I got into a discussion about how Level 1 and Level 2 trauma centers differed at a clinical last night with another medic. I’d been to both of the Level 1 trauma centers in Houston that night.

She said a Level 1 had to have a medical school or residency program. I didn’t think it was a requirement, but was often done because residents could count toward always present specialties requirements.

Turns out she was right. But we both also thought there was very little difference other than that between 1 and 2. So today I did a little research and found the PDF documents on the American College of Surgeons (ACS) website talking about criteria for the levels of trauma centers. ACS certifies most trauma centers in the US. Doing some time consuming comparisons of the two documents, I compiled this list of things a Level 1 has to have that a level 2 does not.

Level I must:

• Admit at least 1200 trauma patients yearly
  or 240 admissions with an Injury Severity Score (ISS) of more than 15
  or an average of 35 patients with an ISS of more than 15 for the trauma panel surgeons (general surgeons who take trauma all)
• A General surgeon or appropriate substitute (postgraudate-year 4 or 5 resident) must be in house 24 hours a day for major resuscitations (must be present and participate in major resuscitations, therapeutic decisions, and operations).
• Emergency department physicians must be present in the emergency department at all times.
• A neurosugeon must be designated as the liaison
• Plastic surgery, hand surgery, and spinal injury care capabilities present.
• Anesthesia services are available in-house 24 hours a day.
• Both must have a adequately staffed OR that is immediately available, but in Level I this criterion is met by having a complete operating team in the hospital at all times, with individuals who are dedicated only to the operating room.
• In-house CT technologist.
• A surgically directed ICU physician team.
• In-house physician coverage for ICU at all times.
• A full spectrum of surgical specialists available. (orthopaedic surgery, neurosurgery, cardiac surgery, thoracic surgery, hand surgery, microvascular surgery, plastic surgery, obstetric and gynecologic surgery, ophthalmology, otolaryngology, and urology).
• A continuous rotation in trauma surgery for senior residents (PGY 4 or higher) that is part of an Accreditation Council for Graduate Medical Education- accredited program in any of the following disciplines: general surgery, orthopaedic surgery, or neurosurgery; or support an acute care surgery fellowship consistent with the educational requirements of the American Association for the Surgery of Trauma

I should point out there are two specialities for trauma centers adult and pediatric. Which is why I went to both, because one was a pediatric patient so we went to Memorial Herman Downtown for the pediatric patient. We went to Ben Taub for the adult.

Don’t know if this really belongs on Newbie, but it was medical related and I didn’t want to put it somewhere else.

In case you haven’t caught it on the show yet, I, Ron, am not a young guy. Matter of fact I’m smack dab in the mid 40s. So it has been awhile since I’ve been in school. Actually almost 18 years.

I did my time in college. Have two BA degrees, one in Mass Communications Radio/TV and one in Computer Science. And I did some time in a graduate program.

But I never learned how to learn.

Sounds a little strange. I really have no idea how to study. What does study even mean? I read what they tell me and then I try to remember it. When a test is near, I look back through the notes and the book. That’s studying isn’t it?

Well not if you want to be an A student. Which I wasn’t but now want to be.

So I decided it was time to learn. I mentioned it to my wife, a PhD English professor, and she suggested I check out the Study Hacks blog. I did and it looked cool, but it was also overwhelming. So I ordered the guys book, How to Be Straight-A Student and have been reading it. Here are a few tips that stand out in my mind.

Time Management

A students have good time management. Cal teaches a pretty simple system that involves a calendar and a daily to do list. You don’t have to have a big complicated system, but you need a system. If you are cramming right before a test, then you are doing it wrong. You should be keeping up with the work and preparing to study all along.

Notes from the Book

This was something that should have been obvious, but I never did before. Take notes from the readings. While you are reading create notes of the important stuff. This is so you don’t have to go back to the book when it comes time to create your study guide.

Oh, and highlighting doesn’t count. There is something visceral about actually writing something out that puts it more in your brain. I didn’t really memorize the Glascow Coma Scale until I started typing it up for my study guide.

You can also use your notes to follow along in class when the teacher is teaching the same material. Then would be a good time to highlight your notes when they say something is important.

Create a Study Guide

Before it comes time for your final studying for a test you need to create a study guide. I did this for my National Registry test and it helped a lot. A study guide is a new document that contains the important facts you need to know for the test, and sample questions you can use to prepare. I created a list of signs and symptoms, key vocabulary words, steps to CPR and Patient Assessment, etc. In my NR study guide I only made questions for CPR because I had JBLearning.com‘s practice tests to use instead.

