Tag: medicine

follow up q&a to my wemt/emt+w post

A friend of mine asked me some questions about my last post (finished my WEMT) and I thought the answers might be helpful for others out there.

What was your favourite part of the course?

Having people in it who had some serious experience. Two guys were heli-ski operators, one guy was a mine rescue technician, several were guides, one guy got shot in the chest point blank, and the instructor is a paramedic who has patients she can’t transport for up to 48 hours because of weather and general Alaskan-remoteness.

In a normal world I’m the most outdoorsy-medical guy around, so it was really humbling and level setting to be around others who experience near daily horror stories and handle them with grace.

What was your least favourite?

I think from an annoyance prospective it was dealing with state and local protocols which are basically always a little out of date with current research. You learn and get tested on some things that aren’t in the best interest of your patients because it takes years for medicine to change (great example: back boards and traction splints, medieval torture devices that are still on most rescue inventories).

At a personal level it was going through scenarios that I had never considered. Like a pediatric with multiple gunshot wounds or a woman who just had a miscarriage, sitting on a toilet, and you being the person who’s going to manage that scene and bring calm. I think everyone has situations that hit them hard in the emotional department, and you never really know what they’ll be until you’re in it or perhaps after the fact.

What surprised you the most?

How quickly a talented person can burn through a primary assessment, establish an airway, stop major bleeds, and prep for transport. It’s like less than a minute (tops) if you’re good, complete with all the gore/mayhem/ppe/bsi/safety.

Going back to the last one, it was also the scenarios that I hadn’t considered. Using a plastic model to practice sticking your hands into a vagina to push a baby’s face off a prolapsed cord and keep the airway patent. Or how to deal with excited/agitated delirium. They’re not scenarios I really signed up to handle, but if you’re functioning as an EMT in an urban setting you can’t pick and choose your patients.

Also, how easy it is to get a bp via a pedal pulse and a cuff on the thigh on a neonate now that I know what I’m doing.

Have you done the NREMT yet, and was it different than what you learned in class?

I’m an Alaskan EMT-1, and have applied for my NREMT course but haven’t taken the test yet. If you’re taking a state’s written and practicals I would really focus on that (which is different than wilderness protocols, which is different than NREMT) because you need to pass it to move on and remembering multiple protocols is rough. It’s a bit dumb because I had to memorize Alaskan procedures I’ll never do in California, but conflicting and head-scratching protocols seem to be the name of the game with medicine in general. Most things are right, but some protocols are bad and just haven’t been fixed yet.

But in general Alaskan and NREMT protocols overlap probably 90%. Dyspnea is dyspnea, a biphasic AED is a biphasic AED, and COPD is COPD. The differences are more subtle like: emphysema patient with a 2LPM nasal cannula complaining of difficulty breathing. Do you crank up the flow a bit or swap her out for a NRM at 15LPM? Either way you’re increasing their O2 but  what’s the specific blow-by-blow protocol? Did you need to use pulse oximetry and if so how? Stuff like that.

My sample tests I’ve taken for NREMT are going well; there’s a few items that are new but nothing mindblowing.

Are you planning on working as an EMT, or did you just do the class for the knowledge?

I think like sailing you suck unless you do it so I’m going to try to work at the local hospital maybe 20 hours a month covering other people’s shifts. My neighbors are trauma surgeons at the local hospital so if I’m lucky I can work with them, or try to hang in the ER in general.

I studied vital sign ranges before the class but from taking literally over 100 blood pressures from various people I actually learned way more about the ranges and concreted in the numbers. Ages and sex matters it seems but I learned that a skinny 14 year old girl probably just has a really low BP and that for little pediatrics I’m high as a kite if I think I can get them to sit still. So the practical application seems to be part of the knowledge to me, if that makes sense.

Do you plan to register in California by county?

So after I get through NREMT I’m going to hit up the hospital in town and just say “Hey, I’m a NREMT EMT-B, what else should I do and what other training would be helpful?” I think there’s ancillary stuff they’ll want too like phlebotomy, probably some blood borne pathogen training, etc. It’s a super rural county so I’m expecting some hoops but probably not a million.

What extra study materials would you recommend?

