What I learned in the ED tonight

Tonight I had the opportunity to shadow my medical director while he was working in the ED. I leanred many things:

Every blog I’ve read about how drug seekers present in the ED is completely true.

Every blog I’ve read about faking a seizure and “status dramaticus” is completely true.

Healthcare is a strange mash-up of completely differently evolved professions

A litre of NS and a dose of zofran will cure almost anything.

There are no mean paediatricians – even when you call them at 0100 for an admission. This particular saint actually drove in an hour to evaluate the child, and still left with a smile on his face.

Doctors don’t actually talk to or touch patients. They mostly read labs and sign things.

My pre-hospital calibrated BS-detector is apparently as well refined as anyone who works in the ED full-time.

Medical patients appear to get better pain management and sedation than trauma patients.

Healthcare professionals do not wash their hands or use gloves nearly enough.

More Med Math Tips: Drip Rates

Maybe this is why 60-drip sets were invented…but no one ever told me, so I feel clever having figured this out.

Your medication dose in mL per hour is equal to the required drips per minute when using a 60 drip set.

Here is the proof. Keep in mind that we’re essentially converting units

Remember that 60 drips = 1 ml, and 60 minutes = 1 hour, so we’re only multiply by different versions of one to maintain equality. Drips and minutes cancel, leaving mLs and hours.

If you’re using a 15-drip set, just take your mL per hour rate and divide by 4. Because…

For a 10-drip set you can try dividing by 6, but chances are that won’t be easily done in your head.

Memorial Day – Appendix

Some might be wondering how I wrote an entire memorial day blog without a mention of soldiers, perhaps accusing me of missing the mark or being unpatriotic.

I know we all occasionally forget about or take for granted those in the armed services who make the ultimate sacrifice to provide us the freedoms we hold  so dear, but it also doesn’t take much to jog our memories  — hopefully.

Let me point out another way our fallen soldiers continue after they die to benefit us civilians.

War leads to advances in trauma care. Historically this includes everything from the invention of the IO to the resurgence of tourniquets. This year the 7th edition of Pre-hospital Trauma Life Support is coming out. A lot of the changes in those care guidelines will be fueled by the research coming out of the Middle East.

For some the shear amount of death in a war is beyond comprehension. But the advantage of collecting all that data is creating a scatter plot so to see what’s actually killing our soldiers, then we can fix it, and then we can apply that to the private sector.

Please don’t think I’m heartless because I’m looking at the benefit of collecting data. I know that when your family is touched by tragedy all that matters to you is that single data point – a human being with a family, friend, hobbies, loves, interests, and stories. I hope I made that clear in my last post about body donors.

Please, just recognise and remember, that after a solider makes the ultimate sacrifice (even if you object to the war) that the data collected from their death will benefit other soldiers, keeping them safe, and will eventually benefit us – keeping us safe at home just like they were fighting to when they were alive.

Memorial Day

Today I had the opportunity to attend a memorial service for the body donor programme my anatomy and dissection courses are affiliated with.

When I’m dissecting, I see these donors in their physical entirety. I see their scars, their disease ravaged organs. I find every deformity, variation, and imperfection in their bodies. I find surgeries that suggest medical history: apendectomies, coronary bypass, hysterectomies. I find tumours. I can’t help but wonder: What pain were they in? How was their disease managed? How did this happen? How long were they tormented by this? Were they glad when it was over? Sad to be gone? This person is someones son or daughter. How did their family handle everything that happened?

I know this donor very intimately in a physical (and I feel also spiritual) way, but I still know nothing about them aside from a reverse engineered medical history. I don’t know who they are. I don’t know what this brain thought, what these eyes saw, or what these hands did. I can’t help but wonder – I know the tremendous educational work this person is performing in death, but what did they do in life?

After both the dean of the school of medicine and the head of the emergency medicine residency programme had spoken and shared experiences about the value of having body donors, it was open mic for the donor families.

