Friday 29 February 2008

Working with Patients: Common sense, a bit of medical knowledge and a dash of art

Most of what I’ve come to find when working with a patient is that there are three factors that need to be taken into account to ensure the process goes well for everyone; common sense, medical knowledge and a certain finesse that you have a little of at first and develop with practice.

I’ve heard of a few Paramedics becoming qualified through a three year university degree, started working on the job and realized they either hated it or were no good at it. This is incredibly sad – imagine spending three years of your life, as well as accumulating a massive financial debt to find it isn’t for you. While of course you have the option of translating that knowledge to another field (as I have done with a medical research background) to ‘save’ some of the effort – I’m fortunate enough to still intend on returning to research (long) down the track when the situation improves.

The trick lies in balancing those three factors of sense, knowledge and art to the benefit of the patient and enjoying it. Bowel pain could be cancer. But it also could be related to the aspirin and beer they took earlier. Common sense differentiates the two. But combined with other symptoms, your medical knowledge may flip that back to the cancer scenario, and you recommend further checks. The art is knowing when to use what – as well as how to relate all this back to the patient.

It’s this constant juggling that appeals to me – I like to think I’m a creative person (I play two instruments, design websites and am about to dabble in photography), I like to think I’ve got medical knowledge (BBMedSc(Hons), SFA w.AdvResus inc. SAED, HAZMAT and BIOHAZ trained) but know I still have a lot to learn (especially regarding emergency medicine) and in the common sense department I feel confident – but I can always do with a little bit more! A couple of times I’ve come up with a plausible diagnosis that was previously missed or hypothesized a scenario which has later been revealed as correct – but all of this means nothing if you don’t know how to work with patients.

A patient (usually) doesn’t have your medical knowledge, and so for them this triangle is incomplete, they’re often in pain and in whole the experience is unpleasant. Working with patients is in its own right an art form, a delicate dance of trust, respect, care and assurance. To be able to assess, if possible reassure and always relate the situation back to the patient is an integral part of the work, and something I have thoroughly enjoyed so far.

As always, I want to be better at what I do, and perfecting this balance is something I see myself being devoted to for some time.

Reverse Voodoo Doll

I’m in the ward again for the clinical trial – and I’ve become somewhat of a celebrity with the nurses and doctors.
‘Number 19 - the one with the crap veins!’

Yes, we’re numbers – occasionally we’ll be referred to by our initials but I kind of like the ‘Hitman’-esque nature of the number… I’ve always known I’d make a horrible IDU – I’ve got the smallest, deepest veins… Once you’re in they bleed well, but getting a needle in is much akin to the haystack story… Luckily for me needles don’t phase me in the slightest (working in a HIV research facility gets you quickly used to them, as scientists need a lot of ‘control’ samples… guess where they come from?) and I’m more than happy for them to take a few stabs.

One of the doctors has it down to an art taking from the veins on the dorsal surface of my hand, but most people don’t like taking from there. So most take a stab at the Median cephalic or Median basilica veins, and miss. Or the Median cubital, and miss. My Radial vein is actually quite big and juicy – perfect for venipuncture – but unfortunately it rolls quite easily away from the needle and both times one of the nurses tries she’s forgotten to stabilize it and missed. Oh well, live and learn.

I can’t help if there’s a doll somewhere in the world wandering why it keeps getting these stabbing sensations…

Given my studies, I’ve come to help them find the best veins to use (much to both of our amusements), together we’ve come to find a few that work and many that don’t. I like learning the practical skills and many of the newer nurses enjoy the practice on a ‘difficult’ case who is willing to give them as many shots as they want.

Here’s hoping I get someone like me when I go on hospital placements!

A growing burden on us all

As mentioned last post, the growing rate of binge drinkers is, in my opinion, becoming an epidemic in Australia. Worse still is the younger age of onset, with 14 year olds being given addiction counseling for drinking habits. Despite previous posts implying that the vomiting, wasting our time and resources as well as the physical discomfort associated with working with the soberly challenged being the bad parts of heavy drinking – the really bad parts are things I’ve never really mentioned.

