my posts wherein I post pictures of torsos for anatomical reasons. You know, science! FOR SCIENCE!But to be perfectly honest, its not really my thing ^-^I'll try to do a post about butts so we can see what reference images are needed. It'll be about about... butt... medicine....FOR SCIENCE!

[brams-medical-tutorials]

Addendum to the nerve palsy question: (I know, I know, why don’t you do things properly the first time!?) BUT the degree of swelling required to compress a nerve is waay past the point of, you’d definitely have airway occlusion. HOWEVER, the vessels that supply blood to the nerves are fair game.

So I thought about it a lot and two acceptable processes for the symptoms you wanted are, - a fracture to the cricoid cartilage (but NOT displaced) because it goes around the larynx on all sides. Feasibly, this could happen without airway occlusion. This is probably the best option for the timeframe required.  The other thing is: - swelling causing occlusion of the vessels supplying the recurrant laryngeal nerve! (thought this is more likely to only be a short period of time if you want it reversible)

In both cases, they'll still be able to speak, they will just have extreme pain/difficulty. 

There you go. Those are the best two options, and it took me waaay too long to answer. Sorry!

[brams-medical-tutorials]

Well, you certainly have more experience, given that I'm only a pre-clinical student haha. I've been taught that cardiovascular problems that present as hoarse or a lost voice because it impinges a certain nerve that loops under the aorta. According to our great Overlord Wikipedia, trauma/tumour/surgery involving this nerve around the neck can damage this nerve. But as this may involve breathing problems due to its control over the vocal cord. Aka, I have no idea, brilliant blog, you're awesome

Aww no I’m not. I’m a human. We’re all just floundering along trying to be helpful.

Thank you for this information!What kind of cardiovascular problems? Do you mean like atherosclerosis or increased pressure of the aorta? I’ve never seen that clinically. It sounds rare? Would that kind of pressure be enough to cause nerve palsy/dysfunction?? Or is it not about the pressure?I did consider the possibility of nerve damage, but, as I don’t have much knowledge of specific nerves and their functions, I thought I’d leave it out. And just pin my hopes to ~if its an injury that is bad enough to cause dysphonia, it is an injury bad enough to have a buttload of other complications~ But you know what, I might do a bit more research now. You certainly piqued my will to fall into the rabbit hole that is wikipedia! And then later, databases!

[brams-medical-tutorials]

Submissions?

Harmlessghost's ask just gave me a thought that should probably have been obvious earlier but hey, never too late! If anyone has any kind of expertise and wants to input on this platform, that is MORE than welcome! I have a bit of a follower base, and the distribution of information is my favourite thing! I'm pretty limited in my own knowledge, as I've been taught and practice pre-hospital interventions only, and very specific injuries are well... very specific and probably better answered by specialists. I do have access to databases, and I do a lot of research outside of my scope of practice. But it is still out of my scope of practice.  Or even, if you have some favourite tutorials, link me, and I'll reblog if its accurate. That or submit.  The only think I'll ask is that there must be a source to the original author. Plagiarism makes me really unhappy cause someone put a lot of time into whatever you just stole : ( Oh and, I really don't want to post any information that would help people in things like committing suicide or otherwise cause harm, like specific pharmacology. I know its a risk with any of this stuff.

[brams-medical-tutorials]

In response to the voice thing: what about impingement or otherwise damage of the left recurrent laryngeal nerve? Or would that be too complicated?

Too complicated for me, certainly! Honestly, my treatment options for throat injuries (besides transport) are, pain relief, antiemetics, treat hypoxia, prevent airway occlusion, CPR. I’ve never been taught that because its not really applicable to the pre-hospital setting. But if you have a medical background or just an enthusiasm for science, do share with me and the asker! I love to learn!

[brams-medical-tutorials]

First, LOVE your information. It helps improve my writing and makes things more believable. Thank you for taking the time to enlighten those of us who are untrained medically. Second, I'm working on a story where a character gets whacked in the throat with a sheathed katana or sword. I need him to loose his voice for a week. What would other symptoms be? Recovery time? Treatment options? What's the medical term (other than throat contusion) so I can do more research? Thank you so much!

This is my second go at answering this. I’m so sorry for the delay. I am not a fan of Tumblr at the moment. Take two:Thank you Mari! That makes me so happy to hear. 

