#EMSSA2017

emssa 2

JoziEM are attending the EMSSA conference in Sun City this week, the link below is a comprehensive summary of the content and themes for the first day, this data was captured and collected through “crowd sourcing” co-creation with @bad__EM and @EMManchester.

EMSSA Day 1 review. Co-created review with St.Emlyn’s.

Pre-hospital ultrasound

So I have always been the gadget guy.  Always trying to have the latest piece of tech to make life easier, the latest iPhone and the tools to make them all talk to each other. I don’t get why everyone isn’t living in the cloud??

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When I started seeing ultrasound machines in emergency departments, it naturally got me interested.  This black and white grainy picture was only found in the radiology space surely?  My inquisitive nature led me to do some reading, and that led to an attack of the FOMO…there were already paramedics in parts of the world using ultrasound on the roadside!

Then luckily my favourite enabler invited me to attend an ultrasound course (Thanks Mande!).  I wandered along and did the EMSSA course, and then had to work quite hard at getting the skill practice to be able to complete the requirements.

But then an interesting realisation hit me.  What was the point?  There are ambulances running around in southern Africa without oxygen, and here’s me wanting to explore placing a device worth more than an entire ambulance into practice.  A little internal conflict ensued:  on a personal level I wanted this new technology, but at the same time I was struggling to justify WHY.

The personal side won, and I forged ahead with trying to do some roadside scans.  Two cases stand out, and will support my argument in favour of the technique

  • Paediatric trauma patient with a distended and painful abdomen. Clinically the patient appeared sick, tachycardic and pale.  Another paramedic had asked for a helicopter due to the distance to a paediatric facility.  While waiting, I thought this was the perfect opportunity for an e-FAST exam.  And all that was seen was a really really full bladder. There was no free fluid seen in any view.  After allowing the patient to empty his bladder, everything changed.  The heart rate normalised, and the previously distended abdomen was now soft. The patient didn’t need that helicopter ride. He didn’t even spend a night in hospital

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An adult gunshot patient, left parasternal wound. He walked to the ambulance, smiled and asked if he had to go to the hospital.  His vitals were all perfectly normal.  So while waiting for the ambulance I put a probe on.  And there on the screen was a distinct layer of fluid around the heart.  The closest trauma facility was a long way away, so I boldly drove past the local facility.  Just after arrival at the hospital he arrested. But because he was in the right place, he got the emergent thoracotomy he needed. He survived to ICU discharge.

So why do I think ultrasound does have a place on our tip of Africa?

  • It’s not that expensive anymore. New devices are continually being released, with more accessible and more suitable devices hitting the market all the time.  And the price is coming down.
  • The value as a triage tool is undisputed. If we compare the accuracy of pushing with your hands to feel an abdomen to looking inside; or the use of a stethoscope versus an ultrasound to look at lungs, then why wouldn’t you use it?  Getting the right patient to the right hospital is certainly important.
  • In the draft EMS Clinical Practice Guidelines released by the HPCSA, it was encouraging to notice that ultrasound use has made an appearance.

The naysayers will hold that the price isn’t worth it.  It’s a first world thing – it will never happen in South Africa.  Like 12 lead ECGs.  Or ETCO2.  In the service I work for, if you don’t use ETCO2 on an intubated patient today, best you start looking for a new job.

So where do we sit now?  Yes, it’s not going to be an everyday EMS thing today or tomorrow.  But it’s made it onto the scope of practice, and the number of paramedics doing the training is growing.  We need to work on the equipment suppliers to get the best possible prices.  And then we need a local curriculum on training.

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Most importantly in the pre-hospital setting is when NOT to do an ultrasound.  If it will delay transport or treatment, then don’t do it.  It needs to be performed in parallel to existing on-scene assessments, and then specifically when an answer needs to obtained.

If you are in the prehospital space, and you have any sort of drive to improve yourself, then take the opportunity to learn sooner rather than later.  Take the few minutes to watch the ultrasound done in the ED after you handover. Ask questions.

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Some cool references:

Quick, J. A., et al. (2016). “In-flight ultrasound identification of pneumothorax.” Emerg Radiol 23(1): 3-7. (www.doi.10.1007/s10140-015-1348-z)

Lee, C. W., et al. (2016). “Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound.” J Crit Care 31(1): 96-100.  (www.doi.10.1016/j.jcrc.2015.09.016)

Wydo, S., et al. (2015). “Portable ultrasound in disaster triage: a focused review.” European Journal of Trauma and Emergency Surgery: 1-9.  (www.doi.10.1007/s00068-015-0498-8)

Nelson, B. and A. Sanghvi (2015). “Out of hospital point of care ultrasound: current use models and future directions.” European Journal of Trauma and Emergency Surgery: 1-12.

