Posts Tagged ‘BLS’

An afternoon with 3 patients

June 2, 2016

This afternoon, I was happy to see

Patients, but really just three

I couldn’t send the prescription

Without a description

Of where the button happened to be.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter found me working in western Nebraska and, later, in coastal Alaska.  After the birth of our first grandchild, I have returned to Nebraska. Any identifiable patient information has been included with permission.

No work for me on this last Monday because of the holiday; I spent Tuesday getting trained for the new EMR. The Basic Life Support (BLS) class took up most of Wednesday, and I left without seeing a single patient.

This morning I looked in on two hospitalized patients that I’ll care for on Friday.

Then I listened to jackhammers outside my office window for the rest of the morning while I did more BLS instruction on line. After all, hospitals only finish up their construction when they die.

My afternoon included 3 patients, scheduled at the rate of one per hour to allow me to figure out the new system. Two came from my generation, one from my parents’ generation.  The first I treated by taking away a medication.  The second, with a very complicated history and a long med list, I treated with gravity.  The EMR guru, sent by the vendor to help the transition, and living away from home for months, gently and patiently talked me through the documentation.  Then, after hours, he needed to leave for family business.

I had to prescribe a medication for the last patient, something I’d not done so far. My nurse, a stranger my end of the EMR, couldn’t help me with a very confusing task.  At that point, late in the afternoon, all the other providers had gone home.  One other remaining nurse stood over my shoulder, and told me what to do.

She had me click on an ellipsis, and then clicked her tongue and said, “Well, I’ve never seen that before.”  Fifteen minutes later, we resorted to calling the prescription in.

It reminded me of the time when the airline scanner wouldn’t take my boarding pass and my name ended up hand-written on the passenger manifest.

At the end of the day, Bethany picked me up. We stepped into an afternoon with a light breeze and a perfect temperature.  Atypical rains have left the sky clear blue and the countryside lush green.

I regretted keeping her waiting when all I’d done was take care of three patients.

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A refresher in resuscitation and a visit to Te Papa, the New Zealand National Museum

March 16, 2011

I’m trying hard to decide

When everything else has been tried,

     What drugs should we give

    To make the dead live,

After a patient has died.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, we’re in Wellington, New Zealand.  I’m prepping to work here.

The third morning of orientation today started with a discussion of emergency medical services in New Zealand, while concern about fallout from the Japanese nuclear disaster remained an undercurrent in everyone’s mind.

Four entities provide EMS in this country; three cities have their own, and St. John provides the rest.  They also do a lot of other civic stuff, including operating the largest youth group in the country.  There are four levels of providers. 

It came as no surprise that the lowest level of emergency service provider administers acetaminophen (Tylenol or Panadol) routinely.  It came as a shock to learn that the more advanced can also administer low doses of Fluothane, an inhaled general anesthetic that fell out of American OR favor in the ‘90’s. 

The higher levels paramedics are allowed to give small quantities of ketamine, which is closely related to angel dust or PCP.  It’s also a great general anesthetic, dissociating the patient from the pain experience, but sometimes people freak out.  I learned that in the low doses used by the EMS providers, pain relief is prompt and bad reactions are rare.

In some circumstances, specially trained rural GP’s attend trauma patients at the accident scene.  

At the Advance Trauma Life Support (ATLS) course I took in December, the instructors recalled the days when they went out in the helicopter and took care of trauma victims in the field.  Their faces lit up when they told their stories.  Doctors in the States don’t do those things anymore.

The instructor gave us a brief refresher in ACLS.  The Automatic External Defibrillator movement has just started here.

New Zealand has prioritized resuscitation to those people with a reasonable prognosis (for example, not those with massive stroke).  By comparison, the barbaric American way gives everyone gets a “full code” (including shocking, intubation, ventilators, and chest compression) unless a document to the contrary comes to hand immediately.

 Resuscitation trends have come and gone, algorithms have changed, and the rate of successful resuscitation has improved in the thirty-two years since I first took ACLS.  Most of the drugs originally recommended have been dropped from the armamentarium.  Since I took the Basic Life Support course last spring, chest compression only has supplanted mouth-to-mouth combined with chest compression.

But some things don’t change.  Our instructor mentioned his wife, now thirty-eight weeks pregnant and four hours away, and his concern.  I remembered back to February 1984, when we lived in New Mexico and Bethany’s second pregnancy went past her due date.  I worked at an outlying clinic forty-five minutes distant, and I hated leaving her.  I had no peace of mind till I started back home.

Three of the docs and two of the wives lunched together and went to Te Papa, the New Zealand national museum.  I was impressed by the wisdom and knowledge of our Maori tour guide, who has instructed at the University level in, among other places, Wisconsin. 

I would have loved to just sit and talk with him for an afternoon.