Feb 17, 2009

Know your author....

My personal review of
"Paramedic Practice Today - Above and Beyond"
by Barbara Aehlert (Author)
  • Publisher: Mosby/JEMS; 1 edition (January 30, 2009)
  • Language: English
  • ISBN-10: 0323043747
3.0 out of 5 stars "More info on the editor please....."
"February 11, 2009
As an educator and author I support my colleagues and peers in their professional publishing endeavours and I applaud Ms Aehlert for this most recent publication she has worked on.

Given the scope and breadth of her prior works I feel this will make a good core textbook for EMT/Paramedic programs, HOWEVER - I do not see Ms Aehlert's credentials relevant to her published work.

I would like to make it clear that Ms Aehlert is a Registered Nurse, and she is listed as the author/editor for a PARAMEDIC course textbook. I have researched her background and I cannot find her to have Paramedic or National Registry credentials. If I am wrong in this, and someone shows me some references, I will humbly stand corrected.

My personal feeling is that if you are going to put yourself so visible as an educator, author, editor then you should at a minimum state clearly the relevant credentials. In the classes I've authored and taught as well as my own publication, I clearly and unashamedly cite my credentials and I will never try to stand myself up as an authority figure on topics/material that I don't hold the appropriate credentials.

To the reader of this review, please be aware that I am not trying to bring any ill-will to Ms Aehlert nor to adversely affect her professional publishing, editing or authoring venues; I am only trying to point out something which I felt was lacking in reviewing this text and trying to help other potential purchasers as well due to the limited information presented in Amazon's product page.

Web citation regarding Ms Aehlert's background...

"Barbara Aehlert Is The President Of Southwest Ems Education, Inc. In Phoenix, Arizona And Pursley, Texas. She Has Been A Registered Nurse For More Than 30 Years With Clinical Experience In Medical/Surgical And Critical Care Nursing And, For The Past 18 Years, In Prehospital Education. Barbara Is An Active Cpr, First Aid, Acls, And Pals Instructor And Takes A Special Interest In Teaching Basic Dysrhythmia Recognition To Nurses And Paramedics. She Is A Consultant With The Southwest Ambulance Paramedic Program In Mesa, Arizona, And An Active Member Of The Pursley, Texas, Volunteer Fire Department" (www.eruditor.com/books/name/barbara_aehlert.1019422.html.en)

Feb 13, 2009

Brian Regan - Emergency Room Comedy

Hey all, I just came across two OUTSTANDING comedy videos. Comedian Brian Regan does an excellent job of pointing out some of the funnier aspects of our jobs in the ER. Watch and ENJOY!

Embedded video is courtesey of YouTube.

Part 1 (approx 2.5 minutes)

Part 2 (approx 5.5 minutes)

-KMG-365, Clear...

The EMS Truth Detector

Ever wonder if your patient is telling the truth or not? Often this is a dilema for pre-hospital and ER folks. Now after EXTENSIVE research and LABORIOUS review I have compiled some common patient sayings and given you a way to weigh the possiblity if your patient is speaking the truth or not. Look down the LEFT side to find your patient's statement, then look ACROSS to find the PERCENTAGE CHANCE THAT THIS IS THE TRUTH. Good luck and BE SAFE.

-KMG-365, Clear

How to predict injury severity

Okay, now we have a tool so you can predict just how serious/severe your next dispatch will be. Look on the bottom for any pertinent dispatch information given to you by your 911 Center, then cross reference it with the severity/seriousness description on the left side. ENJOY!

-KMG-365, Clear

Feb 12, 2009

The REAL reason for spinal precautions!

-KMG-365, Clear

CEN Practice Questions 2-12-09

(ANSWERS POSTED 2/15/09 - Scroll to bottom of this article for link)
Here's some sample CEN like review questions. Try to answer them and write out a rationale. Try to justify why the answer you choose is correct and why the others are wrong.....

The link to the answers with rationales will be posted here in 1-2 days.....

Category: Professional-Legal
(1) Local EMS brings you, into your trauma bay, a 17-year-old female, who was involved in a pedestrian versus motor vehicle crash. A CT of the head shows that she has an epidural bleed and the neurosurgeon is summoned for emergent, life saving surgery. However, the neurosurgeon refuses to come in for this pt. Which of the following best explains the possible liability for the neurosurgeon in this case?

