Contemplating life.

How To: Mobile Guidelines/Protocols

Following from yesterdays post how to add flash cards to you smartphone – here the second part how to add you guidelines/protocols and how to keep everything neat and tidy. Same equipment used as last time.

1. Get an electronic copy of you guidelines/protocols.My service has them on the staff intranet, many services make them freely available online (a few here), and some…

…I guess you’ll have begin harassing your boss, or just start typing (hey, it’s a good way to process and learn the stuff!)

2. For easier access in stressful situations (i.e. on the way to an emergency), I have taken out the most important pages of my guidelines, and made individual PDF documents. In this instance, I am making a single PDF for Epipens (n.b.: we don’t carry Epipens, it’s from the volunteer guidelines. Email me for clarification.

3. Highlight the page you want to single out on the right hand sidebar

4. Open a Finder window

5. Drag the highlighted page to the finder window. It will appear as the filename with the name appendage ‘(dragged)’

For ease of overview, I have all drugs as slideshow flashcards for learning purposes in a flashcard folder, plus all my individual drugs and guidelines in a PDF folder for quick reference on the way to a job. Here’s how to sort it nicely:

1. On you iPhone/iPod Touch, go in to iBooks. Tap on the ‘Books’ button, top middle (in the below screenshot it says ‘Flash Cards’. You will get the ‘Collections’ menu. Tap ‘New’, and add the collections you want. I have my guidelines in ‘PDFs’, and my flash cards in ‘Flash Cards’, as you can see. Tap ‘Done’.

2. You will have a bunch of files in your folder. Tap the top left button ‘Edit’ – this is the screen you will see:

3. Mark all the ones you want to move to a specific category. In this instance, I will be moving Amiodarone, Aspirin, Cophenylcaine and Fentanyl to the ‘PDFs’ category.

4. Tap to select your category, and tap ‘Done’.

5. All my Flash Cards are in the Flash Cards category. To change to my PDFs category, just tap the top middle button.

No excuse not to have all your guidelines/protocols in your pocket anymore!

Hope it helps, and that it wasn’t too difficult.. As always, any questions at all feel free to email me.

How To: Mobile flashcards

For all you smartphone users: Take your guidelines with you on your phone, and make easy flashcards for on-the-go study!

Equipment used was MacBookPro running OS X 10.6.6, Apples iWork Keynote and an iPhone 4 running iOS 4.2.1, with iBooks 1.2.1 installed. Other hardware and software options should work in a similar fashion.


1. Create a presentation. For learning my medications, I have the prompts on one slide, and the answer on the following; e.g. Indications / list of indications / contraindications / list of contraindications.

2. Save the presentation as a PDF document (Share -> Export -> PDF). For other programs you may have to print the file to PDF (OS X), or save a file as PDF.

3. Go to your iTunes library, click on ‘Books’ in the left menu bar. Open a Finder window at the location where you have saved you PDF flashcards, then drag and drop them in to the main area (the grey colored file hovering there is me just dragging it from the Finder window to the iTunes window. Be sure to name them properly, so you know what you’re looking for in the heat of the moment.

4. Sync your iPhone/iPod Touch with your computer.

5. Switch to you iPhone/iPod Touch. You should see your imported PDF documents!

6. Start studying to your brains content!

7. Stuck? Send me an email!

Tomorrow: How to easily put your guidelines and protocols on to your smartphone, and keep everything in order. Until then – happy studies!

EDIT: I received an email from a reader who uses the Flashcards app. I did not know about the app, but also wanted to stay with apps that I already have on the phone.

Thanks though for pointing it out Chris!

Learning Sources: a reflection

Everything. I wanted to know everything about ambulances, what’s on the outside, what’s on the inside, what system do they operate in, who works in them, what do they do, and why?

In other words, I was a boy full of questions. I’d read up a bit about what pre hospital care was about, but when I joined the ambulance service as a volunteer, that was the first time I had access to first hand information. The questions never stopped flowing. What is this for, why do we do that, what should we do if this occurs, why didn’t that turn out the way we expected, and yes, parasympatholytic is a bloody cool word.

Changing careers to work in the ambulance service full time exacerbated this. First of all, I needed to know everything to do the job right. How do you learn? You get taught at school, and everything they tell you is the Gospel Truth. It’s based on our guidelines. It is right, and that is how it is done. I remember taking a CPR practical exam, and my instructor stating at the end: “good work, that was textbook. Congrats, passed!” Too easy, I thought.

A few weeks earlier, we were shown a simulated resuscitation at school. Resusci-Anne had died (again), and needed life-saving green men at her side. Calmly, said men walked in with their equipment, checked for any signs of life and started breathing and pumping her heart for her. All this was done in a very quiet, calm and matter of fact manner. It was surreal; this plastic doll lying in the middle of a clean room, with two men serenely doing their routine movements around her as if they were lubing a bike chain. They finished, and I stated questioningly: “That looked far too calm, simple and easy. Surely reality is different!?”. “No” was the short answer, piped in an equally calm and matter of fact manner.

