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No Easy Trail

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woods

Police cordon off the abandoned vehicle with yellow tape. It is an 86 Plymouth – an old man’s car.

“Am I going to need all my gear, or just the monitor?” I ask the officer.

“The monitor.”

I look across the grass toward the tree line at the eastern end of the cemetery. I don’t want to have to get all the way in there and find out he’s workable. “He’s been there awhile?”

“Long enough. There won’t be an issue.”

I walk in alone. The leaves of late fall rest brittle on the ground. I have to watch my step on the uneven terrain. Bare branches pull at my pants and workshirt. There is no easy trail here. Still the air is fresh and it is good to be out of doors. No stale wheelchair lined hall this trek.

Fifteen minutes later, I reemerge with burrs on my clothes and blood on my hand from a thorn scratch. In my pocket I have a six second strip of asystole, a man’s name and date of birth on the back. 74 years old.

As I walk back across the grass, the late afternoon sun in the west makes me squint. I can hear the traffic from the main road that runs along the northern edge of the cemetery.

Indians lived here 300 years ago. When they grew old they too used to walk into the woods to die.

Posted by on November 27, 2009 • Filed under: ems-topics • Tagged: , ,

Oxygen Heresy

9 comments

220px-The_Scream[1]
Oxygen has long been considered the mother’s milk of medicine, particularly in EMS.

The first thing many patients get on arrival of EMS responders is a nonrebreather oxygen mask over their face cranked at 15 lpm whether they are hypoxic or not.

The thinking is it can’t hurt and can only help.

Journal Review

But check  out the conclusion of a recent article in the noted British medical journal Heart, Routine use of oxygen in the treatment of myocardial infarction: systematic review, which examined the only randomized placebo-controlled trials of oxygen therapy in MI.

Conclusion: The limited evidence that does exist suggests that the routine use of high-flow oxygen in uncomplicated MI may result in a greater infarct size and possibly increase the risk of mortality.

The authors postulate that high flow oxygen may vasoconstrict the coronary arteries as well as possibly causing increased reperfusion injury.

In an accompanying editorial, Challenging doctors’ lifelong habits may be good for their patients: oxygen therapy in acute myocardial infarction, the editorial writers begin with the following observation:

“Medical history is filled with widely applied therapeutic habits that replicate longstanding practices based upon theories that have no true scientific background.”  They note “the extraordinary discrepancy between the high incidence of myocardial infarction, affecting millions of people each year, and the paucity of scientific data on one of its most widely used methods of treatment.”

Their conclusion:

“The case against routine use of oxygen therapy which is presented in the paper from Wijesinghe et al is barely sufficient to formally rule out this technique; it should rather be considered, as the authors state in their conclusion, an incentive to design future trials to assess whether this treatment as used in contemporary practice (ie, guided by arterial oxygen saturation monitoring) is truly useful.”

And in a September 2009 article Systematic review of studies of the effect of hyperoxia on coronary blood flow in the American Heart Journal, the authors of the previous article are at it again.  This time, in a literature review looking specifically at coronary blood flow and oxygen, they conclude :

CONCLUSIONS: Hyperoxia from high-concentration oxygen therapy causes a marked reduction in coronary blood flow and myocardial oxygen consumption. These physiologic effects may have the potential to cause harm and are relevant to the use of high-concentration oxygen therapy in the treatment of cardiac and other disorders.

Bryan Bledsoe

Bryan Bledsoe, the noted EMS physician and educator, wrote a article in March of this year that also questioned the routine use of oxygen by EMS in The Oxygen Myth.  He summarizes research on the use of oxygen in stroke, cardiac arrest, MI, trauma, and neonates, and concludes:

“If the patient’s oxygen saturation and ventilation are adequate, supplemental oxygen is probably not required. ”

American Heart Association

Here’s what the American Heart Association has to say about 02 and MI in the chapter Stabilization of the Patient With Acute Coronary Syndromes, which explains the science behind their 2005 guidelines.

EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).

And

Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation _90% (Class I). It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy (Class IIa). Supplementary oxygen limited ischemic myocardial injury in animals, and oxygen therapy in patients with STEMI reduced the amount of ST-segment elevation. Although a human trial of supplementary oxygen versus room air failed to show a long-term benefit of supplementary oxygen therapy for patients with MI, short-term oxygen administration is beneficial for the patient with unrecognized hypoxemia or unstable pulmonary function.

Regional Guidelines

My regional oxygen guidelines are confusing. In our appendix, the indication for oxygen is listed as:

Indications: Any hypoxic patient or patient who may have increased oxygen demands for any reason.

Dose: Patient dependent 1 liter/minute via Nasal Prongs to 100% via rebreather face mask.

Under Acute Coronary Syndrome, it says the following:

Oxygen: Oxygen Therapy (90-100%)

Is that 90%-100% referring to the patient’s oxygen saturation or that they should be given a 90-100% mixture of oxygen?

I sit on the protocol committee and would vote for the saturation interpretation, but it needs to be made clearer.

The Future

While we should all continue to follow our own EMS systems current medical guidelines, we may consider that in the future, we may talk about the old days when we gave everyone oxygen.

***

The comment section of my recent STEMI Redux post produded a discussion about the use of high-flow oxygen in the setting of an MI, thus spuring this post.

I previously addressed the issue of changing views on oxygen in a December 2007 post titled Oxygen).

Posted by on November 20, 2009 • Filed under: ems-topics • Tagged: , , ,

STEMI Redux

12 comments

The call is for a “heart attack.”

We get dispatched to “heart attacks” fairly often. “Heart attack” is a layman’s way of describing chest pain or stroke or cardiac arrest. It could be anything really. We sometimes even get called for heart attacks in doctors’ offices and it turns out not to be a true heart attack, but some just version of chest pain.

But there is a difference this time. The location of the call is a cardiologist’s office.

“This is going to be a STEMI,” I tell my partner as he hits on the lights. “And I bet they are going to want us to go right to the cath lab.”

I wrote about a similar experience with this office a number of years ago in cath lab, when I lamented that a golfing buddy of a cardiologist could go right from the field to the cath lab, but any regular Joe had to go to the ED where I would have to persuade a doctor to look at my ECG, and then he would have to call a cardiologist to convince him to open the cath lab.

But as my last post STEMI Alert shows, there has been progress in recent years. We can now activate the cath lab from the field. We are still required to go to the ED where the patient gets registered, a hospital 12-lead is done, any appropriate care we haven’t already done is started (such as giving Plavix or starting heparin), and the patient signs the consent form for the procedure.

Sure enough, when we arrive we are led down the hall to the last room where a 12-lead machine is spitting out an ECG. I can see the ST elevation from the doorway. The doctor tells me the patient – a 65-year-old female is having an acute anterior MI. When I ask what medicine she has already gotten, he tells me they have given her aspirin and NTG.

“Are we going to the ED or…?” I ask.

“Right to the cath lab. Dr. Blank is waiting for him in cath lab # 2.”

And it is off to the races. While we transfer her over to our stretcher, the doctor gives her some plavix. Then we are out the door, back in the ambulance and on our way.

Our normal procedure is to call the ED with a STEMI alert. This time I just call and say I am en route from (I name the cardiologist’s office) with an acute STEMI going directly to the cath lab. Can they have someone from the ED meet us at the door and escort us up? I know where the cath lab is, but there are some locked doors that you need an ID swipe to enter.

heart1

I manage to put the patient on oxygen, get a set of vitals, do a 12-lead of my own, and put in an IV and start to run fluid (Her BP is in the 90’s, which she says is low for her), while getting a cursory history (none, she says) on the way in. We talk about what is happening to her – she has a blocked artery in her heart and what they are going to do to open it up – insert a balloon. She is intelligent and has some medical background. When I start to explain why I am putting on the defib pads, she shakes her head and says, “I don’t even want to know.”

