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Medical Assessments

Scenarios are always difficult due to the fact that it gets hard to suspend disbelief. When arriving on “scene” and finding your healthy 20 year old patient acting like a dying Vietnam veteran, it can be difficult enough not to laugh. Having to remember to ask seemingly unnecessary questions like “Where are we” and “What is the patient’s skin like” as part of the general assessment is thus difficult... but vital. 

A run through:

BSI/SCENE SAFETY- It’s basically become a chant at this point but do NOT forget this.

Nature, Number, Needs- A quick way of saying: What do you see? What do you need? Determine quickly if you’re overwhelmed or in need of ALS. The faster these needs are determined the better the care provided. *Hint this is when you would call ALS* This is additionally a great time to determine any possible mechanism of injury/added trauma to your medical assessment. 

Your next level of Assessment is the General Assessment/Chief Complaint run through:

LOC- (Level of Consciousness)- Are they AVPU? Are they AOx4? Make sure they are oriented to Time, Place, Person, Event. 

Airway- Is it patent? If not, stop everything to resolve this step.

Breathing- Is the person breathing adequately? Again, if not stop everything to resolve this step.

Circulation and Skin- What does their skin look like? How is their capillary refill? Act on your results

After checking your LOC and ABCs, determine transport priorities. Namely, is this a “Load and Go” or “Stay and Play”. Any situation where the patient is not stable (aside from a cardiac arrest in which case you are REQUIRED to remain on scene for 30 minutes) is an automatic load and go.

The next few steps involve:

OPQRST- based on patient complaint

SAMPLE- Make sure to ALWAYS ask about allergies and medications before attempting any interventions. A patient’s history could serve as a contraindication for certain interventions you would have originally provided.

Focused Physical Assessment- Do NOT be shy about this step. When something is wrong with the patient remember to Inspect-Palpate-Auscultate (Cool Mnemonic: What is Oliver’s favorite type of beer? IPA). For trouble breathing, listen to lung sounds. Abdominal pain, palpate the quadrants. It’ll feel personal but DO IT.

Vitals!- Practiced a million times but still vital (get it?). Pulse, Resps, BP, SPO2, Pupils, Temp, BG. Take those before and after an intervention and repeatedly throughout a call.

Interventions- Based on the patient’s need. Remember your 5/6Rs for Medications, Call Med Control if it what you’d like to administer isn’t a standing order. Know your dosages and routes. A lot of harm can be done when medications are badly administered.

If this was a stay a play- Now again indicate transport.

The next step is a detailed assessment. Looking for less life threatening issues and also reassessing the areas of your original focused assessment. Be thorough.

 Finally reassessment- Every 5 minutes for unstable patients, 15 for stable patients. Continue until you’ve arrived at the hospital. *Hint a reassessment includes a FULL set of vitals every time*

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DCAPBTLS Bootcamp

So there was a lot going on today. I’m talking buns, amputations, eviscerations, penetrating injuries, extruding bones, just generally a lot of body parts in places where they didn’t belong and non-body parts in the places where body parts belong. Either it was a full moon or someone said the q-word (“quiet”).

Number one take-away: Treat life threats first! ABCs/CABs always come first and should be continuously assessed (aka don’t go off looking for the amputation if the pt is still bleeding—you can’t reattach the leg if the pt is dead ... too morbid?)

Other notes:

The traction splint worked if the pt stopped screaming (also lay your pt down—it makes your job easier and the pt more comfortable)

Open fractures require DRY sterile dressings (not wet)

Put hands over the sucking chest wound before doing anything else

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Ma'am, I wish I had your porcelain skin.

a wonderful response to a difficult patient

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Breathing is it Important?

Eh... ask Tswift. (Her song Breathe in case you didn’t get it).

Here’s a list of things that take your breath away

1. Baja’s (Carlin and Nicole were here)

2. Your first kiss (ok maybe not depends how that was)

3. Orgo (okay well not the good kind of taking your breath away- more like from intense panic)

4. Amy Sanderson (are we allowed to say this?)

5. anaphylactic shock, asthma, allergies, choking, pneumothorax, bronchitis, emphysema, smoking, anxiety

How to bring your breath back (ok or keep your airway patent but roll with this)

1. NPA -- nasal pharyngeal adjunct -- (make sure to lube that baby up the whole way, and you gotta be deft on the left)- remember, from the right nostril it’ll go in anatomically, left will require a twist. NPA are used as a means to open up an airway, the same goes for OPAs.

2. OPA -- oral pharyngeal airway -- because I gag thinking about my reflexes, don’t you?? (hint, this means that you should make sure a patient is properly U in AVPU- namely, no gag reflex).