I’ve seen families being torn apart following a member binge drinking, with often fights spilling out into the street as they leave whatever venue they’re in. I can only imagine what this must be like at home. I’ve seen ‘normally quiet, fun-loving and calm’ (friends testimonies) people swear, spit and bite and those trying to help them – including their friends. The toll taken on the private lives of binge drinkers, their families and friends is phenomenal.

Add to that any medical costs for ambulances and hospital care, police fines for drunk and disorderly, public nuisance and the financial toll becomes enormous, on top of the funds required to actually purchase the alcohol. To make this final step easier, liquor suppliers are more than happy to provide you with cask or clearskin wine at a fraction of normal costs and budget spirits and beers to keep you happy. Thanks.

Add to that the cost of a liver failing on you. Kidneys can no longer keep up with the demands being placed on them. Eyesight can fail as the small vessels that supply blood slowly waste away. Internal organs die as they’re literally preserved (and not in the good way) inside the living body. If you try and stop you might go into alcoholic seizures, your body going through withdrawal of its vicious routine. This doesn’t just happen to every-day-and-night drinkers, this can happen to those who binge drink only one or two nights a week. The physiological cost is your life – in every sense of the word.

When I recently got called to a young woman who felt the need to drink an entire bottle of spirits I wasn’t laughing about it like her friends. It’s almost a given that at parties like the one I was at there’s at least one person in this state – it’s a joke that they’ll be teased for over the next few weeks, but nothing more. I usually treat in a ‘kids… *sigh*’ attitude in these situations, which truth be told I did in this case. And, as usual, I gave a brief spiel about the dangers of drinking in excess, both the kids and myself knowing full well that it fell on deaf ears but that it had to be done – as if this too was part of the ritual. I’ve done it enough times now to know it isn’t going to change anything.

I wanted to grab the girl and scream at her – she was a university student, bright and with a good future ahead – was this how she wanted to live her life? It only takes one mistake to ruin an entire life. What if her friends hadn’t been there when she fell? What if she was alone, and started choking on her vomit? What if a sexual predator had found her instead?
A parent came later and took her home, a look of mild amusement on their face behind their outside ‘anger and disappointment’ as if they were internally reminiscing on when they were that age and got drunk. The cycle continues.

God I wish it would stop.

Vomit transfer protocols

I’ve mentioned quite a few cases of dealing with drunks in my short time blogging, but I’m always amazed at the people who feel it’s perfectly normal to put themselves into a state of severe inebriation. Now I’m no saint – I’ve sported more than a few hangovers in my time and, on occasion, put myself into a state of severe inebriation – once following what I’m sure was a reaction to the high preservative levels in extremely cheap wine (I’m allergic to sulphur, of all things…). Thanks go out to Clare for looking after me! (Still sorry…)

I can say however that those events were fairly few and I know for a fact that my days of drinking more than a glass or two are well and truly over. But I’ve noticed some of my friends show a little disappointment in this decision – it’s very Australian to go out to the pub and crawl home.

Working with St John (and also a few bursts of looking after friends at parties) I’ve been abused verbally, had punches thrown at me, had a bag of vomit thrown at me, pulled people out of gardens, been vomited on directly and passively (explanation to follow!). You reach a point where looking after the drunkards makes you realize just how unappealing drinking is – and not just for yourself.

The times I was vomited on directly usually run something like this; security bring someone over who is obviously drunk. They deny being drunk, despite their breath smelling like the bathrooms of Young and Jackson’s Pub following St Patrick’s day and a stupor that would impress a Zen master. After taking their obs they suddenly announce they don’t feel so good, you turn to get an em-bag only to find they project over the bag and onto your uniform. I’m proud to say I have since become the ninja of vomit dodging. Unfortunately, practice made perfect.

The passive vomit stories are the worst though. We get called to a drunk who is passed out in a pool of their own vomit. They are covered in it. A sterna rub or shoulder pinch brings them to (usually angry) but we convince them to sit up. Now we have to walk them over to a post, and the fun begins. We can clean up the vomit off their face and hair, but clothes soak in the stuff – and as we’re sometimes forced to do the old ‘throw your arm around my shoulder’, we get to join in the soaking. Occasionally we’re lucky enough to have waterproof (and hose-clean-capable!) jackets or a scoop and stretcher – but often resources are spread just thin enough to make the shoulder the only quick method of transport. That is passive vomit transfer, and the stink stays for the rest of the duty.

