DwayneEMTP

I can't see the vid...any chance someone can give a synopsis?

Thanks Brother, but like I mention above...way more about getting lucky on a WAG then any real competent medicine...

I can't help but think Kiwi whenever you mention that 'we have NO online medical control!" that that is held up as a standard of excellence, when in fact the Afghanis I worked with, as well as the Mongolians, and certainly the Papuan's don't have it either, yet I wouldn't really want to send them to do my recerts... Just a thought... :-)

This made me think....A sponsorship to EMTCity wouldn't go far wrong as part of the package you want to give him. There are more good resources available than he could ever possibly explore, but here he will have the advantage of a gazillion years of experience (some of our members are that old!), all in one place. I too think that it's cool as hell that that you are doing this. Perhaps along with the other things that you get him you could include the schedule for the Paramedic program from the local college? :-)

Thanks all.... To tell the truth the only way that I figured it sort of out as when I started Googling for the heavy metals used at the mine. He had no joint/skin aches/pain, no headache, no fever. Malaria was no where on my DDx. But shit, stroke scale neg, ECG neg, drug test Neg, BGL WNL, suspicion of heavy metals dropping on my DDx, pain free, afebrile, vitals WNL (no, doesn't mean I didn't look), no sig history, no meds, no allergies, etc, etc.... Then decided that malaria was huge here, so just lobbed a hail Mary and gave him a malaria test and it was positive! If that sounds smart, it wasn't really, it just happened to be the only test left in the clinic that I hadn't given him yet. But the symptoms didn't match...so I started searching for things that might fool a malaria test, and that bumped me into rereading about malaria, and then I stumbled onto the cerebral malaria, and though it didn't seem to be a perfect match, I went and got the LN medical manager out of bed and brought her in. I'd not done it before because I didn't have any malaria symptoms, and the level of medical care here is very primitive so I didn't think that she's have much to offer with concern to a neurological patient.. But she said, "Oh yeah, this is cerebral malaria. They often present like this. His liver is hurting him, that is why he keeps trying to touch it. The parasites can make the liver very sore. It is in his brain now. We will treat it, probably he will be ok...or he will die. We'll see....." This clinic sees about 3-5 malaria cases per day, though most are not cerebral, and most from PNG have such a heavy resistance that they get little more than mild flu symptoms. They are experts so I let them treat him. I don't remember the meds. Two vaccinations and some pills, a Litre of fluid and off to bed. 12hrs later his mentation issues had resolved, but he had a gnarly fever.... They gave him another injection the next day and sent him on the bus to Lae...that was the next bus leaving... chbare I was pretty sure that you would get it figured out, but was also confident that you wouldn't queer it until the learning had been gained... You know what's funny. I'm not religious, but I do have some weird theory about energy and such. But I remember earlier in the day thinking, "Man, I'm in charge of training, but they don't seem to know anything really. Where in the hell do I start?" And then, as often happens, the EMS Gods came and kicked me in the gnads and I had to be saved by the folks that 'don't know anything.' Such is my life in EMS...

You know what helped me? Remembering that I chose a career where people call me for help. That I've chosen to be the highest level of care on a call, and that getting nervous retards my ability to provide the best care that I can. That I've given up my right to feel that way. It sounds silly of course, but I believe that it's true. You worry about how you'll look, what the OR staff will think, whether or not you'll succeed..and that is all very indulgent, selfish thinking. You have no right to think like that any more, right? The ER staff is going to respect you if you go into your clinical with non arrogant confidence, with a belief that you will do all in your power to succeed and if you find that you are unable, that you will lateral to someone else at the appropriate time. And then ask them to explain where you went off into the ditch. Just like a real, live, paramedic. You MUST stop worrying about what other people think, and you MUST stop considering failure or you will second guess every decision to the point of being impotent. Now's the time to decide if you really want to be a paramedic. And if you do, take a deep breath, focus on your tasks, remove all of the nonsense, and go in and get your tubes. People that shouldn't have the right to carry your bags have been doing it for ages now...you can do it too. Ok? See? Simple... :-)

