Rules of EMS, Part Two

Rules of EMS, Part Two

Posted by kellyg in Genera
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1. You fall, you call, we haul, that’s all.
2. There are two kinds of EMS calls: “Oh, shit!” and “Bullshit!”
3. When you join the kidney club, you usually cannot go.
4. Common sense isn’t.
5. The more reflective striping there is on your jumpsuit, the easier it is for the only drunk driver going by the MVA to find you.
6. If you have a ride-along you want to show the real world, nothing will happen that shift.
7. 95% of the time, EMS is simply thwarting the process of natural selection.
8. Just because you’re paranoid doesn’t mean your supervisor is not around the corner.
9. You can’t cure stupid.
10. If at all possible, avoid any edible item that firefighters prepare, especially the tuna casserole.
11. Heaven protects fools and drunks.
12. We are all slaves to the god “Motorola.” And that god requires sacrifices of hot food at least once a shift.
13. The address is never clearly marked.
14. Avoid bringing your patients to teaching hospitals in July.
15. EMS doesn’t save lives. We only postpone the inevitable.
16. Even sterile water tastes great on a hot day.
17. The stereo must always be louder than the siren.
18. At the beginning of your shift, your main O2 tank, fuel tank, and stomach will be empty…but the call volume will be full.
19. You know you are in trouble when the directions to a patient’s house include, “Turn off of the paved surface…”
20. Anyone with a tooth: tattoo ratio of less than 5:1 is guaranteed to be drunk, on drugs, or both.
21. Anyone with more than five listed drug allergies is automatically a psych diagnosis.
22. Avoid hospitals with Saint, Mercy, or Memorial in their names. And St. Mary of Mercy Memorial Medical Center is a definite no-no.
23. All arrhythmias eventually straighten themselves out.
24. Dead is dead, leave it at that.
25. Your seriously ill patient will miraculously get better after five minutes in the ER. We call this “fluorescent light therapy.”
26. Periodically, aliens will abduct your patient and replace him with an exact duplicate with a totally different chief complaint and set of symptoms. This usually happens right after you call report.
27. Don’t get excited about blood unless it’s your own.
28. The pain will go away when it stops hurting.
29. If nothing has gone wrong, you obviously don’t understand the situation.
30. You should always stop CPR after the second “ouch!” from the pt.
31. People don’t call an ambulance because they did something right.
32. The quickest way to gather the relatives is to leave the primaries on while at the scene.
33. Every nurse is right, as long as you are in their E.D.
34. When in doubt, always take another set of vital signs.
35. If your patient is violent, you can always use topical oxygen therapy. The green paint usually wears off in about a week.
36. The larger the house, the furthest from a door the patient will be, and the sickest patients are always in the back bedroom.
37. If the patient fell and was moved by the family, they will have moved them so that climbing stairs will be involved.
38. The furniture will always be arranged so that a stretcher or stair chair will never fit easily.
39. The problem won’t be that bad until a major disaster strikes: “You’ve had chest pain for three days and you waited until the middle of a blizzard to call?”
40. History never repeats itself. This is never more apparent than in the E.D., when the nurse asks the patient the same questions you did five minutes ago.
41. You’ve never been as sick as just before you stop breathing.
42. If someone is pointing a gun at you, two things become apparent: 1) You should have waited for law enforcement; 2) You wish you just hadn’t made that wise-assed comment.
43. Fellow medics always have a better story than yours.
44. Just when you say, “You know, I have never had a hanging….” you will get one.
45. The only time you go out on a limb (as a dispatcher), and not provide coverage so a crew can eat, a serious call will come in that area.
46. The only time you need to fart is when you have your patient loaded in the elevator.
47. The only time your pants split is when there are gorgeous police officers there to assist you.
48. You will get caught sleeping, eventually.
49. Never say the kind of call you are in the mood for in the beginning of the shift, because you will get it in the worst way, i.e. an MVC in the pouring rain.
50. God made Paramedics and EMTs to give him a chance to change his mind.
51. Beware when a firefighter says, “Y’all check this out.”
52. Your driver will never hit a pot hole or curb unless your patient has a bad fracture.
53. The worse your patient’s breath, the more quietly they will talk, forcing you to lean very close to hear them.
54. If ever in doubt of which house you were called to, look for the stairs.
55. If there aren’t nurses around when you get called to a nursing home, go to the last room in the hallway. That’s always where the sickest patients are.
56. Never start putting your stuff away before you are told to go home, because you have just given yourself another call.
57. When in doubt, let your partner handle it.
58. When getting a TMJ (too much Jesus) call on a Sunday, never say it around your patient. It sucks when you have to tell them what it means.
59. If the patient pukes, it is not unprofessional to puke along with them, it is sympathetic puking. You have something in common with your patient and can relate to how they feel. This is why they made the big step well by the side door.
60. If the patient only moans when you listen to lung sounds, they aren’t as sick as they want to be.
61. If a patient calmly tells you they are going to die, you had better believe them.
62. When the patient is really sick, remember that the ambulance has wheels for a reason.
63. 911: The government’s answer to Dial-A-Prayer.
64. The more addicted your patient is to morphine, Demerol, Fentanyl, etc…. the more allergic they are to Toradal.
65. You can have circulation with no breathing, but you can not have breathing with no circulation.
66. On trauma calls, survivability is inversely proportionate to social worth.
67. How you know an unconscious is a DOA: 1) If it weighs over 300 pounds… DOA; 2) if it lives more than three flights up in a walkup apartment… DOA; 3) if it’s less than 30 minutes left in the shift… DOA.
68. EMS providers know how to say “got shoes?” in 7 different languages.
69. At haz-mat scenes, remember to use the Copological Indicators: If the stripe on the officer’s trouser leg is vertical, it’s safe to go in. If the stripe is horizontal, wait for the haz-mat team. At a gas leak, send the cop in with a lit road flare. If the cop passes out and the flare goes out, it’s an asphyxiant. If the cop explodes, it’s a flammable.
70. Never go past the first dead cop.
71. There will be no dying or multiplying in the back of my unit.
72. The worse you have to use the restroom, the farther the distance it will be from the location of the call to the hospital.
73. If you haven’t yet had to use a patient’s bathroom… you haven’t been in EMS very long.
74. Some people can do this job, some can’t. Pray your partner is one who can.
75. All rhythms will eventually degenerate into one you will recognize and can treat.
76. If God had intended you to have a rapid response to the call, you would have been parked in front of the location.
77. Upon arrival at a code, check your own pulse first. If it is still there, everything else is easy.
78. As soon as you finish cleaning the rig up for a parade, you’ll have to drive ten miles down a muddy, unpaved road for a difficulty breathing.
79. If you ever go to a call and find the cops laughing on the front lawn…worry!
80. Remember, it’s the patient’s emergency, not yours. Try to keep your pulse rate lower than theirs.
81. If you drop the baby, fake a seizure.
82. The most effective prehospital fluid for trauma patients is a diesel bolus.
83. Sometimes people will die despite our best efforts.
84. Dead people very seldom get any better, but they never get worse.
85. “Can you walk? Have you tried?”
86. If EMS workers never eat, sleep, or go to the bathroom, nobody would ever get sick or injured.
87. Better to be looking at it than looking for it.
88. Go to work expecting to get screwed. You will occasionally be pleasantly surprised, but you will never be disappointed.
89. The size of the IV needle and the number of attempts is directly proportionate to the patient’s attitude.
90. All people eventually die.
91. If there is a God, you are not him. This even applies to paramedics.
92. The patient’s need of medical attention is inversely proportional to the amount of noise he/she is making.
93. If the patient says she’s in labor, it’s a UTI. If the doctor said it was a UTI, break out the OB kit.
94. If she says the baby is coming, believe her.
95. If a patient presents you with a problem you don’t know how to treat, change it into something you do.
96. All bystanders, and the majority of your patients, have more medical training, experience and knowledge than you. And they’re never shy about offering advice.
97. The best way to make a bystander go away is to ask for help.
98. The amount of vomit produced always exceeds the size of the container by at least a factor of 2.
99. The seriousness of an injury is inversely proportional to the number of escorts wanting to accompany the patient to hospital.
100. When your patient says, “I’ve called my doctor, and he’ll be meeting us at the hospital,” this actually means, “I am a hypochondriac and my doctor doesn’t have caller ID.”