This question was actually really hard for me to answer, and then I realised, and I should apply this always, no two injuries are the same! Sure, most people’s anatomy and physiology colours within the same broad lines, but what are the chances that two people are going to be smacked in the neck in the exact same way? A million to one!

A&PThere are a heap of really vital structures in your neck, and pretty much everything is serviced by structures that travel through your neck. There is your airway, your oesophagus, your cervical spine, a shit ton of nerves, and a shit ton of large vessels. I’m really glad you didn’t ask about penetrating trauma!

The structure that controls your voice is your larynx or voice box. It is part of your airway. It is made up of your vocal chords and a lot of cartilage. Here is a picture of your larynx.

If you are interested, there are a lot more pictures on google images of the larynx. In more than half of them it looks like an alien vagina. I’m just saying what everyone else is thinking…

Shit that can go wrong:

With any blunt trauma, there will be inflammation.I feel like, for a person to sustain a blunt trauma that is forceful enough for them to lose their voice, they would have to have a lot of swelling. But you know what, you can totally sweep this under the rug of ignorance. Like I said, no two injuries are the same.The reason inflammation is so bad is because it can occlude your airway. Like we said, the larynx is a part of the airway, so damage to it = swelling = airway occlusion. There is definitely going to be /some/ airway occlusion. But if you don’t want it to be life threatening, then don’t occlude their airway. You are their God. Injuries to the throat or larynx have a HUGE potential to rapidly deteriorate because of swelling. You’ll need to have a mother-hen observe and worry over your character for ages, or perhaps a love interest?! >8DIf they lose their airway (or if they are heading in that direction), then there are only two treatment options, one is emergency intubation, in which your character will need to be sedated and have a tube crammed down their throat and then surgery to fix the injury. The other is a tracheostomy (an incision in the windpipe) or a cricothyroidotomy (an incision made through the cricothyroid membrane), to basically cut a hole in the neck to make a new airway because your other one is a lost cause, then more surgery. The latter is going to be a permanent problem, the former is going to be maybe a few weeks recovery, but its still a surgery.A great sound that you will hear when there is airway occlusion is stridor. Here is an audio clip of stridor. It is super dorky and hilarious but a good sound to hear, you know. Can’t really replicate it. 

Anyway, if your setting doesn’t have the resources for delicate throat surgery, don’t have an occluded airway. I wouldn’t. Still, a little bit of friendly asphyxiation never hurt any storyline in my opinion. Just don’t kill them if you love them.

The other thing is, fractured cervical spine. Don’t do this to them if you want them to have a few weeks of recovery. Do this to them if you want them to be a quadriplegic on a ventilator all their life (thought again, there are degrees of injury, but still…). If the injury is enough to snap their neck back, and if they have pain in their midline C-spine, or any neurological deficits, it is suggestive of a C-spine injury. Just steer clear of this. Here lies heartbreak, buried alone.

The other thing is, do you see all that cartilage in that picture up there?All of it can fracture. The most common one to fracture is the cricoid cartilage because it is at the front so its more exposed. The next most common is the thyroid cartilage. As long as the pieces of cartilage are not displaced, there doesn’t necessarily have to be any surgery. With fractures, you would definitely expect some swelling though (probably airway occlusion but this is not the real life, this is just fantasy).

Ummmm, I don’t know, I think I got the main ones.

Edit: after a prompt from harmlessghost (thank you!!) I thought I should include nerve palsy/paresis. Harmlessghost says "The recurrent laryngeal nerve branches off the vagus and loops under the arch of the aorta before going back up again" (I thought that was very well worded, don't you?). If I were you and I was thinking of nerve damage I would go with the recurrent laryngeal nerve because the vagus nerve controls basically everything and you need it to work if you want to live, don't fuck with the vagus nerve. If you have damage to this nerve, another common symptom would be aspiration (food and drink going down your breathing tube; VERY BAD, can cause dry drowning and infection++)Though people with this are much more likely to have been injured with penetrating trauma rather than blunt, but if there is a mass or a pressure applied to the nerve, then you can get palsy, which is a temporary paralysis. 

I must be honest in saying that I don't know much about this. My understanding is that you can still speak with it, but your voice will be very breathy. Will update more later. Watch this space!

