Thursday, November 29, 2012

So you gonna be a Doctor, Mr. Paramedic?



One of you recently asked me about the transition from Paramedic to Doctor, if it was easier or harder? Not really sure where to begin but I'm going to try. It was easier... and was much harder at the same time. In what aspects? hmmm...

It was harder to sit in class for hours at a time getting the taking of "blood pressure" explained to you, and follo
wed by a "practical" session where I had to show them how I could successfully do it... ***facepalm*** The amount of hours that I wasted in medical school re-learning the crap that I already knew was enormous... so don't let anybody ever tell you that you are "just a paramedic" or "just an EMT" or "just a nurse" because it is quite unbelievable how much I already took in before ever stepping foot in medical school.

It was very hard to keep a straight face when my classmates were raising their hands asking the difference between "anaphylaxis and an anxiety attack, because to me it seems like they present exactly the same way." ***facepalm*** ugh...

It was hard for me to stay awake during our ECG class while students were arguing how to tell the difference between a "p-wave" and a "t-wave." ***facepalm*** ugh...

It was also very hard for me during clinicals to not shove somebody out of my way when they were royally messing things up... I just kept telling myself... "I'm not yet a doctor... they are going to be writing my evaluation... breathe... breathe... I know it is wrong to give amiodarone to an asystolic infant ***facepalm***, but he is the doctor... I know we should be restarting compressions since we haven't done any in over a minute ***facepalm***... but he is the doctor... I'm just 'a wanna be docta-paramagic'... You are not a paramedic here today... you are a med student that doesn't know anything."

However, it was much easier to impress everyone on clinicals when this "dumb med student" could pull some kickass ECG knowledge out of his rear end... nothing like having your "med student" call that MI when no-one else did... or when I got laughed at for offering to start an IV on a pt that 4 nurses missed 12 times & a doctor missed x2 via ultrasound... yet I got a 20gg on the first try. I'm not saying I'm all that & a bag of chips, but having stuck enough people through the inner city potholes at 60mph with crappy ambulance lighting... I do have a bit of an advantage there...

It was also easier for me to walk into a pt's room and start chatting with them while at the same time getting their PMH, HPI, and doing the PE... while the other med students were pouring with sweat trying to ask the pt's name. I definitely received plenty of weird looks when I just gowned up & started doing stuff during critical medical & trauma pts while the other students were huddled in a corner with their clipboards. Paramagicking was an advantage there.

I elected to rarely tell anyone that I did anything medical prior, because it was easier to amaze when their expectations were low of me as they normally are of regular med students, than when I set the bar high and mess up... "oh so you were a paramedic huh?! you think you know everything then huh?!"... ***facepalm*** I'm not exactly sure why everyone's stereotype of paramedics is a bunch of "know it alls," but sadly it was the case on numerous occasions.

EMS is an extremely unique facet of medicine. Our skill set & knowledge is a giant mix of nursing/doctoring/social work/CNAing/counseling/hospice... we hold people's hands/we talk about their depression/we intubate them/we start IVs in their feet & necks/we bring them back from their ODs/we resuscitate them... and we pronounce them dead. There is no other facet of medicine that does all of that at the same time.
*****Please do not think that this is some sort of an attack on any of the professions that I just mentioned above, I am simply stating that EMS possess a blend of select skills from all of these professions. Every medical profession is unique in itself with its own set of +/-... remember teamwork, everyone has a role within the playground of medicine *****

As a medical student AND a paramedic, I had a much easier time understanding the entire patient. I was comfortable with patients, regardless of how sick/dead/or malingering they were... I could smell BS before I even walked in the room, but I could also tell when my pt was sick...or ready to code... something a lot of students & actual doctors were clueless about. Do this long enough & EMS will make you develop a 6th sense for pts, and that helped out a great deal in medical school.

I had a doctor (one of my school professors) kind of heatedly exclaim to me how "paramedics have an unfair advantage" over the regular medical students... "you guys excel at clinical way too much." Still to this day, I'm not exactly sure whether he meant it as a bad thing...

Many doctors and other clinicians will disagree with me on this, but seeing a patient is seeing a patient, regardless of what certification you carry in your pocket. They will argue that it is different seeing a patient as a doctor or seeing a patient as a nurse or a paramedic or an EMT... That kind of rhetoric comes only from someone who never did medicine before getting his current clinician level.

