Suprise Resus!

Hello there.

Saturday day shift was - once again - steady and interesting.

Day Shift: 3x Priority 1 and 2x Priority 3 = 5 jobs.

1. After a wonderful sleep on the recliners, the first call came in at about 12:30hrs as a 3yo male, fall from height on to head. So off we trot, blues-and-twos to a nearby address. The kid was fine. Fell about 3ft off an indoor plastic cubby roof. Egg on head.
2. Transfer from Aged Care Facility (ACF) to renal dialysis unit. The resident in question used to go by taxi to his appointment every few days, but since he has taken a turn for the worst, a stretcher vehicle is now required. This now ties up our depot's ambulance for 2-3hrs every four days. Don't get me wrong - the fellow needs to get to his dialysis, however a patient transfer vehicle would be more appropriate; a resource our region does not have the privilege of.
3. SOB with tightness in chest, bells and whistles. Upon arrival to patient she informed us she was awaiting results for the H1N1 virus. On go the super hot and sticky P2 masks and goggles, which fog up from the masks. Her sats weren't great, so we o2'ed her to hospital.
4. Now. We were sent on a Priority 2 for a lady who had fallen over on the pavement. No bells and whistles. Lucky it was only a couple hundred metres from our depot as our patient was in cardiac arrest. So my partner and I rock up, pull calmly up onto the kerb, expecting to find old Doris a little worse for wear. And I'm driving today, so he jumps out, calmly puts his jumper on, grabs the medication pouch and wanders on over. I jump out and ask the police what the go was. The constable says something like: "I don't think she's breathing." I look over to see my partner calmly introduce himself to the patient,look puzzled, then promptly deliver a precordial thump. Uh-oh. I rush and grab the defib and BVM from the van. Bugger bugger bugger. Off goes her jumper and on go the pads. Wow, VF. STAND CLEAR, ANALYSING PATIENT. SHOCK ADVISED, CHARGING NOW...BEEEEEEEEP all the way up to 200 Joules. I say "All clear" and press the little red button and the first shock gets delivered, and the crowd gathers. Still VF. I let my partner continue CPR with a cop as I get organise the gear to get her out. We do a further 2 rounds of CPR and 2 defibs and then get moving. I jump in the front I get a cop to jump in the back to help with compressions. Scene time: 6mins - good. I patch to the hospital and then move off. The ride to hospital was good fun - I must admit. Police escorts are awesome. A police station wagon blocked off the intersections as we sailed through. 7 defibs later and we arrive at the ED with a patient in asystole. Dang it. The ED staff continued for another 2 rounds and then pronounce the old dear deceased. The smoothest running resus ever, but the outcome was just as poor as the others. Nearly 90 years old, so she had a good inning, but these ones still hurt. After printing a few metres of report from the Zoll, we have a good old chat with the nurses, who say we did a good job, and then mosey on.
5. Transfer renal dialysis guy back to his ACF.

Back to the depot at 20:30 - 2.5hrs after knock off. Long day, but you get that.

Now for some good news! I start another round of hospital based prac tomorrow for uni. Yay! Two weeks worth in a surgical ward. I am very much looking forward to the new experiences, and I'm now at a stage where I can do all essential nursing care, such as showering, toileting, obs, etc. Also medications PO, IMI, Subcut, IV. I can insert nasogastric tubes, urinary catheterization and much, much more!

Can't wait, shall be bliss.

Clinical Case 001: Metabolic

Hi, this is the first of these clinical cases I hope to present (see previous post).

Initial Emergency call:
32yo F, states she "feels like she's going to die", ?ETOH.

You are dispatched on a low priority, and you get to the address in about 30mins. A knock at the door rouses no response. A glance through the open window reveals a woman in her thirties curled up on the ground. As you enter, you don't notice any smell of alcohol and the house is clean and tidy. Patient is clammy.