A) Federal laws that require all patients who present to an emergency department receive stabilizing treatment and state laws concerning professional negligence.
B) Case law requiring a specialist on call to respond and federal law requiring all patients who present to an emergency department receive stabilizing treatment.
C) State laws relevant to professional negligence and case law requiring a specialist on call to respond.
D) There are state laws covering professional negligence and case law requiring a specialist on call to respond.

Category: Special Populations
(2) An elderly trauma patient "might" be considered for early, invasive hemodynamic monitoring because the geriatric population has:

A) Decreased peripheral vascular resistance and cardiac workload.
B) Increased pulmonary compensatory mechanisms.
C) Increased physiological reserves
D) Decreased cardiac output

Category: OB/GYN
(3)A patient with an ovarian cyst may present with signs/symptoms similar to which of the following?:

A) Pyelonephritis
B) Pelvic inflammatory disease (PID)
C) Intrauterine pregnancy
D) Ectopic Pregnancy

Category: General Medical
(4) What is the treatment for acute sinusitis?

A) Over-the-counter nasal decongestant sprays for 1 week
B) Hypertonic saline nose drops
C) Use of a humidifier
D) Application of ice or cool compresses to the sinus area

Category: Cardiovascular
(5) The MD has ordered a heparin drip to be started at 1000 units/hour. Your pt weighs 220 lbs. You have on hand a heparin IV bag with 20,000 units of heparin in 500 cc of D5W. How fast (ml/hour) would you run the drip at?

A)20 ml/hour
B)25 ml/ hour
C)40 ml/hour
D)100 ml/hour


KMG-365, Clear

Feb 10, 2009

"Designer" Hospitals

Don't be fooled...hospitals are "competing" for your business.
They want YOU to come to THEM and spend your money (well your insurer's pay-outs more specifically) with THEM and not the competitor.

In an effort to do this, there are many marketing
strategies - a hospital that wants to be successful strives to become a "system"; it's gone way beyond the brick and mortar building itself and it extends into many different venues in our community.

In one of the latest trends we see these "Boutique" Hospitals (BH) springing up, or old ones getting "Contempo" facelifts. These BH are adorn wit
h the latest in aesthetically pleasing exterior facades, window designs, landscaped (er sculpted) grounds and picturesque exterior night time illumination (ala' Cideralla's Castle lit up at night at Disney World)....

You enter them and you will feel the "ebb and flow" and the feng shui and the healing air that permeates. The "energy" is filtered, your endorphins are calmed, free-radicals are held at bay...heck, you probably don't need as much pain medicine post-op!

The palm trees, the bonsai trees, the falling w
ater wall, the light airy music fills the hall.
The colors; earthy hues of subtle color tones, dark and quiet - greens, blues, grays; you might even feel so at peace you wonder why you came to this BH in the first place.

Now don't get me wrong, I appreciate a calm, quiet, soothing environment as much as the next person; but the extent to which the BH is going these days seems a
little overboard to me. The personalized, individualized and engaging care by the clinical and non-clinical care team is great; maybe even just a little too much for my tastes - I'm a big boy, when I need something, I know how to ask....

So we went to one of these BH this am for the wife'ys thyroid surgery
first I noticed a near-empty parking lot! It was nice to be able to park up front and close, but for a minute I thought we were too early and maybe they hadn't opened up yet. Later as I left for errands and drove around the campus, I notice that strategically all the staff and MD's were relegated to parking in the back and out of sight. So for this first impression it was good but again as I said, it looked DEAD (bad choice of words for a hospital) this AM.

Ah, then we come to the foyer to healing... through double glass doors (frameless mind you - so it looks like the doors are merely windows to the outside world) Uh memo to local bird flocks, look out for the doors! Then immediately you are met by a "personal representative" who it seems was expecting us. She takes us by the hand pretty much and leads us to a business clerk who gives a smile and a nod and dispatches us with the escort to the next step. She leads us through the garden er, uh "hallway" of healing all the while giving a running monologue like a tour guide of the amenities and points of interest (just not as funny or slapstick like the 20 somethings who are the "tour guides" on the Disney Jungle Cruise ride...).

