Too much TV?

I teach a couple of classes every Saturday. It being New Year's Eve, I wasn't sure everyone would be able to come to class, so I combined the two for the day.

Nearly everyone showed up, so we had twice the number of people we usually have. It was great!

Before class, while people were arriving, we were talking about some stuff, just shooting the bull. I don't remember how the subject came up, but I asked the class how many of them knew CPR.

This was not an EMS related class, and the age range was from about 9 to 16.

One student raised his hand.

Then I asked them how many of them WANT to know CPR, and they all raised their hands. Hmm. We'll need to remedy that as soon as possible.

We had a brief discussion about how there are people who don't want to know CPR, and what their reasons might be.

Then I asked a question I had never asked a group of students before.

"If someone goes into cardiac arrest, and there is a person there who starts CPR, what percentage of the time do you think it saves the person? How often do you think the person survives?"

The answers were stunning.

The LOW estimate was 73% of the time.
The high estimate: "I guess it always does."

I think we're raising a generation of people who see CPR on TV all the time- and on TV, if they show CPR, the person almost always survives. There is an occasional "We did all we could," but most of the time, they start CPR, and then SHOCK THEM OUT OF ASYSTOLE (which is another HUGE beef I have with EMS on TV!) and the person wakes up, coughs a couple of times, and then is walking and talking as if nothing ever happened.

Makes for dramatic television, I suppose. For people who aren't popped right out of their willing suspension of disbelief by such things.

But I don't think it does real people any favors.

My students today were very surprised to hear that CPR doesn't save everyone, or even nearly everyone, or really, all by itself, anyone at all.

We had a short discussion of the cardiac chain of survival.

The good part is that they were all very interested.
As if no one had ever told them any of this before.

The bad part? No one had ever told them before.

How are we getting kids up to high school age without ever hearing this information, without ever learning CPR? Without ever learning basic first aid?  This is a large part, I think, in how we end up with a population that has no idea how to take care of itself, so they call 911 for a finger cut.

If I were in charge...
First aid skills would start in preschool. Parents would be teaching them right from birth.

It's not like stopping bleeding and putting on a band-aid is such a difficult skill.

I sure as heck wouldn't leave it up to TV.
Don't get me wrong, I don't have a problem with TV, per se. I think it's a very useful medium. You can learn a lot from TV, and find a wide range of entertainment.

It's just when it teaches something that isn't true, that I have a problem. And this is one of those cases.

Working Through It

Most of my blogging has not been stories of calls. It is difficult to write about any of the more outstanding ones without violating HIPAA. We don't get that many calls out here, and everyone knows everyone. Almost anyone could trace a story back to a specific event, and figure out who I'm talking about, and that's not good.

So any stories I've written, I've changed some of the information. Names, gender, location, body parts, symptoms, family members, etc. There is no way anyone could read any story here and accuse me of divulging any personal information about someone. Some of them have been so disguised that when I'VE gone and re-read them, I wasn't sure which incident prompted the story.

Even so, some stories don't disguise easily.
Fortunately, I have a friend who is a professional television writer, who has shared with me the process of writing and rewriting stories to meet the demands of various outside influences (budget, location, available actors, etc). I learned from her that the heart of a story can survive many changes, of various types, and still be emotionally valid.

I have a few stories I need to tell in more detail than I've written before. I'm working on one. I'm changing enough information about it that it is no longer the story of specific patients. Instead, it is the story of those of us who responded to the call. It is about what we saw, what we felt and how it has affected us.

Writing it is difficult.
In order for the emotional content to really be communicated, I need to re-experience it as I'm writing. It is draining. I have huge respect for the bloggers out there who have been writing stories of calls for years now. I don't know how they do it.

At the same time, it is healing, I think. At least a little. I know that is what drives some of my friends in the blogosphere, and I understand it more now.

I don't know when I'll get it finished and post it here. Possible never. Depends on how it feels when I'm done.

In the meantime, I'd like to encourage those of you who haven't used writing as a method of working through something emotionally intense to give it a try. Even if you don't share it. Write it for yourself.

Ellery Queen

One of the things I received for Christmas was a set of Ellery Queen DVDs.

I used to watch the show when I was a kid. The best part about these mysteries, compared to most TV shows, is that they don't give away whodunnit. Most "mystery" shows (at least at the time), the audience knew what really happened, and watched, waiting for the characters to catch up. But in this show, there is a commercial break before the main character solves the mystery, so the audience can try to solve it themselves.

All the clues are there. You just have to be observant, have a bit of general knowledge, and put things together.

Not so very different, really, from what we do all the time in EMS.

We need to be very observant on scene.
The more knowledge we have that we can connect to the "clues" we find, the better, and more likely we are to figure out what is going on.

Of course, we don't always have to start with a dead body, which is a good thing.

I watched a couple of episodes this evening, and it was much like I remembered.

I tried to find some online to share here, but couldn't find a full episode of the series I used to watch. I DID find a full copy of one of the original episodes, from the 30's!  A good mystery is a good mystery. Enjoy!

Middle of Nowhereness

I've been thinking that some of what I post may not be that interesting to people who have a lot more experience, or who live in an urban area.  Ah, well, it is what it is. Life is... different out here. Part of why I'm blogging at all is to share the experience that comes with my situation.

I've been playing with a couple of lists, things I do and don't have to worry about here, that might be different from a lot of you. They aren't anywhere near complete, but it's what I have so far, so I thought I'd share.

We're a small volunteer ILS non-transporting agency, in the middle of nowhere.

Things I Do Not Have to Worry About:

1. What to do with down time on a slow shift. No shifts.
2. Being "posted" somewhere.
3. Whether or not to call for ALS backup; it's automatic.
4. A high crime rate.
5. Frequent flyers- at least not nearly as much as more populous areas.
6. Not being able to figure out which apartment a patient is in. Very few apartments.
7. How much I'm paid, or whether I can get the vacation time I prefer.
8. Being observed by a supervisor.
9. Language barriers: rare out here.
10. Choosing which hospital to go to.
11. Patients anywhere higher than the second floor.
12. Heavy traffic.
13. Traffic lights. We don't have any. There are only two intersections with four-way stop signs.
14. Nursing homes or schools; we don't have either.

Things I DO Have to Worry About:

1. Going to a call alone, without a radio.
2. Overall having little help.
3. Seasonal roads that are at times impassable.
4. Waiting a LONG time for law enforcement. Availability is limited.
5. Not being able to get to a patient in time to help: furthest house from here is over 15 minutes.
6. Running out of gas on the way to a call in my personal vehicle.
7. A call being for someone I know. It is almost a given.
8. Whether or not the helicopter can fly: nearest trauma centers are 50-75 minutes away by ground.
9. Waiting a long time for an ambulance to get there. Sometimes they get lost.
10. Finding unmarked houses down long dark roads and driveways.
11. Having the only other responders be people with little to no training.
12. Hunting accidents way off the road and/or people lost in the woods.
13. Elderly people living alone in isolated houses without nearby neighbors to check on them.
14. Calls phoned in by a passerby who has no idea where they actually are.


I'm not saying no one else has to worry about the things we have out here, but urban/paid and rural/volunteer EMS definitely have some differences in what things are most likely.

Move Over

It has been nearly a year since the NYS Move Over Law took effect.
In the past couple of days, there have been a couple of articles about the law being changed, to take effect on Jan 1st 2012.

The new law will include a requirement to move over for ANY flashing lights, not just emergency vehicles. If it is not possible to change lanes, the driver must slow down. This means tow trucks and utility vehicles will now have added protection.  Works for me.

This is one of those things that makes me wonder about what people are thinking.

I've always moved over a lane, when possible, whenever there is a vehicle on the side of the road. I don't care what kind of vehicle it is, I'll give it room, just as I would for a pedestrian or bicycle or whatever. Why would anyone NOT do that? Probably for the same reasons they don't pull over for emergency vehicles, and I don't understand that, either.

I bet there are very few of us who don't know anyone who has been hit, or come close to it.

Just a couple of days ago, I got into a conversation with someone about the Move Over law- and he had never heard of it. I wasn't terribly surprised, since no one seems to be making a big effort around here to be sure people are aware of it. Not the original law, and not this new addition to it. I know about it because it affects me, and information about it is on my radar, so to speak. But the average person? Not so much.

There was somewhere I drove to in the last year that had great signs- the overhead kind with LED lettering, that reminded people of the law. But other than that (and I don't recall where that was) I haven't seen anything that would remind your average driver out there. Until it is common knowledge, it's not going to make much difference in anyone's behavior. I certainly wouldn't count on it happening if I'm in the road on scene.

I don't have a solution for this, though. What would be the best way to be sure every driver knows about the law? New drivers might have it in the manual they can pick up at the DMV, but who else ever reads those? No one. What other mechanisms are in place to get that information (or info about any new law) out to the people who need to know about it?