On examination:
GCS: 6/15, withdraws to painful stimuli. Pupils slightly dilated.
HR: 125bpm, regular and bounding.
RR: 24/min, shallow and regular.
BP: 170/90mmHg.
SpO2: 99% on room air.
BSL: 1.2mmol/L (or 22mg/dL).
ECG: Sinus Tachycardia.

Nil patient history available, and patient is not wearing a medical alert bracelet.

Q1: How would you deal with this case of hypoglycaemic coma within your scope of practice?
Q2: How could you obtain a better patient history?
Q3: Do you think your ambulance service's hypoglycaemic guidelines are appropriate? What more could be done?
Q4: What other investigations are you authorised to carry out?

Please post your answers in the comments section. Please include where you work (Country, State) and your qualification (Eg. Paramedic, VAO, Student, EMT-B, etc.).

Clinical Scenario Introduction

Hi all.

As a part of this this blog I'd like to occasionally present some hypothetical (and perhaps some not-so-hypothetical) cases with some questions for readers to answer. A lot of the questions will relate to how your ambulance service would handle the call - namely your policy or clinical practice guidelines or whatever you follow.

Also, the questions will relate to your own scope of practice - whether you be a First-Aider, Volunteer Ambulance Officer, Student Paramedic, Paramedic, Critical Care Paramedic, EN, RN, Doctor - whatever! The more allied health professional involvement, the better!

These cases will be presented in categories:

• Anaphylaxis,
• Circulatory,
• Environmental,
• General,
• Gynaecological,
• Medications,
• Metabolic,
• Neurological,
• Obstetrical,
• Paediatric,
• Psychiatric,
• Respiratory,
• Toxicology,
• Trauma, and
• Urological.

The rough format these scenarios will follow is:

1. Initial emergency call.
2. Prima facie presentation.
3. Patient examination/assessment.
4. Patient history available.
5. Scenario questions.

Hopefully these scenarios will be as educational and insightful to you as to me.

Some Videos of SJA in WA

Here are just a few videos of St John Ambulance in WA - mainly in the metropolitan area - to give you a better "vibe" of the service I work for.

Here is a "high action" report from Perth's A Current Affair, featuring Darren Mudge - a Clinical Team Leader on the road in Perth.



Most WA ambulances have three different types of sirens: This video demonstrates what is affectionantly know as the "Space Invader" siren:



As you get further and further from the metro area, medical assistance becomes fewer and far between. This is where the RAC Rescue 1 helicopter (known as Rescue 65) can come in handy, transporting critical patients to specialised care faster.

Arrr-Efff-Deee-Esss

It's good how night shifts will usually work themselves out according to what you have planned the next day - especially for Volunteer Ambos as many will have work commitments. For myself, last night was one of those nights as I had a Mid-semester test for Applied Pathophysiology and Pharmacology 2.

1 job, which is fairly standard for a night shift at my depot. An Arrr-Efff-Deee-Esss. Or RFDS for normal people; Royal Flying Doctor Service job. What the Perth city slickin' Paramedics and Ambulance Officers will call a "Jandakot" we call "RFDS" as we take the patient from Regional Hospital to Regional Airport, whilst the Perth Ambos take the patient from Jandakot Airport to the admitting metropolitan Hospital.

Two patients were on this particular flight, and after losing the traditional fight with the nearby Paramedic crew over the intubated/respirated/cannulated/spasticated patient, we got the STEMI fellow. The really sick intubated ones have the RFDS crew ride along in the ambulance to the airport (and do all the work) then we get to relax. Can't win 'em all.

I receive the handover from the ED Doctor: "60yo ♂ presented to GP's office complaining of 4/10 chest pain radiating down L) arm. Too hard basket, sent to A+E. ST-elevation in inferior leads, positive Troponin, responded well to MONA (Morphine, O2, Nitrates, Aspirin), nil pain for 2hrs. Up to metro for cardio review at CCU."