Booth, K. L., et al. (2015). “Training paramedics in focussed echo in life support.” European journal of emergency medicine: official journal of the European Society for Emergency Medicine.  (www.doi.10.1097/MEJ.0000000000000246)

Taylor, J., et al. (2014). “Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors.” BMC emergency medicine 14(1): 6.  (http://www.biomedcentral.com/1471-227X/14/6)

Brun, P.-M., et al. (2014). “Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma.” The American Journal of Emergency Medicine 32(7): 817. e811-817. e812.  (http://dx.doi.org/10.1016/j.ajem.2013.12.063)

Jørgensen, H., et al. (2010). “Does prehospital ultrasound improve treatment of the trauma patient? A systematic review.” European Journal of Emergency Medicine 17(5): 249-253.  (www.10.1097/MEJ.0b013e328336adce)

Post by David Stanton @davidstantonza

 

 

 

Plastic Family on Safari

Resusci-ann’s Ethiopian Adventure

Travelling to Gondar

It occurred to me, at around 02H00, whilst tightly nestled between two well-built, champion snorers (who just so happened to be the friendliest Nigerians I had ever met), that perhaps, I was slightly out of my depth. The plane was packed to the max with passengers, and I was convinced that at any moment a scrawny chicken might burst forth from the overhead locker (this alas, did not happen). A melting-pot of languages, cultures and nationalities surrounded me. I felt overwhelmed knowing that I had accepted the task of heading off to ETHIOPIA of all places for 6 full days of basic and advanced resuscitation training, and was now more than halfway across the vast African Continent, hurtling through space and time at whatever the top speed of a Boeing 737-800 is. Too late to get off now…

I sat quietly between “praying man” and “goatie guy” (I had already affectionately nick-named my seat sharers) thinking about the fact that I had no visa yet (having been heavily reliant on potentially dodgy internet information about landing visa’s and tourist/business declarations), only some few Dollars in my wallet, and absolutely no idea what the beautiful, lilting Amharic voice of the airplane intercom lady was saying. What on Earth have I gotten myself into? 

Once we landed, (I spied my ALS manikin box chilling on the tarmac and said a quiet thank you to the universe) the Amharic got intense. Surrounded by the constant sounds of this gentle language, the smell of incense and cooking spices that seemed to permeate the entire airport and tarmac, I realized that something was about to happen that had never, in my life happened to me before. I was for sure going to miss my connecting flight.

Racing through customs and security in my socks (because the little man in a suit at security thought my shoes could be concealing explosives…) I screeched to a halt at the back of the check-in queue, which seemed to snake around the terminal. Numerous guard types approached me to determine if they could assist, but alas, boarding was no longer allowed and the doors were closed. I purchased a second ticket to the city, whose name the locals laughed at when I pronounced (Gondar is apparently not pronounced Gonedaaar, more Gunder) and headed to the airport exit, determined to find the Wi-Fi the internet had boasted about.

Buying things with another country’s money feels a lot like Monopoly, especially when the notes are literally the same colour as the Monopoly notes. 350 Birr to pay for the next flight to Gondar (I have no idea how much money this is) and am fairly sure I would have been the easiest target if I had wandered from the safety of the airport, which I considered, as the security guard pointed me in the direction of a faded Coca-Cola sign in what appeared to be a beer garden right outside the airport gates. Giving the beer garden and slightly suspect looking cab drivers, clamouring for tourist attention, a miss, I decided it might be safer to sit out this wait in the boarding lounge.

In the distance Addis Ababa was bustling, with the mandatory taxi hooting and garbage smells wafting about, mingling again with the smell of incense and cooking oil. Ethiopia seems to be a place of smells. I hope my little plastic family managed to make the flight I missed.

After what seemed like a lifetime of waiting in the small tin-roofed building that turned out to be the domestic departures lounge, I finally made it onto the plane to Gondar. The wait was not uninteresting (the highlight being that lunch at the airport cost more than the missed flight payment). I soon realised that all meals in Ethiopia would follow a very similar theme, Western food was all heavily spiced so as to disguise the fact that Western food in Ethiopia SUCKS. “When in Rome” is probably the best advice I can give when eating in Ethiopia, try the local cuisine, they are AMAZING at all things Ethiopian (surprise). Initially, this was problematic as the menus in Amharic were fairly difficult to translate, and the only food whose names were written in English were “Western foods”.

Arrival in Gondar was a culture shock of note. I assumed that having worked in many rural spaces, and been privy to the private lives of some of Johannesburg’s poorest and most vulnerable populations, that I was well equipped for the poverty and development levels I was going to find on my arrival. I was horribly wrong.

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Air side at Gondar Airport

My first surprise was the general level of development within the town. As the second biggest town in Ethiopia, there seemed to be 2 or three major tarred roads in the town. The buildings that did exist are reportedly left over from the Italian occupation more than 80 years ago. The countryside struck me as wildly hilly, and ridiculously treacherous, yet on each rocky outcrop there seemed to be a small community of shanty buildings precariously perched.

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Gondar Town Centre

I am fairly sure that on my drive through town towards my hotel, my jaw must have hung open a fair amount of the time. Small children scantily clad with massive eyes that seem present in all rural African settings were present. The people are the same, the problems are the same, but here they just seem so much bigger.

Culture and Teaching

My first day of teaching was interesting to say the least; the people of Gondar with whom I came in contact were incredibly soft spoken and did not initially take well to my less than traditional teaching methods. The first hour or so of day one was a nightmare of confused stares and side-way glances. It took me a while to realise that I may have been speaking too quickly in a language that was foreign, in a South African accent (which is tricky at the best of times). More than before, these first few hours had me thinking “what on earth have I gotten myself into?”

Over the course of the programme the students definitely warmed up to my ridiculous sense of humour, and silly jokes. The students grew more excited at the prospect of learning new things, and I learned to speak a little slower and with a lower pitch. In terms of culture, I absolutely realised that teaching and interaction is VERY different in different countries. Cognitively this seems obvious, in practice however, this was a big surprise for me. At the end of the course, the magic that is hands-on, simulation learning won over, and by the end of the programme, a new culture within the classroom had been created. A new community of practice had been set up, and some of the students have since joined the Twitter world to follow #FOAMEd for further learning.