Getting sick and vomiting is only a small part of the problem however – but I’ll save that for next post.

Stay safe.

Tuesday 19 February 2008

Took their breath away (but gave it back again)

There are a few perks to being a member of St John that often get either overlooked or blown completely out of proportion - the one I had recently was that of the adoration of dozens of schoolgirls. I had to laugh.

The basic story - at a high school sports carnival we had two kids run into the first aid post yelling that their friend couldn't breathe. This usually translates to asthma attack, so we grabbed our gear and off we went. The girls ran ahead, but we (professionally) maintained our steady walk. We got to our patient, a young girl with (*surprise!*) asthma. She was breathing shallow with a bit of a wheeze, but was conscious, alert and stable. We administered Salbutamol - she had her own but had left it upstairs in her bag - as well as a nice steady flow of oxygen to give her that universal pick-me-up. When she was a little more recovered we walked her over to a room we had set up and put her into a stretcher for a little bit to rest it off.

I could have told her that morning that participating in two endurance events without her Salbutamol handy might not be the best idea and a minor asthma episode was to be expected. What I hadn't expected was to emerge from the room to have dozens of girls staring at me. It was very... Children of the corn.

One of them piped up with a worried look on her face "Is she going to die?" - I let out a grin.
"It's ok, she's fine - just a little asthma. She just needs to rest for a few minutes and she'll be out again."
"Thank you!" the girl cheered and ran off.

The rest of the duty went quietly and quickly - another minor asthma episode and I was free to go home from yet another job well done.

Getting ready to say goodbye

Possibly the hardest part of my life at the moment is getting ready to say goodbye to Melbourne - my family, friends and life as I know it.

I have done a fair bit of travelling in my life, having lived in several places across Australia - but somehow Melbourne was always 'home'. Well, for at least the next several years I'll have to learn to call Sydney home - and having been there a few times I don't think that should be too big a problem. Except for the heat.

I'm a winter baby - give me rain and snow, I'll be happy. Give me sun and I'll be looking for shelter faster than you can say 'Gollum!'. Having said that, the past few years have actually been warmer than Sydney during the winter, so I guess the shock won't be as big as it could have been.

The hardest part is the financial side of things. Having lived as a PhD student, I got into the routine of surviving financially - but now that I have to move to Sydney I realise I'm broke. Enter the clinical trial, which should pay for (thus solving) all of my problems. It ends on the 15th of March, I drive to Sydney the 16th and classes start the 17th - the downside being that I don't get my cheque 'till the end of the 15th. It's a Friday. This means there's a high chance I won't be able to access these funds until the Monday classes start, despite the fact I'll need the money to actually get to said classes. I'll figure something out - I always have - but it'll no doubt be a blogworthy tale!

Wish me luck ;)

Side note: Only just got onto the internet after a considerable length of offline time - it was horrible! Also, the power cable for my laptop decided to snap, denying me access to my pre-written posts. This means double the whammy when the new cable arrives as I post the articles.

When vehicles attack!

It's common knowledge that some Paramedics attract certain kinds of jobs - even before I've become a fully qualified Paramedic I know my niche.

I attract car accidents.

Since joining St John Ambulance, I have had at least 8 car accidents happen right in front of me. Normally I'm in civilian clothes, but have my trusty kit in the back of the car (something I highly recommend people get!) and have been able to help out where possible.

Usually they've been low speed collisions, for a long time the most major injury I had to treat was a bleeding scalp following a minor spidering of the windshield. Of course, I made a point of saying 'until recently' because this leads into todays story...

A car was t-boned (one car ramming head first into the side of another) in front of me, the scene instantly turning to chaos. I pulled my car onto the grass and jumped out, kit following me. Fortunately I was in my StJ overalls, so people actually listened when I yelled for an ambulance. The driver who hit head on was fine, walking from the wreckage left behind him with only a look of disbelief and slight tremble of the hands. The driver who was hit side-on was a different story, having not had the luxury of a full crumple zone to lessen the impact.