Great. I flick through the notes, and steal the pink copy of the transfer form. Mine! I see the patient has Insulin Dependent Diabetes Mellitus (IDDM), and note the last urinalysis (u/a) with Glucose++ noted. Might wanna do a BSL en route to make sure he isn't getting hyperglycaemic with the stress of his predicament, which is understandable for a older bloke about to fly, after an MI.

Stress → Sympathetic Nervous Response (flight or fight) → Adrenal Glands release Adrenaline → Glycogenolysis from Liver = ↑ BSL.

This isn't what happened.

We got the patient onto our guerney, monitor on, then into back of ambulance.

So how are you feeling Mr Angina Pectoris? Yeah, good thanks. Goodo, let me know if you get any more pain or such wont you? Yeah, no worries. Goodo, so you take insulin for your diabetes? Yeah mate. Okay.

I do a set of obs, and off we trundle to the airport when I notice the Gent getting a bit restless and sweaty. Uh oh. Are you okay? Yeah Buddy. Hmmm, BSL time methinks.

After squeezing what felt like the last drop of blood from the man, the glucometer revealed an impressive 2.0mmol/L.

Do you feel Hypo at all Mate? Oh, yeah, a bit...

I internally chuckle as I crack open a Glutose 15 and hand it to him. "Here, you better eat this."

It made for an interesting handover to the RFDS staff.

See where the Royal Flying Doctor Service has it's planes LIVE, so you know when to expect those good 'ol Priority 3 "Jandakots" here...

Busy of Late...

For those unaware, the WA Ambulance Service (WAAS) is run by St John
Ambulance (WA) Inc. which operates both career Ambulance Officer and Paramedic
service (in the metropolitan area, and also larger regional centres) and also a
country Volunteer run service (for rural, remote and outer metropolitan).

The ambulance depot I work at is fully staffed by Volunteer Ambulance Officers (or VAOs), and is a Sub-branch of a depot fully staffed by career Ambulance Paramedics, about 15km away. Unlike many volunteer depots, we have easy access (and prompt back-up) to the experience, knowledge and skills of highly experienced Paramedics. Our depot has a high callout number for a volunteer depot with an average of ~3.4 jobs/day in 2008, but has had as high as a dozen calls in one 24hr period - and on some days we get none.

We volunteer normal shifts of our time, i.e. Day Shift = 0800 - 1800 and Night Shift = 1800 - 0800. When there is no one able to cover a shift, sometimes officers will respond from home, like most other volunteer depots which does increase response times, but nevertheless puts another ambulance on the road!

The last two shifts I worked was a fairly busy ones, which I much prefer as it increases satisfaction, and reduces time spent on Facebook and studying.

Night Shift: 2x Priority 1, 1x Priority 2 and 2x Priority 3 = 5 jobs.

1. A chest pain, which turned out to be a ?H1N1 Influenza Virus. Pt. was worried as she wasn't getting better. Back to the van to don PPE. The husband cried "CHEST PAIN" for a faster response. Straight to the waiting room for that one... Cue evil laugh.
2. Back pain, which our 3mL of Methoxyflurane didn't touch, as per normal... POWER OUTAGE, caused by...
3. Car Vs. Powerpole, which both promptly burst into flames. After frantically manually rolling up our electric roller door, and continuing on our Priority 1 to the scene, O/A pt. was ETOH and A-OK, naturally! ("Hi Comms, 62-82 thanks." "Really?!")
4. RFDS transfer from A+E to the aircraft. Pt. was real car accident victim. Pt. was all Vac-matted up and suffering a confirmed # pelvis and ?abdo injuries, ?spinal.
5. A lovely, butt-naked elderly lady who tripped backwards, sustaining a decent (L) occipital boggy mass. Nil LOC and a good historian = fall, not collapse. BSL was hard/impossible to get peripherally, so I scooped some from the wound on her head which was still seeping from the 2x dressings and bandages... Damn you Clopidogrel!

Sleepy time from 0300 - 0800! Not bad, 5 hours!