Could you explain why you chose to go with that? And no, no blow gun injuries noted... :-)

Yeah man, excellent question. It is, and lots of it. But that's not it either. And for the record, this is one of those scenarios that pisses many people off because 'they never happen.' Four hours to the closest hospital, I'm the highest level of care on scene, no chance of a chopper, and high winds have misaligned the satellite dishes so there are no phones. For some reason there was internet, and I used the hell out of it. The first thing that I did was Google the materials used in gold and copper mining...No love there...

No man, no chance as it would be expensive... Those that have worked remote will understand why it's not going to happen, but this is one of the rare times when I'm actually going to channel my inner Babs and not say something out loud... Negative to all but the malaise, as I might describe the 'muddy feeling' in such a way. But perhaps I'm using the term incorrectly. I'll give you a hint, though it might be too big... Doc: "Any recent stings or bites?" Dwayne: "Not that he's aware of."

Gotcha. And that is this area, if you're referring to cannibalism. It's my understanding that it's still common, though dying out. Man, amazing thought, but again in hindsight, I can say that this is not the issue. But, that type of geographical reasoning is going to solve this problem..at least it sent me in the right direction.

I'm not sure what you mean by nervous system matter Doc. Possible I guess. I didn't explore that. But can say in hindsight that that isn't the issue. None that the patient is aware of, though I didn't strip him and search for myself. That is part of what had me thrown, is that he's 'tweeking' but doesn't seem to know it. As soon as I saw him I knew it was drugs or sugar, but was able to rule both out. I couldn't trip him up mentally in any way. Dwayne is a hard name to remember, so I gave it to him, asked him all of the standard mentation questions, then my name, and he said it without hesitation. Edit: The reason that I mention this is that I believe that if he'd had any such issues that he would have been competent to report on them. It's a quandary...

It's unlikely. But if so, the tribes actually have a very low incidence of food born issues, if that's what you mean. They've lived as they do for so long that most of the nasty stuff can't sneak past their immune systems.

It varies between patients, but I've been told by a doc I contacted after between 5-15 days. All unremarkable. He at once claims that he's not fidgeting, and then next says that he can't stop and doesn't know why. Though he really doesn't seem to notice that he's doing it. I believe he started answering "I don't know" because I kept asking him and he was tired of saying, "I'm not." Pt states that his skin, muslces, joints, have no discomfort, no headache, dizziness, loose stools. No discomfort of any time other than his chest/insides feeling muddy. And he keeps wrapping his left arm around to his right upper ribcage, but again, claims he's not doing it when asked. Facial expressions are strange...think tweeker. Excellent questions, as I've run into people chewing beetle nut here and it can present wierd. But it also stains the teeth and lips bright red. None of that here. I truly explored this exhaustively, to the best of my ability, as i didn't have a friggin' clue where to go, and couldn't find anything out of the ordinary. He at the mess hall food same as the rest of us. I even gave him a drug screen. Negative.

Good on you man! I think that's cool as hell... You're going to get a bunch of responses likely about buying him books instead of junk. And the sentiment is right, but I know that's not what you're looking for. When I was a new basic, nothing made my nipples hard like the thought of a new, good stethoscope. The problem with that is that a good one is over a hundred bucks and they tend to grow legs and walk away. One of those nifty over one shoulder backpacks would be good. Perhaps you can have it personalized..but not with anything that is giant and screams EMS, or people will laugh at him. But he will want to take his own stethoscope to work likely, some reference books, some snacks...in fact I wish I had one right now!! Just a thought... Dwayne

