INTERNSHIP!!!!

Yep! Finally!

This past Monday, I met with my preceptor and the chief of EMS for the fire department I am doing my internship with. They asked if I could start the next day. It took everything in me to not blurt out, “HELL YEAH!”. I told them very calmly that I could start, no problem. My heart was jumping at this point. My preceptor then grabbed my binder, and grilled me on protocols. I passed. Yay! Then, I had to tell my supervisor at my day job. Last year, I was mandated to take a class called Crucial Conversations. It came in handy. By using the skills I learned, he is an ally, and not an enemy to my goal. Some here at my day job are shall we say, flat out against less than supportive of what I do. If it were up to them, I would not be able to finish my goal of getting my paramedic license. I had no idea that he really was clueless about my educational goal. But I explained to him what I had done, and that it is a part of my IDP (Individual Development Plan) here at the day job. As a result, he said he understood the importance of completing goals and that he supported my internship. I assured him that my work during my time in the academy did not suffer, and it would not during my internship. Yes, I would be gone in two-day spurts, but not all of those would occur on work days. He and I worked out a schedule that keeps things working, and I started my internship immediately on Tuesday.

Even at 50 years old, I was so stoked! I felt like I was back at the first day of class. Excited, scared, but ready to GO!

I just got off my first 48 hour shift (Yes, 48s) at one of the two fire stations my preceptor works at. I had a fast start to my shift. Literally, I was dropping my gear in a side room (I arrived ahead of time, as expected), as was my preceptor, when a call came in. We switched with the crew that had just returned from a call and would be coming off their shift at that time.  My “slow start” (as planned by my preceptor)… nah. Why start slow? We responded to an MVA (Motor Vehicle Accident for those who don’t know) on a highway. My first patient was considered a critical trauma (By definition in protocols). So, I got an I.V. started at 60 MPH while we were headed to the E.R. Prior to this, my preceptor was very concerned that I had been out of school so long, she actually wanted me to put in some more time in an E.R. doing I.V.’s and intubations. After that first I.V., which was on someone who was self-described as a “hard stick”, she told me I’m good. Yes! Those hours would not have counted toward my requirement, and would have been outside my internship, or would have potentially put off my internship longer. I was happy to hear that!

I saw a lot on that first shift. Initially, first shift is more watching than doing. But she let me start doing as I felt capable. I did watch a few runs, and assisted as needed. This was more to see how SHE and the rest of the crew does things on calls, and to learn where things are on the ambulance. Practice finding the stuff, and you don’t think about it when you need it.

The first shift is a HUGE learning curve. REALLY HUGE. You learn the rules of the house, where to sleep, how to set up my room alerts, the way they want things done on the ambulance, where things go (and don’t go), prepping the rig for the next crew, assigned job functions, how alerts are done for calls, how to behave in the house (House rules and behavior change from house to house, even shift to shift), and then there is the medical component. Yeah, the protocol reviews, the reminders of the stuff I learned in school, remembering not to kill the patient (I had 3 separate people tell me that!), being called out for not answering correctly, BLS before ALS, anticipating need, requesting others to do the work I have been doing as an EMT (That is actually hard to do!), etc, etc. My preceptor has made her goals for me clear. I prefer that. I have specific homework for each shift, and I am expected to present what I am reviewing. I have new equipment to learn, especially the defibrillator. It works differently than any other defib I have played with. Thank God for YouTube! Oh yeah, I am teaching how to use the defib next shift also. To people who already know how to use it. This should be interesting.

I may post specific cases as time goes on, but the information will need to be sanitized to protect identities, and possibly approved first.  This will be for a learning experience for all, not for any “Hey, dude… wow, check this out!” factor.

For those concerned about my back issues, trust me, my preceptor knows the ugly. As do a few others that are at the fire station on my shift (And at least one that is on another shift). I said I put it in God’s hands to guide me, and he did. I am not saying surgery won’t happen. It just won’t happen now. For now, my internship is on track.

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From provider to patient

How many of you have become a patient since becoming involved in EMS? More than just a minor injury or illness? I know of providers who have battled cancer, major injuries (One of my friends is currently coming back from being hit by a car while on his scooter off-duty.), and other major illnesses. I have had a few times where I have been a patient, dealing with a moderate problem. But never a major issue. Until last July.