Day Shift: 3x Priority 1, 1x Priority 2 and 2x Priority 3 = 6 jobs.

1. A nice Priority 1 during van check to start the day to a severe SOB with wheeze. Hx of 41 (cardiac) and dementia. Response time was ~2mins as the address was 100m down the road. O/A SpO2 92% on RA and tachypneic, nil lung sounds, nil PmHx of COPD, asthma, recent respiratory tract infection, etc. Cardiac Hx as long as one's arm. Hmmm. O2'ed into A+E.
2. Collapse of a 20yo ♂ with epistaxis. Turns out he fell flat on his face and seized for ~1min. Was relatively post ictal, however oriented to TPP. Nil Hx of epilepsy. O2'ed into A+E.
3. Post fall c/o back pain. Basically a lift assist as the pt. had the same back pain since her fall 3/7 before and the pain meds were yet to reach their therapeutic level. 62-82'ed - ANR.
4. A P3 to take a poor old dear from her home where she had been living independently with home carer visit support to medical care as she had not eaten anymore than 3 mouthfuls of porridge for the past week. She was now too weak to walk and required a 2 person assist. She had been sitting in the same kitchen chair overnight as she couldn't fathom the strength to stand up. After helping her to the toilet and giving her some good ol' H2O we trucked her off in her first ever ambulance ride, at 84 years of age. She had been travelling great until this. She will definitely need to be reACATed (Aged Care Assessment Team).
5. What I like to call a "Green & White Taxi" job... The classic D+V, onset 12hrs prior, waiting outside with her bags packed. Rx was a lesson in 000-etiquette and off to the waiting room.
6. Teenage ♂ pedestrian vs. car. Turns out he was riding his bike across the street, without looking, with no helmet on. Tut-tut... He got off lightly with minor ear lacerations and a head contusion, with spinal precautions. Not to mention the 3rd degree from the Highway Patrol boys.

All-in-all, a couple of busier and more stimulating shifts which gives me valuable experience and opportunity to apply what I learn at uni into practice within my VAO skills scope of practise - however there's no scope on assessment or knowledge.

Remember kids, wear your helmet.

P.S. Thanks to all for the support and particularly to Outback Ambo for the
plug!

Reflecting on Regret and the Gibbs Reflective Cycle

Here is another entry from my previous blog which covers the topics of regret
and also presents my take on the Gibbs Reflective Cycle and how it can apply to
both nursing and ambulance work...

I wish I updated this blog on a regular basis. I wish I didn't drink so much last night. I wish I didn't treat my parents like dirt when I was younger. I wish I didn't attend that ambulance callout. I wish I could have saved that little boy's life...

I wish. I wish. I wish...

Unfortunately, life is full of things we wish we did or didn't do. It's full of regrets. Big regrets, and little regrets. I have a list as long as my arm. My regrets make me feel less confident about myself. They lower my self-esteem, like a bully - but more personal. When I think about them, I feel negative emotions, such as shame, guilt and helplessness. Some more than others.

Do you have regrets?

Why do we feel so terrible when we think about things we did wrong? I mean, everybody makes mistakes. Why should I feel terrible about the things I did, while other people sit in jail cells for doing way more unacceptable things? Is it to do with the way we were bought up by our parents or guardians? Perhaps. Is it because it keeps society in line with the morals and standards of the wider community? Maybe. Or is it a way to help us reflect on and evaluate past actions and experiences, and making them a negative memory in our minds so we don't readily repeat the same route we took previously? I believe this might be so.

Recently, I have been studying a process called 'Gibbs Reflective Cycle' in one of my units called Foundations of Nursing: Social, Indigenous & Cultural Perspectives. It is basically a list of steps to take after an experience - negative and positive - to better understand what you did, why you did it, and what you would do differently in the future. It is a great way to structure your thought process after a negative experience or even while thinking about a regret you have from the past. It not only prompts you to think and acknowledge your feelings, but helps you formulate an action plan for future similar experiences.

