Ask A Medic

That's easy. Any Vietnamese place along Tully in East San Jose.

 

Did you get that through Facebook? Cause it showed up on mine like 3 weeks ago. I'm curious to see if the chain came around to you.

 

yea parAmedics on facdbook had it up a couple of weeks ago

 

Le'Funny.

 

He passed away Source.

Sad day.

 

Destroyed his pager... That's lucky.

 

Alright guys now that I am on preceptorship I noticed a few problems I am having, I hope you guys can help me. First is IVs, this is probably one of the most common problems Medic students have. Do you guys have any tips. Second is my questioning and obtaining a good pt Hx, I tend to hit all the points, but I don't have a good flow. Again, any tips?

 

Only time and practice will help with obtaining a history. You have to get used to talking to complete strangers and asking them personal questions. I will have students write down sample and opqrst on a piece of paper to help them with flow and to make sure that they don't forget any pertinent questions. As for iv's always make sure u are holding traction and that you are choosing a good vein. That also takes practice. I hope you are doing all non critical iv's en route to the hospital instead of on scene too

 

Thanks, to tell you the truth I haven't had the chance to start IVs while on the trucks, only in the hospital. It seems that I am a bit of a white cloud, most of my calls are either refusals, anxiety attacks, or transfers which already have a line in place.

 

I always put iv's into anxiety attacks. Remember you are just ruling out anxiety not diagnosing. Symptoms are sometimes very similar to a MI. Also why not give them a little versed, Valium, or Ativan if your protocols allow for it.

 

protocols don't allow any of those. The atacks I have had have either been resolved before we arrive and get refusal or after talking to them and they calm down S&S go away, I have only done 1 rotation, so I've been mostly following my preceptors lead, and he hasnt seen any need to do any treatment and them

 

As it's been said, the history taking is going to come with practice... try not to sound like a robot... get the patient to "tell a story" if you will... It would blow your mind how any people with chronic illnesses forget that they have one...

Medic: "Do you have any medical issues?"
Pt: "Nope, just feeling lightheaded (ect.) today."

Medic: "Okay, do you take any medications."
Pt: "Yes a give myself insulin shots and take a thyroid pill and a blood pressure pill."

Medic: "Oh... so you're diabetic and have been diagnosed with a thyroid disorder and high blood pressure?"

Many people just don't consider themselves to have "medical issues" once taking medication(s) has become a part of their everyday life.

As far as IV starts go... Almost all of your issues with starting a line can be completely averted with one thing: limb control.

Almost everyone tries to start IV's with the patients arm positioned in a textbook, anatomical position, palm facing up, with the arm almost parallel to the body with the wrist near the hip.



You will try to hold the patients arm steady by tightly gripping their wrist with your non-dominant hand, and pulling downward, towards their feet, you'll also probably try to hold their hand/wrist against your leg for additional support.

Assuming you're sitting on an ambulance bench seat, your body will be at about the patients hips.

Look at the anatomical position, and consider that you are going to have one hand for the IV itself, and one hand dedicated to limb control. While your pulling on their wrist, the patient has a mechanical/physical advantage of being able to lower their shoulder, bending their elbow, or being able to pull their arm away from you towards their core, because they have the full range of motion of their shoulder and elbow to work with. It takes quite a bit of effort to keep their arm steady in this position and start an IV.

There is a better way...

Move your body up on the bench so that your knees are at the same level of the patients chest, rotate your body about 45 degrees towards the pt's head, and extend the patients arm to be perpendicular to their body (palm up) and place their tricep on your knee that is closest to them, now the fulcrum of their arm is the elbow, not the shoulder. Place your non dominant hand on their wrist, and you now have the mechanical advantage.

You can literally control their arm completely with almost no effort. You can use one finger of your non-dominant/non-iv-start hand, on their wrist, or better yet, the forearm/elbow of your IV start hand on their wrist, combined with moving your leg up or down to increase tension on the elbow. Now you've got a very steady limb to start an IV on, and you've got a free extra hand.

To see what I mean, stand against an open door way, with your hands relaxed down at your sides, and your shoulder against the threshold - think about the range of motion you have; up/down/left/right... you can move your arm any way that you like... Then take a step to the side and extend your arm to be perpendicular to your body, and place your tricep against the door frame... now think about your range of motion... with nothing against your wrist, you can bend your elbow, that's it.