Newspaper articles don't reach people who don't read, and there are a LOT of those.
Information online doesn't reach anyone without internet access, and there are a lot of those, too.

I can't help but think that the people who are least likely to find out about the law are the ones who most need to know about it.

Any ideas for how to spread the word?
Any thoughts on how to encourage compliance?

What would the average person respond to?

A Trap?

I've been thinking about this post for the last couple of days, since it happened.  I'm not sure exactly how to say what I want to say, so we'll see how it goes.

Early Christmas morning, a fire department near here was called to a structure fire.
My first reaction was to hope it wasn't a case where lights on the tree had caught fire, with a sleeping family.

It wasn't.

To make a long story short, the next bits of information I heard on the scanner strongly suggested that it was arson, and it sounded very much like things were set up to intentionally injure firefighters. Fortunately, the first person on scene was very on the ball, and was able to relay information to arriving responders so that no one was hurt.

But I can't stop thinking about it.
I've been to a variety of calls where someone could have gotten hurt.
I've been to some where someone DID get hurt.
And I've been to some where the person at the residence behaved in some way that was threatening to responders, once we arrived.

But I have yet to go to a call where the PLAN was to hurt someone who was coming to help.

Back in early training classes, both for EMS and Fire, the concept was discussed at some length. We were told to watch out for such things, and discussed some of the possible scenarios.

Still, I hadn't seen it.

It's such a horrible thought. Why would someone do that? What is the point, exactly, of setting up some sort of booby-trap, and then calling for "help," to see innocent people, the very people who are coming to your aid- and often, it's volunteers, who aren't paid- get hurt, when all they wanted to do was help you?

I can't imagine what would be going through the head of anyone who would do that.

I hope they catch whoever this was, and send them to jail for a long time.
It isn't something that should EVER be taken lightly.

Small Tools

Added a couple of small tools to the household for Christmas.

The first was a gift to me.  Last I looked, these were pricier than they are worth, at around $80, but my daughter found some on amazon for cheap cheap.

A Pulse Oximeter for less than $20. They come in a variety of colors (prices are slightly different for different colors; I have no idea why).

A lot has been written about how useful- or not- these are. There is merit to the concept that what they show doesn't change our treatment, so why bother, but I think they have some limited value in a couple of specific circumstances.

One is to show the response to being given Oxygen.  It still doesn't change any treatment I would provide, but as one piece of information I can give to the providers I transfer care to, I think it is useful in a general impression.

The other is something that can happen out here.
Sometimes, I'm on scene before the rescue. I have a limited amount of my own equipment, so I can take vitals, but I don't have any Oxygen to give. In a situation where I can't really provide much in the way of treatment, the more information I can give the medics when they show up, the better, I think. Especially if it changes significantly, which mostly it won't.

But mostly, it's a cool toy to play with at home, really. It shows SpO2 and a pulse rate, and we're having a good time seeing if we can alter the pulse rate on purpose, and seeing what different things make it change the most. We've also been trying to see how long you'd have to hold your breath to get the SpO2 reading to go down. We don't have a job where we spend any time hanging out in or near an ambulance, waiting for a call, so we have very limited access to the equipment on our Rescue, or I'm sure we would have already played enough. The fun will probably wear off in a week or so, but for now...

What I'd really like, of course, is a capnometer, but that's still a bit out of my price range. Like a LOT.

The other tool is a little thing I saw at Home Depot and couldn't resist getting.

It's a Non-Contact Infrared Thermometer.

Amazon lists it at $50, the price I just saw was $30, but I got it on sale for $20.

It's like the baby, baby brother of a thermal imaging camera.
A little, anyway.
Really, it's a heat detector. No image, but a laser pointer with a digital readout of the temperature.
It reads temperatures from -4 to 600 degrees F.

In a pinch, it might not be a bad tool.

I've already found a couple of fun things to use it for at home. One was when I overheated the pan I was cooking French Toast in. Recipes actually specify a temperature for frying things, but there isn't usually a way to know what temperature a pan is. There is now. It was also interesting to see the temperature variations on different parts of the pan.

Anything new in your house?

When it Rains...

Out here in the Middle Of Nowhere (TM), we never know what we're going to get.

During an unusual storm, we can easily get a couple of dozen calls in a couple of days, starting to rival the typical call volume of a more urban department.

On the other hand, we've gone a couple of weeks without a call.
When that happens, I start to get nervous.
We all do, but no one will say anything about it. To do so would be to accept the responsibility of being the one who "jinxed" the call.

So I start looking up things we haven't seen for a while, and double checking to make sure my preparations are in place. I'll start staying up later, since I'll be getting a good night's sleep, and I might even procrastinate some things.

I learned early on that procrastination is a bad idea. As soon as you do that, you'll get a call at the last minute, and whatever it was that you've been putting off will end up rushed or simply not done.  Most things, it doesn't matter all that much.  But some things matter.

We had a slow November. One of the slowest months in a long time.  Granted one of the few calls was a fully involved structure fire, which is rare enough around here.  But all month, we only had two EMS calls. That's unheard of.

December rolled around, and still, things were fairly slow.
Nothing at all the first two weeks.
Then a couple of calls here and there, but nothing major, and all during the day.
Starting to get nervous.

I've been making a lot of Christmas presents this year. Money is short, and I like making things, so much of my plans for gifts have been time-intensive homemade things.  It has been a challenge to make things for my kids when they are here most of the time. I don't really have some place to hide away to work on things, so some of the tasks kept getting put off, hoping there would come a day, or days, when they'd have other things to do.

So here we are Christmas Eve.
Several gifts are not finished.
They finally had plans to spend some time with their father, who is in town for a few days.

So what happens?

It's so obvious, I probably don't even need to say.

Four calls in the past twenty-four hours, so far.
Naturally.

So I had better get off the computer and get back to work!

Holidays

It's that time of year. Holidays. For a lot of people, anyway.

Last year, we had a call on Christmas Day. No big deal, everything turned out okay, as I recall.

The patient was a little apologetic about having called us on Christmas Day, and we told him it was not a problem.

One thing that happened made me smile, but I have been thinking about it a lot since then.

When the ambulance arrived, one of the medics hopped out wearing a Santa hat. It was adorable, and cheerful, and in the circumstances, made everyone smile.

But what if the circumstances had been different?

None of us wears anything special for any holidays. We don't have a uniform, either, but I wish we did. We've come up with our own semi-uniform, but at this time of year, we don't have anything that is both well marked and matching- and warm enough.  Need to work on that.

Whenever there is a holiday that has typical clothing associated with it, especially something cheerful, I wonder whether it's appropriate to show a little holiday spirit of some sort.

I haven't decided.

It seems like it might be nice, with kids, especially, to have a Santa hat, or bunny ears, or something.

But I worry about walking into a bad situation, and upsetting someone who might think we're making light of their serious difficulty. I don't want to be dressed like an elf, and end up doing CPR, for instance.

I'm curious about what other people think about this. Unprofessional? Always inappropriate? Sometimes okay, depending on the circumstances?

That Santa hat last year really did cheer everyone up. In that moment, in that place, under those circumstances, it was great.

Maybe I just worry too much.

In My Inbox

A few posts ago, I mentioned getting training opportunities in my inbox.

I'd like to share a couple of them.

First is EMS SEO.
I first ran across them on Twitter, because of their podcast, EMS Office Hours.
In addition to the podcast, they offer approximately a bazillion learning opportunities.

But maybe the best part is this:
If you sign up for their newsletter, you get weekly friendly e-mails, usually with some sort of special offer for members. Many times it's free access to webinars or other learning materials. I'm not big on giving out my e-mail address, and I tend not to be crazy about getting a lot of e-mail newsletters, but this one is well worth it.

The other thing that shows up regularly in my inbox is something I started getting sort of by accident. I got an iPod Touch a couple of years ago or so, and started looking for interesting Apps for it. One that I found was something called Medscape.  It's from the WebMD folks and has gotten some pretty good reviews.  Little did I know when I downloaded it, that I'd end up with a case study sent to me by e-mail. They have a "case of the week" that is sent out every week, and CMEs are available- although I haven't ever bothered to try to get "credit" for any, so I'm not sure how that works, exactly.

It is set up more for doctors, really, but even so, the cases are pretty interesting, and there is always something to learn from them.


Those are just two of the opportunities that show up regularly, and I don't have enough time to take advantage of everything they offer. I check them out whenever I can, though.  You should consider it.

Responding

At long last, Michael Morse's new book "Responding" is available, and my copy arrived today!

It reads a lot like some of his blog, Rescuing Providence.

From the Forward:

"They think I help them, and I do to some degree, but more often than not it is they who help me. Every person who crosses my path teaches me a little more about things, some great, others small, but always something."


