The radio crackles, the screen in the ambulance jumps in to life as we are diverted from our lower priority call.

The surroundings light up in a mixture of red, white and blue LEDs, stopping traffic while we U-turn the ambulance towards this trauma call.

More information is sent our way: Patient has been stabbed with a stool.

After a short moment whilst I try to envisage such a scene, I turn to my partner and say: “We’ll need a stool sample”.

To which the reply comes: “Probably won’t be too difficult, they should have some stool hanging out of them”.

I would like to share an article with you that I recently found. Please feel free to access the full article (link in the reference) after you have hopefully found interest in the two quotes below.

The paradox of experience

Although experience is often considered as a reliable indicator of physicians’ expertise, many researchers state that experience is not necessarily synonymous with expertise. Several studies underpin this assessment, in many fields of medicine. They show that the physicians’ level of performance in daily clinical tasks is not constantly correlated with their level of experience.

Or, as they say: “Have you got ten years experience, or one year experience repeated ten times?”

I came across this article whilst searching for clinical reasoning – the reasons behind the decisions we make day in, day out. The main focus of this article is not the above quote (but it backs up so much we have all experienced), but the journey in how decisions are made; intuition vs. structured analytical reasoning. May I quote a little more?

Indeed, experimental studies show in both novice and expert physicians that using purely analytical or purely non-analytical strategies leads to lower diagnostic performance than when subjects are asked to use a combination of both processes

There you go. Nice to have the research back you up: walk in to a patients house, get a feel for the situation, get your facts right (history, vital signs etc.), and then compare your subconscious intuitive thoughts with your data that you have consciously acquired and structurally processed – et voila – your patient will benefit.

Now if only there were such a study in a paramedical environment…

- ~ -

Reference:

Pelaccia, T., Tardif, J. Triby, E., & Charlin, B. (2011). An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Medical Education Online 2011, 16: 5890 – DOI: 10.3402/meo.v16i0.5890

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060310/pdf/MEO-16-5890.pdf

Recent misunderstandings and differences in opinion have reminded me of the multitude of names (and misnomers) applied to our line of work.

For clarification and standardisation, I am using the International Paramedic recommendations:

• The Paramedic is the professional practitioner
• A Paramedic Service is the provider of emergency medical services staffed by paramedics; and
• Paramedicine is the discipline and the area of medical study and knowledge.

Source: International Paramedic. Initiation Document (2011), retrieved from http://internationalparamedic.org

New professional dress-up geekery:

At a recent training night, I had the pleasure to listen to a victim and consequent survivor of cardiac arrest. I was really taken by his story, so, with Paul’s permission, I am quite excited to be allowed to share his story with you:

A few months ago, I was riding home on my motorbike, when I pulled up at a truck stop for a rest and to fill up with fuel. I was about to set off again, when I accidentally overbalanced the heavy bike – first it fell over on to the ground with a heavy thud, then I followed with a painful ouch. I was more than just a little miffed – not only had I scratched my bike, but I also managed to land on my bike, landing with my sternum on the handlebar, resulting in quite a sore chest. A little winded, but more embarrassed than anything, I heaved the bike back up and headed back home.

The chest pain never quite went away. It was really quite annoying. A few days later, I was sitting at home, watching TV with my wife, and it still had not improved – in fact it had become worse throughout the day. “I must have cracked a rib”, I told myself. It was progressing from annoying to painful – the pain being in the top of my sternum. The wife (probably sick of my complaining) offered to drive me down to the hospital to get some decent pain relief, as the Panadol wasn’t helping anymore.