When you have easy control of the limb, you can concentrate on the manipulation of the catheter/tamponade/tourniquet/line attachment.

 

hypothetical situation, you get called out to a residence because a teen is having problems breathing, he is coughing, and his breathing is wheezy.
His blood pressure is 165 (systolic) and 86 (diastolic), pulse is 96/ min.
he is obese, ID says 265lbs at 6'3'', his parents say he has had allergies, and a runny nose, they have given him some medicine, one dose of theraflu, hot tea and honey, and lemon juice and honey.
what would you do?
let me know if you need more info.

 

Start by asking questions. I mean unless the kid is in full on resp failure.

What his history? What kind of meds does he take? What was he doing when the SOB started? What is sudden onset or did it increase over time? They say he has allergies, what kind? If he has serious allergies that could explain some of it but his bp would dump if he was having anaphylaxis wouldnt it? The vitals seem pretty standard for someone being nervous. Sounds like he is having a standard asthma attack/allergies issue. If he has a inhaler help with that, throw him on a O2 mask and see if he perks up. Re access after 5 minutes or so and see if he wants transport.

My BLS view. In reality if this was a 911 call in Socal it would be an ALS call from the beginning so I would assist and be thinking all this stuff in my head. Lol

EDIT: I am assuming he is having wheezy lung sounds cus you said he was wheezing? No cp, n/v too Im assuming too?

 

SAMPLE/OPQRST. history of asthma? O2 sats?

 

Like someone else said...a good SAMPLE history and an OPQRST assessment.

Allergies? Possible allergic reaction to something? Coughing/wheezing steers me in that direction.

A good focused exam is in order...Lung sounds, SPO2 on room air, look for any rash/urticaria/hives...onset/what was he doing/where was he when it started. Take a peek at his upper airway with a penlight.

Regardless..would start him on an Albuterol neb tx, IV, monitor, 12 lead if I was bored, 125mg of solumedrol, and if I was thinking allergic reaction (dependent on my exam) 50mg of benadryl. Would probably skip the IM epi unless he was really wheezy

 

the allergy info is down below.
ok, thanks for the info, hopefully i never have to know this, but i think i have to take a basic first aid/responder class to be a fish and game officer.

ok,he is just having problems breathing, his chest tightens up when he breathes, his history is no known allergies, the weather report says that tree pollen is extremely high, he is taking no medicines, started after waking up in the morning, no inhaler as he has no history of asthma.
unsure of wheezing lung sounds because when he breathes you can here and feel something thump in his chest.
i'm not sure what cp or n/v is either

 

Chest pain, nausea/vomiting...

If possible wheezing is being drowned out by heart tones, take lung sounds under the arms, and on the back.

Define chest tightening... Could be pleuritic in origin, secondary to a lung infection.

OPQRST will narrow the chest tightness causes. Onset fast or slow, what makes it better/worse, quality of pain (tight/sharp/pressure), severity...

Any sputum/mucus? Is it green/yellow/clear... Bloody?

If the wheezes are actually ronchi it would raise your index of suspicion for a respiratory infection of some kind.

Fever?

What's the breathing rate/depth/quality/effort? Skin coloring?

Is the pt tripodding? How many word sentences? Normal mentation?

Also... Did it start after he woke up, or did it wake him out of his sleep?

 

Allright guys, thanks for the info, from what i gather questions with answers are your friend.

I have a serious question now, i've always had knee problems, after being on my feet all day i'd have sore knees, my doctor said it was just from me being overweight which i'm sure part of it is, but my knee's always popped funny, and tonight when i was in the tub i put my feet up on the wall and i noticed my lower legs are offset from my upper legs, is this normal?

If i find about the center of the bone on the upper leg, find the center of the knee, then draw a imaginary line along those 2 points and continue it down to my foot my inner ankle is about the center of my upper leg.
sorry for the long description, any thoughts are appreciated.

 

Have you ever had x-rays done on your back? You may have mild scoliosis or just misaligned hips or something.

My girlfriend had the same issue, and it turned out she had very mild scoliosis and her hips were misaligned. Some visits to the chiropractor and therapist and she has improved.


And about the knees...if you are mildly sedentary and overweight (couch potato) like me...and you do a lot of walking and standing, your knees will bother you.

If your knees aren't used to constant load and use, they will give you problems once you start using them a lot. Doing some walking and mild weight training will condition your knees (and the rest of your body)