Not Dead, Just Resting

Wow.

I didn’t think it’d been five years, but yep, advanced mathematics confirms it.

So, real quick, just a very important link that’s been rolling around various other sites and social media:

“Dr Z” has addressed what most have called, until now, “burnout”, in this short video which is well worth your next six minutes.

While his focus seems to be with physicians, PAs, and nurses, I think it applies to us street grunts.

Dr Z makes a strong case that we who go into healthcare do so because we want to help people. It is NOT because we want to send people bills.

Speaking for myself, while we are all adults and understand that our institutions need to generate revenue, limiting patient care for the sake of churning out one more transport is absolutely NOT the way to go.

Years ago my colleagues and I formed the Medics of Anarchy. Stupid kid name, but, y’know, fun. We at the time were all involved in non-911 transport.

Our idea was this: Do patient care.

Yes, follow protocols. Yes, clear calls and don’t dawdle. But there is a way to do this and still provide quality patient care.  Even a simple patient transport should always be about more than just the vital signs. We should be checking our patient, and that includes more than just blood pressure and pulse rate.

If that takes a few extra minutes, so be it.

E-fun-ephrine

So the family went to King’s Dominion the other weekend.  As a teen, between 1975 and 1979  my friends and I went once or ten times every summer.  Roller coasters, flume rides, hideously overpriced food (we thought at the time – how little we knew).  It was fun.  But that was before EMS.

Now-me arrives with the family, and the first ride I get on is the Drop Tower.  Sit in your chair, which raises you to almost 300 feet.  Nice view.  Then it drops you.

During the second or two I fell, I thought, “Well, this is fun.”  But afterwards?  Meh.

The roller coasters teen-me had loved were worse.  Whether it started with a slow climb or shot like a bullet down a barrel, the initial “Whee!” was followed immediately by a feeling of inconvenience as the coaster turned, swiveled, looped and banked.  Each bump, jerk, twist, and abrupt change in direction, which used to elicit a “Wow!’, now annoyed me.  Like a scene in a movie where the main character is not enjoying a show, but is being constantly prodded and bumped by the popcorn eating fat man beside him who points and laughs and can’t get enough.  No, I’m not enjoying it, and you can’t make me.  When will it be over?

I reacted thus to every ride, when suddenly I had the terrifying suspicion that I might be getting old.  Isn’t this how old people react to these rides?  This is terrible.  I don’t want to get old.  Old people take cruises, and leave the ship to visit shoreline gift shops.

The more I considered this dire prospect, however, the more it became clear to me that while my body might be aging, it was not “getting old” that did in these rides for me.  It was physics, law, and mostly EMS.

Physics:

In my uninformed teen years, when I last enjoyed this sort of thing, it was because I suspected there was an element of danger.  After all, the TV ads played up the speed, the screaming, the terror.  That’s dangerous, right?  Dangerous and exciting, and fun.  One expected reporters and cameramen at the end of each ride. “My God, he made it!”  “Welcome back!”  “How did it feel?”  “Were you ever afraid?”  A teenage male steps from a roller coaster as a warrior steps from a longboat to the shores of a conquered nation.  Plant that flag and on to the next.

The truth was always there, but we chose to ignore it or, more correctly, were in ignorance of it – it’s all physics.  This weight going this fast exerts this force in this direction, plan accordingly.

This visit there was a particular roller coaster which was completely indoors, and mostly dark. Flight of Fear.  Just ahead of me, a determined ride attendant was bravely trying to secure a lap bar onto a woman who hasn’t had a lap in probably 20 years.  While the occupants of the cars around her ratcheted down their restraints with a satisfying tick-tick-tick-tick-tick-tick, the attendant grunted and shifted and struggled.  Finally, a single “tick” was produced, and he pronounced her good to go.

It occurred to me that the system *must* be designed so that the weight of the cars made the additional weight of the passengers negligible in the calculations.  The only way to make a ride safe is to factor in, say, a 10% margin of error and make sure that a 500 lb person is only 5% of the car weight – or whatever numbers the engineers used.  That, or these poor fools were doomed.  (They made it).

Law:

I vaguely recall that as a teen, the signs around a ride did nothing more than identify it:  “Rebel Yell”, for instance. Oh boy, here’s the roller coaster, Rebel Yell.

Now, there are multiple signs at each ride, giving one something to read while waiting in line.  Some of these signs I think are there for marketing purposes – there’s some sort of rating system such as ski trails use, the “black diamond” marking this as an Advanced Level Ride or some such.  Following this is another sign warning the usual suspects – the pregnant, heart patients and such – about possible injury.  “May cause dizziness”.