He said he had lower back pain and pins and needles down his legs, so I told him to stay sitting and try not to move while I did a quick primary survey to check for bleeding. Luckily I didn't find any (although this does not rule out internal bleeds), and quickly jumped into the passenger seat behind him to immobilise the c-spine (his neck) with my hands. Unfortunately I had switched from a marked St John vehicle only a few hours prior, and would have had the luxury of proper fitted collars - but I knew this would do until the ambulance arrived.

To everyone's luck the ambulance arrived in short time and we got a collar on and we got the driver onto a spine board to be loaded. The crew thanked me for my help and everyone went on their way.

This job left a firm thought in my mind that I was doing the right thing by applying for the ambulance service - and also gave me the confidence to believe that I could actually do this. I hated the feeling of not having the equipment I knew I needed, but at the same time enjoyed (not the right word, but you get the idea) the fact I had to think on my feet.

I also learned a quick lesson in patient management, having my friend in the front shifting from time to time (with me grumbling at him to stop each time) until eventually I just warned him he could move one more time, shift something and never be able to move his legs again. It's strange how these words can make a grown man sit as still as a well trained schoolboy.

I wander how he ended up - it's hard not knowing. Hopefully it was nothing but a bit of pressure from a swollen disk, or a pinched nerve that healed itself. There's always the chance that was the last day he ever walked, and I have to be open to that possibility no matter how much I dislike it - being honest with yourself is the only way to survive the job for a long period of time. I doubt I'll ever find out, but I like to hope maybe I made a difference by being there.

Wednesday 13 February 2008

Can't we all just get along?

This post is something I struggled with for a long time in terms of how to go about writing it. It involves two organisations, both of whom are involved in emergency health care, one on a professional level and the other on a voluntary level. Let's call these organisations St Peter Ambulance and City Ambulance Services to ensure that you realise I'm talking on a hypothetical scenario ;)

Now I'm well aware that there are members of St Peter Ambulance (StP) who probably shouldn't be allowed within a 100m radius of a patient. Still, they somehow slip through the cracks of screening (a problem associated with volunteer organisations) and end up on the wrong end of a pair of nitrile gloves. The wearing end, that is. Still, overall I would say that the members of StP are competent and professional in their conduct, are highly trained and motivated people giving up their time for a good cause.

I could understand, however, why some members of City Ambulance Services (CAS for short) might have some problems with some of StP's members and their conduct in potentially dangerous scenarios (such as extrication with severe trauma, certain drug episodes and other events requiring extensive medical knowledge). Sometimes this gets taken to an extreme, and unfortunately everyone suffers.

At a major music event somewhere in Australia some time ago, the members of StP's were informed by CAS that they were under any circumstance allowed to move a patient, and that this must be done by CAS. In addition, the StP's 'acute trauma unit' staffed by Doctors and Nurses wasn't to be used if the patient couldn't walk to it unassisted - they would be taken directly to hospital again by CAS. The event had multiple performance sites with crowds in the thousands, StP's in the dozens and CAS's by the handful. Unfortunately, CAS were under equipped and were forced to borrow StP's gear and had insufficient 'buggies' to move patients from site to site.

Two conflicts were (hypothetically) created from this scenario - the StP's were, for the most part, unable to perform their duties fully with the restrictions in place, and the CAS members were run off their feet trying to move people from site to site or to hospital for things that the StP's and the StP trauma unit could have treated.

I won't comment on the origins of this hypothetical situation, but I will say this: the day was made significantly harder than it needed to be because two organisations couldn't play nicely. Blame lies on both hypothetical ends and, unfortunately, it's the patients who suffer because of it.

Situations like this - and it's not the first one I've hypothesized - are one of the many things that are wrong when various health care organisations don't play nicely.

I know we might not always like each other, but come on people - can't we all just get along?

Monday 11 February 2008

Living in the darkness...

It's a funny thing being cut off from the internet (or, as I affectionately know it, the Life Source or All-Spark *ba-dum-tish*), but since leaving my previous job, being in a clinical trial and getting myself organised for the move to Sydney I haven't had a chance to get online!