Family members shared stories that answered the burning questions I had. These strangers I’ve been bonding with at the dissection table were civil rights activists, esteemed professors, physicians, nurses, lawyers, veterans of wars, and other just plain good people who wanted to do some good after their body is no longer of use to them.

Many of the donor families don’t know exactly what we’re doing, but through the various speakers during the service and side conversations at the reception that followed, I hope they learned one thing: When we walk out of that room that contains their loved ones, that we are better for it. We’re smarter, more skilled, more experienced clinicians. As someone who learned anatomy with a human cadaver lab, I cannot imagine the course without it. I remember one day looking at a textbook illustration, then at a photo, then at a model, and understaning how these various representations worked together to communicate an idea. Then I went to the cadaver and had to relearn it because these were abstractions of the reality on the table.

Every one of us is special and unique. I believe I first learned that lesson in grade one. However, without the generous gifts of body donors, and the incredible sarcifice of their families, medical students (paramedics, physicians, nurses, etc) would not have the ability to really see and feel how different we each are – and more importantly how those differences can affect the care we will later provide.

So today I say this – thank you body donors. Thank you for you generous gift. Thanks to your families for their sacrifice. They’re giving you up for two years. They’re putting off receiving closure for my benefit. Thank you from the bottom of my heart.

To the familes, your loved one’s time is well spent. I love them and care for them knowing they are someone’s son or daughter, husband or wife, father or mother, sister or brother. They give me a tour of the marvelous human body. I get the chance to see and make connections between things that other people will only ever see in artist’s renditions. I get to connect the dots when I interact with a patient – I know what’s really going on under the hood, and it makes all the difference.

Know that for as much as your loved one has affected me in the last two semesters I’ve had the privilidge of working with them, that the experience they’ve given me will touch the lives of every patient I encouter for my entire career.

The military medevac motto is “so that others may live.” Your loved ones have died by some means – perhaps tragic and unpreventable such as a disease that currently cannot be cured. Through this donation, their death has new meaning. While they may not cure the thing they died from, they are arming me to save lives for the rest of my career. Your family member died, and now others may live.

Body donors, I salute and thank you. To the donor families, thank you also. Please sleep well at night knowing the difference you and your family are making in my life and the lives of those who I will care for in the future. Please know that I love and respect your family members. To me they are people, and I want nothing more than to know them better. Thank you for sharing them with me. Thank you for sharing the details of their lives. Thank you for helping me connect the dots.

Thank for you making me better. Thank you from me, and from every patient I will ever touch.

Lifeguard FAIL

This weekend I’m visiting southern California. My first stop after landing was a bonfire on the beach. While getting the fire going and cooking some hot dogs, I noticed a regular pattern of Lifeguard vehicles driving back and forth. Meh.

A while later I notice a change. One of these all-wheel-drive eco-friendly SUV’s is clipping across the beach on a different path at a much faster pace. Maybe something is up… but he’s not running code 3, so maybe he’s just in a hurry to get somewhere. A few minutes later another unit comes screaming down the beach, this time lights and sirens blaring. I know each vehicle has only one guard in it, and I’m presuming that they don’t have much additional medical training. I mosey over a couple hundred feet to the incident to poke my head in to see if the situation warrants offering assistance. Their patient is seated in the sand, sitting up on his own, answering questions. One guard is taking a blood pressure, the other asking questions. I have already made my “from the door” assessment of not sick/not hurt.

I’ve had multiple incidents where Lifeguards have identified themselves on a scene to insist they help, or they passed judgment on my ability to provide care (“You’re not from the fire department? When are the *real* EMT’s getting here?”). I had to resist every urge to reverse the tables for once and say “I’m an EMT, I can help!”

Anyway, I digress. Fast forward 45 minutes.

Yes 45 minutes later they are still on-scene. In the distance I hear the dulcet tones of the federal Q2. An engine?… And a rescue? Are they coming…here? No…really…now?

