Stuff I learned today: I'm really really tired

I am sacked, and tomorrow is a full day for us: 8 hours of class, quick dinner break, and then a nighttime mock rescue during which we're supposed to get the first rain we've had since our class began.  On Saturday we learned about altitude sickness, how to identify its different stages and the best treatment approach for each (the short answer: go down).  Bites and stings, including how to deal with poisonous critters.  (more myth busting: pretty much anything you've seen in a movie is outdated and no longer recommended.  You can't suck the poison out of bite, nor should to put a tourniquet on to isolate the poison. you just have to monitor and evacuate.)  We also covered lightning and submersion.   There's a guy in Canada doing really interesting studies on hypothermia and cold water accidents, and this was the most interesting tidbit from the day.  According to his findings (gathered from making himself and his willing students/participants intentionally hypothermic) there's a fairly universal rule for the timeline of cold water submersion, which they call the 1:10:1 rule.  If you fall into freezing water it generally takes 60 seconds for your body to recover from cold shock.  The best thing you can do is to just focus on getting control of your breathing during this time.  After that, you have about 10 minutes of "meaningful" movement before the cold begins to immobilize your muscles, regardless of how cold that water you fall into is.  And after this, you have about 1 hour during which you can stay conscious.  If, say, you fall through some ice, and you've used your 10 minutes of movement with no success, the best thing you can do is to try to get your arms to freeze to the surface so that if you lose consciousness your airway will remain above water and someone can still find and rescue you.  We also learned that if you do drown, your chances of survival are much higher if you drown in cold water, because it slows down your body, which slows down your dying.  We read an article by a girl who was trapped underwater in a snowy stream for 66 minutes as a child and was successfully resuscitated.

Yesterday was our day off, and after napping all afternoon I get myself together to grab a drink with some folks from our class.  Most people don't live in Portland, and it's been fun to show some of them around a little bit and recommend places for them to check out.  One day of brain recovery time wasn't really enough, and I'm glad today was some easy to digest information.  Today we did cardiovascular and respiratory medical issues, as well as CPR training.  We spent a lot of time with the CPR... although it's conceptually quite simple we spent a lot of time practicing to develop the muscle memory and rhythm of it.  There are some well known songs with a tempo of 100 beats per minute, which is the rate of chest compressions for CPR.  One of them is "Stayin' Alive" and another "Another One Bites the Dust".... like I said they have a good sense of lightness in this class.  Also learned how to use a defibrillator (modern ones are placed everywhere, and the machine literally talks you through the process.)  I was interested to learn that King County (Seattle) has a roughly 50% success rate in CPR, whereas the national average is somewhere between 10-15%.  Apparently it's a combination of having a population that is better educated in CPR, and having the money to have more defibrillators placed around and faster EMS response.  As heart disease is the leading cause of death our country, it makes you wonder what a populace better educated in how to handle a heart attack might be able to do for our national life expectancy.

Oh, and I learned how to remove a fish hook if someone gets it caught in their skin.

Don't think I'll make it onto the blog tomorrow, as I've been told our mock rescue could run as late as midnight.  I'll catch up in a couple of day... wish me luck and calm!

Frostbite and Fake Blood

After the long day yesterday today felt like a breeze, especially because the material we covered was a little more strait forward, at least for me.  Today we covered wound management, which included some pretty gnarly stuff, like how to control an impaled object that you can't remove from your patient, and how to treat an amputation.  We're lucky to have really awesome instructors for our course, who have the ability to inject some comic relief into our interactions without losing the weight of the situations we're talking about.  Case and point, Lisa referred to the fake finger that popped off of her patient's hand as "little patient."  As in, "we want to take care of big patient, but I can't forget about little patient over here either."  Unlike many things, this was pretty in line with my media experiences.  Clean that little patient and place it in some sterile, damp gauze in a ziplock baggie and keep it cool.

After wounds and lunch (what a combination for one's morning) we got on to environmental issues: heat exhaustion/stroke, dehydration, hyponatremia (low sodium, usually caused by over hydration), hypothermia, frostbite, and non-freezing cold injury (also known as trench-foot).  This section was also fairly familiar to me, although we did some interesting myth busting.  Getting into a sleeping bag naked with a hypothermic patient won't do any harm, and might help them feel more comfortable, but isn't going to be especially helpful in raising their core temperature.  Waiting to pee doesn't make you colder, and you don't lose more heat from your head than from an equivalent sized surface elsewhere on your body. With environmental risks, the focus is definitely on prevention, although treatment is obviously thoroughly covered as well.

I can't tell you how unexpectedly fun this class has been.  Pretending to be a patient (which I did twice today) is a blast, and I finally get to utilize the skills from that acting class I took in college.  Today I suffered a head wound, broke my wrist, and had some internal bleeding!  Even more amusing is watching the reactions to the regular folks walking their dogs through the park, wondering what 10 of us are doing splayed out in the grass with fake blood on our heads while the other 20 crouch over us.