The Medicine/Clinical Environment

After day 1, having completed the first part of the programme with the students, I found myself with a few hours of spare time. Dr Mezgebu (my humble and soft spoken tour guide, and also Specialist in Internal Medicine at the University of Gondar), took me on a grand tour of the facilities. I was intrigued to find the hospital was in fact a large collection of small buildings on a huge piece of land. Each small building houses an individual department, and these buildings are often separated by 800m – 1km at times. As Gondar is, as previously mentioned, very hilly, the hospital is laid out from top to bottom gate over what seems to be a ridiculously steep hill (not so bad on the downhill, but the uphill climb left me breathless every. single. day.). The top gate and bottom gate appear to have been allocated arrival and departure gates as the locals seem to be dropped at the highest point, and then work their way through the facility to the exit gate so that patients can move constantly in a downward direction.

The ED surprised me; the first image on walking into the unit was a MASSIVE poster showing the triage scoring system. I don’t believe I have ever seen a larger, prouder poster in my life. The resuscitation room showcased another winning poster, with the resuscitation algorithm taking centre stage. The planning and thought that had obviously gone into the creation of these posters was evident.

The Emergency Department is situated at the top gate, which creates some excitement as when a patient requires an x-ray or admission, there is a rather steep, bumpy, downhill walk to any other department, with one benefit being that once a patient has been bounced to x-ray the chance is good that any fractured bones have been jostled back into place. Admission to the medical ward entails a hair-raising downhill ride along a steep gradient with an abrupt stop against the wall to the Internal Medicine Department if the stretcher driver is even slightly over-zealous.

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At the very bottom of the hill – the medical wards, with hospital beds squashed into every conceivable space. Rooms that patients in our private facilities would complain are too small for a single patient housed up to 4 patients, with rooms separated by shoulder-high walling to provide some privacy. Drip bags hung from nails in walls, humanity packed into tight spaces, heaving with the blistering afternoon heat and scents. Mostly emaciated faces looked up in surprise at the only light skinned person on the hospital property.

The beds, despite being numerous, were spotless, floors clean, bedding neatly folded into comfortable-looking nests in each bed, each patient apparently well taken care of. Family members bustled in and out of the wards bringing a constant supply of food and drink to their loved ones. Nurses, doctors and family members seem to provide a network of round the clock care for the patients. The rooms were hot and musty, and the mandatory flies that can be imagined in a warm African town at 16H00 were flitting around the ward. I can’t say the wards were pleasant, but that was made up for by the care and concern that went into the care of each of the patient’s present.

I taught in a room next to the 4 bed ICU, where 2 ventilated patients could be catered for, however on my visit only one vent was in use. The staff were welcoming and warm, very keen to show off their ICU and equipment to visiting practitioners. It astounds me how much good medicine can take place in a space with so few resources. It cannot be emphasised enough however, that resuscitation courses are potentially NOT the ideal training programmes for the low income setting.

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Equipment used for the simulation teaching: Ipad (old..), paddles and pacing clips for the manikin, and DartSim application and remote (http://ecg-simulator.com/)

The training mandate for this programme was resuscitation training, and that is what was completed, however, the systems to receive the post arrest/pre-arrest patient are simply not there. With no EMS system to speak of in the more rural spaces (like Gondar), response times of 2-3 hours over horrendous terrain, limited/ no ICU cover (and limited beds and ventilators if the patient even makes it to the ICU), no cathlab within 12 hours, no CT scanner within 4 hours, no access to ABG on the hospital grounds, the basic outcomes and requirements for the basic and advanced resuscitation are relatively pointless.

Nonetheless, we soldiered on, and applied the most relevant information to the setting and available equipment to the teaching. We spent a lot of time discussing and practicing interaction where monitoring of vital trends to prevent arrest was the focus. During the teaching I had a fairly large clinical epiphany of my own.

It is strange to notice how far removed from the clinical, hands-on medicine we have become when we have so many tools to assess a patient. It is not that we are incapable of clinical assessment; it is that we have become removed from our patients ECG cables, and SPO2 probes and side-stream samplers and numbers and waves on screens, instead of using our senses to assess the patient, and even just make eye contact.

Some of the students had never in real life seen Pacing pads (or ECG pads of any sort). One of the ICU nurses relayed an experience where defibrillation had been delivered to a patient who was in ventricular fibrillation and woke up, despite the fact that he was defibrillated with paddles and wet crepe bandages for increased conduction. This is the true edge of medicine; it was a true privilege to teach these “McGyver Medics”.

I estimate that approximately halfway back over the vast African Continent, whilst on my way home after 7 days of teaching and interacting in Gondar, I realised that I had more than likely had one of the defining moments in my teaching career to date. I had participated in something I would probably look back on in years to come as one of the experiences that changed how I think about what I teach and how I apply the teaching to the settings in which I teach.

Probably the biggest lessons learned in this teaching experience, were learned by the instructor. The concerns that had plagued my journey to Ethiopia had been chased away by the absolute awe of the experience.

 

 

Thank you to:

  • The University of Gondar (Dr Mezgebu Silamsaw, Yonael Mulat, Rezika Mohammed for hosting my stay in Gondar)
  • Medicines for Malaria
  • Africa Institute for Emergency Medicine (AIEM)

 

Author: @epicEMC

70 Shades of Grey

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How I became interested in medical ethics

The truth is: I should get out more. I mean, who likes medical ethics as a subject? That 160-slide PowerPoint presentation on some random Thursday afternoon at undergraduate level when you spent the time updating Facebook (and not about the fascinating lecture!).