Recall is Knowing

So now it is time to study. You pull out your study guide and start reading it over. How do you know you are done studying and have the material?

When you can recall it by memory.

You know you know the Glascow Coma Scale when you can write it out completely. You know you know pediatric two person CPR compression to breath ratios when you can say it without a multiple choice answer. You know you know APGAR when you can write it out. You know you know the rule of 9s when you can draw a stick figure and put the percentages on each part both adult and pediatric.

Those are the things that stand out to me about the book and I’d recommend it to anyone wanting to learn to read. I’ve started a new category on the blog for learning tips and there will be more as I learn more.

1. You fall, you call, we haul, that’s all.
2. There are two kinds of EMS calls: “Oh, shit!” and “Bullshit!”
3. When you join the kidney club, you usually cannot go.
4. Common sense isn’t.
5. The more reflective striping there is on your jumpsuit, the easier it is for the only drunk driver going by the MVA to find you.
6. If you have a ride-along you want to show the real world, nothing will happen that shift.
7. 95% of the time, EMS is simply thwarting the process of natural selection.
8. Just because you’re paranoid doesn’t mean your supervisor is not around the corner.
9. You can’t cure stupid.
10. If at all possible, avoid any edible item that firefighters prepare, especially the tuna casserole.
11. Heaven protects fools and drunks.
12. We are all slaves to the god “Motorola.” And that god requires sacrifices of hot food at least once a shift.
13. The address is never clearly marked.
14. Avoid bringing your patients to teaching hospitals in July.
15. EMS doesn’t save lives. We only postpone the inevitable.
16. Even sterile water tastes great on a hot day.
17. The stereo must always be louder than the siren.
18. At the beginning of your shift, your main O2 tank, fuel tank, and stomach will be empty…but the call volume will be full.
19. You know you are in trouble when the directions to a patient’s house include, “Turn off of the paved surface…”
20. Anyone with a tooth: tattoo ratio of less than 5:1 is guaranteed to be drunk, on drugs, or both.
21. Anyone with more than five listed drug allergies is automatically a psych diagnosis.
22. Avoid hospitals with Saint, Mercy, or Memorial in their names. And St. Mary of Mercy Memorial Medical Center is a definite no-no.
23. All arrhythmias eventually straighten themselves out.
24. Dead is dead, leave it at that.
25. Your seriously ill patient will miraculously get better after five minutes in the ER. We call this “fluorescent light therapy.”
26. Periodically, aliens will abduct your patient and replace him with an exact duplicate with a totally different chief complaint and set of symptoms. This usually happens right after you call report.
27. Don’t get excited about blood unless it’s your own.
28. The pain will go away when it stops hurting.
29. If nothing has gone wrong, you obviously don’t understand the situation.
30. You should always stop CPR after the second “ouch!” from the pt.
31. People don’t call an ambulance because they did something right.
32. The quickest way to gather the relatives is to leave the primaries on while at the scene.
33. Every nurse is right, as long as you are in their E.D.
34. When in doubt, always take another set of vital signs.
35. If your patient is violent, you can always use topical oxygen therapy. The green paint usually wears off in about a week.
36. The larger the house, the furthest from a door the patient will be, and the sickest patients are always in the back bedroom.
37. If the patient fell and was moved by the family, they will have moved them so that climbing stairs will be involved.
38. The furniture will always be arranged so that a stretcher or stair chair will never fit easily.
39. The problem won’t be that bad until a major disaster strikes: “You’ve had chest pain for three days and you waited until the middle of a blizzard to call?”
40. History never repeats itself. This is never more apparent than in the E.D., when the nurse asks the patient the same questions you did five minutes ago.
41. You’ve never been as sick as just before you stop breathing.
42. If someone is pointing a gun at you, two things become apparent: 1) You should have waited for law enforcement; 2) You wish you just hadn’t made that wise-assed comment.
43. Fellow medics always have a better story than yours.
44. Just when you say, “You know, I have never had a hanging….” you will get one.
45. The only time you go out on a limb (as a dispatcher), and not provide coverage so a crew can eat, a serious call will come in that area.
46. The only time you need to fart is when you have your patient loaded in the elevator.
47. The only time your pants split is when there are gorgeous police officers there to assist you.
48. You will get caught sleeping, eventually.
49. Never say the kind of call you are in the mood for in the beginning of the shift, because you will get it in the worst way, i.e. an MVC in the pouring rain.