So our personal escort ends when we are introduced to the matron who is the "overseer" uh I mean "hostess" over the surgery waiting area. And she too takes her personal interest in us and "guides" us to a quiet corner of the waiting area to await being called back; oh and don't forget the electric-pager-coaster-blinking-thing to let us know when our table is ready, I mean our pre-op room. "Will that be smoking or non tonight?"....

And thus it went, this very personal attention was nice - but again for me a little too much maybe. Im a point-me-in-the-right-direction kind of guy and I'll find my way; but nice nonetheless.

So back to our original point here - we start to see the dramatic lengths hospitals are going to in order to get customers. Yeah we USED to call them patients, but realistically now they ARE CUSTOMERS and you know the "customer is always right".

Personally I have seen these efforts from the inside and out and the strategies/philosophies come wrapped in different missions/mantras: "A healing environment", "An atmosphere of high quality service" etc.... Which is all fine and good, but let's look at some bigger issues:

1) In my observation, one of the LARGEST revenue sources for a hospital is it's elective surgery operations; STRATEGY: Build a nice, new, fancy hospital to have your surgery at. Have some fancy/schmancy gizmos, monitors, equipment and methods so you can have the "latest and greatest" - I mean c'mon, who wouldn't? Latest and greatest must be BETTER for me eh?

2) Again, in my observation, one of the LARGEST expenses for a hospital is it's payroll. So how do they manage this to their economic benefit? Well you do MORE with LESS which either means less staff or lesser-paid staff. How's that for the satisfaction of the employees? Think they are feeling the "healing winds" in the same hospital? Have you checked out the decor in the nurses station and lounge compared to that of the patient rooms?

3) In business they say "first impressions" make "lasting impressions" or something like that. So we see these fancy, picturesque, landscaped buildings that look like hotels popping up. To compete you have to be bigger, taller, do it faster and better - and LOOK GOOD while doing it! YOu sit back and look at these BH and wonder about the millions and millions of dollars financed towards construction or remodeling and think "didn't they teach us that prevention is more cost effective than treatment?" Shouldn't we be building more "prevention centers" instead of treatment centers?

You can see where this is going.
I'm not overtly upset with how hospitals and health care is changing, but I am watching with a leery eye. One part of me sees these BH concepts abounding and then wonders are we still taking care of the employees as much as we are taking care of the buildings.....

When I think back to the recent speeches and political diatribe about the economic crisis and how parts of it were based on irresponsible consumer spending as well as irresponsible behavior by creditors - I wonder does this parallel our health care crisis and irresponsible spending by hospital corporations as well?

-KMG 365, Clear

Feb 9, 2009

The Economy and Specialty (CEN) Certification...?

So I was sitting down tonight watching President Obama's first press conference (8:00 pm EST ????)....Anyways, as he was explaining his take on the pulse of our current economy and how he has seen "first hand" the effects of it on places like Elkhart IN that saw it's jobless rate nearly triple in the last 3 months, and how people are out of work and loosing jobs; I was considering what relevance this state of affairs has to achieving specialty board certification for nurses.

Mr. Obama was explaining his take on principles of economy that decreased consumer credit causes people to spend less, companies to produce less and companies to have to reduce their costs on such things as payrolls and numbers of employees. He went on to talk some about the hardships faced by "Main st" while on the unemployment dole and I got to thinking about nurses...Specifically my brethren Emergency Nurses.

Through many online and in person conversations, one of the recurring themes as to why more ER nurses don't pursue specialty certification (CEN) is their "lack of interest or motivation". Some people I've talked to have even said the extraordinary lengths their employers will go through to support and encourage certifications. At some facilities, the nurses actually risk NOTHING at all due to employer compensations - and they (the nurses) still aren't motivated to pursue certification.

Although we hear about a nursing shortage (and I'm not here to tell you there isn't one) we know that in hospitals, the payroll is THE SINGLE LARGEST line item and it is a direct reflection of the current numbers on the employee payroll. So if a company is going to start "downsizing" to control it's costs, don't you think the choice of who stays and who goes will factor in things like credentials or qualifications.