This is an open pit gold and copper mine in PNG. No testing on site that can't be found in an ambulance. I don't believe there is any thing more than that at the hospital with the addition of xrays. Treatment would have to be done in Port of Morsby, but that's not going to happen for this patient. The patient is in finance, so should realistically have no direct contact with the metals. Water standards are monitored fanatically, not only for camp safety but as part of the contract for the local tribes to assure their water is not being damaged by the mining. Valium. Yeah, I'm not sure why unless they suspected anxiety. Which was at the top of my differential originally. That treatment was 10 days past. Though I see where you're going, that can't really be assumed. Many of the places that I've been the locals have believed that a cool breeze, from the air conditioner or a fan causes untold numbers of seemingly unrelated pathologies. This patients said, 'I thought that if I could just poop, or fart, that I could get rid of the toxins and I'd be ok." Pooping and passing gas had no effect on symptoms. The point being that their diagnosis likely has more to do with their opinion of 'bad air' than the patient symptoms. The same diagnosis would likely have been offered for hair loss, runny nose, acne, and pregnancy. Oh, probably not pregnancy. Mine too.... No symptoms of the nails. No chance to get this patient tested for it, as mentioned above. But, I'll tell you this, that if you don't figure this out that this patient will almost certainly die. Dwayne Edit: In case you're thinking that this is some sort of freakish Nigerian Butt Slug answer or something..it's not. Though it made me a little batshit for a bit. I did ultimately figure this out on my own. Just so's you know I'm not cheating.

And you know what's amazing? The fire dept is going to come out and rally the public because 'the evil ambulance company is stealing our jobs!!' without ever mentioning that the jobs were cut not because they were stolen, but unneeded. Should other depts follow? Well, I'm not going to dignify that with a response! (Just kidding brother. Knowing you I know it was rhetorical.)

I'd considered that too....But how to know? Next level of care is the Lae hospital, about 4hrs drive from here. No chance of getting a helicopter for this patient. Think of the least sophisticated rural bandaid station hospital, and then go below that about 30% and you'll have an idea of the level of care there. Not trying to be facetious, or disrespectful to them, but accurate.

I'm going to try and get better at posting scenarios, and maybe others can too? They're so valuable... 22 year old male Papua New Guinea native. Coworkers call to say that he's been acting strangely since lunch. He's fidgety, turning the ceiling fan off and on, he seems to be making strange expressions with his face. Four or five times/min he reaches across with his left hand and seems to be grabbing his right ribs. Today he was working in the 'gold' room. I'm unclear exactly what that is other than it's super secure and because of that his coworkers complain that 'the air is sick there.' It also requires him to stand on hard concrete with very little movement for nearly all of 12hrs, which they also believe causes this type of sickness. They said that they were going to bring him to the clinic themselves but when they tried he claimed that he couldn't walk. U/A pt is seated in his office chair in the accounting office. He's a 27 year old male, well groomed, appears in good shape and well nourished. He focuses on me when I enter the room with a good humored, though distracted affect. He has no trouble understanding me nor responding in clear, appropriate speech. Sitting in his chair he's unable to sit still. There are two water bottles on his desk that he keeps arranging in different places, switching their places, standing up and putting in his pockets, then back on the desk and sitting down. When he stands to put the bottles in his pocket his balance seems intact and the next time I ask him to sit in another chair across the room and his gait is even and confident. Skin is P/W/D/Afebrile, pulse 62/full/regular, b/p 156/106, resps 16/full/clear all fields, pt appears, and reports, being atraumatic globally. No daily meds, no traditional treatments, no significant history other than being in the clinic 10 days past with difficulty breathing. He was sent out to a local hospital where they found nothing conclusive, no allergies. What do you think is going on? Dwayne

Each of these errors would have been avoided had they just followed the tenet of patient advocacy first...even if it means getting jammed up later. What kind of a douche stays on scene, for any reason, with a traumatized, intubated child in the ambulance? I don't care if the President gave that order...the baby is going to the smart people at the hospital. I can't even imagine the level of care delivered by a medic that would have even a moments quandary over that. Dwayne

