BSI. Scene Safe!

     Almost two Saturdays ago I took the Oregon EMT practical exam. My fellow candidates and I had to prove our ability to perform six skills in a competent manner. These skills were medical and trauma assessments (if you want to know what this looks like, here's an example of a Trauma Assessment), providing spinal immobilization for a supine patient (getting a patient onto a long spine board), providing CPR and using an AED (see my PSA below), ventilating a patient with a Bag-Valve Mask and inserting a supraglottic airway, and then a random skill that was either caring for a bleeding wound and shock (what everyone wanted to get because it takes 30 seconds to do) or splinting a long bone (the skill I ended up doing -an easy skill that's made difficult by the 5 minute time limit). Everyone had done the skills so often in class that we all knew how to do them, and do them well. However, nerves are tricky things, and there's a lot of waiting that goes on at the state exam so you have plenty of time to agonize over mistakes you think you've made or all the ways you could mess up the next skill. Plus, the proctors aren't allowed to give you any indication of how you've done, so you often leave a station convinced you'd done something wrong, and since you can't talk to anyone about the exam, you sit there and go over everything over and over in your head. Then you just try to figure out if it was a critical fail or not. Luckily for everyone in our class, we eventually realized that our instructor had held us to a much higher standard than the state exam and I think almost all of us passed. We went to a place down the street to celebrate, talk about how we'd done, and cheer each new victorious compatriot as they joined us. It was a great way to end the class.

Guess I'm going to need to get one of these. ; )

     The final step to becoming an EMT was to take the national exam, which I did last week. That exam is cognitive rather than psychomotor and thus tests you on your knowledge, and not on your ability to perform skills. Like the state exam though, this one also plays with your head. It's an adaptive test, so if you get a question right the next question will be harder, but easier if you get the question wrong. The computer keeps asking you questions on a particular topic until it's clear whether you should pass or not, and then it moves on to the next section. You can be doing really well, but still fail half the questions because you keep getting harder and harder questions, which is a bit unnerving. Also, the test doesn't tell you when it's switching to a new section, so you might get some easy questions all of a sudden and think you must be doing poorly, when really you're just starting a new section. Oy. Anywho, I got out in about an hour, but then had to wait four days to find out how I'd done when I received the official results in the mail because they forgot to email me my results the next day like they were supposed to. It doesn't matter though because I passed and come Jan. 1 I'll be a licensed EMT!!

How hypothermic was he when he was unfrozen? Question for the ages.

     Now that the class and whole process is over, I've certainly enjoyed having more time to focus on work and prepping for PA school interviews, but I'll admit that there are things I miss. I miss debates about whether or not Han Solo was profoundly or only mildly hypothermic when he was thawed from the block of carbonite (I hold to "mildly" since I don't think he was mentally altered). I miss hearing about real calls and how responding to a patient with ruptured esophageal varices is pretty much just sloshing through blood to check a pulse and confirm death (I would gladly explain what happens, but I don't think everyone would enjoy the details as much as I do, so look it up if you're interested). I miss quizzes where questions such as "what should you do with bystanders at the scene of a motor vehicle accident" have possible answers like "lay them in the road to act as human traffic cones" or "douse them with gasoline and tell them to light flares." I miss the bad jokes the other students would tell when we were loopy from sitting around for hours waiting to perform skills for our practical exam. All said though, I'm glad to move on to the next step and start using my new skills. First though, I have a couple Public Service Announcements.

You really should.