 

That was me. When you’re trained to give drugs and not hugs surely everyone should be treated the same, regardless of how actually dead or dying they already are? I mean, the motions of resuscitation should be administered without deviation to give the patient the best chance, innit? Well, I thought so until 3am one morning when I got told: “Sonny boy, how long are you going to continue because we can all see Granny is dead?!” And another morning, slightly earlier, at 2am when I got told, “thanks for coming but please let grandpa go, he’s suffering” only to be met in the next room by another family member begging me to do something.

 

Who do you call for advice after pumpkin hour when you’re actually the one in charge and everyone is looking at you and you’ve only read Fifty Shades of Grey and now there are at least Seventy, just like the patient’s age (is that even a factor in itself? Three score and ten, good-innings, and all that.).

 

Well shit. Suddenly words like beneficence, non-malfeasance, justice, utilitarianism, adjhgskjgsahkjns, and etc. come rushing back to mind but since you weren’t paying attention you have no idea what they mean, how to apply them, or what the hell to do now. So you do what any skilled professional would do: you ignore the family and RESUSCITATE.

 

It’s a pretty good thing we pick on the dead to do this stuff to because of we did it on healthy, alive people they would take your glasses off and crunch them under their feet before smashing your face in with a brick.

 

Try this as an exercise: Ask ten colleagues what they would do in these situations and you will get fifteen non-committed, VAGUE answers and probably see a goat.

 

The problem with this (as warned by THE Maggie Thatcher) is that when you stand in the middle of the road you get run over by traffic from both sides.

 

So, it became clear that I had to get across the road somehow and so I started reading and consulting… and the more I read and consulted the more I had to read and consult. Basically back in matric trigonometry where nothing made sense from any angle. And so I enrolled in UNISA’s year-long Certificate in Medicine and Law where things became a little clearer and less muddy, like algebra where if you worked through things you got an answer. And the marks come from the logic and workings, not the final answer.

 

Oh, and I learned not to rely on what the law says because that’s another branch of study entirely that doesn’t always answer our ethical questions…!

 

 

So I’m not here to give you the answers. I’m here to show you that I’m just like you: full of confusion, ambiguity, and terror (at 3am). And that this stuff matters because we’re dealing with people – something I think we often forget. And not just dead people, also the ones left behind. And it’s for them that we need to know what the hell to do in various unclear situations. Even if it means putting away the drugs and getting out the hugs.

 

So, my plea to YOU is to please speak with colleagues, read books, consult, attend that blerry two point Ethics CME, and do some scenario planning so you feel comfortable in dilemmas of Ethics.

 

Oh, and don’t phone me. I’m gonna get out more.

 

Post by guest blogger Darren van Zyl @darrenmedic911

Too fast? = REVERT

When is Fast too FAST?

“Is the problem causing the rhythm or is the rhythm causing the problem?”

If the answer is the latter (and the patient has a pulse), you are probably dealing with a heart rate in excess of 150b/min in the adult patient.

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So what does this have to do with REVERT?

If you consider vagal maneuvers for the conversion of a SUPRA-VENTRICULAR TACHYCARDIA, you should be thinking about using the modified valsalva maneuver to achieve conversion.Presentation2.png

For the full algorithm referenced above refer to: http://www.resus.co.za/index.php/tachycardia-management

So what is the modified Valsalva?

First off: lets start with some of the basic maneuvers that are available for the conversion of an SVT (fast, narrow, regular rhythm with a pulse).

valsalva.pngWith slightly less intensity that displayed to the right… the valslava maneuver is described as “a forceful attempted exhalation against a closed glottis”.

The result of the valsalva maneuver is an eventual decrease in the heart rate through a system of complex physiological mechanisms. (for more information on the exact physiology follow the link: http://www.cvphysiology.com/Hemodynamics/H014)

There are a number of ways this maneuver can be performedsyringe and valsalva.png

Now we modify it?

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The patient performs the valsalva maneuver as normal in a 45 degree head up position. They attempt to maintain pressure for at least 15 seonds.

At the end of the attempt, the patient’s head is dropped to flat and the legs are raised to 45 degrees for 15 seconds.

The patient is then returned to seated comfortably, and monitored closely.

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OK…but why?

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Post written by @epicEMC

References:

Appelboam A, Reuben A, Mann C et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet. 2015;386(10005):1747-1753.

Bouthillet, T. 2016. SVT, Adenosine, and Postural Modification to the Valsalva Maneuver (REVERT Trial). available online:[https://www.ecgmedicaltraining.com/svt-adenosine-revert-trial/].

Rescuscitation Council of South Africa. 2016. Tachycardia Management Algorithm. available online: [http://www.resus.co.za/index.php/tachycardia-management].

Wish I was here

A stream of conciousness

Guest post by @real_paramedic

Disclaimer:  The words you are about to read are by no means a masterpiece, nor do I even believe them to be any good. They do however describe events exactly as they occurred, barring the fact that names and locations have been omitted. Some of the events described below reference traumatic events and reader discretion is advised. In point of fact, I wouldn’t recommend the reading of these words by anyone. So there.