I'm sure most anyone who reads this blog already knows about his, but on the off chance that you don't, you should. He's one of the good guys, who does this because he cares, because he is driven to help people. I have learned more than he probably imagines from reading his stories and commenting back and forth.

To look at a picture of him, you'd think he was some crusty old firefighter. :-)
And he is.
A crusty old firefighter with the heart of a lion.

Missed One

Missed a call today.
I hate when that happens, and this is the second time in the last week.

I was out of the district, running errands.
Pager went off.
We headed out here anyway, because I recognized the address and knew the patient, and because of the type of call, and not knowing whether it would end up needing additional manpower.
Got stuck behind not one, but two school buses.
Made it to the driveway of the house before being told to remain in service.

Do I think I could have provided better care than what happened, had I been home at the time?
Maybe.
I knew more about this specific patient (including expecting this call because I knew the patient had not been feeling well for over a week). I've known the family since I was in high school. I have more training, more experience.

Would it have made a substantial difference to the outcome?
Probably not, this time.

Even so.
One of the things I value most, one of the things that keeps me here, is the sense of providing care for my community in a way that people who don't know these people can't do. I want to be there for them, and it sucks when I can't be.

At the same time, if I let this turn into stress, and then into guilt, I'm not going to last very long.

I don't feel guilty for not being there today.
Disappointed, maybe.
Do I wish that I could have been?  Yes.
But remember the point, of providing care. In this case, I know that my being there, although I could have been a familiar face, would not have made much, if any, difference in the actual outcome, and that has to be enough.

Otherwise, I'll end up never leaving the house.
And that's a bit too egotistical, even for me. :-)

Little Old Ladies

Saw a comment somewhere today where someone said they think that people who say they hate geriatric calls must be "doing it wrong."

She went on to talk about how older people often have amazing stories to tell, that you'd never guess just by looking at them.

People who are "old" now have lived through some interesting times, that's for sure.

We had a call recently where the woman described herself right off the bat as a "stubborn old lady." That's when I knew we were going to get along!

My daughter has mentioned how much she enjoys meeting some of these incredible older people. We have some characters out here, that's for sure.

It is a sad thing that this culture separates young people from old people so much. There are still places where groups of kids might go to some "old folks home" for a holiday event, but in general, there isn't a whole lot of interaction between young people, and older people they don't know and/or aren't related to.

One of the things we've noticed is that the feistiness and spirit of some of them seems indirectly proportional to how sick they actually are. As if maybe they've figured out that it's better to go out with a bang, and to hell with worrying about it. They are the ones who banter with us. Once, I saw a young male assistant chief totally discombobulated by an elderly woman having a great time flirting with him, while having to stop and catch her breath every little while.

I've mentioned it before, and I'll mention it again, and I hope I have the opportunity to frequently be reminded, that some of these people have enough heart for a dozen lesser folks, and the spirit to match. It is an honor and a pleasure to be able to be there for them when they need a hand.

Friction

The Fire Service, and other Emergency Services, are one big happy family, right?

Sometimes it seems so.
I've walked into fire stations hundreds of miles from my home and felt welcomed and at home.
I've hung out with medics I had never met, and felt a kinship immediately.
I know some of them would go out of their way to help me if I needed help, because they have.

It can be a very wonderful thing.

But sometimes, it can be a pretty dysfunctional "family."
With the same power trip issues and rivalry issues as many families.

Other times, it doesn't feel much like family at all.

The thing is, none of that matters much to the patients.
They don't know, or care, whether you are working with a friend, a family member, or the person you hate most in the world.

They called for help... and that's what they expect, and should get.

So how do we do that?

How do you stay focused on the patient, when you're working with someone you don't like?

I think there are two different scenarios, and they require different solutions.

If I need to work with someone I dislike because of some personality conflict or difference in politics, someone I don't get along with, someone who I'm not friends with, it basically makes no difference at all.  Just like how my kids and I have had to learn to work as professional partners, and not "mother/daughter" or "mother/son," or, in their cases, "brother/sister," working with someone I don't care for simply requires me to remain professional. The personal part really doesn't enter into it.

Working well together on scene does not require being friends elsewhere. We don't have to hang out. There is no requirement of a social connection of any kind. They may not be invited to my birthday party, but they can still set up the Oxygen or take a blood pressure.

The other scenario is much more challenging.

If the reason I dislike someone is because they are not professional, or because they are incompetent, dishonest, or unreliable, then it is a different ballgame altogether.

I may not be able to trust them, but I may also have little to no choice about working with them. I don't get to make those decisions.

In that case, I have to stay alert, and not count on them for anything that may affect the patient's care.
There are some things that anyone can do, like carrying equipment (but make sure to double check what they have carried in), and other things that require a certain level of skill. I would be very hesitant to ask such a person to do any direct patient care, unless it's for something I have some confidence they can do. Since I would be somewhat less likely to spend time with this person other than on scene, and therefore less likely to know what they can and can't do, I would have to be pretty conservative on scene.

Still, some stuff is pretty easy, and either less critical, or easy to correct. I might ask them to do any number of simple things- but I can't delegate responsibility.  Anything I ask anyone else on scene to do, regardless of who they are, I am ultimately responsible to see that it was done correctly.  With someone I trust, this is easy. With someone I don't trust, it can be more challenging, with a greater need to double check. This can create a higher level of stress, and therefore requires significant consideration to be sure that the stress does not affect patient care, or the patient's perspective of their care.

The patient should not be able to tell whether you are working with your best friend, or your greatest enemy. It's your responsibility to be professional enough to see that that is the case.

My slogan?

Heard a funny story today.

To make a long story short, and more importantly, understandable, it has to do with someone I spoke with on the phone last week, after not having spoken for about six years. He was a student of mine at one time, but I was speaking to him the other day in his professional capacity.

That person talked to some friends today, and told them that he recognized my voice immediately when I called.

Not an unusual thing, I'm sure.

But the funny part was that he said that what he heard in his head, when he recognized my voice, was "Go slow; be perfect."

Something I've said to my students thousands of times.
We focus on gaining physical skills, and the only way to do that is repetition.
Mindful repetitions, not mindless.
It isn't about being fast, it's about being accurate.

That holds just as true with EMS skills as with any other skills.
Accuracy and precision are what is important.
Often, there aren't any do-overs. You have to get it right the first time.
When you practice, stay focused.
Don't rush through it just to get it done.
Go slow; be perfect.

That applies to just about everything I do, really.

So if I'm going to be remembered for something, I'm pretty okay with it being that.

Drop Everything!

This time of year, we make a lot of cookies. And by a lot, I mean a LOT. It's a significant investment in time, energy and money.  But it wouldn't be Christmas without them.

Imagine this:
You've spent hours mixing the dough, using the cookie press to make fancy designs, decorating them, and you've just put a batch of cookies in the oven.
And then... the pager goes off.

One of the big differences between working someplace that has shifts, and being a volunteer out here, is that we need to be ready whenever the pager goes off, any moment, night or day. No warning. It means either sitting around doing nothing, in case there is a call, or having things interrupted. Some things aren't meant to be interrupted.

Here are some suggestions and tips I've gathered from various people and places.

1. If you are cooking, you need a plan in case you are interrupted. You can't just leave things on the stove or in the oven, most of the time.
The best plan is to have someone who stays home who can finish it for you.
If that is not the case, consider whether you can simply stop where you are, and finish when you get back. Sometimes you can; other times, not so much. A timer may help, if it's something in the oven that can hold for a while.
If you leave, make sure to put the food where any pets can't get it while you are gone.
If there is someone else who can cover the call, and what you are doing is time-sensitive or can't be interrupted in the middle, consider not going. If you don't mind scrapping whatever you are making, then don't worry about it, just go.
Do plan ahead, so you know what to do, instead of trying to figure it out in a hurry and under stress.

2. If you are in the shower, you need to be able to get dressed, and to deal with wet hair. Keep a set of easy-to-get-into-while-wet clothing in there with you. Hair ties are good. Hats, too. You may want to just go without a bra, if you can get away with it, rather than struggle with straps over wet skin- but probably not if you might be doing CPR.

3. If, like my daughter, you like to dye your hair, keep a stocking cap handy. You can put it on over the whole dyeing process. Remember that leaving the dye in longer will change the color.  In the summer, you might get odd looks, but who cares? Better than dripping dye everywhere, or not going.

4. If you are in the grocery store, it's kind of rude to just abandon your cart. Around here, some smaller departments have a sort of "arrangement" with some stores that if they need to go to a call in the middle of shopping, they put their cart in the beer cooler, and it can wait until they get back. Consider carrying a written note saying that you are a volunteer, got a call, and will be returning, to leave on the cart when you go.

5. Ditto some restaurants and diners. There are a couple of places near here where there is sort of a standing agreement that people can just go, and come back to pay later. Build trust with the restaurant, and this might work. I've also asked for the check and paid right after ordering, and explained that we might need to leave in a hurry, and don't want to stiff them.