As the Doc said, IFTs are often really sick, plus they often know much about the conditions that they suffer from then you ever will. Don't miss the opportunity to learn from them! They are often so used to people transporting them like cattle that if you show interest they appreciate the opportunity to teach as well as allow you to practice and learn. The phrase, "What can you tell me about your condition that they didn't teach me in school?" will serve you well. And SEE them. They have names, and fears, and hopes, and broken hearts. You need to add those things to your assessment if you're going to have a complete patient picture. I was once transporting a "cutter" from the ER to a psych hospital. She had 4 full thickness lacs to the anterior forearm approx 8" long. There had been exposed muscle tissue in each. This isn't one of the 'scratches' suicide attempts. I asked her, "Babe, (don't use babe, it's unprofessional and...well, you know) what don't I know about what's going on with you today? What can you teach me today that will make me better for the next person that I'm called for?" She said, "That it's not about attention. That cutting feels so amazing because it makes the pain come to the outside of me for a while. That having painful arms, but a quiet head is almost orgasmic." That changed the way that I looked at her, and all like her, forever. Feel their pulses, all of them! Listen to their lungs, notice what their skin looks like, ask about their conditions. How did they first know that they were sick? How did they progress? What kind of complications do they suffer that might not be obvious? I don't think that I've ever done an IFT that a patient didn't teach me something new. Denny, you're going to be really good at this brother. But now that you're actually working, you're going to daily face the most massive challenge of your career. Not allowing people to convince you that being callous and disinterested is the way that you show competence. That being different, within logical, intelligent parameters, is bad. I'm not even in the top 70% of the smartest people here, or in my field, but I often find things, and I believe, give more competent treatment than many of my peers because I choose to not only asses each patient to provide care, but try and learn something new from each one as well. With that attitude you'll discover some surprising things that you never expected. Good luck my friend...keep us informed, ok? Edit: And don't forget that like you, many, many people will follow here that will wonder what it's like to start a new EMS job. As it's now your responsibility to be continuously learning, it is equally your responsibility to teach those that come after you. Post and allow them to learn from you while the experiences are still fresh in your mind. Dwayne

What happens in Vegas stays in Vegas....Just sayin'... Love you too Brother.... Wanna start a pool on how long it will take someone to say 'get a room!?'

Yeah, leave it to a hosemonkey to be an expert on the automated BP cuff... Yeah man, I don't have any experience with it, but, and mentioned before, as long as it's sized right, I can't really see an issue with it. Did you ask the "preceptor" why it would not work that way, and if you could take 10 BPs of the guys comparing auto to manual? Dwayne

How does the flipped cuff reading compare to your manual?

Other than, as mentioned before about having a patients family member hold the fluids, it certainly hasn't been a regular part of treatment, but it has happened. We brought in an arrest on night in the Springs. The man's 30ish year old daughter and his wife followed us into the ER and were allowed in the resusc room. Approx. 20-25 minutes into ACLS the Doc asked the mother and daughter if they would like to help, and to my surprise the daughter jumped up immediately and said 'yes.' He taught her how to take over the BVM and she did a great job with the most amazed, focused look on her face. After probably another 10 mins the doc decided to cease resusc measures, explained his rationale for doing so, encouraged anyone in the room to speak up if they felt that there was anything else that they thought might be done, and ended by asking the mother and daughter if there was anything else that they thought might be done. They both said no...it appeared obvious to me that they were terribly grateful to be allowed into the process. After that I've once had a husband offer to do compressions on his wife, and another time a son offer for his mother, and both times I've accepted, and though I didn't follow up in any way, at that moment in time both of those decisions seemed to have been really, really good. Both family members seemed really focused, and much calmer than you'd expect, and both seemed more at peace when it came time to stop. Neither of these men were healthcare professionals. As far as taking over care of their loved ones, I would do all in my power to stop that. It's just not a mentally healthy option, and I believe that it's well accepted at least, perhaps been proved, that family members emotions often cause the delivery of less than optimal care. But to answer, no, I've never had a family member attempt to do so. At least not in any rational way. Dwayne

Then my work here is through....