PSA 1: If you find yourself a bystander at the scene of an accident, here are three things you should not do: a) run up to the ambulance (running people are considered panicked/unstable and no one will exit the vehicle until you calm down), b) frantically wave us to where you think we should park/get angry if we don't park there (it's usually fairly obvious where the accident is and there are regulations about the best places to park to avoid hazards), and c) assume the EMT is an idiot. The last one may need some explaining. Often EMTs and paramedicswill do things that may seem stupid to bystanders, but only because the bystanders don't know the reasons behind the actions. For instance, my instructor was once at a motor vehicle accident where the driver was severely injured. When he first came up to the patient he asked them if they knew their name, where they were, what had happened, and if they hurt anywhere. One bystander became infuriated at this because it was obvious that the patient's leg, and pretty much everything else, was very broken and needed immediate care. What the bystander didn't understand was that the paramedic was collecting important clues that would determine care. From these questions he could determine if the patient was alert (altered mental status would increase the patient's priority), oriented (and to what degree), and whether there was any cause to suspect severe spinal cord injury (if the patient didn't feel pain, this would clearly be a problem). So, as in any area of life, don't assume that you know or understand all the reasons behind someone else's actions. 

This is all you need to do. Smiling not required.

PSA 2: CPR. It's important. Sadly, few people learn how to do it, and even fewer perform it when it's needed. I have two things to say about it. First of all: just do it! CPR cannot, by itself, restart someone's heart and save their life (that's why you need a defibrillator aka an AED), but it causes the blood and oxygen to circulate so that the other cells of the body are still alive when you restart the heart. CPR classes take just a few hours, and the skills you learn are vital. You can find a course here: AHA CPR Classes. Even if you have never taken a class, you can still perform CPR. Lay people are now taught "compressions only CPR" which just means that all you do is the compressions -the pounding on the chest, rib-breaking part. There's no need to count or give breaths. It's simple. Scary, but simple. Basically, the compressions are the most important part of CPR, so please just do them until EMS can arrive. This podcast includes a discussion of the effectiveness of CPR: PodMed. In class we watched a real video of a guy who had a heart attack in his office and it took FIVE MINUTES before anyone began CPR, even though his wife arrived just as his attack was beginning. This should not be. My second tidbit about CPR is a slight modification to the first: definitely do CPR, but make sure the patient actually needs CPR first. This means you shake them and shout in their face, then if they don't respond you check for breathing and a pulse. If they have no pulse start CPR immediately. If they aren't breathing but have a pulse, you need to breathe for them. If they are both breathing and have a pulse chill out. They probably just fainted. Call 9-1-1 but don't go breaking their ribs. Our instructor told us about an old man who fainted while waiting in line at the bank and then woke up when "Rescue Ricky" immediately began CPR and broke his ribs. "Ricky" thought he'd saved the guy's life when really he just caused him agonizing pain. Or there was the group of "rescuers" who told the paramedic that a surfer had collapsed when walking back from the beach on a hot day, but was resisting their efforts to perform CPR. The poor surfer was merely overheated, and these people were trying to hold his arms down so he would stop fighting them as they tried do CPR. Please do CPR when needed, but don't let these latter stories be you.

P.S. -The title of this post comes from all the skills we perform as EMTs. The first two things you have to do when performing any skill is state that you have taken appropriate precautions by using body substance isolation (gloves, glasses, anything that prevents contact with bodily fluids) and that you have determined the scene is safe. We said "BSI, scene safe" so often that it almost became a single word we spat out without even thinking. That's good, because if you forgot to say either of the two phrases, you automatically failed the skill, even if you did everything else correctly. 

We all started doing jazz hands whenever we said BSI to represent the imaginary gloves we had one. Then we started doing it without realizing it. Our instructor enjoyed mocking us for it.