Some of you are aware, either through my previous posts, or through Facebook, about my recent diagnosis of spondylolisthesis.In case you don’t know, here is a definition of spondylolisthesis (ala McGraw-Hill):

  • The forward slippage of a lumbar vertebra on the vertebra inferior thereto, which usually involves lumbar vertebra, most often at the level between the 5th lumbar vertebra and the 1st sacral vertebra; ranges from mild to severe Etiology Congenital defect in 5th lumbar vertebra, stress fractures, traumatic fractures, bone diseases; it may be associated with and produce lordosis. Clinical Low back pain and pain in thighs and buttocks, stiffness, muscle tightness, tenderness in slipped area, paresthesias, sciatica due to nerve root compression
Grades of Spondylolisthesis

Grades of Spondylolisthesis

Mine is at L4/L5 (Assuming you count from L5/S1). Although initially diagnosed a Grade 1, even my physical therapist stated it was most likely a grade 2. At this point, I think the slip has gotten worse than the initial diagnosis. It was thought to have been due to a recent injury, but the MRI and other diagnostic tests show that it most likely occurred in my teens or twenties. My thought is that it was a moment when I slipped on ice in 1985 in Indiana. I landed smack on my butt, and was stuck there for about 20 minutes, until my husband rescued me when he finally realized I wasn’t back from the laundry room across from our condominium. At one point, I saw a chiropractor out there, but basically, I hurt like hell for about 6 weeks. Gradually, I healed. I also had a moment in 1988, when I was leaning forward from a sitting position while holding my daughter, reaching down for a pacifier that was on the floor (Dumb move, yeah). Next thing I knew, I was on fire. I honestly don’t remember the trip to the ER, or much of the ER visit, but have some memories of the ride home. I specifically remember looking back at my infant daughter (This after I was drugged up on demerol and visteril), and the look on her face which was “What the hell is mom on?”. Or maybe it was a combo of the two… I don’t know. Either way, the diagnosis is “acquired spondylolisthesis”, meaning it happened sometime after birth, that it wasn’t congenital.

Oh, and I found out I have an extra lumbar vertebra. Go figure. At least I know why women’s bike jerseys are too short on me.

Lately, I have been having more and more problems with pain, numbness, tingling, and a leg that feels “laggy”. It still works, but my brain is telling me that it is behaving slowly. It is an odd feeling. The worst time I have is first thing in the morning. Those first few steps are just, well, agony. It generally frees up after a few minutes, especially once I am in the shower. And I am good for the day.

Until Sunday.

I admit, I was sore Saturday evening. Limped around a bit at home, but once moving, it was ok. I actually got a lot done at home that day. I was planning on riding my bike on Sunday, so I made sure it was ready to go. It had just been tuned up by a friend, so all I really had to do was check tire pressure.

Sometime very early Sunday morning, I turned over in bed, and WHAM! Intense pain from my hip down through my leg. I mean, like someone set me on fire. I managed to turn back over into a comfortable position, and fell back to sleep for a few hours. But waking up a few hours later… I realized I was in trouble. I made it out to the couch, and by sitting there with my feet pushing on the coffee table, I could get the pressure off the nerve. But sustaining that posture for long made other muscles hurt. I finally texted my son, and asked if he could take me to the E.R. Like many people in EMS, I don’t want to go to the E.R. unless I am dying. I don’t want to add to what is normally a crazy burden. But this pain was way beyond my management. I detest opioid medications for many reasons. So I haven’t taken any, with the exception of right before I had some epidural injections in November. That was the last time I hurt BAD. But,this time was worse than then.

Ironically, no one knew me at the E.R. when I arrived. I happen to know quite a few folk at the various E.R.’s, because of my work in EMS. I managed to stand up long enough to make it to the intake desk. My leg just wouldn’t cooperate and keep me standing. My son got a wheelchair just in time. They got me registered, and I sat for less than 3 minutes for triage. I think it became apparent to them that I was in extreme pain when they had me step on a scale. They literally took me straight back to a room. Within 5 minutes, I had 10 mg of morphine IM, and 5 mg of valium by mouth. After 45 minutes, after the E.R. doc examined me, I was given another 10 mg of morphine.

That got my pain under control.

Finally.