Tomorrow is the last day before our one day weekend, so maybe on Sunday I'll have time to say more about the experience, rather than just the curriculum, of this class.  For now, suffice to say these have been some of the most interesting, affirming, and fun days in recent memory.

I know something EMTs don't know, nanananana....

Today was very cool, because we began by learning something the urban first responders and even EMTs are not trained in, which is Focused Spinal Assessment.  The reason that emergency workers in urban settings don't have this skill is that if they have a patient with a potential spinal cord injury they can call an ambulance and get them to a hospital in a "spine safe" manner, where an ER doctor will do an FSA.  In the backcountry, transporting someone in a spine safe manner means strapping them to a backboard and carrying them out in a litter or having them evacuated by helicopter.  So if we can determine that it's safe for someone to walk out it's usually better, and might even be essential for getting them help for their other injuries in a timely manner.  If you're thorough, it's actually not very difficult or complicated.

Another cool thing we learned today that is usually only done by doctors is how to reduce (reset) some dislocated joints.  We're not going to mess with elbows, hips, or the knuckles at the base of your fingers or toes, but if you've dislocated a digit, patella (kneecap), shoulder, or jaw, and we're really really far from a hospital, I can help you!  When you dislocate a joint, the muscles surrounding it spasm and hold it in its dislocated position.  To get it back in place, we use traction (pulling) directly away from the joint in the position in which it was presented and allow the muscles to fatigue.  For a shoulder, this is often enough itself.  Digits have bumps at the joints, and so we have to gently pull the dislocated portion up around the other side of the knuckle so that it can slide back into place.

We also learned about how to assess and treat head wounds, and how to splint a boatload of fractures.  Splinting was perhaps the most fun project so far, as it involved a lot of creative arts and crafts time.  A foundation of this that I found particularly interesting is that padding + compression = rigidity.  You don't need a stick or anything rigid to properly splint someone, you just need to pad all around the area well (to avoid direct pressure and for comfort) and wrap it snugly and thoroughly with an ace bandage, t-shirt, etc.  So we spent a lot of time practicing with our own gear, and talking about different ways to improvise.  The most elaborate project in this was to construct a splint for a mid-shaft femur fracture, where traction is used to reduce pressure at the site of the fracture, therefor alleviating a lot of pain.  I tried to explain this in words just now, and failed miserably.  Wound up with a sentence the began "basically" and then ran for 5 lines.  This is worth a thousand words, I think.

Today was our 12 (or 13) hour day, so goodnight!

"Stuff I Learned Today"

I have a problem with this blog that's probably more analogous to my life than I would like to admit, and it's this: I get busy and fall behind on the posts that I want to make, and then when new things happen I don't post about them because I want a chance to "catch up." The stuff of my life builds up and suddenly I'm waiting to tell you abut my day until I can fill you in on everything that's happened since October. In the spirit of breaking this cycle, I'm introducing an new feature, for a limited time, called "Stuff I Learned Today." This and next week Seth and I are enrolled in a Wilderness First Responder course, meaning that we're being trained as medical first responders with specific training for backcountry/extended care scenarios.

Our first class was yesterday, and runs for nine days total: seven 8 hour days and two 12 hour days, including a mock rescue out in the woods somewhere. So, for my own review and your amusement, here's some stuff I learned:

Yesterday:

The medical community loves acronyms. It's not just because they make you sound smarter than the guy next to you; I can now give a rundown of a patient's condition in about 30 seconds in shorthand, whereas it might take several minutes to communicate in plain language. I'll use some of it while I tell you what else I learned, and you'll get a sense of how few full words we use.

Day one basically tackled this question: What do I do when I encounter someone in need of medical attention? Before you even approach the situation you need to: try to guess the MOI (mechanism of injury) and determine if its safe for you to approach/be there, pull on your gloves to protect yourself from fluids, determine if there are other injured persons and who needs your help most urgently, and get a general sense of the severity of the injury (ie does it appear to be life threatening?). This should take less than 10 seconds or so.

Once you approach a person and identify yourself, basically the first thing you do is to grab their head. This isn't always the case; if someone twisted their ankle and is sitting on a log you won't go up and squeeze their face, but if there's any chance that whatever happened to this person could have injured their spine, you're going to stabilize their head until you can rule it out as a possibility. Breathing and circulation are the first concerns, so we check to make sure their airways are clear and that they can take a deep breath without pain, we find their pulse and do a head to toe sweep for any major bleeding. After we make sure that our patient is breathing a circulating blood adequately, we're back to the spine. We're going to ask them about what happened (if we can), and from the MOI determine if they could have injured their spine. If there's any possibility of this, someone is going to hold the patient's head until we can stabilize it on a backboard, on which they will be evacuated. Once you make the decision that spinal damage is a possibility, evacuation is non-optional.