Like myself, ALL RN's came on board with only a generic entry-level license (AKA right to practice) in a general setting. No RN comes out of nursing school with a competency or credential to practice ER nursing. It is through the on-the-job-training, ex
perience, mentoring and good 'ole 'elbow grease' that many RNs working in an ER setting claim the title "Emergency Nurse".

Until those same nurses acquire a professionally recognized and verifiable credential as the CEN (Certified Emergency Nurse), they technically remain just a generalist in nature.

Now, don't get me wrong, there are THOUSANDS of RNs working in our nation's ERs who probably have the experience and knowledge commensurate with that of the CEN credential, however, they have not been recognized in that manner...yet.

Once the ER RN decides to prepare for and sit for the CEN exam, and then PASS it - then they can truly call themselves an "Emergency Nurse".

In today's health care arena we are already seeing a shift in our Emergency Medicine Doctors in that more and more hospitals and practice groups are mandating Board Certification in Emergency Medicine. The days are slipping by where once a Family Practice trained MD could take a job in an ER and practice as an "Emergency Physician". The credentialing, accrediting and regulatory groups are more and more looking to set the bar "higher" for the attainment of an elevated, verified skill, knowledge and practice level. And like the RN's -this does NOT mean that there aren't some FP's out there that are not EM boarded, practicing at an equivalent high level as their boarded peers; on the contrary, there are assuredly MANY who are.

But as we see this push and shift from non EM boarded MD's to EM boarded one's, undoubtedly natural progression will dictate at some point that it is desirable for the RNs as well as it denotes a verified specialty locus of practice.

So as we see our nation's economy stumbling, the workforce dwindling and health care crumbling, it becomes more concerning for the Emergency RN who wants to secure their place in teh workforce to attain certification in their speciality.

Some call it pride,
Others call it professionalism,
Others still call it accountability,
I say it is more and more likely that someday not too far off, it will be mandatory....

LINKS for more information:
-The BCEN (who adminsters the CEN)
-The Emergency Nurses Association (ENA)
-CEN exam preparation continuing education

Feb 6, 2009

ABG Basics

ABG's can be one of the more difficult concepts to grasp when reviewing Emergency Nursing or Critical Care. The whole ABG interpretation process has caused many people lost/sleepless nights trying to decipher and understand the concepts. I can relate. Every time I prep for a lecture that includes ABG's I have to review myself the night before. Over time I've come up with a couple of rules for working with ABG's:

1) Don't do "ranges" (IE: 7.34-7.45), use a mid-point cut off.
For EXAMPLE: I don't consider if my pH is "towards" the low end or "towards" the high end, rather I pick 7.40 as my cut point. If it's above 7.40 even just a 0.01 above, then it's alkalotic and vice versa. Do this for your PaCO2 and HCO3 also - use mid points.

2) I like to draw a 4x3 box and fill in the values starting with the ones I KNOW FOR SURE
For EXAMPLE: My prototype Resp. Alkalosis pt is that hyperventilating-anxiety-stricken-20-something-female that comes into triage. I can easily remember that she has "blown off too much CO2" thus her PaCO2 is LOW. I know it's a respiratory problem because she's hyperventilating. I know that CO2 is a weak ACID so if she's blown off too much of it her pH is HIGH - given that information I can fill in those boxes.

3) Now I look for OPPOSITES. If the above patient is Resp. Alkalosis, then by default, the Resp. Acidosis pt MUST have a LOW pH. Now the prototype pt I use for this is my CARDIAC ARREST pt. We know that they have STOPPED breathing, so too much CO2 is built up (it's a weak acid remember, so that pH MUST be down). So I can now fill in the boxes for that one.

4) Now I move to the Metabolic syndromes. The rules for acidosis and alkalosis pertaining to the pH being HIGH or LOW still hold true - so plug those in under pH.

5) Now look at the HCO3. I KNOW that HCO3 buffers CO2 so if CO2 is an acid, then HCO3 is a base. If my pt is in an acidotic state, then the HCO3 is NOT ENOUGH to compensate and therefore HCO3 is LOW, and thus vice versa. If my pt is alkalotic then the HCO3 is TOO HIGH.