So I've decided that until the situation becomes stable again, I'm going to write up posts from home, then upload them when I get a chance. This means the number of posts should remain consistent, but that most of them will be made in big spam-like posting sprees.

Don't worry too much, it's only till March 17 (the details on that later!).

Saturday 2 February 2008

A big problem

This might be a bit of a touchy subject for some, so I'll start it off by saying that I don't mean for any of this post to be offensive - I'm simply stating the problem as it is and the ramifications of this.

Today's society is fast paced, with less and less time available for the little things in life. Unfortunately, good nutrition as part of a balanced diet with exercise is often left out of the our lives - coupled with an increase in access to quick, cheap fast food, it's not surprising to see that over 50% of Australians are overweight. The reasons for obesity are vast and varied, and it's not a topic I want to go anywhere near right now.

Obesity places many drains on the health care system, with rates of heart disease, non alcoholic fatty liver disease, diabetes and other obesity related illnesses rapidly increasing and showing no signs of slowing down. But even before these long term, usually late stage effects, the drain is felt on th health care system.

Paramedics are often left with no way to safely treat or move obese patients. On top of the physical exertion required and the dangers of a morbidly obese patient injuring you or being injured themselves during transport, the equipment designed for us simply won't hold such excessive loads. In response to this demand for stronger, sturdier and more durable equipment, new designs for high capacity equipment is required - some universities have even been asked to design specialised equipment as fourth year engineering assignments!

Beyond that, it's costing ambulance services millions of dollars for specialised 'heavy duty' ambulances - last year the ASNSW alone spent $600,000 on three trucks to carry patients over 160kg (the weight restriction on the standard ambulance), with another two trucks on order. Specialised beds for the obese cost $30,000 each for hospitals.

In Victoria, MAS has even gone so far as to request the privatisation of ambulances for the obese (in Australia almost all ambulance services are non-privatised), a move unions are currently trying to block. But is it such a bad idea? Often medical transport is all that is needed, with paramedics being called in due to the excessive weights being loaded. The patient is made very uncomfortable during lifting, with stretchers often too small or not designed for that capacity, the patient also receiving a massive blow to their dignity and efficacy as they are often sighted by curious crowds in such a state, having a massive impact on their treatment outcome. Such vehicles and equipment will be in high demand over the coming decade.

But as it is, the ambulance service cannot afford to purchase more.

Privatising this service would allow paramedics to be freed up for emergency medicine (something they're known to take part in from time to time between drunks and headaches),
allowing the trained patient transport officers - with their specially designed equipment - to give the patient the transport they require. Naturally the ambulance services will also require some vehicles and equipment of their own for emergency cases involving morbidly obese patients, but the drain on the public health care system will be decreased with no impact on patient care.

I'm particularly keen to hear what you all think of this, so please drop a comment.

Friday 1 February 2008

They had best not win...

I'm jumping on the bandwagon of bloggers currently posting on the suing-of-the-paramedics topic currently happening in the UK - original article here.

Some posts I highly recommend reading are from Random Acts of Reality and Nee Naw, which sum up my thoughts on the matter exactly (also means you should go read them and save me having to rant ;P).

This is one of several problems that I'm scared we'll start to see more of in Australia - one of the reasons I've chosen Paramedics over Medicine is that you are less likely to be sued (others include how stretchers in the US are now being redesigned as patients are too 'large' for them, increased levels of abuse of the EMS services and an increase in drug induced psychosis and aggression - more on these at a later date).

One thing that really surprised me about the article is that ambulance crews are expected to rush into dangerous situations where their life may be put on the line - but in reality we're taught to do the exact opposite. The very first thing we do on arrival of an unknown scene? The primary survey - DR ABC. The D is for Danger. If it's dangerous to us, we don't proceed, because otherwise you can just end up having to call in more ambulances to treat injured (or worse) paramedics, these days ambulance services are short staffed as it is - just read this to get an idea.

Final words - have mercy on paramedics (including don't sue). It's an underpaid, overworked, sweat/urine and feces* filled job - but one that wouldn't be traded for anything else in the world, and you'd be lost without.

* Urine and feces usually not ours