Watching a CHF-er drown in his own fluid is the same whether you are a doctor, nurse, paramedic, emt or a CNA. The smell of sepsis doesn't get much different the higher up a ladder you go. When a patient pukes on my white doctor coat, it looks the same as when the same patient puked on my paramedic uniform the day before. When a nurse gets blood on her scrubs, or a paramedic gets blood on his boots, that blood looks remarkably the same on my white physician coat.

The higher up a ladder you go, the more you know, and the more you realize how much there is left to learn... the patients do not change, they are the same patients, you just change... your skills get better, your BSoMeter improves as does your S#$+Ometer... and your willingness to ask for help also improves (for most of us).

So the question is, are you gonna be a doctor? My answer is, I am, but I'm gonna be a paramedic first.

Paramedic to Physician.  #paramedic #EMS #doctor #physician #EMT

ECG Case#1: Weakness & SOB

Cool little case: 

I was dispatched for a middle aged patient with "weakness & SOB." On arrival I find a 50ish yoF, sitting on the couch in NAD. Pt states that she has been weak x1mo, SOB x1wk w/ +cough, & out of """some""" of her meds x
3d. No other pertinent ROS. On questioning why she decided to call EMS now, pt stated "I'm just tired of feeling like this."

At this point my "ambulation to triage to waiting room" level rose up as the patient was clearly in no distress with a clear non-emergent condition. Upon obtaining further info, I gathered that her PMH includes: CVAx2, MIx2, HTN, DM, CHF, COPD.... on "fluid pills"... ugh... so much for the ambulation to triage part, my concern level at this point rose up dramatically... so first question to you guys, why did I now get concerned given her +weakness & +SOB???

PE: minor bibasilar rales (possibly baseline for her), +2 pedal edema to knees. no other pertinent findings.
Vitals: nothing crazy

My priority at this point was to get an ECG & 12-lead.... and here it is... what does she have, based on this 12-lead & her presentation...????





Summary:

HYPO K+ ECG changes & pearls: 



1) Depressed and/or T-wave flattening -> Earliest ECG sign!
2) Prominent U-wave that may look almost like a T-wave 
3) +/- QT prolongation with a pseudo-QT prolongation if accidentally measuring the QU interval instead
4) +/- tachy arrhythmias and/or AV blocks
5) will eventually progress to V-fib/VT arrest if left unrecognized & untrea
ted
6) K+ wasting DIURETICs use (lasix/bumex) being the MOST COMMON cause!

Maintain high clinical suspicion in "weakness" patients given the right HPI!

Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383164/

Heard you had a bad day at work.



"Yea, I did." she answers. "Two of my clients hung up on me on the phone... I got into it with a coworker over attitude with me... AND... AND.... I had to work an extra hour, cause I was soooo behind... gawd... I hate work."

I, however, love my work. I also had to work late sadly... got held over 3.5hrs because Asthma attacks were the cool thing to do at 6am. 
So having gone to bed 3hrs late myself... my brain was like... "whoo power nap baby!" and was awake 3hrs later. So here I am, sitting in uniform, at a bookstore, reading, sipping on Starbucks trying to kill time before my shift while listening to these two girls behind me complain about their "hard day" at work. It is 4pm... that's a heck of a "late day" there.

"So this one guy hangs up on me cause I put him on hold... and the other girl was so rude..."

I trail off from the conversation... too damn boring for me. I had a hard day at work too... had an asthmatic almost code AFTER my shift should have ended... pronounced a DOA that's been that day for over a day... endangered my life the majority of my shift... as I'm looking down at my feet thinking I see a smear of blood on my boots. Damn, how did I miss that?! Note to self, clean that jank off before shift start. Not even sure how the blood got there, but it's definitely blood. It has that unmistaken, dry quality on the boots. Wait was it from the shift before? I dunno, whatever...

"... and she was like all up in my face telling me how I'm too loud and all that and how I don't really care about work. It's true I dont...."