Standard fare, and I’ll be very surprised if sometime soon there isn’t a touch-screen with a camera that requires one to tap “I agree” and takes your photo doing so, to eliminate all liability to the park.  While you’re at it add a little note to the bottom showing calories burned on the ride, and remember to send me my royalty check for the ideas.

Still, where every convenience store aisle is now marked with a “Piso mojado” pylon, or else lawsuit, it is actually the lack of signs which nail home the lack of danger.  Everyone is quick to put up “Caution!”, “Warning!”, “Do Not Enter!” signs for the most trivial reasons.  Non-trivial, but let’s be realistic here, hospitals put “Caution!” signs on the doors of patients who have minor coughs.  It’s a hospital, I expect there to be sick people here, but thank you.

Now, to be scary all one has to do is remind people of their mortality.  I have heard that in the early days of air travel the larger airports had notary-publics available to sell you life insurance and notarize a quick last will and testament before boarding.  Add that, and I’ll take it seriously again.

Or not.  When the carnival comes to town, we have a team of inspectors trained to verify the safety of the rides – ferris wheels and teacup rides for the most part – but considering they’re assembled and disassembled every couple of weeks, I appreciate this.  How much safer a standing attraction?

EMS:

The price of my adrenaline seems to have gone up.  A roller coaster used to afford me a big vicious jolt of epi that had me grinning and shaking for the next twenty minutes.  That same coaster now only buys a moment’s worth of anxiety – is my cell phone safe in its case, or will it go flying off? – before seeing me back to my natural, mellow state.

What I saw as a teen:  Accept the Challenge, Traverse the Danger, Exit Victorious and Immortal.

What I see now:  Wait in Line, Get Tossed About, Get Out.

I explained this to She Who Must Be Obeyed.  “I get tossed around in rides every day, but there’s no guarantee that it’s safe.  I guess my adrenaline has a higher standard now.”  Come to think of it, when I was being tossed around on the first roller coaster of the day, my absolute first instinct was to turn to the right and tell the driver to take it easy – which would have been the correct orientation for a medic on the bench seat.

To underscore this, on returning home, I checked the news as I sometimes do and found that Rescue responded to another park that very day.  Even in failure the ride went from an entertainment to a mere inconvenience.  Every one of those passengers owes a debt to the engineers who designed that ride so well that it could completely fail and STILL not kill them.

In contrast, only a couple of days later we had a unit totalled as it was t-boned, responding through an intersection.  The AIC was injured (we would classify it as minor, but tell that to her) and the driver and patient were for the most part uninjured, thanks in great part to engineering.

That is the sort of ride that might get a little adrenaline flowing, certainly.

I suppose what I learned, at the theme park that day, was that for me, now, Adrenaline =/= Fun.  It’s something I suppress so it doesn’t get in the way of my thinking, and of my job.

Fortunately for me I don’t need to get amped up to have fun.  

Parcheesi anyone?

Did I tell you about the time…?

Our patient, c/c “chest pain”, was sinus tach and sprinkling PVCs like confetti.

We’re applying oxygen, he’s got some morphine on board, and we’re just opening the nitro when he codes, just as we get to the hospital.

We hit the ED doors running, pushing, bagging.

“Code! We need a room!”

“Room 4!” The charge is right on top of things.

We roll into room four. “On Three! onetwothree!”

Our patient is onto the bed, CPR resumes, bagging resumes.

The attending physician is a new guy, I’ve never seen him before.

“What’s the story?”

“68 year old male, chest pain for 1 day, took two aspirin 325 at home and called 911, sinus tach with PVCs on the way in, coded three minutes ago.”

“DNR?”

“Full code” Really? Didn’t he see us working the guy? But okay.

The attending says to the nurse, “Get RT down here, let’s tube this guy,”

To us: “Stop CPR. Let’s get a rhythm check.”

We stop CPR. The monitor shows little tremors, minor quakes on the surface of the heart. Some life left, it seems.

“Fine VFib,” the attending says. “Charge and shock”

A nurse grabs paddles, puts her hand on the dial. “What do you want to charge to?” she asks.

The attending seems to consider it.

“Oh, I think he just need about tree-fiddy.”

“I’m sorry?” the nurse said.

“He need about tree-fiddy.”

Well, it was about then that we noticed the attending was a six-story tall crustacean from the Paleolithic era.

