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Tricks of the trade. Got any?
Every now and then I'll see a fellow Medic pull a new trick out of his/her bag that that I find very useful. For example, ever have a patient you suspect is doing a really fine job of faking a seizure? You know, the ones that should recieve an Oscar nomination? If the patient has his/her eyes open, give them a quick blow of air in the eyes. If they are faking, they will blink their eyes. My department doesn't allow ammonia snaps or sternal rubs so sometimes we have to get creative. The pseudo seizure pt also doesn't care for a nasal airway either! Another one I learned has kept the calculator out of my hand during drug dosage calculations. I'm horrible with math but this one is pretty easy to do in my head when time is essential. For Lbs to Kgs, divide the Lbs in half, take 10% of the difference, and subtract that number from the difference. Example for 180 Lb man
180/2 =90
10% of 90 = 9
90 minus 9 = 81 180/2.2 = 81.82 I say close enough!
So, I'm always looking to pick up new tricks, tips, and pointers. If any of you have some you've learned along the way, please share!
180/2 =90
10% of 90 = 9
90 minus 9 = 81 180/2.2 = 81.82 I say close enough!
So, I'm always looking to pick up new tricks, tips, and pointers. If any of you have some you've learned along the way, please share!
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Replies to This Discussion
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Permalink Reply by blair4630 on -
Wow, I'd have to think about this one. There's so many I've picked up over the years, I've probably forgot more than I know, but that's probably the same with most people.
There's a book call EMS 4 EMS, it's full of the stuff you're talking about, sort of. Not so much tricks, more a memory aid for remembering assessment tools, treatment algorithms, etc. Some of it is outdated, some of it will work forever, it's pretty neat, you might pick up a thing or two you find useful.
I actually use that lb to kg myself. I'll try to throw a few in here, although I don't know if they're considered tricks so to speak, but things I've learned from others or from courses, that I like and use.
Backboarding....unless they're critical, if they need a board, I like to pad from the head pad/base down to about the buttocks, so the entire torso is padded. Usually go with 2-3 blankets, double folded, so there's 4-6 layers of blanket between them and the board, it makes a world of difference for them.
I don't use this one, but saw someone else use it and it worked well....If you set up a line (not just lock, but the bag and tubing) in the house and are extricating with a stairchair, he took a D-ring from his belt, ran it through the hole at the top of the bag, then clipped the bag to his shoulder lapel, so it was out of the way and also the pt. could continue fluid therapy during the extrication.
When you're knocking on a door, make it a habit, to stand to the side of the door. If you do it every time, you'll instintively do it on a call where it might save your life.
If you are having trouble reading a rhythm on a Parkinson's pt. with tremors, hold their chest and arms firmly against the chair or litter (explain what you're doing and why first), alot of times you'll get a perfect rhythm, or at least minimal artifact. *I once saw one from a friend of mines call that looked exactly like atrial flutter, then the next strip from when he did the "trick", it was a NSR.
When you shift into reverse, let the backup alarm beep 3 or 4 times before letting your foot off the brake, you may not see someone right behind the unit, that should alert them.
Those are a few off the top of my head, if I think of more I'll post them, and hopefully I'll pick up a thing or two as well from others. One other thing I just thought about, if you read JEMS, Thom Dick does a tricks of the trade column, it's awsome.
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Permalink Reply by Frank Lenoir on -
I love the D-ring idea... that would have come in handy soooo many times with stairchairs / wheelchairs / even dialysis chairs... :D
Be safe.
blair4630 said:Wow, I'd have to think about this one. There's so many I've picked up over the years, I've probably forgot more than I know, but that's probably the same with most people.
There's a book call EMS 4 EMS, it's full of the stuff you're talking about, sort of. Not so much tricks, more a memory aid for remembering assessment tools, treatment algorithms, etc. Some of it is outdated, some of it will work forever, it's pretty neat, you might pick up a thing or two you find useful.
I actually use that lb to kg myself. I'll try to throw a few in here, although I don't know if they're considered tricks so to speak, but things I've learned from others or from courses, that I like and use.
Backboarding....unless they're critical, if they need a board, I like to pad from the head pad/base down to about the buttocks, so the entire torso is padded. Usually go with 2-3 blankets, double folded, so there's 4-6 layers of blanket between them and the board, it makes a world of difference for them.