Preparing for gastric bypass surgery by eating more

by Douglas Perednia, MD

Thinking is hard work.  This is why so few people bother.  At least voluntarily.  So whenever it seems like the threat of brainwork looms in modern American medicine, we can thank our lucky stars for the geniuses behind healthcare reform and guidelines of care.

This comes up as a result of a conversation that I had with a patient the other day.  A pleasant, obese gentleman.  He had been struggling with his weight and type 2 diabetes for some time, and there were now some early indications of some potentially serious long-term complications.  He mentioned to me that he was working hard to prepare for gastric bypass surgery.   I asked him how he was doing that.

“Why, by eating!” he replied.  Huh?  By eating?

“Oh yes”, he explained.  “You see, I’m getting these complications from my weight and diabetes and all of my doctors think that I’m an excellent candidate for weight loss surgery.  Based on my previous weights, if I can just get lose about 40 or 50 pounds, I should have much better blood sugars and need far less insulin.  God, that stuff is expensive when you’re using hundreds of units per day!”

That sounded perfectly reasonable.  This gentleman is a walking advertisement for the virtues of slimming down.  And for gastric bypass, in fact.  So why is he holding that venti whole milk mocha with 508 calories and 27 grams of fat?

“Oh, this?”  He looked a bit sheepish.  “Well the problem is that the surgeons won’t operate on me yet because I don’t quite fit the guidelines they have to follow for doing the operation.  Insurance won’t cover the surgery until I reach a BMI (body mass index) of 40, and I’m a couple of pounds short.  So I have to gain the weight and have them document that I’ve reached the magic number.  Then I’ll actually lose the weight again when they put me on the special post-surgery diet to make sure that I can tolerate it.  If all of that works out okay, then they’ll schedule the surgery.”