SIGNS AND SYMPTOMS!! (besides dysphonia: diffiulty, or inability to speak)

- Dysphagia (difficulty, or even inability to swallow), in this case they might be spitting all the time, which is gross but affords a human sense of realism that I have a fondness for. The spit might have a little bit of blood in it for a while, but not a lot. A nice pink colour. This is if the trauma was hard enough for any small tears or lacerations to occur in the oesophagus. This also means they’ll have trouble eating and drinking, and they probably shouldn’t be eating, because that could lead to an infection of these injuries. But hey, do you have access to antibiotics/magic??

- Dyspnoea (difficulty breathing, particularly when lying on your back, but if they are totally unable to tolerate lying on their back, they probably have a separation fracture which will require surgery)

- You know what, anything throaty is going to hurt. Coughing will hurt like a mother-bitch. 

- Subcutaneous emphysema (this is, and will feel like, air trapped beneath the skin) but yo, aint nobody who got smacked significantly in the throat gonna let you touch it. That will hurt them a lot you fool! Only a tidbit for your interest.

- Obviously they will have swelling, bruising and tenderness around the airway.

- probably are also going to have a moderately high heart rate, blood pressure, and respiratory rate, as part of a normal response to pain and being scared about not being able to breathe. This should return to normal after a while though.

Don’t make them:-Cyanotic (blue skin, around the lips especially, this is a sign of not enough oxygen and is suggestive of no air exchange.- Stridor (that sound that we heard)- Spitting up lots of bright red blood for a long time- Stop breathing- Have tracheal deviation (exactly what is sounds like I think)- Have pain or deformity to the middle of the back of their neck

Here is a link to a case study of a pretty bad airway injury.

Emergency medical treatment

In the pre-hospital setting, there’s not a lot I can really do apart from basic first aid. I might consider administering oxygen therapy if they are having trouble breathing or have low oxygen saturations. I might also put a needle in just in case I need to sedate them and put a tube down their throat if its really bad (endotracheal intubation, which we talked about), aint no way I’m doing a cricothyroidotomy) I might also apply an ice pack to their throat to prevent further swelling. And I would let them sit in a position of comfort, and try to speak to them via charades and pictionary I guess.

I really hope that was helpful, I’m not sure that it was : /If you want more information on the in-hospital stuff, let me know. I didn’t do too much research there, because its not really my area of expertise. But I would be happy to if you were interested?

Let me know, and sorry for the delay.

[brams-medical-tutorials]

I am so fed up with trying to answer asks, typing out a thousand million words, and losing it because Tumblr is hard to navigate.  This is why I am an unreliable blogger!

[brams-medical-tutorials]

Okay, I got some things to work on.  Thanks very much guys, you keep me learnered and I love it!

[brams-medical-tutorials]

Aaaahhhhhh!!!

People are reading my post and reblogging my post and liking my post and learning and leaving lovely comments on my post.  One person told me I am missing an ask button. Thank you. I always type /ask onto the end of the URL. I will try to fix this though. 

Also, Tumblr... Is this what will make you happy?? Trauma?? Does trauma make you happy?

But I don't like trauma. It is not so interesting. It is so easy to treat. 

Do you want to learn about autonomic dysreflexia? Do you want to learn about traumatic brain injury? Do you want to learn about anaphylaxis? Do you want to learn about abdominal pain?? What would you like to learn about?

Can we compromise with multi-system trauma? How about crush syndrome and rhabdomyalosis? How about open femur fractures? They are hard to treat, and there's lots of aspects that I bet you hadn't considered before for a simple open femur fracture?

I am the worst at teaching but I want to be better. 

[brams-medical-tutorials]

DIAGNOSIS IN THE PRE-HOSPITAL SETTING!

You know what I am intensely interested in right now? ABDOMINAL PAIN! I know, I know. Jeez bram, get some new hobbies, you nutter!

Excuse you, I do have hobbies. I bake!

Do you know why I am interested in abdominal pain?  Because I used to absolutely hate having to treat patients with abdominal pain. I hated it because you just can't diagnose them. 

And I was totally right. You can't diagnose them in the pre-hospital setting, we just don't have the tools to be 100%. But it is  actually really fun and challenging trying to. One of the things that I am so happy to have learnt as a clinician is that you don't need to be able to diagnose everything, and you don't have to feel stupid if you can't.