When I lay awake in bed at night, as I so frequently do, listing my regrets, of which I have many, I always have the same list floating up through the time fog: the first (and last) time I killed a patient by missing an open book pelvic fracture; not getting any sutures or even any form of comfort when I fell out of trees or confidently leapt from rooftops because I placed too much confidence in the aeronautical capabilities of the umbrella as a child; spending too much time at work; not having a relationship with my family; working for an unethical company for a brief, but protracted period of time; watching the entire duration of the ‘Fifty shades of Grey’ film adaptation (perhaps it is just the milieu within which I grew up, but I thought that beating lady folk into submission when they provided you with rather lacklustre and pedestrian sex until they either started liking it or stayed with you as some warped form of Stockholm Syndrome was stock standard behaviour); not treating people I love better; my first round of burnout; destroying every relationship I ever had; my second round of burnout and so the list goes on and on.

The problem was, that of late, I had started regretting becoming a paramedic, a notion that was new to me, in that I found it difficult to contextualise. I suppose if I’m being honest, the regret that surfaced the most … no, wait… Perhaps this is one of those stories that should not start right off the bat with an existential conundrum. Perhaps I should start at the end – the end of my operational career, that is.

Let’s start with the last patient I saw. I was at the base and the phone rang. It was night time and I was stuck in the middle of some deplorably long shift. I answered and was instructed to attend to a paediatric patient that had been severely injured.

As soon as they started reading the vitals out to me, I found myself slamming the handset against the table, until an esteemed colleague removed the device from my hand and reminded me of the duty I had undertaken to fulfill during my shift.

I arrived on scene and found the little-one immobilised, supine, gargling in his own blood.

Another provider on scene said: “He was just so difficult so just waited for you.”

A voice inside my head was saying: “I’d like to de-glove your face and leave you in your own blood and see how difficult you get.” But I just gave them the stock standard reassuring smile.

Mom wanted to be close, so I allowed her to hold his hand. He settled after a dose of intramuscular Ketamine and I started clearing the blood and loose tissue from his mouth.

He had weak pulses and a relatively low mean arterial pressure, so as part of his resuscitation an intraosseus needle was placed in the proximal tibia followed by a 20ml/kg fluid bolus. He soon thereafter received appropriate doses of Ketamine and Rocuronium to facilitate intubation. I asked a colleague who was close-by to pull the looser facial structures aside with forceps in order to facilitate a better view.

Despite his massive facial injuries, I was faced with a Grade 1 Cormack-Lehane view…when it hit me like a ton of bricks.

How many little cords have I seen over the years?

How many small tubes have I passed?

“I’m sick of this shit. I don’t want to do this any longer” I said aloud whilst passing an appropriately sized cuffed endotracheal tube through the little cords. He ventilated well at low pressures with some adjustments in PEEP, but was ultimately presented to the Emergency Department with a good BP, good capnography, in a head-up position, with an elastic dressing holding down our tube.

In terms of meeting the requirements clincially, we were sitting pretty.

“Should we Lodox?” I was asked.

“It’s only the head and face.” Was my reply.

“Let’s just Lodox, you guys always miss something.”

In true form I did – a clavicle fracture.

I handed the patient over and when asked to complete the tracking form, couldn’t remember if it was 2015 or 2016. I didn’t even think to use my phone. All I wanted to do was sleep. I put my head on the counter I was in deep contemplation:

“15/16/16/15/16/15?”

How many sleepless nights and endless days had this gone on for? How can I not even know what year it is? I was too embarrassed to ask, so I sort of drew a 5 that metamorphasised into a 6.

For the life of me, I could not remember the year.

Have you ever smoked a cigarette and after a brief lapse in concentration you look down to see a sideways or upwards curl of ash and you think to yourself: “Surely the wind smoked most of that one?”

Well, the cigarette was the year I’d had, and underneath the snake of ash, I was burning away. I wondered how I got there, but of course my unraveling had already started a few months back.

burning

I woke up a few months ago after an hour-long nap after night shift. At that stage I never slept more than two hours a day, no matter the circumstances – I just couldn’t prevent my brain from keeping me awake. That morning it was as though the first beams of light that hit my eyes immediately filled my brain with a kind of melancholic discomfort and I knew what I had to do.

You see, I was among the small demographic of people that was awake all night assisting others, so what I needed was to attempt to kill myself in the gym, immediately followed by the consumption of a strong drink.

Most people look down on alcoholics, but not most people in my profession – and nor do I, for that matter. Not that I am one, but I can certainly understand the appeal. Alcohol works, for better or worse and it works immediately. So I did just that. I went to gym and after exercising until I vomited, I set my sights on a bar.

I suddenly realized that I lived in a really inappropriate part of town for drinking by myself, so I decided to pack up the car and relocate temporarily to a place where I would be better tolerated.

I was driving through the suburbs when I almost missed a little bar tucked away on a corner. I saw a neon sign flashing “open” through a haze of smoke and immediately pulled my car into a rather acute left turn and braced for the G’s, bringing her to a screeching halt in front of the bar.

On exiting the car, I became excited when I saw smoke slowly drifting out the windows. I often think I was born too late into an era that unfortunately is ill-prepared to deal with my flamboyant nature. I have always envisaged myself living in an era where you could just smoke wherever you wanted to – this was obviously a smoker’s bar.

My excitement was dialed up a few notches when I discovered that the bar had an electric gate and that I had to be buzzed in. I have always appreciated the notion of having to be buzzed into a bar through an electric gate, as it always raises the curious suspicion as to whom is being buzzed in and whom is being buzzed out.