“Dammit, monster!” I said. “We ain’t chargin’ to no tree-fiddy! In this ED we *work* our patients! Ain’t no protocol for tree-fiddy! Monophasic, bi-phasic, ain’t none of them call for tree-fiddy!”

Sorry…

New App – Rampart BLS

A new app has been submitted to Google Play and should be appearing shortly.

Rampart-BLS is a BLS  scenario emulator.  PLEASE have one of the many fine, natural-sounding voices (such as IVONA or SVOX) installed on your Android device!

In this app, you are the ED doc or OMD.  Your EMT-B is calling from the scene and requesting medical direction.  Tell him (or her, depending on the Android Voice – installed separately) what to do:  Get vitals, splint, hold c-spine, etc.

The app is designed for EMT-B students, to give practice in acquiring SAMPLE, OPQRST, and DCAP-BTLS information, as well as head-to-toe assessments and vital signs.  There are 29 scenarios by default, and a built-in scenario editor so you can change things or even add your own – no limit.  An optional Debrief mode will provide feedback at the end of the scenario, letting you know how you did.  The app runs in standard phone mode or speakerphone mode.

The full help file (available in-app) is reprinted below.

 
A simple little scenario operator for EMT-B students.

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Quick Start

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Start the app right away by pressing the “Play” button on the main screen, OR you can change things around first.

You can pick a scenario by:

• Tapping the Scenario # box and selecting a scenario;
• Swiping across the main screen, left (next scenario) or right (previous scenario);
• Selecting Menu -> Previous or Menu -> Next;
• Selecting Menu -> Random;

Once you have a scenario selected:

• Use the sliders on the screen to control how fast the EMT-B speaks, and how many seconds you have until a response is required. You can adjust these at any
  time, and they take effect with the next sentence.
• Tap “Debrief” in the upper right corner to toggle post-scenario debriefing.

Once you’ve clicked the Start Scenario (Play) button, guide the EMT-B on the phone through his emergency. He’ll explain the situation and ask for orders. Tapping the
“pause” button will pause the scenario after the EMT finishes speaking. Long-press pause to interrupt the EMT and pause immediately.

Your EMT won’t do anything you don’t order. In general:

• Consider the chief complaint;
• Order immediate interventions, if necessary;
• Have the EMT-B get SAMPLE information;
• For medical situations, have the EMT-B get OPQRST information;
• For trauma scenarios, request DCAP-BTLS information;
• Direct the EMT to apply secondary interventions (O2, splint, etc.) as appropriate;
• Direct the EMT to transport the patient

There are certain criteria common to every scenario:

• Some patients may have prescriptions (Epi-pen, nitro, etc.) but NO patient will have taken medication prior to the EMTs arrival;
• If you order activated charcoal, for scenario purposes you have already spoken with Poison Control and that is the correct action;
• All patients will agree to be transported;
• Don’t forget Scene Safety and isolation precautions!

Telling the EMT to transport the patient will end the scenario.

This app is meant to reinforce good BLS skills. As such, you are required to do things a bit differently from “real life”. For instance,
if the patient in the scenario is a stabbing victim, you can’t just ask, “Where is he stabbed?” or “Is he bleeding anywhere?”. Instead, you should conduct
a proper head to toe examination of the patient. You can’t ask, “What are his vital signs?” but must instead request BP, heart and respiration rates,
breath sounds, etc.

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Debriefing

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At the end of a scenario, if Debrief=On, you can press the Play button and get a screen which roughly shows how you did. If there was information
you remembered to check (ostensibly by following SAMPLE, OPQRST, and DCAP-BTLS) it is green; stuff you missed is red, and stuff you didn’t ask about
but was blank anyway will be greyed out. Debriefs are not stored, but you can “long-press” anywhere on it and bring up a share dialog, allowing you to
email it (to yourself, if you like) or send it elsewhere.

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I need more time!

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After the EMT speaks, a countdown timer appears (controlled by the “Your Reply in…” slider). If you need more time to think for this particular moment,
at the beep tell the EMT to “Wait”. If you continually need more time, adjust the slider to the right or say, “Slower”.

If for a particular exchange you don’t want to wait until
the countdown has elapsed, just tap the timer and the EMT will be ready for your input immediately. You can say “Faster” at the next beep or adjust the
slider to the left, too. You can change the default countdown time in Menu -> Prefs.