Why yes…45 minutes later ALS backup was called for. I also see a Coast Guard helicopter in the distance, closing in rapidly along the shore-line. Was my assessment that far off the mark? The helicopter banks over the incident and continues along the beach – apparently just a coincidence. Fire Medics were on-scene for 5 minutes and then left.

It’s understandable, being with a patient where something just doesn’t feel right, you watch them and wait for them to either get worse or get better, eventually establishing whether you will release or transport. We’ve all done it – or at least I have. 45 minutes is a while to wait for such a decision, but I’ll go along with it. Having had an ALS evaluation, I imagine our punter will be on his way any moment now.

Fast forward 60 minutes.

Yes, now the lifeguards have been on-scene for almost 2 hours.  I hear multiple sirens in the distance converging from different directions. Two stations are now responding. I meander over again just because I want to hear the exchange between the Lifeguard and the Medics. Our patient is now laying in the sand covered in a blanket. The medic walks over and simply declares “I don’t care, this time we’re taking him! Get him on the backboard!”

I know hindsight is 20/20 and I wasn’t actually on-scene evaluating the patient – but as a trained observer it seemed like this call was full of all sorts of fail.

Lifeguards provide absolutely life savings extrication and rescue manoeuvres. They can perform BLS care early in an incident when it has the best chance of savings someone’s life. But…that’s about all they do. Lifeguards are not God’s gift to emergency response. More than once I’ve been on a scene and had someone bound up to declare “I’m a Lifeguard, I can help” or “I’ll take it from here guys.” I actually had one guy try to muscle in between me and a patient. A quick glare and he was put in his place by the officer on scene.

One of my rules is that if it felt good to say it then it probably shouldn’t have been said. The second time a Lifeguard did this to me on scene I said “Well does it looks like he’s drowning? Back off, Baywatch.” He looked at me like I’d kicked a puppy, then slowly sulked away. I almost felt bad.

Almost…

Tip: Kg and Pounds conversion

When I was taking my Intermediate class, I came up with several medical math shortcuts. I’m sure I”m not the first person to discover these, but I figure if you stumble across my blog maybe they can be helpful to you.

We all know that to get an estimation for converting pounds to kg that we can just divide by 2. Here’s the problem, the actual conversion factor is much closer to 2.2 – so you will always be off by 10%! That’s a large margin of error in my engineer type mind. Luckily, 10% is easy to account for – we just have to move the decimal over.

So try this the next time you want to be more accurate going from pounds to kg.

Example:
Convert 170 pounds to kg.

10% of 85 = 8.5 (move the decimal one digit left)
85 – 8.5 = 76.5
Round to 76 or 77.

Let’s compare that to the actual conversion factor.

You can see that taking into account that 10% makes a huge difference in the accuracy of the conversion.

If you want to go from kg to pounds, multiple by 2 and then add 10%.

Nerd Speak Ahead — Why this Works


This comes down to reducing fractions. Here is the down and dirty:

Multiplying by .9 is the same and subtracting .1 from the original – what we’re actually doing because .1 is much easier to computer mentally. Here is the proof for that:
I hope this helps you get more accurate drug doses quickly. I also hope you’re not more confused than when you got here. Any questions? Leave a comment or drop me a line.

Education Rant

I recently had a chance to help with an EMT Basic class. I was asked to teach spinal immobilisation.

I was grinding my teeth the whole time.

Why do we still teach to immobilise based on mechanism? Why do we seem to think that spinal immobilisation is a completely benign procedure? Why don’t we teach our students to actually assess the PATIENT? Why aren’t we teaching them better or new physical assessment techniques? Why don’t we teach them to think?

Our textbooks are a few years old. They took several years to write. They were written based on accepted information and studies that were old at the time of writing. Net result: Our latest graduates have an outdated education when they finish their course.

They’re also tested on that outdated information by all the regulating bodies. That outdated information is our “standard of care.”

Why are we holding ourselves back? As it stands now, I think EMS is it’s own worst enemy.