It has six components:

• Description: What happened? Describe the event in detail.
• Feelings: What were you thinking and feeling?
• Evaluation: What was good and bad about the experience?
• Analysis: What sense can you make of the situation? Break-down the components.
• Conclusion: What else could have you done?
• Action Plan: If the situation arose again, what would you do differently, or the same?

As you can see, it covers the whole range of thought processes, from what actually happened and how you felt, to what more you could have done and why.

This relates well to nursing and ambulance work, as you are faced with numerous new experiences and you cannot be expected to handle these 100% correctly all - or any - of the time. Also, you can be faced with some very traumatic incidents which need to be thoroughly thought about and dealt with. By answering the questions that the Gibbs Reflective Cycle probes, you can not only get a lot of conflicting thoughts out of your head, you can make more solid plans for future experiences so you are not continually making the same mistakes over and over.

An example of mine is the first ambulance callout where a sudden death occurred. It was about 23:30 hrs when the call came through and by the time I arrived in the ambulance with a Volunteer Ambulance Officer and a Volunteer driver, the gentleman involved was receiving CPR and advanced life support from the local Police Officers and the Remote Area Nurse. After determining that the man was asystolic and his pupils were dilated and fixed, the nurse - under the direction over the phone with a Doctor in the next town - pronounced life extinct at approximatly 00:00 hrs.

I knew the man who died, and I knew his distraught wife who had been with him for 40 years. It was 0330 hrs by the time I got home after assisting my colleagues with putting the man into a body bag, transporting him 70km to the closest morgue, having a coffee and making the trip back. It was quite the night.

At the innocent age of 18, the whole experience of sudden death was a foreign concept to me. Weeks after I felt quite confused as to why I was thinking the incident over and over an a daily basis. I also was full of "what ifs". What if we were quicker to respond? What if we had of tried for a little bit longer? I felt quite helpless in regards to where I could go from there. What actions could I take so I feel I'm actually making a difference relating to the incident?

If I had known about the Gibbs Reflective Cycle during this crucial debriefing period, I believe my 'cooling off' time would have been reduced, and I would have gotten more sleep at night. I not only would have thoroughly thought over the incident itself, I would have addressed my feelings during and after the job, thought about some of the good things that came of the incident (eg: gained valuable experience) - not just the bad and I would have formulated an action plan as to what I would do differently if a similar scenario arises - which is quite likely considering my line of work.

So regret is a natural response to a negative situation - whether you were the cause of the situation or merely witnessed it. It is a prompt for us to evaluate or 'mull over' our experiences and if done correctly, we can decrease our levels of regret, shame and guilt by creating a plan that we will always take with us in the future in the anticipation of a similar event taking place.

Identity and Development: Introducing Me

This is an entry from a blog I half-heartedly attempted
at the start of my first year of my nursing degree. It basically gives a
background of who I am and, more importantly, where I come from.
Enjoy!

I started my Bachelor of Science (Nursing) degree thinking everything would be all science, clinical practice and medical skills. How wrong I was. Here I am, having just survived my second week of lectures, tutorials, laboratories and study, thinking: "What have I gotten myself into now?!".

I was right on the mark with the science. I was mildly expecting the theory of nursing. But imagine my surprise when I entered my first Psychosocial Nursing: A Life Span Approach lecture.

Psychology? I want to become a nurse. Perhaps after that a Paramedic. I don't even fully understand what psychology is, let alone want to study it! Why does a nurse need to know psychology?! My lecturer must be familiar with this reaction, as she promptly reassured the fifty-odd students in the room that they were, in fact, not in the wrong lecture, but undertaking a vital unit in their course to become a Registered Nurse of Western Australia.

You see, this was no ordinary psych class (if there is such a concept). This was a unit that not only teaches us who our patients are, and why they are the people they present as, but a unit that helps us as individuals to understand better who we are.