So basically it's a process of elimination and fill in the blanks. When you're done your little table should look a little something like this....

Good Luck!
-KMG-365, Clear...

Feb 5, 2009

CEN Practice Questions 2-5-09

Here's some sample CEN like review questions. Try to answer them and write out a rationale. Try to justify why the answer you choose is correct and why the others are wrong.....

Answers with rationales will be posted here in 1-2 days.....

Category: Professional-Legal
(1) A 49-year-old woman with a subarachnoid hemorrhage is identified as a potential organ donor. The patient’s family consists of her husband, from whom she is separated, elderly parents, her 18-year-old son, and 44-year-old sister. Who is the legal next of kin that can give permission?

A) Her son
B) Her sister
C) Her parents
D) Her husband

Category: Neuro
(2) The normal range for intracranial pressure (ICP) in an adult is:

A) 0 to 15 mm hg
B) 5 to 30 mm Hg
C) 30 to 45 mm Hg
D) 45 to 60 mm Hg

Category: Pediatrics
(3) A 3-year-old presents with N/V/D for 36 hours. The assesment shows: pale skin, sunken eyes, and is tachycardic. The child is unresponsive to pain. The priority intervention for this patient is to administer:

A) Intravenous fluids (IVF) immediately
B) Oral replacement fluids in small sips
C) Prochlorperazine (Chlorpazine®) 12.5 mg IM
D) Ciprofloxacin (Cipro®) 500 mg PO

Category: Respiratory
(4) An obese 33-year-old female presents with sudden onset of left-sided chest pain and shortness of breath. She is diaphoretic, pale, and in acute respiratory distress. There is no history of trauma, fever, nausea or vomiting. Medical Hx is unremarkable. Current Meds: Birth Control Pills. VS: BP = 100/60, HR = 118, RR = 36.

ABG's are done which show:
pH 7.27,
PaCO2 53,
PaO2 61 and
HC03 26.

These results suggest which of the following?

A) Uncompensated respiratory acidosis
B) Compensated metabolic acidosis
C) Uncompensated metabolic acidosis
D) Compensated respiratory acidosis

Category: Wounds
(5) An 78-year-old is being discharged after having a laceration of his left leg sutured. Which of the following methods of patient education is most appropriate for this patient?

A) Use preprinted instruction sheets.
B) Prepare handwritten instruction sheets.
C) Instruct the patient to call his physician if he has any questions.
D) Conduct a one-on-one discussion with the patient.


Feb 4, 2009

"Rampart, this is Squad 51..."

Motorola Biophone 3502
(From Wikipedia, the free encyclopedia)

The Biophone was a combination voice and telemetry radio communications system commonly used in the 1970s and 1980s by field emergency paramedics (typically firefighters or ambulance attendants) to talk to the doctors supervising them from a hospital base station, and also to transmit EKG rhythms. It was this sort of communications equipment that first made emergency field paramedic programs practical.

The Biophone was produced by the Biocom Company. Motorola produced the Apcor which was very similar to the Biophone. The Biophone 3502 used the internals of a General Electric PE series handheld radio mounted into an orange case, which was made of an orange laminated fiberglass with aluminum trim. The Biophone had an internal rechargeable battery which powered the sensor equipment, the PE Handheld and an amplifier that raised the transmitting power to 50 watts. The unit had a connector for a vehicle-mounted antenna for when driving in an ambulance because signal could not penetrate through the steel skin of the ambulance. The Biophone could have any 6 (the maximum that could fit in the PE radio) of the 10 UHF "Medical" duplex channels in the 450-470 MHz range. This allowed flexibility in the overall system. The battery was a NiCad which could charge in only 15 minutes. This Biophone radio can be seen throughout the series of Emergency! being carried by the fictional characters Johnny and Roy. The actual Biophone 3502 radio that was used on Emergency! was donated to the Smithsonian's National Museum of American History because of its public service. It is now on display in Washington, D.C..