I don't use this one, but saw someone else use it and it worked well....If you set up a line (not just lock, but the bag and tubing) in the house and are extricating with a stairchair, he took a D-ring from his belt, ran it through the hole at the top of the bag, then clipped the bag to his shoulder lapel, so it was out of the way and also the pt. could continue fluid therapy during the extrication.
When you're knocking on a door, make it a habit, to stand to the side of the door. If you do it every time, you'll instintively do it on a call where it might save your life.
If you are having trouble reading a rhythm on a Parkinson's pt. with tremors, hold their chest and arms firmly against the chair or litter (explain what you're doing and why first), alot of times you'll get a perfect rhythm, or at least minimal artifact. *I once saw one from a friend of mines call that looked exactly like atrial flutter, then the next strip from when he did the "trick", it was a NSR.
When you shift into reverse, let the backup alarm beep 3 or 4 times before letting your foot off the brake, you may not see someone right behind the unit, that should alert them.
Those are a few off the top of my head, if I think of more I'll post them, and hopefully I'll pick up a thing or two as well from others. One other thing I just thought about, if you read JEMS, Thom Dick does a tricks of the trade column, it's awsome.
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Permalink Reply by Nathan on -
Wait, they dont allow sternum rubs???? What do you use for painful stimuli? One of the favorites Ive seen some Docs use for pseudo seizures (I just use ammonia) is to pinch their nose and then cover their mouth, they start to fight you in a few seconds if they are faking :)
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Permalink Reply by V-fibber on -
As far as the Kilo thing the way I use is take the weight in lbs, cut in have, then take 10% off. Example....250 lb pt. 1/2 is 125. take 10% off 12.=112 kilos.It does work
As far as un unconscious or seizure faker very simple. The drop test. Take their arm.Lift it up straight so it's over their face and drop. If their faking it will "magically" miss the face.
Also if you use the LP 12 or 15 and you get that annoying "12 lead cancelled due to excessive noise" Next time before you push the 12 lead button, hold up the connections off the stretcher and patient.
Try wrapping up the disposable head blocks in an adjustible collar. Just add tape inside the package.
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Permalink Reply by Tom Sasso on -
First: Thom Dick's "Tricks f the Trade" are GREAT!!! (He actually used to be my supervisor for a short while... years ago in San Diego before he left for the greener Mountains of CO: Miss you Thom).
I LOVE the D-Ring/IV trick, I haven't seen that one before... though I have seen a lot of IV holding tricks... that sounds the best I've heard.
Now... on the the debate (I really don't want to do this because I know I'm in for some heat coming my way). Be careful on the "faking a seizure" patient. I don't say this as some overly careful or rightous care provider, but as someone who spent about 2 years before I was an EMT taking care of patients specificly with Seizure disorders. So let me make this simple... you CAN absoultely and 100% sure be having a seizure and still react to painful stimulus, flick your eyes when stimulus is given, open your eyes with ammonia and all the other tricks i've seen. The fact of the matter is, seizures come in MANY forms. Grantly, in EMS we are primarily taught the classic "Grand-Mal: Tonic Clonic", but there are peti-ma, focal, jacksonian etc... focal can be manifested as a seizure in one part of the body and not the other (it may effect musclur portions without effecting the occular motor nerve effecting the eyes. Especially be carful of jacksonian... these are (oversimplified) a spreading seizure... starts as a focal and spreads to full grand-mal. I've seen many a medic do one of their "faking seizures" tricks and get the faking it response... just to see the patient go into a full gran-mal moments later. I forget the classification, but there are even seizures that manifest as what i call "behavioral" episodes, usually as the patient taking off their cloths inappropriately and at bizarre times (it is a type of petit mal I think but not the typical "staring seizure we think of with petit mal). Now, just to prove that I'm not arguing against recognising someone faking it, this is what I do. Every altered parient I get, everyone one... immediately gets a Nasal. 2 reasons, they are faking it and this helps them prevent it in the future, or they are really having one, it this helps secure an airway. Either way, no harm, i've treated appropriately and within established protocols and just may have helped them (i'm always aazed at how well a nasal stops snoring respirations... it eeally is a largely underused procedure. The only real indication for a nasal is an altered LOC... it is designed to protect the airway in an ALOC patient, if there is another recognised airway problem, you are probably doing more. As for the painful stimulus: i used it as an assessment tool, but i have seen many a bruising from a medic trying to wake up a patient they thought were faking. ammonia can do harm in a patient with ICP, the "arm drop" is great as long as they are faking, but the mment they aren't: you just gave your patient a busted nose. The eye flick is actually a realitively harmless trick... but the reality is it isn't conclusive, they CAN still be having a seizure. We all know when someone is faking (well, usually), you don't need the tricks to prove it.. just drop the nasal as if they are having one, either way, you're a hero.