I didn’t believe them one bit.

Fast forward a few weeks, my initial training had finished, and now I was out on the road. And boy was that exciting. From a guidelines point of view I had close to 100% knowledge, but on the other hand close to zero percent experience. More questions then. Mosby’s Paramedic Textbook became a good buddy, and every person I worked with was consulted about this and that. It slowly emerged that different people gave me different answers on the same questions. Why? ‘This is how we’ve been taught’, ‘this is how we did it in the UK’, ‘we always did that in South Africa’, ‘a doctor told me’, ‘my horoscope recommended this’. Hmm, what to do? Ask doctors, surely they should know? Unfortunately, I quickly realized that doctors study much longer than paramedics, so they can different opinions – than each other. Apparently, if two doctors agree on something, one of them isn’t a doctor. Damn, running out of options. What to do? How to treat?

Oh yes, there’s this thing that sucks money out of me, eats up a lot of my time and sends me strange emails occasionally. Maybe academia may have the answer. They must be sending me to university for a reason. Triple blinded, retroprospective and real life lab conditioned trials – could they tell me something? Not only one persons opinion, but third party, unbiased data collected multiple times, coming to a hard conclusion. Might be on to something here.

Evidence Based Practice (EBP) is the future direction of answering questions. And being able to answer the question why. Why do we use wave form capnography for checking the tube? Why is there such a push for compressions? Because these are hard facts, with level 1 evidence to back them up. Why do we give oxygen to everyone? Because there is…oh, never mind. Just follow your guidelines.

That’s where I am at now. I still ask questions, just not quite as many, as I already have a neat amount of answers in my head. And when I hear answers (sometimes of questions I didn’t even ask), I will always listen, but not always take them on board as readily as I used to. After all, critical assessment of the answer is just as important.

The End?

Or: The beginning of the end of the beginning.

Completed my final academic exam for my Bachelor of Paramedical Science yesterday, and celebrated with a glass of Hendricks G&T.

So, a few announcements:

  • Study is officially over (except for a four week stint back at Ambulance HQ later this year).
  • Whats the point in studying theory for three years when you forget everything? Revision time is beginning at
  • New posts for this blog are brewing, but slow due to a) privacy issues, and b) referencing issues. Revealing patient data on the net is not the done thing, and there is no point popping out statements without decent information to back you up (just ask RogueMedic)

Keep up the good work out there everyone!

A Good Day

Not a bad one at all.

After taking over from this crew, and subsequent desperation to avoid said nursing home at all costs, we checked our truck with no jobs interrupting us. Nice to have a bit of down time to start the shift! A team leader then popped in and brought us up to date with the current direction the service is heading, and what may lay ahead of us.

The conversation quickly turned to exchanging war stories, how the new resuscitation guidelines affect us including general light talk about death and destruction. And to add to the fun, we then got call to what turns out to be a resus in progress!

I was attending, so the job was my call. My first where I am in the hot seat, and first on scene. Grab gear, off to the patient. No response, on to floor from bed, rescue breaths, CPR (first time bone crunching and cracking…), get line in (my first in a cardiac arrest victim!), push drugs (again, a first in a cardiac arrest) and then set up for Endotracheal Intubation (My First Tube! Success!). Few defibrillation shocks in between (yep, had seen them before), package, go. Working with a competent partner, and having some good backup made the scene run pretty smoothly. Happy how it ran from my perspective.

Later on we attended to a not-too-elderly lady who had a fall, but just needed some picking up and some assurance (especially the bystanders who called us). She was in good spirits, joked around and even became flirtatious.  And asked why we aren’t in a Paramedic Pin Up Calendar. Nice self confidence boost.

I maintain she had perfect eyesight.

Last but not least, we attended to a not-so-young lady who again, had a tumble. We were not sure initially if she warranted transport, so we stayed on scene for a bit. My partner explained to the patient and relatives how to use a walker properly, how to get up from a chair on to your walker (rock, stand up, tuck yer bum in, lean on the handles, make sure the brakes are on…). The chair seemed too low for easy getting up, so he offered advice how to jack it up, bricks, timber, the lot. I added my bit of information to the relatives about different home help services that are available, and how to access them. They were very pleased with the help, and thanked us with a smile on their face and a twinkle in their eye.

Learnt a fair bit that day!

Alternatives: Ur doin it rong

Writing this post reminded me of Justin Schorr (of The Happy Medic fame) talking about what is wrong with the current EMS system:

“We put the two least experienced and educated people in charge of deciding how the system will respond to an emergency: the calltaker, and the customer” -> October -> Justin Schorr EMS 2.0 discussion


We don’t have many alternatives for less urgent cases, but we do have healthdirect, “a free 24 hour health advice line staffed by Registered Nurses to provide expert health advice.”