My excitement reached a peak, or so I thought anyway, when I heard slot machines as I entered and the acute realization dawned on me that I had discovered a real bar. Momentarily I considered turning around, as I was fully cognizant that this majestic old institution would in all likelihood get the better of me, but poor decision making had sort of become a sub-specialty of mine.

I walked closer to the bar and there, behind the counter she was. She had majestic, long black hair, fiendish hazel eyes with long eye lashes, plush red lips, pale skin and was in possession of a good 10kg’s of baby fat, something that has always appealed to me. Then she spoke … she was Russian, or so I thought, and I knew that she would get the better of me.

She immediately planted little worms in my brain and I could immediately feel the little bastards skilfully scraping against the inside of my skull. The locals of the bar were giving me the eye and I felt a tad uncomfortable. I ordered two black labels and two double shots of silver Tequila, and they knew that I wasn’t fooling around. I would elaborate on my interactions with this girl, but my description thereof would in all likelihood pale in comparison with the actual experience.

So let me cut right down to the nerve of the thing: I fell in love with this girl and she said that she fell in love with me – although I never knew whether she was just on the clock, in a manner of speaking (although my tips weren’t that good).  Anyway, the lines got blurred and I lost my way. I started drinking there on each off-day and our conversations started extending beyond the usual friendly banter of day-to-day life, which was wrong of me as a married man. My penance for visiting her on every off-day was that I had to sit and experience first-hand how the dregs of humanity that comprise her daily clientele treated her.

It was during this time that the unraveling started. I started losing interest in treating patients and was in the process of ruining my marriage. I had only known two constants in my entire life: Firstly, the treatment of patients and secondly, my wife, and I was losing both.

I also felt like I had no control over it; as if I was experiencing a great loss of autonomy at the time. I suppose one could speculate that the second round of burnout or the third or PTSD or just working long shifts whilst helping very sick patients, was getting to me but, it was as though the veil had been lifted and the spirits of all calls passed were swirling around me.

Every intersection, every outlying road, schools, hospitals and houses suddenly revealed to me past calls that I experienced with such vividness that I struggled to distinguish between reality and what had happened in the past – or what had never even happened at all. Before long I felt like a passenger to my body. Like my body was just carrying out actions and I was following.

I sat down on each off-day, drinking, writing down my thoughts and dealing with whatever drifted up from the time fog in as gracious a manner as possible. I couldn’t explain how I got to this particular juncture in my life.

Sometimes, with the right kind of mind, I could think back and uncover certain intersections in time, like peeling back the layers of paint on a wall and discovering the remnants of earlier days – recalling the first time I wasn’t excited for shift, the first time I hated being woken up at night, the first time I made an unethical decision, the first time I wanted to withhold analgesia, the first time I threatened to anesthetize I patient if he touched my face again, the first time I didn’t want to go to work and, finally, the point where I felt like I never wanted to see another patient in my life.

It felt to me like my only passion had slowly chipped away at me until there was nothing left and that I had somehow lost myself out there in the streets within the interminable dross that is my job, with no prospect of ever recovering any part of me ever again.

I was staring out in front of me and the bar lady, whom I later found out to be Belarusian, leaned over to me and said: “Penny for your thoughts handsome.” I looked at her reluctantly as I was unsure of whether it was safe to share what was floating through me, but simply replied: “I wish I was here.” I think she knew what I meant and reached out in concern. “But you are.” “No ma’am, you should have seen me when I was still here, I was something to behold.”

Just in case you were wondering, I’m better now and I wasn’t always this bent, burnt and broken. More than a decade ago, before my eyes became less bright and my tail less bushy and more crooked, I entered the service with the best intentions.

I grew up watching my EMS heroes on the television and I decided on the spot that I wanted to become – that guy. After years of hard work, I became that guy and more than just that guy, I became the guy that people phoned when others were struggling.

I loved it all from the start. The rush, the sweat, the blood, the guts, the swearing – everything, and then I went and flushed it all down the toilet. Now you might think that, considering my flamboyant nature and my recently discovered penchant for Belarusian bar-ladies, that I flushed it down the toilet through some malevolent or self-destructive act, but you would be wrong.

If I am being honest – when I lay awake at night, listing my regrets, the regret that surfaces most frequently and clearly through the ether was never being able to utter one simple word: “No”.

Can you come in early? Can you work late? Can you cover the whole weekend? Would you like to be a full-time manager and full-time paramedic at the same time? Can you do an extra shift? Can you stay for another after that? Can you work Christmas?

Had I said “no” to those questions, I would probably be a stable individual happily treating patients on a full-time basis, as opposed to providing you with the ramblings of my idle mind.

I have flushed my operational career down the toilet in little over a decade, like so many of my predecessors. The story never seems to change, only the characters shift in and out of the same story: young practitioners, pushed until they can no longer carry on, tossed aside and replaced by another young, unsuspecting practitioner.

To all new Paramedics, be forewarned by the words of a famous poet:

“My dear, find what you love and let it kill you. Let it drain you of your all. Let it cling onto your back and weigh you down into eventual nothingness. Let it kill you and let it devour your remains. For all things will kill you, both slowy and fastly, but it is much better to be killed by a lover.” Charles Bukowski (allegedly)

Post Scriptum: My apologies if you find my thoughts to be esoteric, protracted, convoluted and difficult to follow. This should give you some insight into what it is like to be stuck within my own unfortunate mind.