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Permalink Reply by Nathan Jennings on -
Tricks of the trade....some good, some bad, some ugly! Before I go on a rant, I want to start by saying that I am in no way myself innocent and have used some of these "tricks" myself. But as the years go by in this job, I find I really don't care if the patient is faking or not. In fact, if they wanna lay on the cot and not mumble a single word, all the better for me. As long as I've done my assessment and everyone gets to the ER w/o a hitch, I'm gonna mark that one down as another happy customer. I agree that one should always do their best to determine a pt's airways status, quality of breathing and circulation, and LOC. Painful stimuli is sometimes warranted in this situation (sternal rub, skin pinch, etc). If you then determine that the patient is faking it, then let them fake it. It concerns me that anyone would cover the nose and mouth of a patient in attempt to "arouse" a pt having pseudo szs or whatever else they are complaining of, and because an MD did it does not make it right. And of course a pseudo sz pt doesn't like an NP, because they already had a patent airway and didn't need a hose rammed down their nose! There is also a reason ammonia is not found very often in EMS or ER's any longer, it is has been deemed essentially worthless in pt care. Remember that little saying of "Do no harm?" It would be wise to take a step back and realize what it is you are trying to accomplish. If someone wants to fake unconsciousness, it truly doesn't change the end result. Get some vitals, give 'em some vitamin O, maybe a lock and a dex, and take them to the ER. Causing undo pain and grief does nothing but piss off the patient and possibly family, which could potentially lead to a physical altercations, patient complaints, write ups, legal actions, and so on. The risks far outweigh the benefit in these situations.
Ok, off my box. Neat tricks that I have learned...leave extra sheet at the end of the cot to put over the pt's shoes so you don't end up w/ shoeprints on your uniform. If someone is drunk as a sailor and can't hold the basin to there face, elevate the head of the cot ~45 deg, take a med red bag, cut a hole in the side of it and put their head through the hole, it will resemble a bib like you used to see @ long john silvers and it will catch the vomit. Please remember basic airway skills though and make sure the bag isn't over their face! Blanket rolls: lay down a sheet, take ur thermal blanket and lay on top of that, fold into thirds and roll up both ends. When you need to cover your pt, lay it in their lap and unroll it, then snug it in. Spanish speaking pts: find the young ones, typically they are bilingual and make great translators! Venigards make great securing devices for nasal tubes, put the clear window over the nose and wrap the 2 "fingers" around the tube. Pill bottles from hospitals can have a wealth of knowledge on the label if they have a medical record number and you can call that ER and get a PMHx from them. This has saved my arse many times on an unresponsive pt. One last thing, the paperbag thing for hyperventilating pts doesn't work.
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Permalink Reply by The Cannulator on -
"Never get out of the boat. Absolutely goddamn right. Unless you were goin' all the way."
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Permalink Reply by Duncan Hitchcock on -
Nathan, excellent advice. "Trick-of-the-Trade" are suppose to help us do our job in the wierd world of the streets; like the d-ring for an IV bag, the VeniGard for securing nasal tubes (I also stretched the the long single strip and used it as an extra means to secure the tube to extend across the face) or the prepped long board with the blanket rolls. They aren't suppose to teach little irritating things to do to patients. Find another way to defuse that doesn't include abuse.
Amen to your statement "just because a doctor does it doesn't make it right." Expand that to include a nurse or another paramedic.
I used hemostats for hanging IV bags. Insert it thru the hole for the IV hook and clamp it to something; a curtain, the sofa, your shirt. Disclaimer: The hemostats in question were obtained by permission of a local ED from a disposable suture removal kit and were not used on a patient.
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Permalink Reply by Trent Baker on -
Wow. Good advice and thanks to all of you. I Will most certainly put some of the suggestions to use.
Tom, I am familiar with most of the seizures you mention and have been lucky enough to see most as well. I should have been clear, I was in fact speaking primarily of the Grand Mal variety. Or the attmpt at faking them. My bad.
Nathan, I understand where you are coming from and agree with you to an extent. However, the Pt's condition dictates my urgency of care. That's what I'm trying to accomplish. Before I EVER put myself, my partner, the pt, and other motorist in potential harms way, I make sure it's worth it. EVERY TIME, you, me, and other EMS providers run lights/sirens we are putting our lives in danger. Risk vs Reward.
