things they didn't teach you in school

[DwayneEMTP]

...If you could do over would you have tagged her yellow or made the same decision based on the information you had at the time?

See, that's one of the reasons I'm glad that you're here..You being the only one to notice that there was a $64,000 dollar learning question hidden in that post...

Would you Yeti? Do it differently? How come?

Dwayne

[Lone Star]

A couple things that I learned in the field (under fire, you could say) was

1. what a disgusting feeling it is when you're doing CPR on an 85 year old female and you feel every one of her ribs either break or separate from one side of the sternum

2. We constantly hear about the patient expressing that 'feeling of impending doom' ("I think I'm gonna die!"), but they NEVER tell you about walking into a patients room or house and YOU getting whacked with that feeling of 'impending doom', and its so thick you could cut it with a knife....

I think what sucked the most about learning those two lessons, is that I had to learn them BOTH on the same call. Unfortunately, she didn't survive (even with ALS on scene)...yeah, that one tends to stick with you for a while....

[akflightmedic]

There are many things from that night I would do slightly different but only if I have the hindsight knowledge. On a repeat of this case, I would have scrutinized her slightly more based on the fact that every one I came to had serious injuries. I had open pelvic fractures, distended firm abdomens, bilateral long bone fractures, ALOC, chest pains, you name it...it was all there. She was the only one carrying on so why would I not suspect her as having internal injuries as well? Why would she be the only one who was a green out of the blacks, reds and yellows?

I actually stood over her and asked her to quit screaming because there were many people far worse than her. I said this to her twice that I recall...she was like a banshee.

Oh well...maybe I would have upgraded her, maybe not. Still hard to say until thrust in that moment again.

[DFIB]

Hindsight is a luxury we dont have. I was thinking that if she was the only green then an update would have had the same effect. Being tha last yellow is the same as the first green.

[akflightmedic]

I get that and I do not beat myself up over any of the calls I made this particular night. This case only stands out as it was one of the last times I worked with the greatest partner ever and was also my last MCI as a street medic.

I mean I could of added another one of those things they do not teach you in school is to double check where you lay your spine board when making access to a vehicle on the side of a highway buried in Florida dense, entangling vines and shrubbery. We had 2 bodies missing...found one right away, did not find the second one until the last patient was tended to.

We went to pick up our backboard which we had laid down as a plank to gain access to the rear of the church bus. The same plank which we all walked on back and forth unloading patient after patient.

Yes, the final missing victim was under the backboard...hope he was dead when I laid the board on him!!!

[txladymedic]

A few years of working overseas with limited resources has taught me to try to know every off label/alternate use of every medication you have access to. Knowing that Benedryl can help with nausea or that mag sulfate can help with severe asthma might save your butt. Of course those are just a few examples of medication uses that might not be in your protocols.

Don't just have one way of doing things. For example know a couple different ways of getting IV access. Don't limit yourself to hands and arms, I've put IV's in chests veins, feet, the head, upper arm, and ankle to name a few. Sometimes starting an IV bevel up works better on the elderly and children.

Think simple, cause sometimes simple works just as well or better than the complicated. Yea, the fancy toys are great but remember to treat your patient not the machine. You never know when a machine will break or you will work for a service that doesn't have that fancy widga gidga. Think outside the box!!

Another example of simple is while working in overseas we had a patient that kept getting a nose bleed and didn't have access to labs. The PA working with us said to stab his finger with a lancet and then touch his finger to an index card and keep doing it every 10 seconds until it quit leaving blood on the card, then count up the spots of blood on the card and then you had an idea of what his clotting time was and helped us rule out a clotting time issue.

ADVOCATE FOR YOUR PATIENTS!

That's all I can think of off hand but I'm sure I could come up with a few more if I gave it some more thought.

Sarah

[usalsfyre]

Airway management consist of more than an ETT

Subtle changes are often important, the difficult part is figuring out WHICH subtle changes are important.

Don't be afraid of opiates, the dangers are way overstated.

It's ok to give NTG without IV access. It's NOT ok to give NTG without an EKG

Take your suction to the patient. You'll use it more than you ever imagined.

Very few patients can't stand a liter of fluid

No matter how scared of foley caths you are, UO is a DAMN useful parameter to know.

[DwayneEMTP]

...Don't be afraid of opiates, the dangers are way overstated.

This is the one that makes me batshit crazy! "Why didn't you manage their pain?" "Well, they were old/young/fat/skinny/drunk (take your pick) and I was afraid they'd stop breathing." "Stop breathing? Wasn't the use of a BVM in, say, the first week of EMTB class?"

And I get even crazier when they try and turn their fear into a virtue. "I guess if you want to take a chance on killing your patients, then you go ahead! I'm hear to make mine better, not worse!" Wankers......

...Take your suction to the patient. You'll use it more than you ever imagined.

+5

...Very few patients can't stand a liter of fluid...

Man..this is another one. Nice.

Dwayne

[zzyzx]

"Your patient may not have read the same textbook as you."

What's wrong with your patient may not be as obvious as when you practiced scenarios in class. Look out for subtle clues. Also, your patient won't always immediately present as being obviously Big Sick. Be especially cautious with patients that are "slightly off" as that may be due to hypoxia or hypotension.

That said, it's hard to be perceptive when we run so many BS calls.

Somewhat related...

[Cougar]

We had a rather odd onel one last night. The call came in from a panicked party saying that someone's "belly button" had exploded and there was blood everywhere!." This is an EXTREMELY rural service and getting to the patient took us over 30 minutes. On the way we talked a bit about what might be going on. We heard on the radio while enroute that now the pt was bleeding from his genitals. Hmm, lets rethink this.

As we were talking we discussed the idea that what was "a lot" of blood to a layperson might or might not truly be a lot. We were thinking something ugly was coming up.

Instead we found a 62 Y/O male in semi-fowlers position with his daughter holding a towel against his umbilicus. There was only perhaps 20-40 CC of blood and fluid. Under the towel was what appeared to be intestine bulging through a tear in the skin. It appeared to be a spontaneous rupture and not the result of trauma. There was no bleeding from the genitals, the family had mistaken urine for blood when his pants became wet.

Pt. was quite thin with a distended abdomen, probably ascites. As far as management of the protruding intestine, we used direct pressure on an AB pad. Coughing or any movement on the part of the patient caused the extrusion to creep out more.

Although I know the umbilicus is a weak spot and people with ascites are obviously at risk, I have not read of a hernia actually tearing through the skin. I was most surprised at the treatment in the hospital. I was told this morning by a family member that they "shoved it back in and put a bandage on it and told him he should get surgery some time and sent him home." I would have thought that once viscera was extruding through the skin tear that it would need more immediate treatment. Has anyone else run into this sort of thing?