Tapping the “Pause” button or saying “Stop” will put the EMT on hold, without a timer. Take your time and consider your next move. Tapping “Play” again resumes the scenario.
If only a minute or two has gone by, the EMT will immediately listen for your next command. If it’s been longer than that the EMT will repeat the
scene size-up as a refresher.

Saying “Restart” will clear everything you’ve done and restart the scenario from scratch. This is useful if you pause the scenario, make changes,
and want to test them out.

If you’re using this as a group to augment training with a manikin, you can easily control the volume with voice commands. Saying “Louder” will raise
the volume; the command “Softer” will lower the volume. The command “Shout” will set the volume to your device’s maximum (this might be too much on
some devices – use cautiously). Your normal hardware controls will also adjust the volume.

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Everybody’s Staring

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Tap the Speaker icon to the left of the Play button to toggle between speakerphone and regular phone mode. That is, you can run the app
with your device laying on the table, or you can hold it to your ear for more privacy. Sometimes, especially in noisy environments, using phone
mode results in better speech comprehension.

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Premise

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On the American TV show Emergency! (1972-1979), the intrepid paramedics Roy and Johnny would be toned out for a call.
Arriving on scene, they would invariably remove their
trusty BioPhone and call up Rampart Hospital, where the on-call doc would guide them through the process of starting an IV
D5W and transporting the patient.

This app is for the budding EMT-B. It places you in the position
of the Rampart docs. Your EMT-B is calling from the scene and asking for instruction.

Your EMT can be ordered to:

• Confirm scene safety;
• Assess the patient (area-by-area);
• Take vital signs (BP, pulse, etc.);
• Check blood sugar;
• Start CPR;
• Provide oxygen;
• insert OPAs or NPAs as needed;
• Use an AED;
• Ventilate with BVM;
• Control C-spine;
• Immobilize extremities (splint) or patient (backboard);
• Assist the patient with Nitro, Epi-pen, or MDI;
• Administer oral glucose;
• Administer activated charcoal;
• Control bleeding;
• Transport the patient

Note that this app assumes a rather strict list of interventions appropriate to the EMT-B level – your protocols may allow you to do things this app will not,
out of the box. You can add stuff, though – we’ll get to that later.

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Hearing Voices

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Your EMT’s sex and age is dependent on the voices installed on your Android device, and which voice is “default”.

Complete instructions for adding, removing, updating or changing your device voices is beyond the scope of this app or help file, and varies
with the version of Android your device is using. Consult expert web assistance to add or change voices.

The app was developed and tested using SVOX Victoria UK English, SVOX Grace US English, and IVONA Amy UK English, but other voices are out there and should
work as well.

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Them’s Fightin’ Words!

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One of the permissions required by the app is Network permission, so the voice recognition in Android can communicate with Google. It is
Google which returns what you said (or what it thinks you said).

If the app doesn’t understand something, it may sometimes ask, “Sorry did you just say…” and read back what Google supplied.
What Google supplies is sometimes WAY off the mark, and can at times be offensive. Just puttin’ that out there, it wasn’t us, honest.

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Sample Play Dialogue

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(Player hits the PLAY button)

• Medic 52 here. We’re at a household where a mother suspects her toddler of eating cleaning agents. What are your orders?
• Hold old is the patient?
• The patient is 3 years old.
• Is this patient male or female?
• The patient is male.
• Is the patient awake or alert?
• He’s alert and oriented times 3.
• What’s his pressure like?
• BP 120/80
• How about breath rate?
• He’s breathing 30 times a minute
• Okay. Put him on oxygen using a non-rebreather at 10 liters per minute.
• Okay, he’s on oxygen. What next?
• Check the patient’s heart rate, please.
• Pulse is 80
• Is he allergic to anything?
• He has no known allergies.
• Does he take any medications?
• He was taking Tylenol last week for a fever, but no current medications.
• Listen to his lung sounds, please.
• Breath sounds are clear.
• Check the patient’s abdomen
• His abdomen is unremarkable
• Okay. Well, go ahead and bring him to the hospital.
• Okay, see you in 10 minutes.

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Menu stuff

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	Newer devices are moving away from
actual keys. If your device has a menu button, it should work, or you can use the icon. Here you have alternate ways to go to the next or previous scenario (you can also do this by swiping left/right on the main screen), select a random scenario, or edit the current scenario.

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Doing Things Your Way

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This app will work “right out of the box”, with about 30 scenarios ready to go.

The Edit area allows you to add new scenarios or change existing; you cannot delete scenarios from here. If you really don’t like a particular scenario,
just overwrite it. Make as many changes as you like. Go nuts.