Just Because I Love Christmas

     Today is going to be a bit of a break from the usual, due to the delightfulness of the season. While fall is certainly my favorite season, and winter probably only comes in at third place, Christmas is one of my favorite times of the year. So, in honor of this fleeting time, which really has a lasting impact on the rest of the year, I present to you a post of Christmas joy and a playlist of some of my favorite tunes this year. It was hard to select just a few songs, because there is such an abundance of Christmas music, and music is so closely tied to my memories of Christmas. Frankly, it's not Christmas at my house until the John Nilsen albums are brought out and someone mentions the dance my older sister once made up to Nilsen's version of Bring a Torch, Jeannette Isabella, or until we hear the cheesy tunes of Mitch Miller and the Gang. So, rather than post all the songs I love, I decided to go with the ones I've listened to the most this year.
     There's probably some clever way to actually have the music play, but I don't really feel like figuring that out, and I think it would really start to annoy people after a while. Instead, I've listed the title and the artist for each song so they're easy to find on iTunes. I've also posted links for some of the songs/albums because there is quite a bit of great Christmas music available for free. I really enjoy both Solid Rock Christmas albums. A couple songs, like Sing Emmanuel (an original composition by one of my friends) and the ones performed by Camerata Carolina aren't available commercially anywhere since they're performed by my friends or choirs I've sung with, but if you'd like them just let me know and I can arrange something. Enjoy!
      

Annika's Playlist for Christmas 2012  

I Wonder as I Wander -Josh White and the Solid Rock Band

The Holly and the Ivy -Wayfarer

O Holy Night -Josh Groban

What Child is This? -Sarah McLachlan

O Come, O Come Emmanuel -Josh White and the Solid Rock Band

Carol of the Bells/Sing We Now of Christmas -BarlowGirl

Ave Maria -Rachael Lampa

Dormi Jesu -Camerata Carolina

Sing Emmanuel -Julie and Lindsey 

Advent Song -Northern Conspiracy 

Midwinter -Camerata Carolina

Christmas Canon -Trans-Siberian Orchestra

All Creation Sing (Joy to the World) -Seth Condrey

White Christmas -Dogs on Tour
Baby, Please Come Home -Anberlin

Merry Christmas, Here's to Many More -Relient K

Let it Snow, Let it Snow, Let it Snow -Michael Bublé

Snowing in Seattle -Sherwood

Winter Night -Little & Ashley

Christmas This Year -TobyMac & Leigh Nash
Coventry Carol -Celtic Lore 

Jesu Joy -David Klinkenberg

Celtic Carol -Lindsey Stirling 
Is There a Place For Us? -Mychael Danna
Waltz of the Snowflakes -Peter Ilyich Tchaikovsky 

March of the Wooden Soldiers -Steven Pasero

Let All Mortal Flesh Keep Silence -John Nilsen (if anyone knows of a good choral recording of this, please let me know)

Christmas Eve (Sarajevo 12/24) -Trans-Siberian Orchestra

Carol of the Bells/God Rest Ye Merry Gentlemen -The Piano Guys

God Rest Ye Merry Gentlemen/Slieve Russell -Dan Cleary
Road to Lisdoonvarna/Swallowtail Jig/Irish Washerwoman -Tony Elman

The Wayfarer Christmas EP (as well as his album of hymns) can be downloaded  here:

http://noisetrade.com/wayfarer 

The two Christmas albums from Solid Rock can be downloaded here: http://www.ajesuschurch.org/music/ 
Two Christmas albums from Dogs on Tour can be downloaded here:
http://www.dogsontour.org/archives/tag/music-for-winter 

The Advent Song (as well as some other great songs) can be downloaded here:

http://marshill.com/music/albums/northern-conspiracy-live 

I'm very much in favor of stealing the idea of Weihnachtsmärkte (Christmas markets) from the Germans

Update: My awesome friend Anne got me a great choral version of Let All Mortal Flesh Keep Silence and it is gorgeous. I also discovered the band Zerbin and they have a pretty rockin' version of O Come, O Come Emmanuel. You can get it here: http://noisetrade.com/zerbin. 

The Answer is Always Airway... and Administer Insulin

     As encouraging as it is that I have a interviews at a couple PA programs, I know that many, if not most, people do not get admitted their first try.So, ever since September I've been taking an accelerated EMT program. So long as I finish the class and pass all my exams (a practical skills exam for Oregon and a written national exam), I will be a licensed Emergency Medical Technician by January. This will help me not only continue my medical education and get a job in a medical profession, but my hours as an EMT will count as medical experience hours. Such hours are required by almost every PA school, but are difficult to get because most schools want these hours to involve "hands on, direct patient care." Simply put, you have to somehow be responsible for a patient's care. This is why most volunteer positions in the U.S. will not count, and is one of the main reasons I spent a month at St. Joseph's hospital in Kenya last summer. 