I was based out of the “Brady Book”, it was the major text we used in conjunction with our wilderness stuff. I bought the workbook along with it and burned through those chapters doing the work before the class. It was probably 100 hours of my life I’ll never get back but the pathophysiology really helped and I liked learning why a pulse oximeter sucks for CO poisoning, as an example.

My learning style is that I need to understand the whole circle and then I can branch out so I felt like (for me) I really need to go ham on the textbook and know underlying health-nerd stuff that there just isn’t enough time in a lecture to cover.

Also, really knowing a lot of the abbreviations and medical terms help. Writing tx is way faster than treatment, ditto pt for patient, hx for history, etc. Sometimes people toss out things like npo and it sucks to have to stop and say, “Huh?”. Yeah, they should speak in normal English but around hospitals they don’t and it’s pretty available info.

In class I made flashcards of things I didn’t understand.

Are there any extra non-study materials you’d recommend?

I made good use of 3×5 flashcards (in addition to pre-made NREMT ones), highlighters, a notebook, and rite-in-the-rain for outdoor stuff. For field scenarios and on actual sar callouts I have WMA’s field guide. It’s 4″x6″ (same size as my rite-in-the-rain book), and both fit in my radio chest harness pocket. On real ops I thumb through it for whatever the suspected injury is to remind myself what the hell I’m doing. There’s also some dope stuff in the back on litter tie-ins, chopper stuff, and medical terms. For whatever field team I’m in I’ll read it out loud (before we get to the patient) and we can discuss what to look for, who’s doing what, what gear we’ll need, what complications we might see, etc.

I just have the boring rite-in-the-rain 4″x6″ because I end up jotting down notes from witnesses, cops, other teams, etc. I’ll write a SOAP and try to format it well enough. In sar land I hand it off to the chopper/ambulance and ask them to give it to the receiving facility as well.

Anything else?

Just because I took so many damn blood pressures I’ll add that quickly being able to ballpark the systolic on a patient, rapidly getting there, then rapidly getting down to the diastolic then rapidly deflating completely is the difference between pro bp readings and torturing a patient by keeping what is essentially a tourniquet on their arm whilst futzing around trying to find their brachial artery for a minute solid.

 

Advertisements

three weeks later, i’m an emt

I’ve previously written up my views on WFR vs WEMT (aka EMT+W), and now I’ve got both of those cards tucked in my wallet.

For two weeks I lived, ate, and breathed emergency medicine up in Skagway, Alaska. I met some amazing people and as an aside I definitely want to write up an entire in-depth post/book/article about not so much the course but the trajectories of those involved. Think about it for a minute: who exactly are the cast of characters already armed with their WFR who are going to spend weeks of their lives up in Skagway learning a super persnickety version of medicine? But first, here are some pictures (some others on my Instagram account too).

IMG_0594
My class. Bent down in the middle is a former CHP trooper, and current paramedic in a fairly remote part of Alaska. When she spoke, everyone shut up and listened.
20170924_125819
On my one day off I hiked with a classmate up to some lakes near the far end of the Juneau Icefield
20170920_131641
The incredibly new and awesome fire department building, where I spent most of my waking hours for two weeks.
20170920_135622
Being in the “south east”, as Skagway is referred to we were actually in a temperate rain forest. As such it rained *constantly*. With the exception of pavement and well worn trails everything else was covered by copious amounts of plant life. The roofs of buildings had green moss, and I dare you to find a single square foot of raw dirt in the area.
20170929_074119
Skagway’s main business is the constant stream of cruise ships dropping off passengers. These folks buy ice cream cones, jewelry, t-shirts, and have a few beers. As such the majority of the town residents cater to these people. This shot was taken the day after “Last Ship Day”, and shows the ghost town that Skagway becomes after the final cruise ship of fall.
IMG_20170922_215407
Wilderness EMTs pass all the regular “in town” EMT training, but then we also have to perform the skills with less gear in jacked up environments and handle longer transport times plus coordinate our transport decisions. This photo was from a campfire after one of our nighttime simulation trainings, somewhere in the Alaskan woods.
20170929_161306
When not in the woods, we trained in the firehouse using the gear from Skagway’s ambulance, sar, and fire teams.
20170923_154603
My bunk and living space for a few weeks.
20170923_154641
The kitchen that myself and four others shared. Thanks to the dog sled gang from Alaskan Icefield Expeditions who let us use their bunkhouse while they were off somewhere else. I left you guys some fishsticks and 3/4 of a bottle of vodka.
20170918_105326
When not in the field or the engine bays, it was classroom land. I of course sat in the back because that’s where the cool kids go.