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Published: 20/02/2017

Adapted from Allergycases.org and KatieFloyd.me and EMCrit.org

You want me to WHAT?

Refelction

How to be a reflective teacher

 “…when making meaning becomes learning…”

Jack Mezirow (1990)

David Schön cultivated the notion of reflective practice in 1983 and described it as “the ability to reflect on one’s actions so as to engage in a process of continuous learning.” Reflective practice involves paying critical attention to the practical values and theories which inform everyday actions, by examining practice reflectively. A key rationale for reflective practice is that experience alone does not necessarily lead to learning; deliberate reflection on experience is essential (Schön, 1983).

Have you ever sat down for 15 minutes with a cup of coffee and consciously thought about what just happened? As the clinician – you resuscitated a patient… and they died. “But I did go through all the H’s and T’s (sh!t, did I really?) YES of course I did, I had the ACLS card with me. It was probably just their time.” And you go about your normal day. As the educator – your student results are poor… meh, there is a supplementary for this test. “I wonder if I really emphasized enough that chapter 5 was really important? Duh, I’m a good teacher, of course I did. Students were probably lazy, it’s their own fault.” And you go about your normal day.

Sound familiar?  Of course, it does… We are human, we can’t get ourselves caught up in eeeverything we go through every day. But on the flip side… why not?

Don’t get me wrong, I’m not saying that you should spend hours every day reliving every happening of your day, but as clinicians (and especially clinicians that are also educators), we HAVE to be more than just the clinician-teacher. Every day students look up to us and learn from us. Students who see their seniors brush off events, adopt the behavior too. We work with people. As clinicians and as educators, we need to cultivate the correct attitude toward learning and reflection, by modelling these behaviors. Competency as a clinician means competency in the realms of knowledge, skills and attitude.

So, what is reflection and how do you do it? It really is as simple as “sit down for 10 minutes and think”?

Reflection is consciously thinking about an event/interaction.

dylan

Summarizing what happened and simply repeating the events in your head is not reflection. Remember, CONSCIOUSLY THINKING!! Think in big words, analyze stuff, describe feelings, evaluate why things happened, try figure out how and why events happened the way they did. What did you learn? What will you do differently? Why will you change that? What do you think this anticipated change will result in?  reflection

Relax, you probably won’t get it right the first time and you are going to feel like you are wasting your time. I can guarantee you that the more you reflect the more your everyday tasks will bring meaning to you. You fill start to find that the time you spend in traffic is WAY valuable thinking time.dewey.png

As clinicians and educators, we underestimate the importance of our role. We have to constantly be aware of how we portray ourselves as the medical professional and also as the teacher. We have students, colleagues, patients and their families relying on us to be the best clinician and teacher at all times. The accountability and responsibility that rests on us every day extends beyond what we realize. We need to mirror the professionals that we want students to be. Health professions graduates need to be autonomous and life-long learners. If you can’t critique yourself, you will never grow. The phrase “do as I say and not as I do” is not the way to create a reflective clinician.

People hardly remember what you say, they remember what they see and feel –  students, colleagues, patients and their families watch us every single day…

reflect (2).jpg

Author: Judy Steyn (@JudySteyn_SA)

References:

Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books.

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods.

Taylor, B. (2010). Reflective practice for healthcare professionals: a practical guide. McGraw-Hill Education (UK).

 

Child Abuse Resources

References and Resources relevant to the care of the abused child/infant

What is abuse?

“Action, or inaction, which results in actual or potential physical harm from an interaction or lack of interaction, which is reasonably within the control of the parent or person in a position of responsibility, power or trust.” (WHO 1999)

Laws that protect our children?

constitution.gifThe constitution:

Provides direction as to the rights and responsibilities of adults towards children in SA. Section 28 is specifically related to the care and protection of children, and what children can expect in terms of their rights

Children are considered to be vulnerable citizens as such they are specifically protected under the constitution and have the following rights:

The Children’s Act 38 of 2005

This Act covers all the information that would be required for decision making according to the constitution in terms of the child in SA. Section 110 of this act is particularly relevant to health-care providers who are unsure of their role in reporting any kind of abuse of a child.

The important concepts have been summarized below:

Section 110

110 (1) Any correctional official, dentist, homeopath, immigration official, labour inspector, legal practitionerMEDICAL PRACTITIONERmidwife, minister of religion, nurse, occupational therapist, physiotherapist, psycologist, religious leader, social service professional, social worker, speech therapist, teacher, traditional health practitioner, traditional leader or member of staff or volunteer worker at a partial care facility, drop-in centre or child or youth care centre on reasonable grounds concludes that a child has been abused in a manner causing physical injury, sexually abused or deliberatly neglected MUST report that conclusion to a designated Child Protection organisation, the Provincial Department of Social Development or a Police Official. 

(2) Any person who on reasonable grounds believes that a child is in need of care and protection MAY report that belief to a designated Child Protection organsisation, the provincial Department of Social Development or a Police Official.

(3) The persons referred to in Section (1) and (2) must substantiate their conclusion or belief and if they make the report in good faith, they cannot be sued.

Form 22 on the following link is the correct form that should be completed when a report of abuse is made with any SAPS official/social worker capable of accepting a report: http://www.centreforchildlaw.co.za/images/files/childlaw/social_development_forms.pdf

Information about other laws that may be relevant in the care of a child in SA can be found at the following link: http://www.centreforchildlaw.co.za/child-law/sa-child-law

What about SIDS?