Pressing Menu -> Edit brings up the current scenario for editing.
On the left are the key values. Since real-life scenes can get weird, very little data validation is done during data entry. For instance, no
attempt is made to validate a blood pressure. You can set it to “120/80”, “50 over palp”, or “He’s dead, Jim.” It’s all good.

All changes are made
to a “sandbox”. When you’re done editing, you need to press Menu -> Save to actually save the changes. If you wish, you can exit the Edit menu
and run through the scenario with your changes first to see if you like them.
Most items on the edit screen are self-explanatory, except perhaps BGS (background sounds, and now it’s clear.)

So, you’ve got scenario #1, female abdominal pain. She’s 36 years old, but you want to make her 99. Menu -> Edit, tap the age, enter your
desired number, click OK. This puts your change into a sandbox. Back out and hit PLAY to try it out, or not. Menu -> Save to keep the change.

If you leave heart rate blank, your EMT will report “no pulse found”. A blank BP will get you some variant of “blood pressure is unobtainable.” Take
a moment to look through any scenarios you edit or it could get confusing when your alert-and-oriented patient has no heartbeat. That being said, most
items can be left blank, and the app will fill in a suitable answer.

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Revealing Patient Problems

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When editing certain fields you’ll find a button near the bottom of the screen, “Reveal…”. Clicking this presents you with a list of problems the patient
might have. You can add one or more of these to any field, such that the problem is revealed, and can be dealt with only after the user gets information from
this item.

For example, if you have an assault victim, perhaps he’s bleeding. Bloody clothes, etc. However, it would be “cheating” for the player to just tell the
EMT to “control the bleeding” as soon as he knows it’s an assault. You haven’t found the bleeding yet. In Edit mode, let’s say you tap EXAM_HEAD.
Tap the “Reveal…” button and select “BLEEDING”. Now, the player has to explicitly check the patient’s head before he’s allowed to “find”
the bleeding. Trying to control bleeding before finding it won’t work.

For those situations where a problem is fairly obvious, put the Reveal item in the scene size-up field, SCENE, which is automatically
spoken at the beginning of each scenario. That is, if the SCENE field tells the player that this is a car-crash, put “SPINAL” right there,
so that taking c-spine precautions is allowed right off the bat. Follow good EMT-B rules of judgement when disclosing Reveal items in the SCENE field.
Rule of thumb: If an intervention would be obvious when you roll up or walk in the door, it should go in SCENE.

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Background Sounds

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The BGS field allows you to place background sounds in a scenario. Editing this field will bring up a file selection dialog. You can select any sound
on your device. The background sounds available from the app are:

airport	nightclub
construction site	office cubicle
department store	opera intermission
grocery store	restaurant, crowded
gym/indoor pool	shopping mall
highway, dry	sports event
highway, wet	train station
hotel lobby	TV on, cartoons
nature trail	TV on, gameshow

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Look, Ma, I’m a programmer!

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The built-in editor gives you a handy way to make modifications to each of the scenarios, or to create your own from the ground up.

The Prefs menu item allows you to set certain things to a default startup value of your choice.

If you’re feeling adventurous, you can do more. You’ll need one of the many fine, free SQL editors available in the Play store.

With an SQL editor you can customize this app. The scenarios, the recognized words, the commands your EMT can follow, almost everything is located
in an SQL database, “dtsemt_emtb.db”. You don’t need a lot of skill to make changes.

Depending on your device, your memory card, and permissions it could be in one of several places, but
a likely location is on the external card, in /Android/data/com.dtsemt.rampartb/files. You do not need root access to change this file.

Opening this file with an SQL editor gives you access to almost everything, and a little look-around in it should show you how. Sort the records
alphabetically by key and the instructions for making changes precede each section.

If you completely trash the file, no worries – just uninstall the app and reinstall from Google Play.

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Suggestions

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Disclaimers and all that jazz is on the Menu -> About page.

Comments made on the app Ratings area are NOT automatically forwarded to the author!

This is Betterware; if you can think of any way to make it better, please send suggestions to DTsEMT@gmail.com.

Clicking an ad link once in a while helps to keep this app free.

Thanks!

New App – Parkland

Available on the link to the left, or in the Google Play store: https://play.google.com/store/apps/details?id=com.dtsemt.parkland

As usual, completely free, and ad-free.  Calculates fluid resuscitation requirements based on the Parkland formula.