Wow. I think. Real world problems right there, those girls have. Staying 1hr late... customers not happy... rude coworkers. Hmmm... I almost got run over on the interstate 2 nights ago by an idiot that didn't move over. That would have been a bad day at work. I started an IV on at least 8 HIV+ patients the last 3 shifts... nothing like brushing with death there... one wrong move, and it's me, that's popping anti-retrovirals for the rest of my life. That would be a bad day at work. My friend got assaulted by a psych the week before... could have been me if I wasn't on that CP call... that would have been a bad day too.

"... apparently my new apartment doesn't have a lot of hot water, cause I like totally ran out of it this morning... gosh that sucked..."

When I came home this morning after a 16hr shift and 18calls... I had 3 options: bed... shower... eat. I had the energy to do only one... so bed it was. It would have been nice to have just taken a shower... or eaten a big ole breakfast... but when you're beat, you are BEAT... your body enters survival mode, your give a damn level drops to zero, and you feed your exhaustion with sleep... shower can always happen when I wake up. It is interesting to note... that as I am sitting there and reminiscing about my "real world problems" that I could not really recall the last time that I cared about any of the issues that the people around me were discussing. I'm not saying I did not have them... my car broke down too... my bills were occasionally late as well... my dog peed on the carpet also... but coming home after mopping up the bloody, humid, violent night... those problems seemed very silly in comparison at this particular moment.

"Where are we going for dinner?" one of them asks.

Where... hahaha... I just had lunch for the first time in days since I had free time thanks to my Circadianly off brain... but man, dinner is going to be elusive. On many nights for my partner and I, dinner was usually more of an "if" and a "how" than a "where." If you were too busy to get dinner before about 11pm, the options rapidly dwindled to only a handful of places. "If" turned into a "how." Cause "how" can you get dinner when the city is holding 911 calls? The majority of dispatchers tried to rotate us through "dinner," but there was only so much they could do themselves when everyone in the city wanted to have a psych problem or CP at the same time. So you grab the local 711 cuisine... or the McDs... or any other fast food joint in the projects that you come across and pray that you have enough time in between the calls to briefly stop for it... cause you could always scarph it down on the move. Man, I got so flipping tired of eating the tuna sandwich out of 711... I am certain that I consumed at least a 100 of those bad boys in my career.... "where are we going for dinner" what a funny question... a very real problem I wish I had the luxury of having.

After re-reading this post, it sounds to me like I am almost condescending to the rest of the world. But I'm not. It is just amazing to me what the real world looks like having the goggles of denial off. Many people around us will never take those goggles off. They will never see the other side of life. They will live in denial that people around them die... that the city they traverse through every single day, has a dark side to it. They will shut out the fact that when the curtain of the night falls... a different city awakens. A violent... ruthless city... a city that does not discriminate. Everyone is equal prey & victim to it.

We in EMS shoulder the burden of being there at time zero when the $hi+ hits the fan... and we in EMS have to pick up whatever the pieces are left of our fellow human beings, and put them back together... and at the end of our shift, we have to go back home... back home to the other world... the "normal" world. We kiss our wives, our husbands, our kids... we have our "normal" breakfast, lunch or dinner... we have those silly talks with our non-EMS friends. We play the part. At the end of our shift, we hang up our uniform, and put our goggles back on. We attempt to shut out the city that almost ate us in the worst possible way if just for a moment... just hours ago... all the while knowing, that we will be back for more just hours later...

Ground rules

At the request of many from my Facebook Page:  EMSDoc911 to create a blog, I finally decided to give this a try.  

As with anything, couple of ground rules:

  • No gross pictures or any HIPAA..ish violations, common sense here only. 
  • No bashing of any specific EMS/Hospital/Fire, etc agencies.  
  • If your posts or replies include names of specific agencies or people, I will take them down.
  • We are all allowed to vent, but within reason in a semi-public place; please keep this professional. 
  • My primary goal of this is to share interesting stories in my 13 year journey from EMT to Paramedic to Doctor, and to give advice to those wanting to do the same.
I will also attempt to make this an educational blog.  It became evident to me over the many years of school that medicine is an intricate science with numerous seemingly impossible to comprehend topics that require years of experience to master.  I will attempt to provide an easy, down to earth explanation of tough concepts that took me a while to master & will be happy to answer any non-Googable questions thrown my way.

For further, feel free to visit my FB page EMSDoc911.