If we did our lab skills with dolls...

     Before you begin to think though that I'm only taking the EMT classes to help fulfill a requirement and it's something I have to force myself to do, I should say one thing: EMT class is a blast. While I'll admit that the 8-hour days, which begin with a 5:15 am wake-up call, are sometimes long and tiring and I probably won't miss them after class ends next week, I have still really enjoyed the course. This is due in large part to my excellent instructor (who includes a Star Wars themed question on almost every quiz and tells us great stories from some of his paramedic calls) and great classmates (who always make me laugh). Of course, I also find the subject matter quite interesting, and it feels so good to finally be able to actually do something to help a person who needs medical attention, rather than simply learn about the molecular basis of their condition. 

A tasty way to combat hypoglycemia

     The class has affected my daily life as well. For one thing, my family is probably sick and tired of all the medical facts and stories I bring home. For another, I study for class and exams using daily occurrences, like the time I cut myself on one of those blasted thick plastic electronics cases (which I think are a bit excessive) and I found myself staring at my injury thinking, "well, it's deep, but the blood seems to just be coming out slowly and sort of oozing, so it's probably just a capillary bleed." This spills over to other people and I've begun to understand better the conditions of friends and family. This happens with strangers too. A few weeks ago a teenage boy came into the coffee shop where I work with his mentor. The man offered to buy the boy, who seemed a bit confused, anything he wanted, but the boy initially refused. Eventually he admitted that he probably should get something to eat since his "blood sugar was low." He ordered a drink and some food... and promptly forgot what he had ordered. The whole time I was watching his behavior and thinking "likely Type 1 diabetes mellitus, probably suffering from at least mild hypoglycemia." I was ready to fill up a spoon with caramel drizzle and just have him suck on it if he seemed to get any more disoriented (and before he became unconscious which would mean such actions would be contraindicated), but a sweet coffee beverage and sugary donut seemed to resolve any blood sugar blues quite nicely.

    I could do into far greater detail about all the things I've learned and the things I've taken away from the class, but I realize that not everyone will find it as fascinating as I do so instead I'll include a list of tidbits that I think people might find interesting/helpful as well as some quotes and phrases from the class that might give you all a better idea of what EMT class is like. One thing to note is that, even though our instructor is continually telling us to use our "big boy/girl words" (i.e. correct medical terminology), many of his phrases for the class sound like they fit in a kindergarten classroom.

Things You Should Know 

• If you're pregnant and your water just broke, you probably have time to get to the hospital without needing EMS (Emergency Medical Services). This is especially true if this is your first pregnancy because the first stage of labor (the contractions) lasts an average of 16 hours for the first pregnancy (labor for subsequent pregnancies is typically much shorter). Apparently a lot of people call 9-1-1 for "imminent delivery" and contractions have just started. Sometimes the patient isn't even pregnant. Sometimes they're not even female (don't ask me how this works). 
• Women who are having a heart attack often do not present with the stereotypical symptoms of crushing chest pain that often radiates to the left arm or leg. Sometimes women just feel like they're having stomachache or back pain. 
• When EMTs respond to diabetic emergencies, they often encounter bystanders or family members who plead with them to give the patient some insulin. In light of this fact, I think I should state that insulin is not a diabetic "cure-all." All insulin does is act as the key that unlocks the cells and allows them to absorb glucose (sugar) from the blood. If someone is suffering from low blood sugar (hypoglycemia), insulin will not help them. It will actually make the situation worse, and might even kill them. This is why EMTs and paramedics are never allowed to give anyone insulin, and even nurses typically are not allowed to administer insulin to a patient without another nurse there to verify that they are giving the correct dose. Our instructor really stressed this fact, so now it has become a standing joke to reply with "administer insulin!" whenever he asks how to treat different patients. 
•  If someone is suffering from hypothermia, DO NOT rub their cold limbs. If they're that cold, it means that parts of them, including the plasma (which is mostly water) in their blood is actually frozen. If you rub them, the ice crystals in their blood can potentially slice their blood vessels to pieces. Yeah... not good. Call 9-1-1 and follow the dispatcher's instructions until EMS arrives.
• People are more likely to get overheated on days that are hot and dry than days that are hot and humid. This is because the moist heat tires you out quickly and people realize that they should cool off, whereas on dry and hot days, people can feel fine and then suddenly experience heat exhaustion or even heat stroke. 