I should probably mention that I actually work at the local (country) hospital as an orderly, and have done for quite a number of years now – I know the procedures, I’ve seen a fair deal going on, but I wasn’t too worried about myself. I was also a volunteer ambulance officer for 35 years – and knew my presentation did not reflect the classic signs or symptoms of cardiac related chest pain. All I wanted is to get this bloody pain sorted out so I could get back to the telly, followed by a good nights sleep. As I approached the triage desk, the nurse on duty eyed me up, cocked her head to one side and said: “What are you doing here Paul, you’re on you’re days off! Can’t get enough of us, can you?”. I tried not to laugh too much (ouch), and explained the situation. “You know the protocol for chest pain Paul, we have to follow it!”. And so I was placed on a bed, wheeled in to the emergency department, a 12 lead ECG was applied, blood samples were obtained and sent off to the lab.

I felt a little silly to be honest, lying in the emergency department where I normally work. Instead of seeing people lying on the bed looking up at me, I was now that person in a hospital gown looking up at others from the bed! I was sure it would be over soon. My wife was sitting on a chair next to me, the 12 lead had not revealed anything, the doctors and nurses told me I was probably right about me having a cracked sternum. The blood samples had just come back, with all results within normal ranges. But just to be on the safe side, the x-ray technician had been called in to give me a chest x-ray.

Damn sternum. That bloody bike, silly me for letting it drop, and for me falling on to the…gee, what a roaring in my ears, and my head is spinning like mad…

- ~ -

I open my eyes. I am lying on my back, in the resuscitation bay of the emergency department. Normally, only the sickest patients are placed here. I’m not quite sure what’s going on.

I turn my head around to try and make sense of it all. I am attached to a few more devices than when I remember last, and surrounded by a few more machines. What really catches my eye (and worries me) is the big white board to my right – it is full of scribbles: times, drug dosages, interventions and oucomes. That white board only gets used if someone was really sick.

That someone was me.

The staff quickly realise that I have regained consciousness, and are glad to be able to talk to me. “Paul, what where you thinking, you scared the crap out of us all!” I am mockingly scolded. Apparently that fast beeping I had picked up was my heart going in to Ventricular Fibrillation – followed by a hectic effort to bring me back to life. I received the full ACLS workup; vigorous CPR was performed, I was defibrillated multiple times, drugs were administered. All written up on that white board. I was lucky to be alive.

Two hours had passed since my heart had decided to fibrillate uncontrollably, and continuing efforts were underway. The coronary care unit in the main city had been contacted, and a bed had been reserved. The Royal Flying Doctor Services (RFDS) were en route to our little airport to fly me up. I hardly had time to get my thoughts sorted when the paramedics walked through the door. “Paul, what have you been up to?” Everybody knows everyone in country towns…

I was loaded in to the ambulance, transported to the local airport, and transferred on to the  aeroplane. The flight was alright, although I still knew in the back of my mind I was in a critical condition. Quite often, the RFDS will fly with a nurse on board only – I had two nurses and a doctor escort me on this flight. Once landed, I was loaded in to another ambulance, and the paramedics took me to the coronary care unit that was already waiting for me. I had one stent put in place the next morning, and was kept in hospital for two days for observation. After the staff were happy with my progress, they sent me on my merry way back home! I was stunned how fast everything happened. Sunday night I was in cardiac arrest 400km from the nearest cath lab, Monday afternoon I already had a stent in place, and Wednesday midday I was being discharged, with a letter to my GP and a specialist follow up appointment in six months time.

After arriving back in town, my colleagues at the emergency department were really glad to see me. They admitted to feeling rather bad after I had gone in to cardiac arrest, and had spent quite some time reviewing and deliberating over my ECG, sharing it around and asking for expert opinions. Still no hint of my impending doom, and another review of the blood work did not show up anything either.

I am incredibly happy to be alive today, and it goes to show how such an atypical presentation (nil shortness of breath, ‘obvious’ history of chest trauma) should not be underestimated, as the consequences could be dire.

And I thought it was my sternum.

Inspired by Steve Whitehead’s recent post, I remember another favourite statement being continuously flung in our direction:

“You must see some horrible things.”

and

“I couldn’t do your job!”