But something that more than half of all patients will ask you is: "what do you think is wrong?" or, you know, they'll scream or cry it.  And there is nothing wrong with saying, "well I can't say for sure, but it could be a, b or c."

At the moment, I am trying to learn how to do a really thorough abdominal exam, because I have only worked with one person who bothers to do it (with phenomenal results). And he is a truly amazing human being and someone to strive to be more like. 

So basically I wanted to give some tips on learning to do a proper clinical assessment in order to form a preliminary diagnosis. This isn't limited to abdo assessment, but that's what prompted it.

This post is less of a resource for writers as is this blog's primary intention, but it could be helpful for paramedic students maybe. Well, I just wish someone had told me some of these things sooner is all.

As always, I myself am still learning (we all are), the minute I stop learning will be the day I die, so if you have any questions/want something clarified/think something is inaccurate/want to add something, shoot me an ask or reblog with additions. I would truly love to hear from you!

OKAY! So here are some general rules for your examination of a patient who is in pain or discomfort, or you know, those ones who are just ~generally unwell~ (this of course, excludes stuff like obvious trauma, etc). These rules might not work for everyone, but hey, if they help one person then that is awesome.  Rule number one: Dicking around trying to diagnose in the pre-hospital setting is absolutely irresponsible if you are prioritising it over treating the patient. If someone tells you they are in 10/10 pain and they look it, do your drug checks and give them analgesia before working out when their last bowel motion was. If someone looks really fucking sick (pale and sweaty), and their vital signs tell you that something is up, treat them and drive them to hospital really flippin fast. Because, in the end, there are only so many benefits that you can get from diagnosing a patient in the pre-hospital setting. Though there are benefits to having a preliminary diagnosis, including but not limited to:

It might help you to pick the best drug for them (analgesics and antiemetics), or it might help you decide not to give a certain drug.

It will help you be prepared in case they deteriorate on you

It will help the hospital as a place to start looking, which will lead to quicker permanent relief of whatever the patient's presenting complaint is (hopefully).

It is nice to keep the patient informed about their condition (because they will ask you what could be wrong with them. They will ask you what the hospital will do when they get there. They will ask you why the pain might be worse today. And you will find that GPs tell patients fuck all about their own conditions, and about the medications they are taking and why, it is something that makes me very angry. If you know that what they are experiencing is a common symptom of their diagnosed condition, tell them. People get understandably scared and anxious when they don't understand what is going on.)

You might be able to predict what the hospital will want to do. For example: a scan, or bloods. For the former, you'd put them on a trauma mat (depending on hospital), for the latter, you could cannulate them before you get there if you have time and can. (as a sidenote, it is totally okay to not know what the hospital will do. This is a big learning curve. And it is totally okay to say, 'I'm not sure, but here is a list of things they might do.' Or, 'I'm not sure', and then ask your partner, '[partner's name], what do you think?'

LEARNING! My favourite.

Being able to look smart in front of your patients/colleagues/the mean nurses at hospital.

But none of those things mean squat if you are withholding or delaying treatment in order to diagnose. So basics first is what I'm getting at. Find it fix it. Having a preliminary diagnosis is a luxury not a requirement.

Don't let your colleagues shame you for being interested in finding out what exactly is causing the presentation. Being interested is awesome. You'll end up being a much better clinician than the people who don't give two fucks. 

Rule number two:

Have differential diagnoses!! Have lots of them! Because as we've discussed, you can't know for sure, you just can't, because there is always going to be that portion of the population that is so atypical it hurts. Everyone is different! I can't use that phrase enough. It is my favourite.

So you can say, 'Okay, it could be this, but it could also be a number of other things!' Don't get so fixated on one idea that you forget to ask about other things. That is bad work! (but that is okay, learn from it, buddy, its the only thing you can do).

All of that brings me to the rest of this post which is Rule number three: LEARN HOW TO DO A REALLY GOOD ASSESSMENT!

This is really hard, so I am going to share with you some secrets that I am still in the very beginning stages of learning. First of all ~ learn to do some really good history taking!