CEN Study Pointers...EXAMS vs TESTS

Recently I have been receiving more frequent emails
asking how I would s
pecifically recommend someone studying for their CEN exam. The answer is as individual as it is long and really no one methodology would be appropriate for everyone. Instead of laboriously typing the same email response to everyone with the similar background information and advice,
I figured I'd put this on a blog and have people refer here instead.

So when someone asks me the best way to begin prep for the CEN exam I like to find out their background and where they're coming from first. Also I try to get a feel for their previous experiences and knowledge level.

One of the first things I recommend to most everyone, is to take an ASSESSMENT EXAM.

Ideally this would be a 150-175 question exam that is identical t
o the actual CEN exam with regards to breadth of content as well as the same representative percentage of different content areas. This practice EXAM should be done just like the actual testing environment: 150-175 questions, a quiet desk w/o noise or distractions and a 3 hour stop watch.

The prospective examinee would take the practice exam (at one setting), then self grade it and correlate the right answers to the different content areas so they can see which areas they are strong in and weak in.

This information would then be used to do FOCUSED studying. Spending the most time on the weaker areas. I wouldn't recommend neglecting the areas they scored high in, I would still recommend some brief, rapid review of those too - but the point is to spend the MOST time on the WEAKEST areas.

As of right now there are a couple of options for this.
The more economical (but probably not as quick as you have to order the book) way is to order the "CEN Review Manual" Third Ed. 2004. (The "white" book). In this book there are 5 full sample exams. Each contains the same content and subject distribution as the official exam. The answer key in the back allows you to self-grade your exam and then identify which questions relate to which of the specific content areas. This allows the student to see which areas they were strongest in and weakest. This book is currently available at the following:

ENA Website: $65 Non-ENA members, $50 for ENA members. S/H extra.
Amazon.com: New and Used from $87-$115.

The other option to take an assessment exam is to do it ONLINE. This is probably the quickest way because you can register for the online exam, take it right away, and get it graded for you right away.

The ENA is hosting a 150 "CEN-Like" online exam for $75. You get one "entry" to take the exam online, at home (timed) and experience the same exam like content in a realistic manner (computer/keyboard). The online exam can be found HERE: ENA Online Exam Info.

Pro's & Cons.
"The Book" method:
PROS: Each question complete with rationale, overall cost is very economical (if you don't get scalped), 5 different exams so you can go back and re-test to check your improvement.
CONS: You have to pay and wait for it to get shipped to you.

Online Exam:
PROS: Quick, immediate, nearly like the actual exam (computer/keyboard)
CONS: You get less "exam" for your money

Whichever route you take, the goal is the same; to identify the areas you are weak in so you can hit those hardest.

So now that you've taken at least one sample exam and you know your strengths and weaknesses, now you're ready to start your true test preparation.

Look back at your score results/printout and look at the percent achieved in each content area and rank them from 1 (highest score you got) to 13 (lowest score you got).
What you'll want to do is try to proportion your study time more on the areas you got the lowest score on, but not to completely ignore the other content areas.

You can use many different ways to divide up your focused review time to the necessary topics.

At this time, now the student should invest in a review book that breaks down into systems; preferably one that matches up with the official CEN blueprint and systems. Find a book/guide that also has specific questions at the end of that system content.

A good book for this is:

"Lippincott's Q&A Certification Review: Emergency Nursing".
I call this one the "Red book". Here is the description from Amazon.com:
Product Description
This comprehensive workbook is an indispensable aid for emergency room
nurses preparing for the CEN exam. The book contains over 1,400 questions and answers in an easy-to-use two-column format--questions in the left column, correct answers and rationales in the right. A bound-in CD-ROM contains over 300 additional questions. Coverage encompasses all subject areas in the CEN exam blueprint, and includes 5-tier triage, ECG strips, long-term complications of ED care, disaster management, and recognition and emergency management of chemical and biological weapons of mass destruction. The book includes sample tests with 175 questions, weighted according to the CEN exam blueprint.
You can go through here and work through the sample questions/answers or just test/quiz yourself over and over using that specific content area.

After you've spent at least 1/3 of your total pre-CEN exam study time, consider doing another sample exam to see how your scores compare.
You can get this book from:

Amazon.com : New and Used; $34-$30

Check back often as I'm going to be posting some "pointers" every week or so.!