Sudden Infant Death Syndrome is a diagnosis of EXCLUSION, meaning it cannot be made without autopsy/investigation into the cause of death.

SIDS does not include death by any of the following causes:

  • Asphyxia
  • Suffocation
  • Aspiration
  • Infection
  • Trauma/injury
  • Metabolic problems (errors in metabolism)
  • Poisoning/medication use resulting in death

None of these conditions can be ruled out without Autopsy, this means ALL infant deaths, specifically if unexpected MUST be referred as an unnatural death for investigation.

The resource on the link below can be used for more information on the topic:

https://www.cdc.gov/sids/pdf/suidmanual/chapter1_tag508.pdf

The Patient Record/Report on consultation

  • In the case that you suspect there may be some kind of abuse occuring, the following information MUST be captured and should also appear on any report made to SAPS (form 22).

what-should-be-reported

Attached is an example of a checklist/report form that could accompany any peadiatric injury:

paediatric-interaction-checklist

For more information or to get in touch with us, please leave a message for us on the contact page of this blog. We look forward to hearing from you!

Who do I call for help?

Below is a resource with all the contact information for Gauteng:

family-violence-child-protection-contacts-2017

References:

  1. Alvarez, K.M. et al., 2004. Why are professionals failing to initiate mandated reports of child maltreatment , and are there any empirically based training programs to assist professionals in the reporting process ? Aggression and Violent Behavior, 9, pp.563–578.
  2. Dessena, B., Wallis, L. and Twomey, M., 2015. A study to determine perceived and actual knowledge of cape town emergency medical care providers with regard to child abuse.
  3. Duhaime, A., Christian, C., Rorke, L. and Zimmerman, R., 1998. Non-accidental head injury in infants- “the shaken-baby syndrome.” The New England Journal of Medicine, pp.1822 – 1828.
  4. Health Professions Council of South Africa. 2015. Annual report p 73. Available at: http://www.hpcsa.co.za/uploads/editor/UserFiles/downloads/HSPCA-Annual-Report_Digital.pdf. Accessed: 28/02/2016
  5. Jackson, A.M., Kissoon, N. & Greene, C., 2015. Aspects of Abuse_ Recognizing and Responding to Child Maltreatment. Current Problems in Pediatric and Adolescent Health Care, 45(3), pp.58–70. Available at: http://dx.doi.org/10.1016/j.cppeds.2015.02.001.
  6. Kemp,  a M. et al., 2003. Apnoea and brain swelling in non-accidental head injury. Archives of disease in childhood, 88(6), pp.472–476; discussion 472–476.
  7. Lynne, E.G. et al., 2015. Barriers to Reporting Child Maltreatment : North Carolina Medical Journal, 76(1), pp.13–18.
  8. Markenson, D. et al., 2007. A National Assessment of Knowledge , Attitudes , and Confidence of Prehospital Providers in the Assessment and Management of Child Maltreatment. Pediatrics, 119(1), pp.e103 – e108. Available at: http://www.pediatrics.org/cgi/doi/10.1542/ peds.2005-2121.
  9. Markenson, D. et al., 2002. Knowledge and Attitude Assessment and Education of Prehospital Personnel in Child Abuse and Neglect : Report of a National Blue Ribbon Panel. Annals of Emergency Medicine, 40(1), pp.89–101. Available at: doi:10.1067/mem.2002.125610 JULY.
  10. Matschke, J. et al., 2009. Shaken baby syndrome: a common variant of non-accidental head injury in infants. Deutsches Arzteblatt international, 106(13), pp.211–217.
  11. McNaughton, J., 1997. Portable guides to investigating child abuse: An overview. US Department of Justice, NCJ165153, p.-.
  12. Nannan, N. et al., 2012. Under-5 Mortaliy Statistics in South Africa: Shedding some light on the trend and causes 1997-2007,
  13. Regnaut, O. et al., 2015. Risk factors for child abuse : levels of knowledge and difficulties in family medicine . A mixed method study. BMC Research Notes, pp.4–9. Available at: “http://dx.doi.org/10.1186/s13104-015-1607-9.
  14. Rocourt, D. V & Nwomeh, B.C., 2011. Injuries from Child Abuse. In Paediatric Surgery: A Comprehensive Text For Africa [Chapter 34]. pp. 222–227.
  15. Survey Monkey. 2015. Sample Size Calculation. Available at: http://help.surveymonkey.com/articles/en_US/kb/How-many-respondents-do-I-need.  Accessed: 24 February 2016.
  16. Sanders, T. & Cobley, C., 2005. Identifying non-accidental injury in children presenting to A&E departments: An overview of the literature. Accident and Emergency Nursing, 13(2), pp.130–136.
  17. Talsma, M. et al., 2016. Facing suspected child abuse – what keeps Swedish general practitioners from reporting to child protective services ? Scandinavian Journal of Primary Health Care, 33(February), pp.21–26. Available at: http://www.tandfonline.com/loi/ipri20.
  18. Warman, M., 1984. Shaken Baby Syndrome : A Review of 20 Cases. Annals of Emergency Medicine, 13(02), pp.104–107.
  19. Worlock, P., Stower, M. and Barbor, P. (1986). Patterns of fractures in accidental and non-accidental injury in children: a comparative study. British medical journal (Clinical research ed.), 292, 100-102.