3. CPAP machine -- because nothing like slamming air down your throat- ONLY for patients that are responsive and able to take commands- strongly contraindicated for a pneumothorax. 

4. King airway -- How sexist. but then again when you’re in a male-dominated society with a long history of toxic and fragile masculinity through social constructionism what do you think happens (that got dark)... Lube the distal tip and btw expect the patient to vomit when you remove this. The King Airway serves as a method to close off the esophagus in patients with NO gag reflex. 

5. Non-rebreather -- The thing you see in the movies all the time. Plus you can feel like Darth Vader with this one on. Standard rate of air flow is 15 lpm and should be given to patients with normal respiration rates but low circulation.

6. Nasal cannula -- It’s 6 liters per minute, meant to be non-intrusive and a friendly way to help support a patient who is generally stable. 

7. Nebulized albuterol/ipratropium bromide -- it’s like vaping but actually good for you. Make sure you get the right dosage though. Used during asthma attacks. 

8. Amy Sanderson -- once she saves your life.

Editor’s note: Beth has noted that Amy Sanderson should be listed as first under both categories.

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Vitals

Vitals... I’m glad to say I have never been subjected to that part of skills nights. I think it has something to do with the fact that I have no heart rate, my respiratory rate is always zero, my pupils completely nonexistent, blood pressure impossible to take and lung sounds impossible to hear. Oh and the pulse oximetry machine never accepts my fingers as legitimate sources of oxygen saturated blood. Even worse is when students attempt to take my blood glucose level.

I have to admit, it’s fun to watch the instructors suffer through their arms turning red (and at times purple) during blood pressure readings, or watching Nikki Fresh subject herself to multiple jabs for the blood glucometer. Some tips though for students:

1. On blood pressure: If you’re going to re-inflate the cuff for any reason, first allow the patient’s arm to breath (meaning, deflate it fully so as to allow for a bit of circulation before cutting off blood supply for a second- or third- time). Sometimes, if re-inflation has occurred too many times, switching arms might even be a good idea. 

2. On Blood Glucometry: Remember, after “sticking” patients with the needle, wipe away the first drop of blood. Then if bleeding isn’t strong enough, milk the area to force out a bead of blood.

3. Heart rates, when taken through the radial pulse, should be taken on the thumb side of the hand.

4. Blood pressure, place the bell of the stethoscope on the inside (medial) part of the elbow. Furthermore NEVER place your thumb on the bell- you’ll only hear your own heart rate.

5. For respirations, don’t tell the patient what you’re doing. They’ll either consciously or unconsciously alter your results. Best way to do this is to take respiratory rates right after heart rates. Keeping your hand on their wrist, crossing their arm over their chest and watching for chest rise can serve as an effective method. 

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F. Scott’s Fun Thoughts

Fun fact: It’s a felony in the state of Rhode Island to punch an EMT

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F. Scott’s History Thoughts

Notetaking, the flossing of EMS calls, you hate it but 9 out of 10 dentists (read: EMTs) recommend it. It’s the job you hope you’re not landed with when roles are dolled out and the suffering only gets worse when one sits down to write the report. But suffering is important, it builds character and reminds you of your OPQRSTs. Notetaking is crucial for both transfer and continuation of care so therefore I’ve provided a SAMPLE (HA get it?!?) history to practice with:

Signs/Symptoms: The part of the call where you let the patient focus on “me”. “What seems to be the problem today?” (without too much sass) is a great segue.

Allergies: Hypersensitivity! Ask about allergies and no, “your face” doesn’t count.*

Medications: Any substances your patient takes to treat their medical problems. Pro tip: if you don’t know what the heck “idarucizumab” is (and you probably don’t), you can do a quick Bing search. And when that doesn’t work, just ask the patient.

Past Medical History: Have you ever been hospitalized before? Do you have any chronic medical problems? Are you or have you ever been pregnant? Most recent alien abduction?

Last Oral Intake: We’re talking about food here, people; it’s not hard.

Events Prior: What was happening before the illness/injury? (i.e. What were you doing when the aliens attacked?)

Onset: What started it? This is a who/what/when/where question. (…aliens don’t come out of the sky for no reason… just saying).

Provocation/Palliation: What makes it better/worse? Pro tip: asking them to demonstrate what makes it worse isn’t a good idea.

Quality: What does it feel like? (And would you recommend it … asking for a friend).

Radiation: Not the carcinogenic kind. Ask questions like “Does this spread anywhere else?”

Severity: 0 to 10, how bad is it? If a patient tells you their pinky finger pain is 10/10, just go with it.