You might be familiar with a few simple mnemonics like SAMPLE (Signs and symptoms, Allergies, Medications, Past medical history, Last ins and outs, Events leading up to) and OPQRST (Onset, Palliation/provocation, Quality, Region/radiation, Severity, Time). There are a couple of other good ones floating around, but those two work for me. Find what works for you and practice it. Learn it. Form a system (It's okay if this takes time). Here is a list of other questions/ways of asking questions that might be helpful:

- A good one to get in early for people who waffle is: “are you in any pain?” because it can and does happen that a patient will go on about their constipation for 20 minutes and forget to tell you about their cardiac chest pain. - “Have you ever experienced anything like this before?/Did you see a doctor for it then?” - “Have you taken anything for the pain/nausea/etc?” - If you ask people if they have any medical conditions, 90% will say no. After they say no, ask them something like: “No asthma, epilepsy, diabetes, high blood pressure, anxiety, headaches? Never had anything wrong with your heart?” Usually, this list prompts them to remember their own medical history or say “oh yes that! I've had three heart attacks!" - “Do you keep a list of medications? Where?” (because very few sick people remember everything they take) - For people with long-winded stories and chronic conditions, “What is different today that made you call the ambulance?” (be polite) - “Can you use one finger to point to where the pain is worst?” (can they localise? Also helps to work out how the pain radiates) - “Have you been going to the toilet like normal?” - “Have you been eating and drinking like normal?” - “Is there anything that makes it worse or better?” - “What were you doing when it started?” - “Besides [presenting complaint], do you have any other symptoms?/is there anything else that is abnormal/that is worrying you? - “Are you sexually active?” (where appropriate) - "Have you been feeling generally well lately?" - Most important question: “Is that normal for you?” (because there is no such thing as normal!) There are heaps more things that you might want to ask, but you need to work out what kind of questions work well for you. Then later you can make your questioning more specific to individual presentations.

Probably the most important thing about all of this is that you need to listen to their answers. Having to ask the same question 8 times is just going to make both of you frustrated. Repeat stuff back to them so you know you're both on the same page. Try to move at their own pace with questioning (if it's not time-critical), but sometimes it is okay to stop them (politely) and ask time-critical questions, like the pain question.

And of course, sometimes you will get patients who know nothing about their own history, or who, because of a medical condition, are in no state to communicate their ails, so don't be afraid to use bystanders who know the patient well, or who at least know where they keep their meds. A good question to ask bystanders (particularly if you are unsure if the patient may be a little bit confused/agitated/ALOC) is: - “You know [patient's name], a lot better than I do; do they seem like they are acting normal to you?” Rule number four: Do not be afraid to touch your patients! Even if you aren't suspecting that there is anything at all wrong with them, auscultate their chest! Palpate their abdomen! "Why?!" I hear you cry? "That's unnecessary!" Because the only way you are going to learn if something is abnormal is by learning what is NORMAL!!! The other part of this is getting in the habit of doing a proper assessment: maybe you think your patient is a giant spoon, and chances are, they probably are, but if you don't do a thorough assessment and there IS something wrong with them, your are gonna feel like a real silly butt, and hopefully your poor assessment didn't lead to a poor patient outcome (but okay, we can still learn from it). So get in the habit of doing thorough assessments on everyone (where appropriate and where transport time permits). The exceptions to this are if it causes them distress or makes them uncomfortable, if they refuse, or if you need to prioritise other stuff because of time constraints.

Rule number five: and as an adjunct to all other rules! CONSENT! Always ask your patient's permission to touch them and explain WHY! Do this before you start touching them! It is really easy to get to a point where you are totally cool with touching people (it comes with time), but you always need to keep in mind that most patients don't know what you need to do for your assessment, and they might not be okay with touch. “I am just going to lift up your shirt and have a feel of your stomach. Is that okay?” Get permission. “I'm just doing this to check for ______” So they don't feel like you are just touching them because you feel like it. “Let me know if it hurts and I'll stop right away, but it shouldn't hurt” And keep that promise. Tell them if you find anything abnormal. Ask them if that's normal for them because it might be (everyone is different). Try not to make them anxious, but try not to lie to them. “Your blood pressure is a little bit high, is that normal for you? No? Oh well it could be caused by a lot of things, for example if you are anxious or in pain.” People deserve to be informed about their health. Having said that, don't tell them they could die unless they are refusing treatment and transport against your advice, in that case, lay it on.