Turning over still sucked, but not nearly as bad. We left about 3 hours after we arrived, went over to pick up discharge medications. Yeah, an opiate medication, and valium (for muscle spasm). I thought it funny as hell that my discharge instructions included back exercises that are not good for people with a “spondy”. Got home and went to bed after a bit. I took my meds that night and yesterday. I spent yesterday sleeping and resting. My cat Scarlett loved it.If I sit still for 30 seconds on the couch, she is right next to me. Or in my lap. She has a penchant for sitting on my hip if I lay on my side. That is a habit I will have to break her of.
Today, I am back to work at the day job, but not taking anything stronger than my nightly NSAID and Tylenol. And using a TENS device for pain distraction. Sitting, I am relatively comfortable, and the last time I got up to walk, felt ok. I am hoping this flare is over very soon. It is impacting my life in ways I couldn’t imagine back in July when I was diagnosed. I want to get back to riding my bike. It helps me with weight loss, increasing my fitness level, and my mental well-being.
I put in a few weeks ago for the fusion surgery when I realized things were starting to rapidly decline. It was both a moment of accepting defeat to this monster, and also a bit of weight off my shoulders. Constantly thinking about my planned surgery in June… I really wanted to lose more weight before I went under the knife, but I probably won’t make it down to 170 where I want to be prior to surgery.  But I am working on it, and have dropped 7 pounds since Christmas. Even with limited exercise. It is a small start. I have taken to weighing myself daily. For me, that keeps me in check. And it is working.
So, surgery is sometime between now and the end of March, and I am on the cancel list. I know this may potentially impact my internship, but I haven’t heard from my preceptor yet, and I won’t be any good as a paramedic if I can’t walk. If my internship starts first, I will try like hell to complete it. But not if I end up with more problems. I am hoping dropping more weight will make it easier on my back, and ease the symptoms, allowing me to work again on core strengthening. And if my back stabilizes with weight loss, I may reconsider having surgery sooner than later. But my body may have a different priority. I can only hope that if I have to put off my internship, the program will let me. I’m still studying, by the way. I haven’t given up. Protocols for my local area are my priority right now.Going from provider to patient isn’t something I want. But it is a reminder to me of what it is like on “the other side”. And I hope it will make me a better paramedic.

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One step forward, two steps back

Since my last post, which was back in July, it seems that I have taken one step forward, and two steps back.

A few things have happened:

1. My wonderful daughter was married in September. Her husband Wade is an incredible young man, who has taken on the role of not only a husband, but of a father to my grandson Jonny. He is a welcome addition to our family.

1378706_697072026988468_2088298505_n(1)

2. I am still waiting for my paramedic internship. This has been frustrating, but I’m not the only one. Internships are finally starting up again, and I am studying hard to ensure success. Getting my paramedic licensure is a major goal in my life.

3. I learned more about my back problem. A lot more. Again, it is called spondylolisthesis. A special Facebook group dedicated to those of us with this condition has been an island of hope in a sea of occasional despair. My back pain has gotten worse. Not something I want to admit, but it’s true. I still am able to work in EMS, but I’ve had to make changes in my day-t0-day life to be able to continue doing what I love.

I was referred to physical medicine, whose primary goal is essentially pain management. This physician ordered a few different x-rays, including extension and flexion studies, and an MRI. Which showed that my particular issue is considered unstable. That’s why my back has clunked for the past few years. It moves nearly 13 cm, depending on what I do. He explained that extension is not a good thing for me to do. Flexion actually puts my back in alignment, as does lying supine (on my back). He immediately realized that this cannot be medically managed alone. Surgery would be needed to correct this. So I was referred to orthopedic surgery for a surgical consult.

I saw an orthopedic spinal surgeon, who strongly advised a procedure called a Transforaminal Lumbar Interbody Fusion (TLIF). This is an open surgical procedure, which uses hardware and bone to stabilize the area at L4/L5 that is unstable. When I met with him, I discussed what I do for work and for recreation. He happens to also be a bicyclist, and felt confident that I could return to both EMS and cycling after I recuperated from surgery. But this is an open surgery, which would be done through a 9-12 inch incision in my back. In this day and age, it seems, well, old school. And I was correct.

I researched and learned that there are other procedures available to do this repair, including:

  • Anterior Lumbar Interbody Fusion (ALIF) – Goes through the abdomen, but frequently also needs to go through the back as well. This is also old school.
  • Extreme Lateral Interbody Fusion (XLIF) – This goes through the side, through small incisions and going through a muscle called the psoas muscle. This is one of the newer surgical methods used. Recovery is faster (from the surgery itself).
  • Minimally Invasice TLIF – Uses small incisions, and does the same as an open TLIF. As with the XLIF, the immediate surgical recovery is faster than an open TLIF or ALIF.

There are variants of these, but the outcome is the same. A stable spine. And hopefully, freedom from pain.

I wasn’t happy that the other options weren’t mentioned to me. I asked him why. Well, it turns out he just does it one way. OK. I’m OK with that. But I want to find out if the other options, or a variant, would work better for me. He referred me to a neurosurgeon, who does this procedure other ways as well.