6. If you live somewhere that your car windshield can ice over at night, use this trick I learned from a volunteer years before I even became one. Leave your windshield wipers in the up position, and use them to hold a carpet remnant, a welcome mat, or even a towel over the driver's side of the windshield. Then, when you need to go, simply remove it, and there will be a clear spot underneath.

7. If the problem is more snow than ice, use a small tarp. Drape it over the windshield, and close the ends in the doors to hold it there. In the middle of the night, being able to just pull it and go saves a lot of aggravation.

8. At night, leave everything you need set up where you can find it and get dressed quickly. Stage everything: clothing, keys, wallet, your watch. Your brain.

9. On the way from your door to your car in the middle of the night, if you have one, use the remote to turn the lights on in your car, so you can see where it is! It gets very dark out around here.

10. If you are attached to any particular TV shows, or watch sports, always record them as you watch them. Or simply always record them, and watch them later. You don't want to get to the last couple of minutes of the show, and have to run out the door.

11. Get in the habit of emptying your bladder frequently. If you don't, it is nearly guaranteed that you'll get a call at the very moment that you've decided you can't wait any longer.

12. Stay hydrated, and feed yourself well and regularly. Have bottled water and healthy snacks handy, ready to grab on the way out the door. If you are going to a call that may last a while (a search, for example) it's good to have your own supplies with you. if someone else is driving, you may be able to hydrate on the way there. Otherwise, you'll have it the moment the call is over.

13. To put it bluntly, consider turning the pager off during sex, unless you have a REALLY understanding partner. And some people do. Especially if your partner is going to jump up, get dressed, and go to the call with you. If they aren't, it may not take too many interruptions before you won't have to worry about this particular issue any longer.

14. If you are at a family gathering or celebration, make some decisions beforehand about what calls you will go to, and what you may not. If it's my father's birthday, I'm not going to take off out the door to go stand around for hours and wait for the utility company to come tell me that the downed wire is the phone, not the electric. If it's a serious medical call, I'll go, and make my apologies when I can.

15. Depending on where you are and what you are doing, consider whether you can even get to the call in time to do anything productive. Sitting at home, I can get to the call first. But if I'm not home, a lot depends on exactly where I am, and where the call is. If the call is going to last a while, or if they may need manpower, I'll go, even if I get there later than usual. If it's a public assist to help a little old lady get back in her chair, while that is one of my favorite kinds of calls, if I can't get there before the ambulance, the truth is they really won't need me.

I'm sure there are other situations, but those are the ones that come to mind.

(Edit: Unlimited-Unscheduled Hours wrote a great post adding a whole bunch more ideas!)

Pre-Hospital Care Simulator

Found this website while browsing some blogs yesterday.

Pre-Hospital Care Simulator

It's kind of silly.
And we've been having a blast with it.

Make sure you try some of the "wrong" things to see what happens. Some of them, you'll never forget! I was going to give an example, but changed my mind. I don't want to spoil the fun.

As ridiculous as this might be, it keys in on one of the most important things about learning: emotional engagement.

There are a few scenarios available right from that page, and a link to purchase the archives. It's a little cumbersome to actually find them, but they are there.
Here's a direct link. I don't know how long that will be accurate, so here's a description of how I found it:

1. Click the link from the simulator page that says "Old EMS Scenarios here!"
2. I couldn't find them on the CD side, so click on the link to download them.
3. Click on "marketplace"
4. In the search box, type "simulator"
5. Use the drop down menu to display the "low price" and they should be on the second page.

They are inexpensive. $6 per collection, and there are three of them.

Also, it looks like their home page might have some great stuff.  I haven't had a chance to check it out today, but I will.

Cultural Differences

I'm a pretty accepting person. I value knowing people from different cultures, and try to be respectful of whatever needs or preferences they have.

If I know what they are, that is.

When my children were babies, I was a La Leche League Leader, and did a lot of home visits, helping new mothers learn how to breastfeed their babies. During my training to become a Leader, I learned about a number of possible cultural issues that might come up.  For example, there was one group that kept babies tightly swaddled, and another that would not take the child outside the home for at least the first six weeks.

In EMT classes, I don't think I've heard any specific cultural concerns addressed.  A little information about the possibility of a language barrier, but nothing about different cultural or religious practices.

A while back, we had an Amish patient. During the call, he did not answer questions I asked him, but freely answered questions asked by a male paramedic. It wasn't until after the call that I wondered if it was a cultural concern that created that situation- or whether he just didn't feel comfortable with me for some other reason.

I've asked a few people, and none of them knew.
I've done some research, but it's hard to know how accurate any of it is. There's nothing like a description of someone's beliefs by someone who doesn't agree with them.

The main thing I found is that there are different Amish groups, and they have different "rules" that they live by. Some have nothing to do with anything modern; others are more relaxed about it. For example, some have nothing to do with cars, but other groups might allow riding in cars, but not owning them.

The restrictions about vehicles might be important. I read one story about patients needing to be treated outside the ambulance because they would not go inside it.

Another interesting thing is that the Amish don't have insurance.
I would not withhold medical care from anyone lacking insurance, but I can imagine a situation where I'd be okay with them being transported by personal vehicle, assuming, of course, that they are allowed to do that.

The other thing I saw in various articles is that there is a likelihood of delayed calls for help in a community that does not have telephones in their houses. Hard to imagine, in this day and age, people not having nearly instantaneous availability of communication devices, but it's common in some areas.

I'm still looking for more information, and may have an opportunity to meet with some people and ask them what things would be particularly helpful for EMS providers to be aware of.

Until then, I'll keep looking online.

Here are a couple of websites that I found helpful:

Amish Culture and Healthcare (a nursing article)


Amish and Healthcare (A blog written by a former Amish woman)

What I Wouldn't Give

Came across something interesting a few days ago.

A large agency EMS training schedule.


Unfortunately, not for my agency, or my area, or I'd be right there.

Still, great to see. This is exactly what I'd work to create if I were in charge. Cooperative, coordinated training. And I'd do it county-wide, not by individual little departments.

If I could participate in these classes that are being offered, I would. But why should I have to? Why DOESN'T this county do such a thing? Why DOESN'T my agency provide any training?

I'm trying to keep this blog as positive as I can, but it is frustrating to get so little help here.

I would love to hear stories from anyone who has had an agency turn around, and start prioritizing high quality training and improving patient care. How can a peon help that to happen?

Who You Gonna Call?

Admit it. You said "ghostbusters," at least in your head. :-)

A couple of years back, I wrote a short piece for our local town newsletter-thing, about how to know when to call an ambulance. I was hoping, of course, that everyone would read it, and become educated, and then they would never call when it wasn't necessary, but always call early on when it was.

Did that happen?
Not so much. :-0

Some of it is because there is a serious lack of understanding and knowledge of medical issues out there in the real world. It stuns me, on a daily basis, that people can grow to adulthood and not know any first aid. Not know how to take care of themselves. Why would anyone do that? Seems to me they'd have enough of a vested interest to go out and find out, if someone didn't teach them already.

I know someone who called an ambulance because she cut her hand opening a package. Was it a deep cut with serious bleeding? No. But she didn't know how to make the bleeding stop, or how to know whether or not she should get stitches. I recommended taking a First Aid class and even sent the textbook from the current Red Cross class at the time.

I have never been one to call a doctor unless it was really necessary. I'm not interested in antibiotics for a cold, for example.
Not one to run off to the ER.
For the most part, I know enough about how to tell if someone really needs a doctor.

And that's the key, right there.
Knowing how to tell.

A LARGE part of that is knowing what the doctor can do for you when you get there, and that varies, depending on where you go.

In a recent online discussion, someone mentioned that her mother thought it was perfectly okay to go to the ER for minor things, because it would give the people there something to do when they weren't otherwise busy. I don't know what image of an ER she has in HER head, but it doesn't match my experience, at all.

But for the sake of discussion, let's imagine that it's true, there are times when the ER is empty, and those folks are just itching for something to pass the time.

The problem in that case is that the ER is only designed to do what it is designed to do. You know, handle emergencies. Or evaluate someone to see if what is happening IS an emergency or not.

If it is, then it is likely that the ER will be staffed and equipped to do whatever it is that needs to be done, or to package the patient and get them to somewhere that can.

But if it ISN'T, sometimes, there simply isn't anything they can do. They can have the patient wait until a doctor can come in and tell them to go see their regular doctor the next day, or whenever they can get an appointment. Contrary to popular belief, ER docs can't magically make things get better, or go away, or whatever. If you go in there puking from a stomach bug, you're going to go right back home in pretty much the same condition. Problem not solved.

So the first step in deciding whether to call an ambulance, or to go to the hospital, or any doctor at all, is to consider what they can actually DO for you, and decide whether that will solve your problem or not.

