Paramedic Training, Doing My Part, I hope. Medical pros

[jar546]

Well, I hope so anyway. I am still an instructor at the local college in the paramedic program. This weekend, as is every superbowl weekend is the culmination of the ITLS training (International Trauma Life Support) where the paramedic students take their written and practical exams. We run lots of trauma scenarios for practice prior to the final testing to see how the students put their training to use by following the established protocols. It also lets us know what the students have retained from all of their lectures and clinical experiences. The paramedic program is 1 full year long for the certificate program and 2 years for the associates degree and will end this June.

Anyway, when we run the students through assessment practice stations, we usually make up scenarios for them. This morning, on the last day of practice before the final practical one of the scenarios that I gave was the following:

*You are dispatched to a local quarry for a scuba diving incident. As they make inquiries about the situation during their initial scene size up, it was disclosed to them the the unconscious diver who was pulled to shore was witnessed accidentally dislodging his weightbelt from a depth of 80' and encountered an uncontrolled ascent. The patient was found floating at the surface and pulled to shore.

The condition of the patient is as follows:

Unconscious, unresponsive to verbal or painful stimuli, airway compromised with pink, frothy sputum, respiratory effort of 40 after clearing the airway with suctioning. Some of the physical exam findings were: +JVD, Slightly deviated trachea to the R, Sub Q air at the left clavical area, diminished breath sounds on the L with no other outward signs of trauma.

What amazed me is that the students were pretty much clueless with this one since they did not fully understand barotrauma. Of course they recognized a probable tension pneumo but were thrown off by the pink frothy sputum and sub-Q air. When we asked what they think happened, they for some reason were trying to establish some sort of a blunt trauma incident which we were very clear was not part of the incident.

I suppose my purpose in posting is to recognize that there is very little of the trauma portion of the class dedicated to diving accidents and I am going to sit down with the head of the department to see if we could add more of this to the program.

Does anyone else spend much time in this area?

 

[Bubbletrubble]

Perhaps more time should be spent on the basics of respiratory physiology. The students should be thinking along the lines of pulmonary barotrauma any time the history involves rapid changes in ambient pressure and the clinical signs point in that direction. They should also understand that pre-existing lung pathology might make a person more susceptible to pulmonary barotrauma. It would probably take running through a handful of varied scenarios (scuba diver, free-diver, airplane passenger, explosive blast victim, etc.) for them to recognize when/how ambient pressure changes occur inside/outside the lungs. Good luck with your efforts.

 

[ScubaVideo]

Back in my PM classes we did study and practice barotrauma incidents. Even an EMT class I assisted in had a full scenario station with SCUBA equipment on hand. Guess that's because the instructor was also a diver. But in PM school, the people running the class were not divers but still recognized the need since many of the graduates would eventually be working near areas heavy diving. I did a paper in EMT school on DCS, it was a lot of fun answering all the questions after my speech.

I wonder if AMR (American Medical Response) here in Monterey has any kind of training for such incidents.

@Jar546, I really liked reading the scenario and I'm surprised the fresh through class students were not all over that.

I injured my neck and back on a lift in 2006, so now I only get to think about the scenarios, they won't let me play with the lights and siren anymore.

 

[TSandM]

Very interesting story. I wonder if the paramedic programs in the Seattle area spend a little more time on diving information?

 

[jar546]

I was very disappointed in their tx of the patient due to:

1) Although they recognized a tension, pneumo, they did not decompress the chest. This one bewilders me as on previous scenarios, they decompressed.

2) Not one mention of the need for a chamber. None, zip, nada

Over all, this is a very poor class, already down to half of those that started and by the time they have ACLS I am sure more will drop. We always start off with 50 and usually only 15-20 are left for registry at the end. I will post updates of my progress to improve this area for anyone who is interested.

 

[Duke Dive Medicine]

Diving injuries are one of those "out there" things that aren't very well covered in most paramedic/EMT courses, much less in nursing or med school. Your students are lucky to have you.
When you went over diving injuries with them, did you specifically cover that it's appropriate to decompress the chest in a diver with a tension pneumo? If not, then the diving scenario probably just threw them a curve ball, especially if they're not divers themselves and aren't familiar with the physics. Even if you went over basic diving physics separately, it can be difficult for students to synthesize knowledge like that - it's a more advanced stage of learning. Thanks to you, their schema for "pulmonary barotrauma" now includes diving, which will help them process the concept better. I imagine you saw a few light bulbs come on when you finished explaining it to them.

 

[Rubber Duckie]

We briefly discussed diving injury's in my paramedic program and it mostly involved airway management, spinal motion restriction. We were taught what decompression sickness was and the need to get to a compression chamber but we did not go into great detail. The service I work for has protocols for diving injuries and includes the number to DAN. When I was a paramedic student I was more worried about learning cardiology and pharmacology rather than something that the average paramedic in the area I live in will probably never encounter. It wasn't until I became a diver that I really understood decompression sickness and other diving related injuries. I think the length of the paramedic programs need to be extended. The standards are being raised, which is a good thing but the length of the training is still the same.

 

[traumadiver]

I am a paramedic instructor here in Va Beach. We are pretty fortunate, some of our Medical Directors are divers and work the chambers as well. We actually have a Diving/Barotrauma protocol and we do some training in paramedic school on diving. I will say however that the total time that we actually train on dive injuries is pretty small. Most students will realize that there is a tension pneumothorax going on or might realize that there may be barotrauma to the sinuses. If you ask them how did that injury occur? What is the patho behind the injury? You will get that all to common response, I remember learning it but forgot.
I must admit that once I started diving I had to go back and research all that patho in regards to dive injuries.

 

[muddiver]

Tension pneumo was one of the main things I remember from basic EMT training. We even covered sub-Q emphysema and all the typical lung sounds from fluids. Diving had nothing to do with it and the school was at the foot of the mountains, not the beach. Good to see someone is minding the store and including lung injuries in their course. The treatment was the same either way, high flow O2 and transport. The doctor at the ER will be the one deciding if a chamber ride is necessary.

 

[mfross]

An instructor at the local college wants me to teach a class on scuba emergencies during the National Refresher that is held in the area. While we are in the middle of the country and don't have a lot of SCUBA around here, it is something that should be an interesting subject during what is usually a pretty boring series of classes. (If you've taken like 10 of them, they get very old and boring--the same instructors with the same slides, and the same lame jokes.)

Anyway, there is no local DAN oxygen provider classes and I'm pretty sure that I'll be only able to take PADI Rescue around here.

I've been a street paramedic for over a decade and have about every possible certification recognized by our state bureau of EMS.

My question is, where can I find formal information on the subject of dive emergencies? Are there any online classes that I can take to learn more about the subject? What classes, online or not, should I try and take? Any ideas or suggestions as to how to approach the subject?

I've learned a great deal hanging around on this board, and am getting classes, equipment and experience as I can afford it--paramedic pay is pretty pathetic around here as we have three schools churning out EMT's and paramedics who are cheaper than us burnt out old street medics.

Thanks all!

Joe Collins
Paramedic/Firefighter