50. God made Paramedics and EMTs to give him a chance to change his mind.
51. Beware when a firefighter says, “Y’all check this out.”
52. Your driver will never hit a pot hole or curb unless your patient has a bad fracture.
53. The worse your patient’s breath, the more quietly they will talk, forcing you to lean very close to hear them.
54. If ever in doubt of which house you were called to, look for the stairs.
55. If there aren’t nurses around when you get called to a nursing home, go to the last room in the hallway. That’s always where the sickest patients are.
56. Never start putting your stuff away before you are told to go home, because you have just given yourself another call.
57. When in doubt, let your partner handle it.
58. When getting a TMJ (too much Jesus) call on a Sunday, never say it around your patient. It sucks when you have to tell them what it means.
59. If the patient pukes, it is not unprofessional to puke along with them, it is sympathetic puking. You have something in common with your patient and can relate to how they feel. This is why they made the big step well by the side door.
60. If the patient only moans when you listen to lung sounds, they aren’t as sick as they want to be.
61. If a patient calmly tells you they are going to die, you had better believe them.
62. When the patient is really sick, remember that the ambulance has wheels for a reason.
63. 911: The government’s answer to Dial-A-Prayer.
64. The more addicted your patient is to morphine, Demerol, Fentanyl, etc…. the more allergic they are to Toradal.
65. You can have circulation with no breathing, but you can not have breathing with no circulation.
66. On trauma calls, survivability is inversely proportionate to social worth.
67. How you know an unconscious is a DOA: 1) If it weighs over 300 pounds… DOA; 2) if it lives more than three flights up in a walkup apartment… DOA; 3) if it’s less than 30 minutes left in the shift… DOA.
68. EMS providers know how to say “got shoes?” in 7 different languages.
69. At haz-mat scenes, remember to use the Copological Indicators: If the stripe on the officer’s trouser leg is vertical, it’s safe to go in. If the stripe is horizontal, wait for the haz-mat team. At a gas leak, send the cop in with a lit road flare. If the cop passes out and the flare goes out, it’s an asphyxiant. If the cop explodes, it’s a flammable.
70. Never go past the first dead cop.
71. There will be no dying or multiplying in the back of my unit.
72. The worse you have to use the restroom, the farther the distance it will be from the location of the call to the hospital.
73. If you haven’t yet had to use a patient’s bathroom… you haven’t been in EMS very long.
74. Some people can do this job, some can’t. Pray your partner is one who can.
75. All rhythms will eventually degenerate into one you will recognize and can treat.
76. If God had intended you to have a rapid response to the call, you would have been parked in front of the location.
77. Upon arrival at a code, check your own pulse first. If it is still there, everything else is easy.
78. As soon as you finish cleaning the rig up for a parade, you’ll have to drive ten miles down a muddy, unpaved road for a difficulty breathing.
79. If you ever go to a call and find the cops laughing on the front lawn…worry!
80. Remember, it’s the patient’s emergency, not yours. Try to keep your pulse rate lower than theirs.
81. If you drop the baby, fake a seizure.
82. The most effective prehospital fluid for trauma patients is a diesel bolus.
83. Sometimes people will die despite our best efforts.
84. Dead people very seldom get any better, but they never get worse.
85. “Can you walk? Have you tried?”
86. If EMS workers never eat, sleep, or go to the bathroom, nobody would ever get sick or injured.
87. Better to be looking at it than looking for it.
88. Go to work expecting to get screwed. You will occasionally be pleasantly surprised, but you will never be disappointed.
89. The size of the IV needle and the number of attempts is directly proportionate to the patient’s attitude.
90. All people eventually die.
91. If there is a God, you are not him. This even applies to paramedics.
92. The patient’s need of medical attention is inversely proportional to the amount of noise he/she is making.
93. If the patient says she’s in labor, it’s a UTI. If the doctor said it was a UTI, break out the OB kit.
94. If she says the baby is coming, believe her.
95. If a patient presents you with a problem you don’t know how to treat, change it into something you do.
96. All bystanders, and the majority of your patients, have more medical training, experience and knowledge than you. And they’re never shy about offering advice.
97. The best way to make a bystander go away is to ask for help.
98. The amount of vomit produced always exceeds the size of the container by at least a factor of 2.
99. The seriousness of an injury is inversely proportional to the number of escorts wanting to accompany the patient to hospital.
100. When your patient says, “I’ve called my doctor, and he’ll be meeting us at the hospital,” this actually means, “I am a hypochondriac and my doctor doesn’t have caller ID.”