Do you need a test they can do that you can't? I can't do my own bloodwork or x-rays, for example, so if that's what I need, I have to go somewhere that can.
Do you need medication that only a doctor can prescribe, or is over the counter appropriate?
If you don't go right now, what will happen? Will it matter, other than your own level of discomfort, if you wait until morning, or the next day? Is this something that needs to be fixed as soon as possible because it will get worse otherwise?

If what I need is to ice and wrap something, I can do that all on my own, and take a couple of ibuprofen. But if a bone is broken... I need help with that.
If I'm vomiting, I can be miserable until it stops, and focus on keeping up my fluids. Pepto works fairly well.  But if I'm vomiting BLOOD... different story.

Personally, my decisions point on calling an ambulance has two parts.
First, I have a pretty good idea of what they can do, and what they can't. And some things that they can do are pretty important at times.
If syncope is likely, the back of a rig is a better place than behind the wheel of a car, for example. If I can get someone to drive me who would have a clue what to do if I passed out, I'll do that.
If I'm trying to catch that occasional arrhythmia, and the medic can get me on a monitor about half an hour quicker than getting to the ER, that's something to consider.
If I'm having chest pain and difficulty breathing, no question. Starting treatment HERE is much better than delaying it. The ambulance can get to me a lot faster than someone can get me to the hospital. If I lived closer to the hospital, things might change a little, but I don't.

What I'm looking at in deciding, is whether I am able to get to the ER any other way, and whether it would increase the danger to me to do that, remembering that in some ways, the back of an ambulance around here may be better care than in the ER. If that 30-40 minute delay is not an issue, I'll drive (if I can) or get a ride. If time is critical, especially if I'm not just talking about transport time, but starting treatment on scene, then I'd call.

I am amazed by how often people will call an ambulance, and then follow the ambulance to the hospital. Um... if you were going ANYWAY, why didn't you just DO THAT?  Sometimes, it's the right choice because the medics can "bring the ER to you" in a sense. Other times, it's just silly.

Just the other day, I heard a medic say that they were heading to the ER with a voluntary mental health transport, and both parents would be following in their personal vehicles. A voluntary transport? Stable patient? What on earth would the medics be able to do en route that is important enough to do? Sit and talk, and fill out paperwork? This was an underage patient who couldn't sign any paperwork anyway.

Bizarre.
Waste of resources.
I don't mind talking with a patient all the way to the ER, but really, there's no medical need at all in cases like that.

Hmmm. I digressed a bit.

Back to the topic at hand.

List your resources.
The list may go something like this:

Primary care doctor
Specialist of some kind
Chiropractor
Physical Therapist
Urgent Care
Free Clinic (limited hours)
Emergency Room

Take some time to find out what kinds of care each of those offers- and what they DON'T offer.
For example, the free clinic here can't do x-rays.
Primary care doc doesn't offer any alternative therapies of any kind, and can only do "sick" appointments if you call early in the day.
Urgent care has specific hours, but otherwise can do almost everything the ER can do- if in doubt, call and ask. They'll refer you to the ER if necessary.

Consider, if necessary, what your insurance will cover. Mine, for instance, is not accepted by the closest hospital, but IS accepted by my primary care doc, and by the next nearest hospital. In an emergency, it doesn't matter, but if it isn't a true emergency, it matters a lot.

Everyone needs to compile their own list, and know their own options.
You can't make a choice you don't know about.

Remembering

I have a wristband with the name of a friend on it. One of my mentors, in fact.

He died suddenly a few weeks ago. At way too young an age.

Turns out, he was a mentor to quite a few people. He was well-loved, by his family, his co-workers, and by friends from years ago, who traveled a long way to come here to show their respect.

One of his coworkers had these wristbands made, for any who wanted them.  The money he has collected for them goes to our friend's family, and the beautiful children he has left behind, as it should.

So now, I carry his name with me everywhere I go, and thoughts of him and his steadfastness help me through whatever I'm dealing with.

But I can't help think of how odd it is in this culture that we wait until someone dies before we spend much time honoring and remembering them.

Seems like we should do more to honor each other before then.

I want a wristband with the names of ALL my friends on it, so I carry them with me all the time as well. They are all an inspiration to me, now, and every day.

Kind of impractical, to make such a wristband, but I'm letting the one I wear stand in for it, I guess.
I've lost three friends in the past few months, all too soon, too young.
I'm trying to be more mindful now.
Trying to remember to tell people how I feel now, when they can hear me.
Trying to show appreciation for what they do now, rather than wait until it's too late.

Losing someone happens so fast.
Loving them should happen all the time.

She put the Lyme in the Coconut...

I'm pretty sure my dog has Lyme Disease.

He keeps looking at me with those big brown eyes, and he whimpers when he moves, and wants me to make it better. And there isn't a hell of a lot I can do about it.

I'm a wreck.

Show me a person with busted up body parts, and I'm fine.
But my dog?

MUCH harder to deal with. At least an order of magnitude harder.

I've spent the day researching and talking to the vet (why do these things always happen on a weekend?!?) and making plans. And thinking about what the likelihood is that one of the humans in the family might get Lyme Disease, or that we might have a call that is related to Lyme.

You'd think the chances aren't very high that we'd get a call for a patient complaining of Lyme Disease, but actually, I already have. It was obvious, too. Tick head still embedded, angry red swelling, red ring like a bullseye.

He had noticed the tick, and tried to pull it out, didn't think much of not being able to get the whole thing, and left it that way for a couple of days. He hadn't heard of Lyme Disease, and had no idea that a tick bite could lead to anything.

Most people I know have at least a little knowledge of the disease. They know they need to check for ticks (we live someplace that they are common) and that they need to remove them as soon as possible. But "most people I know" is not the same group as "the general population," and it may be that this isn't as common knowledge as it should be.

So as a little PSA, I thought I'd include some links to basic Lyme Disease information.

First, not all ticks cause the disease, because not all ticks are infected with it. Trouble is, you can't tell by looking at the tick, so it's a good idea to treat all ticks as potentially infected. That means pulling them out.  Preferably in one piece.

When I was a kid, people would touch a tick with a match head or the end of a lit cigarette, the theory being that it would make them pull back out on their own.  And what, turn around to smack you for burning their butt with yours?  Not so much. Turns out, that doesn't work all that well. Neither does "suffocating" them with kerosene, vaseline, or rubbing alcohol.

There are some great tools on the market that make pulling a tick simple, quick, and effective.  The one we use is the Pro Tick Remedy. There are others, but this is the one I've used the most, so it's the one I can recommend. The important thing is to get one, whichever type you use.

Some places for information on Lyme Disease itself:
CDC Lyme Disease Page
Mayo Clinic Lyme Disease Information
PubMed Health Lyme Disease Information

Read up.

And don't forget to check yourself- and your friends- for ticks.

Drawing a Blank

I'm drawing a blank here.
I had an idea earlier for what I wanted to write about, and had started to organize it in my head, but I can't for the life of me remember what it was.
I need to go to work in a few minutes, so I don't have long to try to either remember or come up with something, but the harder I try to think of something, the less comes to mind.

Nope.
Still nothing.
It sucks, too, because I've kept going posting every day for 38 days now. I really wanted to continue that, and if I miss one day, I might slip right back into old habits and stop posting entirely.

I can almost remember what I wanted to write about, but not... quite. Like it's on the tip of my proverbial tongue, but in writing. And the more I try to focus, the further away it slips.


Okay.
Not really. :-)

But it HAS happened to me, and if I had to bet, it has happened to you, too.
That moment when suddenly, under stress, your mind goes completely blank, and you probably couldn't remember your name, if asked.

It happened to me at my first EMT-B practical exam. Walked in the room to start the medical assessment, and went totally, completely, blank. Deer in the headlights blank.  Fortunately, I had a few minutes to get my head back together, and I did fine, but it wasn't nearly as smooth as I had planned.

The question is, how do you recover from this? How do you get back on track if you blank on something? We work in a high stress and often, high risk environment, and "going blank" isn't an option. It just isn't. But we're all human.

Here are some ideas:

1. Write it down.

This comes into play in two ways.  The first is that writing something down creates a stronger memory of the thing, and, if you're a visually oriented person (most people are) it adds a visual component. Sometimes, when you need to remember something, you can just close your eyes and see the words.

Another way writing something down helps is to create some written tools for yourself. For example, we have the BLS med protocols for our region printed up and laminated, prominently placed in our equipment bag. So it's right there. We can't blank on remembering the protocols if we have them easily accessible, right with us.  Other ideas might be pocket cards, or any other memory aid that works for you. The instructors in my Basic class were fond of wide strips of tape to write things on while on scene. Easy to use, easy to dispose of.

2. Practice a lot.

You had to know I'd say that, but it's true. Practice past the point of competence, to the point of mastery. A competent person practices something until they get it right; a master practices until they can't get it wrong.

