Tuesday, December 05, 2006

PALS and kids

Good news on the injury front. I had a great physical therapy session today. Laurie, the therapist I've been working with, sees no reason I shouldn't be cleared for full duty when I am re-evaluated tomorrow. I'm hopeful that Dr. Leahy (Kathy Leahy, DO, the Osteopath I was referred to after I was injured) feels the same way. Laurie gave me some nasty exercises to do to strengthen my core muscles, and believe me when I say that they are effective. My wife doesn't think I'm ready to go back to work, however - she thinks that I should be given a gradual lift test to see what my ability to move weight is. Perhaps she's right; I simply don't know. All I do know is that I am frustrated and want to go back to work.

Next week I'm taking my PALS refresher. PALS is for Pediatric Advanced Life Support and it is part of the certification requirement for Paramedics. Many others in the medical profession (Nurses that work in the ER and ICU, ER Physicians, and many Pediatricians) have PALS certification; usually it goes hand-in-hand with ACLS (Advanced Cardiac Life Support) and many of these same people carry both cards. Paramedics also have to have a certification in Trauma Life Support (either PHTLS or BTLS) as well. When I was in Paramedic school, I found PALS to be easier than ACLS, in terms of content. I don't know why; most other aspects of dealing with pediatric patients is harder than dealing with adults, at least in my opinion. We're taught that "kids aren't little adults", and that is very true. Kids have more issues with airway protection because the head and body aren't proportionate. Also, kids tend to compensate really well until they get past the point of being able to do that, and they crash faster, and subsequently can die faster. Adults don't do that; it's more obvious when they are "circling the drain" than when kids are. Drug dosages are all based on body mass - well, ultimately all drug dosages are supposed to be based on body mass regardless of what stage of life we're in, but it's especially important with a pediatric patient, plus the other variables you have to consider when providing care. Is this drug going to work on this patient? Is it the right drug? Are they going to have a sensivity to the drug and react to it? Will it be effective? Are they getting this medication in time for whatever condition we're using it to treat? Are there other drugs in play? And the list goes on.

It's not to say that the list of variables for adult patients is any shorter, but for some reason kids tend to be scarier to treat for most Paramedics and EMT's. I don't truly know why that is, but I suspect it has to do with the dynamics of kids, the panic of parents and the fear of doing something wrong for treatment, and the other fear of bringing a child into the ED and not having done enough with the time you have to assess and treat this child. Most ED phyisicians I deal with understand the conditions I've outlined, but there are a few who have no problem ripping a Paramedic a new one for overlooking something during their assessment and intervention.

I've been there a couple of times; the first was when I was a brand-new Paramedic and I had a 2 year-old who overdosed on his mother's Prozac. He was upset because I couldn't get activated charcoal into this boy. My words to the doc when he was done telling me how inept a Paramedic I was were to the effect of, "when they give us protocols for NG tubes this won't be a problem. However, there was the matter of his compromised airway, and I thought that might be just a little more important." My exact words to the doc were neither this clear or calm.... I had to intubate this boy as he was breathing at a rate of about 6/minute. He ended up being med-flighted to Children's Hospital in Boston within the hour. The second was for a 7 year-old boy that was struck by a car and had a mid-shaft Femur fracture. My partner and I transported him to Boston from Manchester. He was secured, had a traction splint in place, had an IV running, and I had orders for 1 milligram or Morphine as needed. He did great during the transfer, but just as we pulled into Children's and unloaded him, he reached up and pulled the IV out. I asked him, "why did you do that?" as I was scrambling to get the site secured and the IV pump shut down. He told me, "I didn't think I needed it anymore." Explaining that to the attending who I gave report to was a total joy. He gave me a really hard time, as though I told this boy he could pull it out. It wasn't until we left Children's that I felt like I could sit down without experiencing great pain to my backside.

Overall, though, as much as pediatric patients are the cause of most EMS provider anxiety attacks, they are some of the most fun patients to take care of. That's especially if they are awake and they're old enough to understand some of what's going on. Given the choice of caring for a sick adult or a sick child, I'd rather take care of the kid because if I get it right then the reward is immense.

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