Flight 027

Dispatched at about 18:45 for an MVC south east of us about 20-30 miles. Arrive on scene and hop into the ambulance. 50ish year old guy with oxygen on his face, no blood. Medic sitting calmly at the side of the rig. He begins his presentation. “Mr Smith began experience chest pain this evening around…”

Hold on a second. We were dispatched for a motor vehicle crash. Is this the right patient?

Yes, it wasn’t a car accident, it was chest pain.

Medic continues his presentation. I give the patient some aspirin, which should have been the first thing he got, even before an IV site. We were getting even more irritated at this particular medic.

We unload the patient and the medic hands me the EKG (a 12 lead) that they obtained in the field. He tells me, “Mr. Smith wanted us to take him to PotHole Hospital, but when I saw this EKG, I knew you guys would be seeing him sooner or later, so I figured I’d just call the helicopter.”

I took the EKG from him. Normal sinus rhythm. No ST elevations. No depressions. No t-wave inversions. Normal rate, normal axis. The EKG has a printout at the top that reads “Anterior Infarct, age undetermined.” He had short R waves in V1 & 2, and the remainder were normal. Essentially, it was a normal EKG with a suggestion that he may have had a small heart attack in the past.

I was livid…too livid to say anything to the medic.

This patient should have been driven to the closest ER for oxygen, nitroglycerin and lopressor and admitted (or observed) for serial cardiac enzymes. He should NOT have been flown to a cath center by helicopter with absolutely no indication that he was even having any reduced blood flow to his heart. Furthermore, the medics have protocol that outlines appropriate pre-hosptial treatment, including aspirin, which he didn’t recieve until I got there.

This medic, while he probably thought he was doing something good for the patient, was poorly trained, didn’t know his protocols and as a result, put 5 lives in danger by dispatching the helicopter unneccesarily. Everyone knows I love to fly, but not for BS calls. Not to mention the HUGE bill his insurance company will get for the flight.

Cancer Comics

Here is a very moving site that you should visit if you have a free half hour or so. It’s called Mom’s Cancer. I won’t spoil the story, but the ending has a nice twist. His web site has sinced spawned family blogs about the experience. I hope you enjoy it.

Link kudos to Beautiful Stuff.

How do I rank?

Today abut 4000 of my colleagues and myself took a four hour exam designed to simulate our actual board of emergency medicine certification exams. We get compared to all emergency medicine trainees in the country at the same training level and recieve an overall percentage score, as well as a percentile score.

My intern year, I was very nervous about the test, but did reasonable well. The second year, all I wanted to do was a little better than my first year. While in the top half of trainees, I was still dissapointed. This year, I dont care. I’ve been so busy interviewing, catching up on sleep, getting paperwork done for my research and quality control projects, documenting patient encounters (computerized documentation DOES NOT save time), that I have had only a handful of afternoons to “study” for the inservice. The only hope I have of doing better than last year is that the constant little things that I take five minutes to look up during a shift are actually clinically relevant. No wait, there were many questions on the test that were not clinically relelvant…which is why AFTER taking the test, I really don’t care much how I did as long as I passed.

Just like my whole medical career, all I really want is to learn information that will help me take care of patients better. The matierial I learn while seeing patients is far more valuable than pulling out my USMLE Step 1 study guide to re-memorize silly facts like where Coccidiomycosis spores are found. (oops…is that a test violation?). I’m just testing you…

Teachable Moments

There are frequently paramedic students in the ED as part of their clinical rotations. I enjoy having them around…but they’ve got a tough job to learn, I think. On one hand, they need to practice skills like IV starts and blood draws and spend a lot of time with the nurses & techs doign EKGs. But they also have to practice patient assessment and figuring out how to treat in the field, and so they sometimes spend a lot of time with the doctors seeing patients and reading the EKGs they’ve just done.

In some ways, I like them more than I like medical students…the medic students are not trying to impress me (unless they think I’m cute), and are eager to learn. The medical students (student doctors) are frequently intimidated and do what they’re told no matter how hard you try to make it a friendly working environment for them…and have the impression that if I like them, they’ll get into our residency (far from true). Medical school ingrains such an attitude of heirarchy and teaching by “pimping” (the socratic method), that trying to have an easy going conversation is next to impossible, especially for medical students that have come straight from college.

Just some personal thoughts for whatever they’re worth. If you’re a medical student reading this…don’t ever do work just to impress someone. Just try to learn whatever you can from every patient you see…and if they are capable of teaching and not just scutting, from the residents too.

You’re worst nightmare

What’s your worst nightmare to have happen while working?
How do you feel about conscious sedation?
Pediatric conscious sedation?
See where I’m going yet?

Well it happened to a collegue tonight. Without going into details, he had a child who stopped breathing…complete respiratory arrest…while getting her face sutured. WOW, scary. I assessed her while he was giving bag mask ventilations. We calmly explained to the parents that the safest course at that point was to intubate. I prepared his equipment while he calmy put the tube in exactly the right place. She did fine. But I think I would have crapped my pants if I were him. He did everything right to begin with, including getting an airway cart at the bedside, getting the pediatric bag mask out and at the bedside, having suction ready and putting on oxygen. All of that had been done out of routine prior to starting the sedation…as step that some of us occasionally take for granted, but I will now do it EVERY SINGLE TIME! And you should too.