Now I realize that I’m revealing some age here, but in the old days we would have looked at the patient, considered his history, physical condition, social situation and medical compliance, and decided whether the surgery was indicated and likely to be beneficial based upon all of those things.  He doesn’t quite meet the BMI criteria established by some study?  Well so what?  He’s a good candidate.  Let’s do it.  And we would.  And the patient would usually get better because we wanted to pick good candidates and have them succeed.  That was our job.  We were the medical experts and we were being paid to think.  Besides, if someone else knew way more about medicine and our patients than we did, why weren’t they the ones taking care of them instead of us?

But of course then we’d have to use our heads.  Thank God those days are over.  Now if the patient’s vital statistics don’t match whatever the insurer’s guideline computer tells the high school graduate who happens to be denying  authorizations that day, then you’d best go away and come back when they do.  No use fretting about it.  You’ll never make it through the insurer’s phone trees or get a reply to your voice mails asking to speak to a medical director anyway.

I wished our patient luck, and later brought up the case with the doctor who was taking care of his diabetes.  He was visibly exasperated about the whole ordeal.

“We’ve been working very hard on his diabetic control.”, she said.  “He’s been pretty good about his diet, but has one of those bodies that really uses energy efficiently.  It just hangs on to every ounce of weight.  We had his hemoglobin A1c down to 7% (normal is 4% to 6%), but since he’s had to start gaining weight it’s back up to 7.9%.  I’ll be glad when this whole ordeal is over and we can go back to treating his disease rather than the damned guidelines.”

Silly doctor.  Why would you want to do that?  You’ll have to think.  Besides, wake up and smell the mocha.  You’re being paid to follow the guidelines.

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.

Trick of the Trade: "Pour some sugar on me

Trick of the Trade: "Pour some sugar on me"

by Michelle Lin, MD

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Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.

How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.

Trick of the Trade: Pour some sugar on it.

Def Leppard is right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The rectal prolapse often reduces spontaneously or with gentle manual pressure.

References

Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum. Dec 1992;35(12):1154-6.

Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9.

Leading a hospital team of foreign trained doctors

by John Schumann, MD

Recently, I had the opportunity to decamp from the the friendly confines of GlassHospital and trek a few miles to the north.
GlassHospital has brokered a teaching and patient-sharing agreement with a nearby religiously-affiliated community hospital I’ll call Our Lady of Blessed Proximity.
Our Lady has a residency training program, just like ours, with the major difference being that nearly all of the doctors come from foreign lands.
Something you should know about medicine in America is that there are many more residency training slots (greater than twenty thousand) than there are U.S. medical school graduates each year (fewer than seventeen thousand). International graduates compete to fill those few thousand “extra” spots. These spots typically occur in less prestigious hospitals that are often in locations less desired by U.S. graduates.

I was supervising a team consisting of two residents and two interns (residents in their first year of training after medical school). We even had a couple of “observers” show up late in the month, as they were going to soon be starting their internships and wanted to get the feel of things around the hospital.

One of the key differences between the residents at Our Lady and the residents at GlassHospital is that nearly all of the former were already full-fledged doctors in their home countries. The residents at my home place, GlassHospital, have all just graduated from U.S. medical schools and are doctoring for the first time.
Take Dipak (names and details changed to protect the innocent). He was a fully-trained surgeon back home in India; in order to land a spot here, he had to give up his dreams of surgery and become an internist. He wants to go on and subspecialize — probably in heme/onc — he likes the increased knowledge and income potential of a subfield like cancer.
Jorge mostly grew up in California. But he was born in the Philippines, and returned there to go to medical school. This limited his chances to get a more ‘prestigious’ residency slot; yet he’s the first one in his immigrant family to become a doctor, so just getting here is an accomplishment. Unlike the others, he had never practiced medicine before, so he was a touch wet behind the ears.
Samar is Jordanian; her husband is also a doctor, and has already finished his U.S. training and is working in a health manpower shortage area in a neighboring state as a hospitalist. They see each other on weekends if their schedules permit. Together they’re raising a six year-old daughter. Samar is ambivalent about whether she wants to return to Jordan to work and live; she likes it here, but feels that she’s not truly part of the culture.
Sharif is from Syria. When I found this out, I was surprised, since officially the U.S. has long considered that country a terrorist state. Sharif couldn’t love America more. He married an American woman. He has no intention of ever going back. He loves the opportunity to ply his trade here, free to make it on his own merits. Sometimes, he told me, the opportunities here feel overwhelming.
Later in the rotation, one of the observers who rounded with us for a day was named Yusuf. He was born, raised, and trained in Egypt, where he’d been an orthopaedic surgeon. The day I met him, I had a sudden urge to sit the whole group down and negotiate peace in the Middle East once and for all.
We were a team, and in spite of our differences, we were working for the common good of our patients. We all wanted to serve, to learn, and to grow as individuals and as doctors. And, I might add, to be able to think and say what we want without fear of persecution. Something that some members of my team do not take for granted.
I admired my group and the obstacles they’d overcome to land spots here. Their paths will not be easy, but with the resourcefulness they’ve all shown, they’ll likely end up successful doctors in America.
John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.