...but for some reason this is just fine.



This is too "invasive" for most states...

• Oregon is one of the most progressive states when it comes to what EMTs can do. For one thing, EMTs in other states can only give someone epinephrine if they have their own Epi-pen. Oregon realizes that not everyone carries their Epi-pen with them everywhere, so EMTs are allowed to give patients in anaphylactic shock epinephrine via an injection just under the skin. We're also allowed to check a patient's blood sugar. In other states, if a patient has a history of diabetes and an altered mental status, the protocol is to just give them glucose, even though the cause could be that the patient already has high blood sugar (hyperglycemia). The thinking is that a finger prick to check blood sugar is an "invasive procedure" and since most diabetic emergencies are due to low blood sugar (hypoglycemia), administering oral glucose should help, and giving glucose to someone who is hyperglycemic won't really hurt them (at least not in the short-term). While this is all true, Oregon still disagrees and says that EMTs should be able to just check the blood sugar so they know what the best course of action is and are also able to give accurate, detailed information to the hospital. Considering that we're allowed to deliver babies and insert supraglottic airways, pricking someone's finger or giving a small injection into the shoulder doesn't really seem like that big of a deal.

Quotes/Phrases from Class 

• Treat with diesel -getting someone to the hospital asap because there's nothing more you can do for them on scene
• Drive by Braille -I'm guessing most people can figure out what this means. It's really not how you want to be driving.
• Let's go get the stair chair -a code used to communicate that the scene is no longer safe (usually because you've just discovered that the patient or a bystander is crazy and/or dangerous). It works because you really only need one person to carry a stair chair, not everyone, but most people wouldn't know that so they don't become suspicious when all of the EMTs return to the ambulance.
• Blinkies and whoo-whoos -lights and sirens 
• No pumpy-pumpy, no livey-livey -our instructor's explanation for why the heart is important
• Talky, talky then touchy, touchy -how to assess a responsive medical patient
• Rappin' and cappin' vs. limpin' and pimpin' -our instructor's phrases to describe the responses produced by activation of, respectively, the parasympathetic vs. the autonomic nervous systems. Most people probably know these responses better as "fight or flight" vs. "rest and digest" 
• "Trauma is a naked sport." 
• "If you don't have an airway, you don' have a patient." -This is why you make sure everyone has a "patent" (clear) airway before treating anything else (even life-threatening bleeding) and why the answer to almost every test question is "airway."
• "I open the patient's mouth. What do I see?" "The mouth is full of secretions and vomitus." "Yes!" -Real soundbite from skills lab 
• "Screaming barfies" -also known as "hot aches," these result from warming extremities after you've gotten them so cold that you've reached the point of frost nip (precursor to frostbite). Basically, reheating them hurts so bad that you want to scream and barf at the same time.
• "Ding, ding, whoop, whoop. Here comes the hero wagon." -how firefighters arrive on scene 

Here's one final soundbite from class. This sort of thing where someone just threw out a random answer happened a lot. It was always good comic relief.

Instructor: "Fresh water or salt water drowning, which is worse?

Everyone: "Salt."

Instructor: "Right, everybody knew that. And why is salt water worse?"

That one guy: "Sharks!" 

Should you be interested in how cops sometimes view EMTs and firefighters, here's a cartoon we watched when we discussed "mechanism of injury:" Freeway Patrol: Episode 5