3. Practice WITH YOUR PARTNER, so you have each others' back. Come up with cues to help someone get back on track.  Be ready to step in with the right question to continue the assessment, or to remind your partner to put oxygen on the patient, or whatever might be necessary. Instead of having one person do all the patient care, while the other carries stuff or drives, or whatever, learn to work AS A TEAM. Become excellent assistants. Learn to tag team.

4. Mnemonics help some people. If you're one of them, OPQRST yourself to your heart's content. EMS is full of them, so learn them and use them. Make up your own, if they work better.


I'm sure there are more ways- feel free to suggest your favorites.

Where in the World?

Great. Now I have the theme song to Carmen Sandiego in my head.

Not only do people not know where Carmen is, much of the time, they don't know where THEY are.
There are several different issues that cause this.

1. What is the name of this street, really?

I overheard something on the scanner yesterday that reminded me how disastrous it can be not to be sure of where a call is. It was a simple thing, an alarm activation, but the dispatcher told the responding fire department that they were on the phone (!) with the alarm company because they weren't sure (!) whether the location was on a road in one town, or a similarly named road, in a town on the opposite side of the county.

Fat lot of good a fire alarm is going to do if it ends up sending the wrong fire department to the wrong town. They got it figured out (when the arriving dept confirmed an activated alarm where they were), but what if that hadn't been the case? What if it had been an actual fire, with the fire department delayed by ten or fifteen minutes while they FIGURED OUT where they were supposed to go?

Over the past few years, there has also been more than one EMS call with the ambulance sent to the wrong address, because of similar street names.

Another thing that happens is that some people have lived around here for a long time. Street names change. People still call them by their old name. There are also roads in this county that have an official name, and a sort of nickname that everyone uses. People may call something in using the informal name, but the CAD system won't have that listed.

And then, my favorite. In the next town over from us, there are street names that all sound similar to each other. And those roads intersect. AND, to make it even more fun, one of them keeps the same name around corners, so sometimes, if you go straight, the name changes, but if you turn, the name stays the same, then at the next intersection, it's different.  wtf?

Dear people who name streets: Pay attention. One name per street, please. And quit with all the similar names. Make it obvious what the name is. Make SENSE.

2. Signs, labels and numbers, please.


It is a constant struggle around here to get people to put numbers on their houses, or at the end of their driveways, that we can SEE. No matter how we try to phrase it, they simply don't understand that we have to be able to see those numbers in the dark, while driving, in the rain, in a hurry. And please, if you only put numbers on one side of your mailbox, make it on the side that WE come from, not the side the MAILMAN comes from, okay? The person who delivers your mail KNOWS where your house is. They go there nearly every day. WE don't, and when we go, we are in considerably more of a hurry than your mail.

And what about those house numbers themselves? There are four places in our town that I know of where the house numbers do not go in order. Right. How did that happen? Did the person handing out house numbers not know how to count? I'm not talking only about a mismatch from side to side, where odd and even don't match up well, but places where the numbers on the same side are out of order. Where, for example, 99 might not be between 97 and 101. Why would anyone do that?

And street signs. Could we have them, please? Consistently. At every intersection.
Reflective. Large letters and numbers. Facing where we can see them.

3. General inattentiveness.

This one, I don't have an easy fix for.

The problem is simple: people don't pay attention to where they are, especially when they are driving.

Sometimes, it's hard to tell. Get on one of those long stretches of interstate, and you tell ME how you're going to call a report into 911 if you witness an accident. Or worse, on some long stretch of two lane road in the middle of nowhere... oh wait, that would be almost anywhere around here, wouldn't it?

I've driven around here for thirty years or so, and there are some places that I wouldn't know how to tell dispatch where to go, or who to send. What about people driving through someplace they don't live?

Better signage would help some.
And again, better numbering on houses, visible from the road at a distance.

But mostly, people need to learn to pay attention. And they pretty much won't. Most people, most of the time, don't need to know exactly where they are, as long as they know where they are going.

We practice.
Whenever we're out driving, I'll keep in mind how I'd call in an accident. I pay attention, especially in unfamiliar places, to how the roads are marked, what information is on those little markers. I remember exit numbers, so I know the most recent. I remember what county I'm in. I notice and remember obvious landmarks. Even if I don't know exactly where I am, I'll be able to say I'm heading North on Middle-of-Nowhere Highway, between this town and that one, in this county; I just passed exit 3 (to other-small-town), and I'm near a big barn with three blue silos. Hopefully, that information will be familiar enough to get me found.

Which brings me to the next thing:

4. Learn Your Way Around


A good idea for anyone.

A critical skill for anyone in emergency services.
Learn your response area cold.

And please, dispatchers, you do this, too. I've said it before, and I'll say it again: you should know the names of roads, especially any that may cause confusion. I know you sit in your cozy little space, with all the computer screens, and you can't see out, but you don't LIVE there, so whenever you aren't at work, drive around, and get to know where things are. Especially any that have caused confusion already. Is that asking too much, for you to spend some of your own time learning to do your job better?

We have a relatively small response area, and I've lived here for twenty years, and in the area for much longer. So I pretty much know my way around.

Even so, I have a map. I use it. I've driven every road in our town. Even the seasonal ones, which I don't necessarily recommend unless you have a truck.

This is how I know about those places where the numbers are out of order. Been there. Seen them.

This is how I know where there are steep hills, and what might be a better way to get somewhere in an ice storm.

This is how I know which way to turn at intersections to get to a particular house number.

This is why I know the house number for the newest house in town, just finished a couple of weeks ago. And how I know that the people have moved into it.

Seems to me, this should be standard procedure, to learn your district. Yet it doesn't seem to be. We had a situation a couple of years ago where mutual aid tankers were given the wrong directions to a fire because the person giving the directions gave bad directions, and then, when the tanker radioed because they ended up somewhere else, didn't recognize where they were to be able to guide them to the right place.

Which reminds me... learn your mutual aid response areas as well. Maybe not in excruciating detail, but certainly enough to be able to follow directions. And have maps of them. Handy.

We are behind the eight ball enough already. Delaying a response because people didn't do their homework is inexcusable.

I'd love a world where passers-by give good locations, dispatch knows where they are, and relays accurate information to responders, who know exactly where it is, and how to get there, and when they do, everything is clearly marked, easy to spot, and no one ever has to slow down, squint through the rain and try to pick out non-existent numbers on the side of a house 100 yards off the road.

I can dream, can't I?

Now go back to singing along with Rockapella.
Where in the world is.....

Pattern Setting

Patterns.
The human brain loves patterns.
One of the things it does BEST is recognize and follow patterns.

Most of the time, this is a very good thing.

However.
This strong tendency to follow patterns means that once a pattern is learned, it can be a challenge to break it. Who hasn't had a bad habit that they've struggled to change?

People talk about needing to "unlearn" something, if they've picked up a pattern that isn't what they want. You can't unlearn something, any more than you can not think about something someone tells you not to think about.

In order to break a pattern, you need to learn a new pattern.

Or, better yet, learn the right pattern in the first place.

THIS is where a lot of teaching goes wrong.
People need to learn a new skill at whatever rate they need to learn it.  Too fast, and they'll learn the wrong pattern. Too slow, and they'll lose focus.

One of the things that I've brought to learning EMS skills from the rest of my life, is knowing how to learn a physical skill. Understanding the importance of patterns.

For example, when I was learning to intubate, I practiced in a way different from those around me. Most people focused on the insertion of the tube, and pretty much ignored the rest of the process.  And it's true that learning to insert the tube correctly is important- so there is often a fairly strong desire to focus on that part of the process, over and over.

I resisted. :-)

Instead, I went through the entire process, from checking my equipment, through confirming the tube placement and securing the tube, in order, A-Z, every time.

In doing so, I recognized that one of the places in the sequence that was giving me trouble was that I'd lose track of my syringe. Inflate the cuff, and then... I don't know. Put it down? Drop it? Ignore it entirely, as I went to the next step?

So I purposely included the whereabouts of the syringe as part of my process. Inflate the cuff, pocket the syringe. Then, when I needed to know where it was later (Time to reset the exercise? Or, more importantly, bad tube placement, which needs to be corrected RFN?), I didn't have to look for it.

Once I had my sequence set, I went through it step by step, slowly.
And again.
And again.
Making sure not to miss any step, no matter how small. Start at the beginning. End at the end.

Speeding up comes of its own accord. There is never a need to try to rush, to keep it "under 30 seconds." Simply practicing the sequence correctly, with appropriate focus and attention, will make it so that the entire sequence can be done smoothly, unhesitatingly, and therefore, in as short a time as is possible to do it correctly. I'm quite sure that under stress, adrenaline will do all the speeding up as will ever be required.

Rushing during practice means skipped steps, and losing awareness.