I finally got to meet him in October. Right away, I felt a calming when he introduced himself to me. He had already made himself very familiar with my issue, and listened to me as I explained what I do, how I do it, and that I want to continue doing it.

And then he spent over an hour with me, explaining the different options to repair my spine. He felt the open TLIF wasn’t warranted, as this is a single-level fusion. He presented 5 ways to do the surgery, and then explained that he felt minimally invasive TLIF was the way to go, or XLIF. Essentially, it is my decision as to which one to do. The outcome will be the same. And I can continue in EMS and cycling, or just about anything I want to do. He did recommend against parachuting. I’m good with that. :-)

So, I am down to deciding between the XLIF and minimally invasive TLIF. He presented the positives and negatives to each. The biggest negative to the XLIF is the possibility of injuring certain nerves. But both avoid cutting through muscles “against the grain”, and going in the direction of the muscles, which will improve post-op pain and recovery.

I feel very confident in his abilities. While the surgery can be done today, I will have a much easier post-op recovery with weight loss. Which I have been doing. That and “pre-hab”; getting my body in good shape before surgery, which will also improve my post-op period. He is the surgeon for me.

Which brings me to today.

Over the past few months, I’ve tried a few things with my physical medicine physician. Non-steroidal anti-inflammatory medications, which help a little. I don’t want narcotics, and told him so. He recently recommended an anti-depressant medication that helps with nerve pain. I tried it for several weeks, with no real improvement. Tapered off of that. What bothered me more about this medication was once I tapered off of it, I realized that it took away my interest in doing things. ANYTHING. I would just go home and want to do nothing. This medication really impacted me physiologically as well as psychologically. I wasn’t on it for depression, but it seems that I became depressed as a result of it. I am quite glad that I stopped it. Now, I feel like myself again.

What I’ve found that helps is ice packs, and NSAID meds, and movement. Takes it down to a level where I can function.

The next step is to try epidural cortisone injections. Yeah. Needles in my back. Officially, it is called bilateral transforaminal steroid injection. No way to say it easily.

I did also make a decision to get back to the gym and begin working out, pain or no pain. As I said earlier, I had no will to do anything when I was on the anti-depressant. But I realized that I MUST DO THIS. More importantly, I WANT TO DO THIS. Personally, I want to be down to 170 for the surgery. And improve my strength.

Today was the first day back. It wasn’t long, but enough for me to remember that my body likes it. I like it. Exercise produces endorphins, mother nature’s natural painkillers. So, perhaps it isn’t one step forward, two steps back. I think it is two steps forward, one step back. I will keep moving forward.

Onward!

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Spondylitho…what???

Spondylitholisthesis.

Yeah, say that 3 times fast.

—–

Several months ago, I went and was seen for low back pain. It was diagnosed as sacroiliac dysfunction. Based on the symptoms, it made sense. Pain and movement in my sacral area. I had pain there off and on for a while, especially when I was driving my old Jeep Cherokee. The seat was off-angle, and it was thought that it had something to do with it. I mean, it’s no secret that I am hypermobile. I have joints that slide around like crazy sometimes. I can dislocate my fingers, my right shoulder, and my right knee a bit, although all of these hurt if I do, so I don’t do it.

Had some x-rays taken, and my physician tested a few things. PT and anti-inflammatory medication were the prescription. I attended physical therapy for a few weeks. No real major improvement, but it seemed to help a bit. I raced my first MTB race in 2 years. And did ok. I finished without a major crash.

Then, out on a ride with friends, I crashed my mountain bike. A good chunk of the exercises I was doing involved the use of my hands. Balancing, pressing, etc. Hard to do when it hurts to pinch your fingers together. Kinda put a halt to the PT for a while.

I couldn’t ride my MTB, so I started riding a road bike. And I’ve been having fun doing that. But after about 5 miles or so, I’d have this odd back pain. Like a spasm of sorts. Sometimes I could work it out while riding, but other times, I would have to get off my bike and walk a bit, or sit and stretch it out, then get back to riding. Due to a few factors, mostly time (I was in a lot of training for my day job), I didn’t ride for a few weeks in June. I began to commute again to work, and realized that the back pain wasn’t just a few miles in. It was pretty much the whole ride. And it would worsen while riding. BUT, again, if I stretched, it seemed to improve.

I adjusted a few things on my bike, but nothing made a difference.