It was an awesome course: no way around it. Being up in Alaska, especially in such a small town, really focused the laser beam on what I needed to do. In the evenings we did assessments and simulations at the bunkhouse, otherwise we’d be out in town taking vitals on random strangers. I’ve probably taken the blood pressure of every child and barstool drunk in Skagway. I’ve auscultated the lungs of infants, found pedal pulses for systolic/palpation readings on neonates, and observed COPD sufferers. Protip: stay healthy, don’t get obese, and don’t smoke cigarettes.

We made jokes about putting a grim reaper sticker on your ambulance every time you screw up and someone suffers, and I watched one of the toughest people I know cry when he discussed a friend who slid in an avalanche and was attacked by a grizzly. The snowstorm cut their visibility down to near zero and as they moved his blood soaked trauma-ridden body out of the avalanche burial. He could still hear the grizzly somewhere close, howling in the hidden whiteout as he provided treatment.

The day after we finished our state practicals we found out about the Las Vegas mass shooting. As the eternal optimist, a silver lining to me was on a day of such madness and mayhem 18 more people walked back into society with the sole intention to help others in their hours of greatest need. It doesn’t cancel out horror or balance the ledger, but it buttressed me a bit to personally know such dedicated professionals that would have been those headed towards the danger.

If any of my classmates ever stumble across this blog entry, I can’t wait to work with you again in the future. Dangling from a chopper or a cliff, pushing the skinny pedal code 3 to a sick child, or just making someone feel better who’s having a bad day: I’d be proud to be there with you.

20171004_124511
Yes, as soon as I got home I popped that shit on my sar chest harness. I know I’m on the lowest end of medical professional but here’s me being proud.

time is the enemy: ischemia and infarction

In many wilderness medicine curriculums a core area of focus is distal CSM. Distal being “away” (in this context from the heart) and CSM being circulation, sensation, and movement. Blood and nerves tend to be wires hanging out in the same conduit throughout your body, collectively known as neurovascular bundles. Slice one and the results are clear: blood pours out and everything south of the severed nerves now has no feeling and muscles don’t work. Pretty terrible. Definitely something to avoid.

nvb
The yellow and red stuff makes it so you get blood, can move muscles, and feel things. You generally don’t want to have that get trashed.

In wilderness medicine you additionally have to deal with those neurovascular bundles getting pinched or squeezed. Even something as common as a dislocation, definitely something with lots of trauma (like a fall) that jammed a bone into some weird position, can now be putting sufficient force on blood and nerves that it went from a nuisance problem potentially life threatening.

In search and rescue, time is always against you. Consider a typical situation:

  1. Someone slips on a rock when backpacking and plants their next foot into a hole, bending their ankle in a way that baby jesus never intended it to move. It’s now 0800 just after breakfast.
  2. The patient tries to move around a bit and see how bad it is. Yep, it hurts like hell. They confer with their friends and decide there’s no way they can walk out. They need help. It’s now 0815.
  3. The friends get to a mountaintop where they can get a cell signal out and call 911, explaining the situation. It’s now 1130.
  4. Search and rescue gets mobilized and a helicopter is put on alert status. 1140.
  5. SAR is staging at the trailhead a few miles from the patient, packing the right gear. The helicopter has been re-assigned to a case of massive head trauma. No chopper today. 1200.

I’ll stop there as even before the first boot step moves in the patient’s direction four hours has already elapsed. You can chop that time down by having a $250 satellite communicator (and $15/month service plan), but it’s still going to take a while for folks to get to that patient and really this article is written towards the folks providing that medical care.

DelormeInReach
My preferred satellite communication device these days. GPS, bad-but-useable text messaging, tracking with a map folks at home can see, an SOS feature, and a good amount of battery life.