Time: Has this ever happened before? What happened last time? How many times have you been abducted by aliens? (On respiratory calls, a good question here would be to ask if they’ve ever been intubated).

*Anything in italics is not genuine, please do not say this to an actual patient … you might get weird reactions

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F. Scott’s Cadaver Lab Thoughts

So... I’m annoyed. I didn’t personally go but apparently the Pre-EMTs took a trip to the Medical School for a thrilling, reality based anatomy lesson. From actual cadavers. A few of the instructors kept me company later that day and described what the day had entailed and I can’t help being jealous I didn’t get to go. Some of the stations had nothing but brains, hearts and lungs laid out on the table. Others had cadavers cut open revealing either the abdomen or airway. One of the stations didn’t even have any soft tissues, it just held a pelvis and several joint bones. All I can say is, I’m upset I didn’t go, I wish I’d seen what my insides would look like. I mean, I know dragging me along everywhere (literally) isn’t the most fun, but I wish I’d been able to at least look on. The intent behind the lab is so cool. Having the Pre-EMTs learn about the actual organ systems, and musculoskeletal structures they’ll be dealing with on calls can be exceedingly useful. 

Some cool information I did retain:

1. The left lung has only two lobes while the right has three. (Think about the placement of the heart)

2. Always tri before you bi. A cool trick to remember that the tricuspid valve comes first (from the right atrium to ventricle) while the bicuspid valve connects the left atrium to left ventricle

3. The Brain has four lobes, the frontal, occipital, parietal and temporal. (And apparently the class members got to HOLD them)

4. The gallbladder is greenish in color and just below (and attached to) the liver

5. Cancer that originates in the lungs will present as one giant abscess while one that metastasized tends to grow over its whole surface. 

6. The Pelvic outlet of a woman tends to be more circular than those of men, which are narrower

7. The trachea is anterior to the esophagus and more rigid. 

8. The lungs of a smoker have much lower plasticity due to destruction of alveoli. When felt manually, healthy lungs should be spongy. 

9. When the trachea bifurcates into the right and left bronchi, the right side tends to be straighter, steeper and wider. In choking children, objects are more commonly in the right bronchus due to the more horizontal shape of the left bronchus.  

10. The mitochondria is the powerhouse of the cell.

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Here’s a hint, these are clear signs of altered mental status. No way these people are AOx4 (not to mention you’re probably going to have to use the KED). And PLEASE people, when you arrive on scene, BSI, scene safety. I’m durable because I’m made of plastic but ya’ll aren’t and neither is the ambulance (ask anybody who worked the fall/winter shifts of 2k16). 

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So we beat on, boats against the current, borne back ceaselessly into the past

F Scott Fitzgerald

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Date night started off well. We went to DenDen. It was all going pretty well until the guy sitting next to me started choking on a piece of chicken karaage. I’ve had the Heimlich performed on me like a thousand times (WHEN I WASN’T EVEN CHOKING, MIND YOU), but for some reason I couldn’t move (this is a common problem and I often need people to carry me places and sit me up). Anyway so this guy was giving the universal choking signal and some bleach blonde chick (I think her name was Katie) sprinted across the restaurant and saved the guy’s life. Three quick abdominal thrusts and the chicken when flying; major props to blondie. The night seemed pretty anticlimactic after that and we paid and left.

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F Scott’s First Thoughts

Welcome to my tumblr. I’d add an exclamation point, but as I’ve proclaimed before “An exclamation point is like laughing at your own joke.” I’m a 20 year old manikin (no not, mannequin), turning 21 in September (coming soon to the GCB).

I’ve been with Brown EMS for what feels like forever now. You would not believe how little attention I get. They just use me for my body.

But this week, for the first time they’re giving me a voice. I think they had this seminar on patient advocacy or something so they decided to stop acting like I don’t have anything to say.

A little bit about me: I have a nice little family here at BEMS, with my wife Zelda and my friends who insist on squatting here (buncha freeloaders). I DO NOT appreciate being stabbed or eviscerated, and no please don’t give me a tourniquet. When I’m not being experimented on I live a pretty normal life. I like spending time with my pregnant wife (p sure she’s been pregnant for like 5 years now), and I’m thinking about starting a writing career. We’ll see how this tumblr goes.

I’ll be writing about my experiences this summer with a new batch of EMTs-in-training, and hopefully they actually listen to me. Boy, have I got stories to tell, and the patient perspective is always important.

Anyway, you’ll be hearing a lot more from me as we go forward. I’m super excited for this class.

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Show me a hero and I'll write you a tragedy

F. Scott Fitzgerald