Learning this way ensured that I fully appreciated the process, from beginning to end.  It isn't that I want to be able to do it without awareness, it's that I want to KNOW what the process is, and where I am in it. Having it be the same each time is important. Confidence is important.

How does that translate to the field?
A heck of a lot better than sporadic, aimless practice.

And then... they changed the pattern on me, no more color change ETCO2 detectors. Capnography!

Back to the drawing board... err... pattern setting.
Relearning a pattern that is substantially the same as an old pattern, with a few changes, can be a challenge.
But the process is simple.

Start at the beginning.
Go slowly.
Focus on the changes, until you don't need to.
Walk and talk it through.
Focus on accuracy, not speed.

People Skills

I was never one of the "popular kids" in school. In fact, I didn't really fit into any of the typical "cliques." Instead, I sort of floated between some of them, with friends in different groups.  I was friendly with a wide variety of people, including some that most people seemed not to notice at all.

Invisible people.
The kind most people would never notice if they disappeared.

The quiet ones.
Or the "different" ones.
I was "different."

Interestingly, most of the people I'm friends with now describe their teen years somewhat similarly. Not the popular group. Floating between different groups. Friends with a wide variety of people. Different.

Turns out, not being popular in high school becomes an advantage later in life.
Who knew?
Sure didn't feel like it then.

The advantage is in having learned to appreciate, to get along with, and to care about all sorts of people. Not just those who "fit in" or who behaved in certain ways, valued certain things. Not just those who believed the same, or dressed the same, or came from the same background.

My favorite medic (kind of like My Little Pony, but different) became my favorite before I even knew his name. I would see him at calls, either out here, at our calls, or sometimes out and about in the nearby larger town, when I happened to be somewhere an ambulance was called. What stood out, even to my totally uneducated eye at the time, was that he was really great with people. Friendly, calm, reassuring. Comfortable. Caring. Someone who inspired trust within moments of meeting him.

I purposely learned his name.

When it came time for me to do my ride time for my EMT-B class, that's who I ended up riding with. Not intentionally- I didn't know HOW to ride with a particular medic on purpose yet- but it would have been intentional if I could have chosen.

I learned a little more about him, including that his childhood had included traveling around and helping people all over the place. That his childhood had brought him into contact with a wide variety of people culturally, geographically, and socioeconomically. That's how he learned to get along with and value all sorts of people, and that really showed in his patient care.

Turns out that the medics I look up to the most have that in common- that they all learned, in various ways, to accept and love people different from themselves, and it is that ability to really care for and about patients that shines through. They all have excellent skills, as well, don't get me wrong. But it is the people skills that stand out.

That's how I recognized that a lot of what makes a good medic (or EMT) isn't taught in the medical-related classes, it's taught by life experiences, and we teach each other, by example.

I am very fortunate to have some excellent examples to learn from. I've had four people, in particular, who have had a huge influence on me, and who've been there during some particularly formative experiences as an EMT. My first serious call as an EMT, first full arrest, first major trauma, first pediatric trauma, first serious call with a patient who was a family member- all had at least one of my role models there to help me not only through that call, but, more importantly, to begin to develop a good pattern for dealing with such calls in the future. To help ME become a more calm, focused, caring provider, even in the worst of times.

I hope I can live up to their excellent examples someday, and pass some of that on.

Getting Cold Out There

I woke up cold today, so I'm inspired to write about hypothermia.

I've been thinking about it since The EMT Spot wrote a post about the possibility of accidentally inducing hypothermia in patients by not warming saline for IVs.

There are a lot of reasons a patient might be hypothermic.

Some are obvious, like the ambient temperature being low. Or a patient not dressed for the conditions.

But some might be overlooked, if you get tunnel vision.

One of the most common of those occurs regularly in my house. My kitchen floor is tile. Real ceramic tile, not some sort of plastic stuff. And while the tile is easy to clean, looks great, and it feels good on my feet in the summer, it is undeniably COLD much of the time. It stays cool in the summer (great!) and is downright frigid in the winter (not so great!).

If, for example, someone were to fall on such a kitchen floor, and not be able to call for help, and not be found until the next morning... I'm sure they would be freezing cold. Whether or not their body temperature drops to clinical hypothermia, they're going to feel cold, and be miserable.

Likewise, consider garage floors to be heat sinks that suck the warmth right out of a person, any time of the year. Basement floors, too.

One of the other reasons a person on the floor for any length of time is going to be cold is that they probably aren't moving, either. Moving creates body heat. If you don't think so, go run a mile. NOT moving will make a person colder than they'd be if they were moving.

Yet another thing to consider is that not everyone out there can afford to keep their house very warm all year. Around here, there are a variety of heating methods, and some of them do not heat the entire house evenly- so consider distance from the heat source. You may not be able to tell if the house is cold, since you likely will have just come in from the cold, and anything inside will feel warmer, by comparison. Unless you are there long enough to notice, or unless you take off your coat and any other long sleeved layers, you can't go by how it feels to you. Look for objective measurements- like a thermostat or thermometer, or even water frozen in a glass if there is no heat at all. Or look at how family members are dressed- do they have on multiple layers to stay warm?

Another thing that will drop someone's temperature in a hurry is if they are WET. Water is excellent at removing heat from something. Like a fire, for example, which is why water can put out a fire.

If you have a patient on the floor who has been incontinent, that greatly increases the likelihood of hypothermia. As does being diaphoretic. Or being outside in the rain... or overnight or in the early morning, when there is dew.

Likewise, windy conditions, whether it's outdoors, or a window fan.

Another thing people often don't consider has to do with medical conditions. There are a fair number of medications that influence someone's ability to thermoregulate. There are also a number of medical conditions that affect thermoregulation- thyroid issues immediately come to mind. Alcohol use can increase heat loss.  Menopause plays hell with the ability to thermoregulate- in both directions. Do some research. Make a list of conditions and medications to keep an eye out for, but you probably won't list everything. It comes down to keeping an open mind. As is often the case, an older person with multiple medical issues, and multiple medications, is at higher risk.

Stay observant and aware of the conditions both of the surroundings, and your patient, and be alert to things that can lead to hypothermia that might be obvious, or not-so-obvious. Be quick to take action to keep your patient warm- maybe even consider assigning someone the task of keeping that in mind, so no one thinks someone else will take care of it. Especially when it's cold outside, bring those blankets out early.

Now I'll go wrap up in a blanket myself and get on with my day, hopefully a little warmer.

Scenarios, part 2: resources

Meant to add this to the post yesterday, but forgot, so here it is today.

I got myself a whole book of scenarios to practice with.
It's called Patient Assessment Practice Scenarios by Les Hawthorne.

Wasn't too terribly expensive, either, but you might want to split the cost with someone if you have the option.

There are a total of 150 scenarios, split 50/50 medical and trauma.
It includes the NREMT practical skill sheets.
They are set up for someone to serve as the "proctor," but you don't have to use them that way.
They have information on them to adapt the scenario to ALS or BLS.
There is space to add notes.

There are some things in them that don't quite match up with protocols or SOPs here, but that's easily adapted.

Overall, it's a huge, easily accessible resource of ready-made scenarios.

You can also use them as a template to creating your own.
You can, for example, take any call you've ever gone on, and write it up as a practice scenario.
You can create scenarios for calls that are particularly likely to happen in your area.
You can use it as a guide for call reviews: how SHOULD the call have gone?
Just like any written piece of music, you can use it as a base for improvisation. What if we change THIS detail, or add THAT information? How would that change things, if at all?

There are other books available as well; that just happens to be the one I have.

The library at the New York State Academy of Fire Science will lend books, by mail, at no cost. Even though technically it's a fire service library, there are a lot of EMS books there. They don't currently have this particular book, but could probably get it if requested.

Search their online catalog, or contact the librarian to ask for what you are interested in. She's the best!

Scenarios

My experience a few weeks ago, at the training that wasn't a training, reminded me how fortunate I am to have been taught how to teach.  For some reason, many, many people seem not to understand that knowing a thing, and knowing how to teach a thing, are not the same skill.

Today's post is about something that I think should be self-evident, but apparently isn't.

Scenarios.
Everybody loves them, right?

What do you mean, not exactly?
Isn't practicing something as closely as possible to the "real thing" the best way to train?

In general, I'd have to say yes. A qualified yes. Qualified by "as long as you lead up to it in a way that makes sure all the skills are covered before throwing someone in the deep end."

Some people understand this. Check out the crawl, walk, run theory of skill development.

Here's how it works, basically.