Amongst ourselves, we often make fun of these statements. Just the other day on shift, with the ambulance parked up on the side of the road, windows down, I hear a car slowing down pulling up, when a shouting voice emerged: “Wow, you guys must see some horrible things. I couldn’t do your job!”

My colleague and I peeked around, slightly perplexed, then realised why the voice sounded familiar: It was one of our off-duty paramedics having us on. They came over, and we couldn’t suppress our laughter – we find humour in the strangest of places.

But the point is, that is the way the public perceive us. I’ve had many patient conversations in the back of the ambulance where just that topic came up. How I handle it? I initially counter them with a question of what kind of work they do – often enough it is an office based or physical labour type job. Having worked in both of those fields in the past, the reply is easy: “You must see some horrible things” and “I couldn’t do your job”.

Seeing people sitting at their desks, cramped up, typing away mindlessly can be a horrible thing to see. I wouldn’t want to do their job.

As they say: “It takes all types”. Everybody has their strengths and weaknesses. You do your job, I’ll do mine – and together we’ll cooperate and make the world a better place.

“Female, post collapse”

Not much information, but we are used to that. I can appreciate the difficulties of getting information out of an emergency caller, but still think there ought to be a better way of extracting such crucial information.

We flick our lights on, the siren parting most of the traffic. A few minutes later we pull up in front of a large, luxurious hotel, and are greeted by a cheery Peter the Porter*.

“Hello!” he smiles and waves, “I’ll show you where you’re off to, you wouldn’t want to get lost amongst the hallways!”

If only more jobs had porters like Peter.

We weave along the passages, under arches, up lifts, and through the door of the room, where we see…our patient laying face down on the bed, limbs sprawled out in a starfish position, with a colleague performing vigorous back massage. If it weren’t for the patient lying prone, the motions and vigour could have easily been mistaken for chest compressions.

Her facial expression shows evidence of discomfort.

We shuffle in to the room, introduce ourselves, and the CPR-esque massage is discontinued.

Her facial expression shows evidence of relief.

Through a significant Kiswahili language barrier it turns out that our patient just needed a lie down after suffering some back pain from lifting a heavy bag. Every time we asked a question to try and ascertain that little bit more of information needed for treatment, her  swahili friends would break out in the most colourful and chaotic of chitter-chatter in order to try and translate between the two languages and get our point across to the patient; the answer would ensue another round of feverish, frivolous and furious group translation attempts, before being relayed to us by six different people. If you closed your eyes, it could have been easy to let ones mind wonder to exotic and foreign lands, with locals bartering at markets, and exchanging the local town news. Instead, we were trying to conduct a medical interview.

It worked out quite well in the end; the patient and their friends were all lovely people with a genuine desire to help us – and with combined efforts we did overcome the language barrier.

* not his name, but it has a certain ring to it, you have got to admit!

Today, three years ago, I commenced my first shift as a student paramedic.

I remember being keen.

I remember the excitement.

I remember having all the theory, but close to zero practice.

I remember the slow and clunky first steps.

I remember sucking up all the knowledge I could lay my hands and eyes upon (and then the confusion who to believe)

But most importantly, I remember my first partner, my tutor, my mentor. The paramedic who supported me, guided me, pushed me when needed, instilled me with confidence and taught me what a great profession we are in.

I write these lines on the day of my leather anniversary as a career paramedic, a reminder to myself of my beginnings as a new student, the spikes and troughs of confidence, the confusion, the hard work, the ecstasy, the rewards.

What a great journey.

After my recent search discovering that we are hot, underpaid heroes – I thought we should look how our friends from the Police fare:

Bit harsh in my opinion. I would like to think that the general public see them as hot, underpaid heroes too.

Goes to show how lucky we are, the trust given towards paramedics, and the (mostly) welcome attitude we are greeted with when we arrive.

Let’s keep it that way.

I recently came across a tweet from a nurse telling everyone about international nurses day - here is some information on wikipedia.