Sounds good, unfortunately we get lumped with a fair bit of work from them. Cases where patients wanted to avoid calling for an ambulance, did the right thing (calling for advice), but got forwarded on to us anyway.

Enter the following situation: We were called to a middle aged patient, who had overdosed on anti-inflammatories. He was complaining of dizziness. Even before we set off, I called the Poisons Information Centre (PIC); the folks over there are continuously helpful, polite, and have a wealth of knowledge. And they’re not afraid to share it in such a manner that even ambos Joe Bloggs can easily understand. Wonderful!

Back to the ambulance. Even with the limited amount of details given, we found out that this patient was in no danger of dying there and then from said ingestion of medication. PIC were quite upfront about that. Armed with this vital bit of knowledge, plus a good deal of background information, we arrived at the caller location.

Upon arrival we see concerned and anxious relatives outside the house, beckoning us in. Inside, after formalities, a short history and some vital signs are gathered, then everyone gathers round and listens to what we have to say:

“All will be good. You’re not going to die. If you are told to take a certain amount of medication spread out over the day with meals, don’t panic if you take the whole dose at once on an empty stomach. You probably deserved the (mild) side effects as a reminder to listen to your doctors orders (I smile, they laugh). You seem to realize that you did something silly (patient looking like a told off child). You are not going to die (big sigh of relief from whole family).”

I called the Poisons Info Line again with the further details. Not much change from the previous telephone conversation, they still think that hospitalization should not even be considered; even seeking a GP would be overkill. Eat, drink, rest, take it easy, and a lesson that more medication does not equal more relief. This was all on loudspeaker so the whole family could hear the expert advice form the PIC.

We leave, and note down the poisons info number for them. They thanks us, everybody is happy, and our ways part.

Two things I learnt from this job:

  1. I can only repeat my intense like for the poisons info team.
  2. Health Care Direct were useless this time. Instead of passing this call on to the poisons info centre (which is all we did), they called an ambulance. The patient would have been fine with some good tele-medical advice, and could have easily been taken to hospital by car (many parked outside, with many willing drivers).

Two comments I would like to make:

  1. There is no transparency how they work. Many ambulance crews believe that healthdirect ask a series of questions, and all algorithms end the same: Call an ambulance. We get some ridiculous call outs from healthdirect. I may call up there myself soon and feign some minor illness, just to judge their repsonse. I have a post about transparency in the pipeline, keep your eyes peeled.
  2. Read the quote at the top of the post again. Either the healthdirect nurses are closely related to (most) nursing home nurses (i.e. useless in emergency situations), or they are bound by far too strict protocols. I suspect (and hope) the latter. Which brings me on the the issues of framework. Our work will only be as good as the framework structured around us, the conditions we work in, the environment we are surrounded by. Again, a post is in the making.

What are your experiences with health advisory hotlines?

Intranasal Medication Administration

The intranasal route of medications seems to be growing in application. This article by Kane (@antidoped) from LITFL brought my attention to a whole new array of intranasal (IN) applications. I was aware of trialling IN Naloxone (e.g. here, and a list of trials here); and the service I work in uses Intranasal Fentanyl for pain relief.

IN Fentanyl has produced satisfactory results in most cases to my liking. The main positive aspect to mention is the quick, easy and pain free application (extremely beneficial for already anxious patients, those with needle phobias, and paediatric patients). The down side list is a little longer though: Many people in pain cry, or in some other way get a snotty and blocked up nose – deeming this route ineffective. I have had some people reporting up to 7/10 pain, and still refusing a squirt of liquid up their nose (questionable reasons, I won’t go in to more details). Application is not always straight forward, some people excessively (against all carefully formulated instructions and advice) breathe in or out during administration, reducing the effective dose. Sometimes seemingly half the dose still runs out of patients noses, or runs down their throat and is swallowed. Discrepancies between given and absorbed doses are bound to happen.

The obvious that IN application brings with it is that it negates the need of IV access, or an IM needle, thus reducing the potential for needle stick injuries. Great for dodgy situations e.g. administering naloxone to a potentially HIV and Hepatitis ridden junkie, or getting some anticonvulsant in to someone actively seizing. Hypoglycaemia, a favourite patient to stay at home (under appropriate circumstances of course), too.

But it shouldn’t be the only option. As stated above, not all patients (especially in the out of hospital environment) have patent nasal passageways, and anyway…if you’re administering powerful medications to patients, you would want a line up just in case.

Or would you? That is a topic for an entirely new post. At the end of the day I recommend looking at the use of intranasal administration of certain medications. If you already are using this route, why not see if you can expand the range of meds given? There are many benefits, most of which relate to the first two rules of a paramedic: #1:crew safety, and #2:patient comfort and wellbeing. Read up the whole story on, and I would be pleased to read any experiences you may have with IN medications in the comments section below. And if you do get your hands on an atomizer, I suggest to squirt some normal saline up your own nose, in order to know what you are putting your patient through.