We'll then do a head to toe exam, looking for any other injuries that might be in need of immediate attention. We'll also check CSM (circulation, sensation, and mobility in the hands and feet) during the exam. Once we've dealt with these, it's time to take vitals. Prepare for acronym madness! V/S (vital signs) are as follows:

LOR (Level of Responsiveness): This can be A+O (awake and oriented) at several levels, depending on how oriented/disoriented they are, V (responsive to verbal stimulus), P (responsive to pain stimulus) or U (unresponsive)

HR (Heart Rate) pretty self explanatory

RR (Respiratory Rate) also self explanatory, although I did learn that you don't tell someone when you're taking their RR, because they will often subconsciously alter their breathing. This explains why nurses often take your HR with your hand resting on your chest, and why it takes them a full minute to take it.

BP (Blood Pressure) You guys know this one too, although I didn't know how to take someone's BP before yesterday. We learned how to do it with a stethescope and without, by using someone's radial pulse (that's the one in your wrist).

SCTM (Skin Color Temperature Moisture) A healthy SCTM is PWD (pink, warm, and dry- pink being the inside of your lip or nailbed, somewhere where we're all pink, regardless of ethnicity). Skin that is PCC (pale, cool, and clammy) is less good.

Pupils- are hopefully PERRL (Pupils Equal Round and Reactive to Light) We note anything abnormal.

Temperature- usually for us this is N/T (not taken) in a backcountry scenario. Specific numbers are less important here than general impression.

After this we get a relevant patient history, document it all, and make an assessment and treatment/evacuation plan. Whew.

Today we learned more about assessing possible spinal injuries and moving a patient in a "spine safe" manner, including: how to roll someone on their side to do a physical examination/treat or dress the back by yourself, or with the aid of one or two additional people, how to move someone from an immediate danger if necessary, how to reposition someone into a stable/spine safe position alone or with help, and how to transfer someone onto a backboard or litter (stretcher) and safely carry them over a distance. That was before lunch.

After lunch we talked about shock, and maybe this was the biggest thing I learned today. Shock is one of those terms that I've heard a million and a half times, but of which I had very little understanding technically. Maybe you're in the same boat: my experiences with television and movies led me to believe that shock is some kind of reaction, physical/psychological, to extreme trauma. I associated it with the nervous system I think. But shock is simply this: a loss/lack of perfusion, or the flow of oxygenated blood to the body. Technically, everyone dies of shock. Heart attack? Loss of perfusion because your heart's not pumping. Car crash? Loss of blood, obvious. Die in your sleep when you're 110? Yup, that too. If you're heart and lungs stop working, that's shock. Shock is generally caused by a loss of liquids (blood, vomit, diarrhea, etc.), and always caused by a primary issue, whether it be trauma or simple dehydration. The best thing is to treat the cause, if possible, and to identify shock early and monitor a patient closely. It's quite nice how our body tells us what's going on inside of itself; when a person goes into shock they will experience a spike of adrenaline, because their brain is subconsciously aware that something is wrong. This will often cause a person to be anxious, elevate their heart rate, and make them PCC, which are the first signs we look for. At first their vitals will look pretty normal, but if shock progresses we'll probably see their HR elevate, but become weaker, their BP drop, their LOR will become more disoriented and their skin will become more PCC. These are immediate, get this person out of here asap kind of signs. Hopefully, we've already got a helicopter on the way if this is the case. As with many of the decisions we're being trained to make, how to deal with shock is super dependent on the MOI. If we know someone is in shock because they've lost a lot of blood, the decision for rapid evacuation is pretty quick. If someone is in shock because they got food poisoning and have been puking for two days, we might try to hydrate them and monitor them closely, watching for any changes in their vitals, especially their LOR.

Believe it or not, we also learned about chest traumas today, including broken/fractured ribs, flail chest (two or more ribs broken in two or more places) and pneumothorax/hemothorax (air or blood in the chest cavity that prevents the lungs from breathing properly. I now know how to sling someone for a single rib fracture (which, by the way, is all the hospital can do for you aside from the pain meds) and how to bind and transport someone with flail chest. Pneumothorax (also called collapsed lung) is another story: unless there's a hole in someone chest through which air is entering and I can plug it, I just need to get this person to a hospital, where they will punch a hole in the person's chest to release the air. Despite some folks having seen George Clooney do this in Three Kings, we were told that this one was outside of our level of training. Fair warning, if you click this link, be aware it's a little gory.

And that's what I'll leave you with, as I should have been in bed an hour ago. My brain is tired, and I'm not going to proofread this, so my apologies for any typos.. Join me tomorrow for another installment of "Stuff I Learned Today"!