Duncan, I agree that some medics do intentionally irritate pt's and it may very well be abuse. But not this medic.
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Permalink Reply by Tom Sasso on
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Thanks and good input from everyone... I still firmly believe in the nasal airway: again, i don't use it as a "trick" to seeif someone is "faking"... it is simply a very good way to secure an airway in all ALOC patients, it is an after the fact lesson learned that it also seems to "cure" some individuals that may have in fact been "faking something". And for the record, I have inseted nasals into myself as a demonstration... uncomfortable, but no harm. Everything is a risk vs. benifit: problem is, some focus on risk, some on benift, some see things differently, that's why we all do things diferently. I think we all do our bestfor the patient, I'm a "do the most you can" for the patient medic, some are "do the least, or you might cause harm" medics, both are good views from their standpoint, I realy don't judge other medics or question their actions but for the most obvious and adusive. We simpy have different views.
So... my "Trick of the trade": understand we all have differnt ways of doing things, it doesn't mean one is right or wrong... they both have goods and bads, risks and benifits, rights and wrongs. Just do your best for the patient, start your justification for whatever you do with "it is best for the patient because..." and you generally won't go wrong. Don't put down other medics, don't tell others about the flaws of Medics you see. Support each other, learn form each other. work as a team. recogise our differeences. Know that the most experienced medics make the best and worst of us, and the brand new medics make the best and worst of us... and just like our patients, there is good and bad in each of us.
Next trick of the trade, try to be understanding of your patient's whenever you can. If thier faking, then they still have a problem to be addressed, why are they faking, are they drug seekers? then they have a problem to address, no diferent from the AMI patient. We do what we have to when we have to, wish I could tell you that i'm nice and pleasant to every one of my patients, but truth is, you have to change your stlye with each situation and each person, sometimes pleasant, sometimes firm, sometimes jsut downright direct and authoritative (I'm also a Cop so alot of my "stearn" may come from that side). But in the end, I don't judge my patients, i just do what has to be done to get them the best care they need or get the other citizens of our community the best system they can have.
Most medics I've worked with are great, some more techically skilled than others, some more book knowledge, some more challenged perhaps, but most everyone there because they care, I have only really see a handful of medics in my day that caused concern or alarm, and i addressed it with them or a direct suppevisor as soon as i saw it, i didn't addresses to anyone else. So thank you everyone for all you do, great job, we are a family.
Trent Baker said:Wow. Good advice and thanks to all of you. I Will most certainly put some of the suggestions to use.
Tom, I am familiar with most of the seizures you mention and have been lucky enough to see most as well. I should have been clear, I was in fact speaking primarily of the Grand Mal variety. Or the attmpt at faking them. My bad.
Nathan, I understand where you are coming from and agree with you to an extent. However, the Pt's condition dictates my urgency of care. That's what I'm trying to accomplish. Before I EVER put myself, my partner, the pt, and other motorist in potential harms way, I make sure it's worth it. EVERY TIME, you, me, and other EMS providers run lights/sirens we are putting our lives in danger. Risk vs Reward.
Duncan, I agree that some medics do intentionally irritate pt's and it may very well be abuse. But not this medic.
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Permalink Reply by Tom Bouthillet on -
Thank you for your reply, Nathan Jennings.
Tom
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Permalink Reply by Tom Sasso on
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ok, lets see if i can come up with some good tricks: my favorite and one I actually use regularly: I tape a soft tip suction cath to my Larg. Blade, the cath hole to control suction is taped to where my thumb is when holding the handle. Then when I go to intubate, I can suction at the exact time and location needed to visualize the tubes. CAUSION: you are going to need to work with where and how to tape the tube to the blade and work with a manikin to ensure you the tube and tape don't block your vision, it took me a few trials and errors before I figured it out. Part of the key is, put the tube to the outside of the blade. Put the tape FLAT (so it doesn't cover your vision down the inside of the blade. Work with it... you'll figure it out. Good luck.
Another suction trick I do for remote EMS (I do a lot of tactical and wilderness stuff): A tummey seringe and a Nasal airway make a neat, small little suction kit. It DOES work... BUT, be careful drawing back that you don't go too much or you just get a big mess. Also, for larger volume, you have to move fast because it obviously only holds so much (and moving fast is what may cause you to draw back too much). Have at it... messes are what we do anyway.
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