My training has taught me that infarction (tissue death) happens within about two hours. It’s not the same for all tissues, but for the arms/legs/hands/feet I go with 120 minutes. Pinch that blood supply off for that length of time and the tissue distal from it is deader than Firefly.

Fortunately ischemia (restriction of blood flow) is typically not an all-or-nothing thing. A bone jammed up against a tube of moving blood might block it a little, a bit, a bunch, or entirely. Think of having a plastic bag over your head versus one with a small hole in it. With the sealed plastic bag, you’re pretty dead pretty fast. With the small hole in, you can eek out a few more moments of life. The more restriction, the bigger the problem. So maybe you’ve got more than two hours since the ischemia might not be so complete. That’s hardly wonderful news since rescue response times can be all over the map with “a few hours” being optimal if the patient’s position is known, authorities were alerted immediately, and the terrain is not too difficult. If a patient’s location is unknown, response times to the tune of days is not uncommon.

And then you have transport time, which of course is wildly dependent upon terrain, the patient’s injuries, available air assets, and the size and ability of the ground crew.

Time is the enemy in other ways as well. Hypothermia in some climates, hyperthermia in others. Increasing intracranial pressure, HAPE, HACE, and a host of other problems get worse the longer they are left untreated. And generally by the nature of the operation you can assume they already have gone untreated for a prolonged period of time. With some exceptions, a properly trained wilderness medical provider can slow or even reverse many of these life threatening conditions.

litterlower
There’s nothing easy about transport.

By constantly remembering the impact of time on our patients, both before we got there and after they are in our care, we can do several things:

  • Shorten the list of serious problems that higher levels of medical care need to focus on. Instead of clinical moderate hypothermia, a patient now might simply want a second blanket on arrival to the hospital due to your interventions.
  • Save a limb. The next time you hug a loved one or stand on two feet, imagine not being able to do that quite so easily. By ensuring proper perfusion our patients can fully live out their lives.
  • Provide more insight to higher levels of care. If our attempts at providing perfusion are inadequate (perhaps through manual alignment in accordance with your training and agency protocols), it’s a clear signal that other issues such as acute compartment syndrome might be at play.
  • Slice and dice between the the original chief complaint (an unstable and painful ankle) and new issues such as dehydration and heat illness from laying in an unshaded spot because of the ankle.

One way that time can be somewhat of your accomplice if not outright friendly:  keep track of things you may want to do during transport and execute them when appropriate. If a belay needs to be rigged, take some vitals. If the litter team is scouting a route, toss in some more heat packs.

And although an entirely separate conversation, haste can also be your enemy. Rigging a belay takes time, but is obviously better for the patient than chucking him or her down a cliff. We want to move fast, but only as fast as safety and the patient’s interests will allow.

Going back to the example of the injured ankle, if the ground team gets there at nightfall and a storm sets in, if perfusion isn’t an issue and there’s no immediate need of extraction would be it safer to set up camp for the night, wait out the weather, and then proceed with daylight and dry footing 12 hours later when potentially more rescuers are available as well? That’s a very big question and can’t be answered in a hypothetical: much more information is needed that only a real scenario would be able to address. I only bring it up to to balance against rapid transport as a rule, rather than a probable option.

My writing is commentary on my training and personal experience. I try as often as I can to discuss patient care with medical teams I interact with in order to learn where I can improve and provide better outcomes. Please don’t substitute my writing for comprehensive and recognized medical training.

 

 

WFR vs WEMT (Wilderness First Responder vs Wilderness EMT) for search and rescue

As I study my WEMT material, I’m pondering the differences between the two courses thus far. Currently a WFR, I’m headed up to Alaska in the fall for a multi-week WEMT course. Sleeping in a bunkhouse with my other classmates, on a somewhat remote Alaskan island (population 741), I’ll have 8am-8pm class 6 days a week, in addition to the months of material I’ve had to go over in advance (doing it now) and the WFR I needed just to register.

 

I started writing a whole primer on the various levels of wilderness medicine but I deleted it all as the topic is huge. Instead, I’ll try something new and focus on the title: WFR vs WEMT, specifically for search and rescue folks.

study
WFR is the books on the right. WEMT is the books on the left *and* the books on the right.