Then I started having problems sleeping. My legs would ache when I slept. I set my phone up to record me one night to see if it was possibly restless legs or something. Maybe my cat was doing something… I checked different things. My bed is normally so comfy! I still wake with night sweats from the joys of menopause, but this was happening in between that. Not good. Sleep deprivation sucks.

And it got worse.

I finally made an appointment. I was amazed that I got a next day appointment, but it is the day before a holiday, and a lot of people are heading out of town. I got seen this morning. Since I haven’t lost a lot of weight since I saw him last, I got a bit of a verbal lashing about that. I explained I had already recommitted my weight loss goal recently, and gotten back on track. I also explained to him about my 100 mile ride coming up in September. After checking my back, having me do some stuff like walk on my tip-toes and then on my heels, reflex tests, he had me go get some x-rays, to compare to the old ones taken in January.

Did that, and came back a few minutes later.

Finally saw him again, and as we were waiting for the films to load, we were chatting some more about possible treatment ideas. Then the film popped up on the screen:

Renee-Spinal-Fracture

Click on the image to see it larger. If you look to the large bones left of the arrow, you will see something “just ain’t quite right”. My doctor stated, “Oh, WHOA!” Yeah, that sizes it up nicely. Basically, I have been walking around with a spinal fracture. You heard me. Specifically, it is a pedicle that I broke. It is in the class of stress fractures, and comes in varying grades. That is a Grade 2, from what I have learned. They are graded by amounts of slippage.

Lumbar_spondylolisthesis_grades

As you can see, the more it slips, the worse it can be on the spinal cord.

So, after discussing options with my physician, we decided on a conservative course of treatment. Anti-inflammatory medications, including my good pal prednisone (BLEH!), PT directed toward convincing the bones to go back and stay back, allowing the pedicle to hopefully heal, and I asked for a referral to a spine specialist. If it doesn’t work, then surgery is another option. Hope it doesn’t go that far. I am rather ticked off (Read: Absolutely pissed off at the moment) that it wasn’t caught back in January.

I can still work EMS. Good thing! I will be allowed to ride my road bike, but need to chat with the PT first. Flexion on a bike is actually pretty good, extension is the no-no. And yeah… taking the weight loss VERY seriously now. More than ever before. Taking things one day at a time. I’m still working toward the 100 mile ride. It is for such an important cause. But, if I have to back off, I will. I won’t want to, but I will.

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Time Flies…

I just realized it has been a while since I posted… time really does fly!

Let’s see… I’m STILL WAITING for my internship to start. This is so frustrating. I am losing skills by not using them. I finished didactics in December, for crying out loud! I was supposed to start my internship then, but I got caught up in politics, and two local fire agencies put a halt to internships. One of them did it to train up a large number of staff they hired to run ambulances only (non-firefighter positions). The other did it due to QA issues with their preceptors. So here I wait.

The past several weeks have been busy EMS-wise. I was working pretty much 7 days a week. Day job, then EMS (Bike races, trail runs, etc). Get home. Sleep. Do it again. Now that most of the evening races have ended for the meantime, I can spend more time with my books again. Good thing, considering the above paragraph. Protocols and drugs. Protocols and drugs. Oh yeah… and ECG review!

My day job has seen change as well. I’m still working at the same place, but my job has changed. I am training up to be a duty officer, a position I was invited to be a part of by one of the duty officers. Not knowing what the next phone call or email will be is intriguing to me. Some folk don’t like that unknown. I eat it up. That’s one of the reasons EMS is so alluring to me. You never know what is next. So as the day job goes, I have a huge learning curve, and I am tackling that, especially now that my work on another project has finally ended.

Biking. Well, it hasn’t happened much lately, and I am going to get back in the saddle beginning tomorrow. Gotta get the miles in. Gotta get more fit. Gotta lose the weight. I’ve been complacent lately, and that isn’t good for me at all. So, it’s back to bike commuting. I’m not working Sunday, so I think it will be a ride day on the American River Bike Trail. Or maybe somewhere else… Napa? Bay Area? Hmm.

I got my hair cut. Not just cut. Cut damn short. Freaked out a few people. I warned them on Facebook I was doing something different. Yeah, well… I guess they weren’t quite prepared. This is the shortest my hair has been since I was 9 years old. It may be shorter than even then! It is a pixie cut. I like it, although when I look in the mirror, I still haven’t gotten it in my head that it is ME I am looking at. Time will fix that. Low maintenance hair! Yay! If I tire of it, I just need to let it grow.

So, that is all for the moment… more updates coming.

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