1. Have a goal in mind. What is it you want your people to be able to do?
2. Plan your assessment. How will you know that they can do it? What do you need to measure, and how will you do so?
3. Break down the goal into individual skills.
4. Teach each of those skills. For very simple things, this might mean a simple demonstration, but for most things, it means you need to actually teach the skill. Not show them, and not assume they already know it. This is NOT the time to expect your students to be able to do the skill, and evaluate them on it.
5. Practice the skills. Practice them a lot. Practice so that it feels like you don't need any practice, because it's so simple and obvious. You will know when you've reached this point when people have no test anxiety.
6. Only at that point should you expect your students to be able to put the skills together to reach the goal. This is when you assess and evaluate.
7. If you don't seem to ever reach the point of "no test anxiety," and/or you have students who still can't put the individual skills together to meet your goal, CHANGE YOUR GOAL. You may need to have intermediate goals. You may need to have a goal closer to "at least 90% correct, at least 90% of the time" instead of "absolutely perfect every time."

Each skill may need to be broken down further into smaller parts, depending on the complexity of the skill.

The moral of the story here, the point I'm trying to make, is that scenarios should not be used until you know your students can do the skills. All scenarios will do if pushed too early is frustrate people, and create a negative association with the skills. No one likes to fail at things, or to be put on the spot, especially if they don't even have a chance at success. Running through a scenario should be the culmination of a series of steps, NOT the beginning, or the entire plan.

That said.
Good scenarios can be excellent tools.

My favorite way to use EMS scenarios, for example, is the following.

1. Read through it, and list (either in writing, or in my head) the necessary skills.
2. Review the skills.
3. Go through the scenario, step by step, using a skillsheet or other written description. Often, I'll create my own written version for this, because writing it down helps me remember.
4. Group some of the skills, when possible, into logically connected sets. Then, instead of having 37 separate skills, there might be 6 or 7 groups of skills.
5. Practice each grouping as a set, first with, then without a written guide. Notice I do not call this a "cheat sheet."
6. Put the sets together. Go slowly, making sure not to skip any step.
7. Once I'm comfortable with the series of skills, I'll write them down again, in order, from memory, to be sure I don't leave anything out.

At this point, it's easy to substitute a different, but similar, scenario. For example, many trauma scenarios are similar. Many medical scenarios are similar.  It's possible to "test" someone on a scenario they have not done exactly, as long as they have a solid grasp of all of the skills, and of the process of running through a scenario.

In general, this process is not what I've seen done. I don't know why not. I have no interest in trying to trip anyone up, or give them something beyond what they can handle, while they are learning. I want to build a pattern of success, of ease, of confidence, along with a solid grasp of foundational skills. Then there is a much higher chance of being able to adjust to the variations that might show up in real life.

I talked about this very thing with a student today.
This particular student loves to ask questions. Questions are great.
But many of his questions are of the "if this happens, should I do that?" variety, with very specific, narrow situations. The truth is, there is infinite variety in the world. It is not possible to train for every single specific situation that could happen, with a specific, "correct" response.
It IS possible to train for more general patterns, understanding that many things are similar, and that it is possible to adapt and apply what you know about one situation to a slightly different one.

But only if you cultivate a solid foundation.

Now what?

A few years ago, we had a house fire. We all got out okay, even the animals (except for the fish). We had good insurance that stepped in to help right away. We had caring friends, who offered help of various kinds.

And we spent the next year or so reassuring people that no, we aren't kidding that we had a fire, yes, we're okay, yes, it was just stuff, yes, people are generous. I found it fascinating how much WE had to convince other people that we were fine.

I have a friend who is fighting breast cancer. She is not the only person I know who has fought this battle. They have been different ages, with different lifestyles, in different situations, but all of them reached a point where they were tired of people treating them like they're "sick," and just like us with the fire, a little tired of being the one doing most of the reassurance, even while appreciating the care and concern.

For some reason, this year has been a tough one as far as losing friends. I've had three die within the last six months. In all of those cases, the survivors are at a place where they would like to have interactions with people that go beyond "How are you doing? Are you okay? I'm so sad..."  It's not that those things are bad, but they don't always help.

I was married for a long time, having been with that person for even longer. When he left, to sum up a long, complicated story in as few words as possible, it sucked. I've known other people who also had a relationship end, for whatever reason, and one of the things I've noticed is that the end of a relationship affects MANY more people than just those two who split up. Each relationship is connected to a lot of other relationships, and sometimes, those get lost as well, through no fault of their own. It is well known and common, for example, for the friends of a divorced couple to "take sides" whether they mean to or not. Rarely will a friend stay friends with both people, so any split means the loss of friends, as well as the loss of a partner.

I think what all four of these situations share is that this culture doesn't have particularly good ways to deal with loss of various kinds. People are left to muddle through on their own, without the support they have been used to, and/or they end up being the ones offering support and reassurance, even while they are the ones who are most affected by the loss. People WANT to be supportive and helpful, but often don't know HOW.

Most of the time, people rally around the grieving and/or the suffering, for a short period of time, after which... I don't know. Life is supposed to go back to normal, and it does for most people. But for the person suffering the loss, whether it is of a loved one, some stuff, or their self concept, life will NEVER go back to the way it was before. They have to create a new "normal."

My thoughts today are about how to do that, and how to support that.
What are some ways to help someone move forward, as time does?

Some thoughts, in no particular order:

1. Be there. But be there as you have been, not only as connected to the loss. Be a friend, be a neighbor, be family.

2. Don't leave the person out of things they would have been included in "before." This includes celebrations, but it also includes more mundane things. Conversations, for example.

3. Offer distractions, things to do, reasons to get out and about, but don't set your mind on the person wanting to participate. Maybe they do, maybe they don't, and either is okay.

4. If you want to help, help. Offer to do specific things. Consider what they might need, and be proactive. Don't wait for them to ask for help, because most people are very uncomfortable with asking, and don't necessarily even know what they need. Consider tasks the person may not be comfortable doing, or hasn't had to do before. Put up Christmas lights, mow the lawn, clean the gutters, do some shopping, take care of returnable bottles. Stuff like that, that always needs doing. Or hang out and talk for an afternoon, bake something, watch the kids for a couple of hours. On the flip side of this, if you are the person people want to help, LET THEM. People like to feel helpful as much as other people need help. Learning to accept help is important. Even if it isn't specifically related to your loss, try to accept the offer. If you can (especially before something bad happens, if you are in that position), make a list of tasks that people could help with.

5. Make plans for help that might be needed in the future. Offer to organize such help. I saw a great thing recently, where someone was grievously injured, and a friend stepped up and offered to take point, and keep all the offers of help organized for the next YEAR, including an offer to send out a newsletter, of sorts, every few weeks, listing what the current needs are at that time. What a GREAT service that person is providing, both to the injured person, and to all of the people who want to help but don't know what to do. It reminded me of the care groups that I've seen for terminally ill people, where someone keeps track of the schedules of volunteers.

6. If the person seems to be doing well, that's great, but it doesn't mean you should ignore them. Both because maybe underneath, they aren't doing so well, and because companionship is still valuable once they ARE doing well. Go with their mood, if it's a good one. It's okay to sing and laugh and be silly, even after some tragedy has happened. In fact, it's vital. Life does go on, even if part of us feels like maybe it shouldn't.  No one wants to feel like they are leaving a loved one behind, so help people to see that they can be moving forward, without devaluing the past relationship. Don't push them to "get past it" but don't constantly dwell, either.

7. Consider writing a letter. If you are also grieving, but don't want to have that color every conversation you have, maybe you could write up what you are feeling, share some stories or memories, and send it. That way, they can read it when they want to, without being put on the spot or expected to be in the mood for that at any given moment. You might explain that as the reason it's in letter form, as well- even before you send it, so they know it's coming. Some things are easier to share in writing than to say out loud, especially very sad things.

8. Touch. Touch is important. Hugs, handshakes, or being a dance partner. A simple hand on a shoulder or arm. This depends on how touchy-feely you are, as well as what level of touch the other person is comfortable with. Be aware that a person who has lost a partner is likely touch deprived now, as well.

9. Last (for the purposes of this post), but not least. We discovered after our fire that people almost universally reacted with one of two phrases. It has become a family joke, of sorts, so whenever anything happens, we'll all start saying these two things to each other. It's funny, now, but it got annoying then. Try to avoid these phrases. Please.

The first was "Oh my God!" Not helpful. How is someone supposed to respond to that? Seriously, what are they supposed to say?

The second was "You're kidding!"  Well no, we weren't, and it wasn't the least bit funny. This is a knee-jerk phrase, but it is almost always inappropriate for ANY unpleasant event. Someone died? House burned down? Have cancer? Husband left? Got in a fight?  Car broken into? See, not much to kid about there.

And most of the time, it was both. "Oh my God!  You're kidding!"
This has become the typical response in our house to almost any little thing someone complains about- as a reminder that it ISN'T so bad, and a friendly nudge to remember how lucky we are.

I know people are HOPING the bad thing didn't happen, that it was a "joke" (as poor a joke as that would be), and that's why these phrases pop out at extremely inappropriate times. So practice, now, to find something else to say. "I'm sorry" might be a good start. Or "What do you need?" Or "How can I help?" followed by suggestions of possibilities.