On that note, let me begin...

I am a male student nurse, as you may have already figured. I was born in a small country town on the South Coast of WA, and lived the first 15 years of my life in a smaller country town, close by.

There is something about small towns that is beneficial to a growing boy. It's called community. This was a topic that was bought up in my Psychosocial Nursing unit today. One main theory the class is focusing on relates to the age old question: Nature versus Nurture. The view we are being encouraged to believe is that genetics and heredity as well as our upbringing and social environment determines our personal development and who we become, which is ever changing due to interacting physical and societal influences. This means that a boy such as myself has certain characteristics determined at conception (genetic information from Mum and Dad - i.e. physical appearance, some personality traits, inherited diseases or abnormalities), and other developmental and personality traits are developed over time from the way my parents bought me up, to my schooling and education and also from what I took in from my community and society.

We learn these theories and their particulars from a number of conflicting (and slightly twisted) theorists. One who supports the argument outlined above is a Russian psychologist by the name of Lev Vygotsky (1896-1934). He states in his sociocultural theory that culture (i.e. values, beliefs, customs and skills) are passed on from one generation to the next, and that social interaction, particularly cooperative dialogues with more knowledgeable members of the community, is necessary for children to acquire the ways of thinking and behaving that make up a communities culture (Berk, 2007, p. 23).

This was definitely the case with me. I grew up, and interacted, with quite wise and decent people. Namely, my Mum and Dad, and other members of the community. These include a youth worker, whom I still have quite close contact with, teachers, nurses and volunteer ambulance personnel - who I worked very closely with for over a year in very high stress, but also quite casual and social, situations.

I also knew who to look up to and idolise. My Mum played a great role in that. My parents didn't let me 'hang' with the wrong crowd, but let me make my own decisions later in life. I believe that I have that skill internally now because of her. I don't, for instance, look at ANY celebrities and wish I was in anyway similar to them. Not for all the riches in the world. That trait was, I believe, inherited from my father - genetically and environmentally. He is quite a humble and earthly fellow who is rather introverted, but can express everything he needs to say through merely his presence. Many hours I have spent sitting in a boat, fishing line in hand, in silence with Dad, completely content with each others presences.

The community I was fortunate to grow up in is notoriously 'community minded'. That means that there are many active residents who are working, as individuals and groups, to make the town a better place. There are volunteer emergency personnel ready to assist 24/7 to people who are in need, unpaid committee members who give up hundreds (even thousands of hours) per year in the interests of maintaining and improving local structures and issues, and there are people who simply care about you, and anything that is worrying or enlightening you. These are the people that I grew up with, and looking up to.

Perhaps that is why I want to become a nurse and Paramedic. Hopefully, from the information I have given you about myself, you can deduce what sort of person I am; relaxed, caring, community spirited, earthly, fun, humorous and accepting person.

I hope to regularly update this blog as a log of my studies as a nurse (hopefully you may be able to learn with me), a release of my issues or problems, and also a place to tell anecdotal stories of both past and future experiences.

Hopefully These Get Better With Time...

Hello, Howdy or G'day, depending on which part of the world you come from.

I have been meaning to start blogging for a while now, and a mixture of inspiration from other bloggers, being in bed sick and procrastination from uni assignments have finally tipped me over the edge.

As the title states, I am both a Registered Nursing student and a Volunteer Ambulance Officer in WA, Australia. I'm halfway through my 3 year "Bachelor of Science (Nursing)" degree and have been a vollie ambo for about 2 ½ years.

It goes without saying, all identifying details such as names, addresses, identifying tattoos, deformities, idioticies and peculiar pets will be cleverly disquised as fictional, but not-so-fictional lies.

Also, the opinions, views and statements I so rudely express in this blog don't reflect those of the organisation I (so kindly) donate my time to, or the University I attend.

That being said, I will refrain from turning this site into a slagging, shit-storm parade - I will leave that to this guy.