WildernessFirstResponder

Coming in with roughly ~100 hours of training is the Wilderness First Responder, or WFR, pronounced “woof-er”. This swiss army knife of wilderness medical response is the expected level of quality sar team members and outdoor guides need.

  • Laser beam focused on the task and environment. You’ll learn nothing about ambulance gear because hey: there’s no ambulances in the wilderness.
  • While still a multi-week time commitment it’s possible for most normal people to figure out a way to pay for it and take the time off.
  • Available in a lot of parts of the world.
  • Fairly uncomplicated focus on critical system stability. Identify and treat the things that are field manageable, identify and prioritize transport for the things that need higher levels of care.
  • By being able to dismiss the urban setting and ambulance (or better) equipment, things get simple pretty fast.
  • You are not operating under an agency’s medical direction so your protocols (reducing dislocations, clearing spines, administering epinephrine, stopping CPR, and declaring dead people dead) is actually much more than an EMT would be able to do provided you’re in a wilderness context (typically defined as two or more hours from definitive care).

wemtpatch

Coming in with roughly ~200 hours of training (tack on another 100 for the WFR you generally need to take the course) is the funky WEMT or EMT+W. It’s basically an EMT+B with special focus given to non-ambulance gear and prolonged care and life support in an austere environment.

  • You can have way more patient exposure if you want it. As an EMT-B you can be treated like shit and underpaid riding around in ambulances with horrible working hours. But hey, it’s work and more importantly it’s experience.
  • On a SAR team you’ll probably be the, or at least one of, the primary medical providers as WEMT is a rare designator that few people trot around with. Again, experience.
  • You can expand your reach by riding ambulances, joining (typically smaller) fire agencies, and even working in hospitals or at a local physician’s office.
  • With all that experience, you can move towards being a paramedic (EMT-P) if that suits you and you have the time/money.
  • You’ll understand more of what’s going on with your patients at a physiological level and have a broader understanding of chronic and acute disease.

The real benefits for WEMT comes down to experience and advancement. Working as an EMT-B sucks for most people. You’ll make roughly $12/hour, which is what I currently pay my babysitter and she sits around watching Netflix not dealing with death around the clock. Even paramedics make roughly $17/hour, and that’s after spending $10,000 – $20,000 to go to paramedic school and after having worked as an EMT making peanuts long enough to get the experience to even apply to paramedic school.

All that being said, your ability to gain experience and advancement as a WFR is basically zero, strictly from a medical perspective. You’ll be limited to the patient contact you have in SAR which can be pretty thin. Also, you’re hogging it and not letting others on your team drink from the firehose that is the primary medical provider role.

It was explained to me when I got my USCG Captain’s License: this means you can do the job, you don’t get good at it until you’ve done it a lot. When you first get your driver’s license you’re a terrible driver. It’s the years of driving experience on top of the license that make you decent. The same goes with all skills including medicine.

Captains with a license but not a lot of time running commercial ships are referred to as “paper captains” on the waterfront: it’s not a term of endearment. Whether it’s driving a car, flying a kite, or diagnosing hypovolemia you are better at it the more you do it.

wemt
Typical SAR work. You’re a long way from an ambulance.

Search and rescue is basically an all volunteer system, as it always has been. Going back to 1000AD, search and rescue is a side gig. And in a big way, that’s what makes it so great. Everyone is taking time away from their families, taking time off work, and prioritizing helping others. I heard a joke the other day that to get into sar you need to take the psychological test, and fail it. Getting a chance to work with these outstanding people is a privilege. And of course it is a privilege and not a right to treat a patient when they are in one of the scariest moments of their life.

Everyone in sar needs to make the decisions for themselves as to how far “good enough” is. Perhaps because I’m a bad climber, middle of the road tracker, and crummy mountaineer I think my medical skills are where I can do the most good. It’s not lost on me that my own daughter’s life was saved by a sar team’s medical chops.

If you’re a WFR and keep your skills sharp, I’ll work with you anytime. I’ve seen firsthand a WFR keep someone alive for hours in a jacked up situation before evacuation could occur. If you’re a WFR and want to get more time with patients and perhaps go onto other aspects of medicine short of nursing or doctoring, consider the WEMT route.