Communicate with them. They deserve that from you. And ask them what they want, or what they think they are capable of doing. “Can you walk to the stretcher or would you like us to lift you/move it closer/get a wheelchair?” Always ask “would you like something for the pain?” explain their options but limit it to what you are willing to give them based on their presentation (The worst thing is deciding on a drug for a patient who looks like they are absolutely suffering, and then drawing it up only for the patient to decide they don't want anything). “I can give you a drug that you inhale/swallow/whatever, or I can put a little needle in your hand and give you something else.” “I can give you a drug to help with your nausea, but I'll have to give you a needle.” “Based on what I've found, I think you need to go to hospital, but I can't force you. Are you happy to come to hospital with us?” “I think you could probably go and see your GP tomorrow about this, but I am happy to take you to hospital now if you'd like to go. You can always call us back if...” It's their health, it's their choice.

Learn different assessment techniques!

Learn something new every day! Learn what normal bowel sounds sound like (best place to auscultate the right lower quadrant, and you want 5-15 per minute). Best place to auscultate the chest is on the back, or for patients who are a bit larger, the axillary line. Try not to auscultate through clothing! Try learning percussion (a bit hard in the pre-hospital setting). Watch youtube videos on different assessment techniques, they are useful! Use all your senses to assess!  Learn about different kinds of pain! Learn different types of referred pain! Have a really good understanding of your anatomy and physiology or your organs! Learn percussion! Don't forget your vital signs! Never forget to take a temperature, particularly if you can't work out what's wrong. Learn which kinds of analgesia are better for which kinds of pain! Keep learning! Never stop learning! And I think that is the end of that unless I think of something else to add later.

Okay, next post I want to make is about specific kinds of pain and what the patient might have based on the information you gather in your awesome assessment.

[brams-medical-tutorials]

HI REIVAYLOR!!! Sorry about the delay. I was on shift for a few days. Still am but I get so easily distracted with other things that I want to look up when I am working.  Short answer is yes. I was going to dump a load of pathophysiology on you, but then I thought, why?

This has not so much been documented in people, like soldiers or 'adrenaline junkies' who have a lot of opportunity for endogenous adrenaline rushes, so to speak, because those are pretty terrible clinical conditions. Ehehehe. However, on people who use adrenaline regularly as a treatment, they will find that over time they need a lot more for the same effects, and they will get a lot less side effects.  For example, for a person who uses intramuscular adrenaline to treat severe asthma. If they were say, a smoker, and it was spring so there is a lot of pollen, and they had a chest infection, and basically everything aligns so that they are having a severe asthma attack regularly, they will find that 1) they will get less tachycardic/hypertensive effects, they will get less nausea/headache, they will get less tremors when they administer this drug. But also, it will have less of a bronchodilatory effect.  It is a tolerance. Not to be confused with addiction. 

However, research on this has indicated that this tolerance will reduce to normal after not having received the drug for a little while. 

Sorry I can't source this at the moment. But it shouldn't be too hard if you do a google scholar search for 'adrenaline tolerance' or something. But you should note that these are LARGE doses of adrenaline. More than your body would produce when it is stressed. 

Then there is the body's own adaptive process to stress, termed 'General Adaptive Syndrome' which is a kind of adaptive process which decreases the body's sensitivity to stress hormones. It is a period in which your body strengthens its resources (energy, kind of) in order to cope with the elevated stress levels, and this usually gets people (and other mammals) past the initial shock of whatever a stressor is.  This can't be sustained, however, and it will eventually lead to exhaustion.

Which leads me to a thing called 'combat stress reaction', which is different to post traumatic stress disorder, but can precede it. It is where someone is so exposed to danger (for example, in a warzone, and that is where it was first studied, hence the name), that they have constantly high levels of other stress hormones, your catecholamines like adrenaline but also things like cortisol (longer term stress). 

CSR has a pretty good wiki article on it, though I suspect it is the opposite of what you were searching for. People with combat stress reactions will usually have fatigue, slower reaction times, disconnect, indecision, blah blah, all things that make a poor soldier. If you're a Band of Brother's fan, I am pretty sure Gene Roe is suffering from this during the battle of Bastgone. Though its never explicitly stated. 

Hope this helped!  Sorry its not more researched.  Love Bram. 

reivaylor answered: Is it possible for a person to get accustomed to adrenaline rushes and their bodies be able to process them? Like a soldier vs. average man