She tells me she started feeling badly about an hour earlier so she called her cardiologist (she had to have some history, but I didn’t have time to get into it) and made an emergency appointment. While I wish she had called 911 instead of the cardiologist, at least they recognized what was going on right away and they have the pull to get her right into the cath lab. No need for my interpretation or a stop in the ED.

Our guide from the ED meets us at the door and clears our way up to the cath lab, where we transfer her to their table as the cardiologist holds out a clipboard with the consent form on it.

Instead of staying to watch the procedure this time, I go back downstairs and write up my run form. When I return to the cath lab, while the patient is still on the table, I learn the balloon has been inflated. The blockage is now clear. The stent is in. And the patient is doing well. The patient had a 100% occlusion of the Left Anterior Descending Artery (the LAD) — also know as the Widow Maker, or in the case of female patients, the Widower Maker.

Door-to-balloon time is 28 minutes and 911 call-to-balloon is 60.

Using the STEMI I did the other day as a comparison, bypassing the ED saved 7 minutes.

While these were special circumstances (the patient coming from the cardiologist’s office), I am hopeful that we can build on calls like this one to the next logical step for our area – joining some other progressive areas in the country in making field to the cath lab the routine rather than the exception.

Posted by on November 18, 2009 • Filed under: ems-topics • Tagged: , , ,

STEMI Alert

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“What’s a STEMI?” My partner is a retired police officer, who works once a week. He asks because just the day before, his neighbor was whisked off the cardiac cath table just before he was to have a scheduled procedure when the doctor said they had an emergency STEMI coming in.

Little does my partner know, but he has touched on one of my favorite topics. Instead of a three word answer, he gets an lecture.

STEMI

A STEMI, I tell him, stands for ST-Elevation myocardial infarction. It is sort of like the mother of all heart attacks. A coronary artery becomes occluded and the tissue beyond the occlusion starts to die. The heart is electrical. When we put someone on a heart monitor, what we are looking for is an electrical picture of the heart. If the heart’s electrical system isn’t working, then the pumping muscle is endangered. The pump stops working, the patient dies.

An ST elevation is caused by the electricity having to detour around the area of the heart that is dying. It produces a distinct shape on the ECG. A full 12-lead ECG can actually pinpoint the area of the heart that is threatened. We respond to chest pains all day long, but chest pain rarely turns out to be an actual heart attack, and even rarer, an ST elevation heart attack.

STEMIs are great paramedic calls, I tell my partner. Once you spot one, that patient is relying on you to get him to the proper hospital on time and to make certain that hospital knows the patient is having a STEMI.

You need strong assessment and ECG skills to recognize a STEMI. You need persuasive skills to convince the hospital over the radio that this patient — that they can’t see — is indeed a real STEMI so they can mobilize the cardiac cath lab before your arrival. You have to be able to educate your patient about what is happening to him, and to be able to assure him that he is going to get the best care possible.

And you have a lot of general work to do. Get the patient on oxygen (usually a cannula will suffice), give them aspirin (life-saving), get them in a hospital gown (something I like to do to make the transition easier at the hospital), put in 2 IVs, give Nitro (unless it is right sided MI, some would argue don’t even give it in an inferior MI), consider morphine (with the same warnings), give Zofran (if the patient is nauseous), do repeat 12-leads (to see if the infarct is evolving), apply defib pads (in the event the tombstone ST suddenly becomes v-fib and you need to shock the patient), all while getting patient’s history (meds, allergies, and demographics such as DOB, SS, phone, address, etc.) .

One of the nice points about a STEMI patient is while they are critically ill, they are usually working with you and are not combative or hard to manage like a patient with a stroke, pulmonary edema or a patient with ruptured esophageal varices.

STEMI Alerts

The local hospitals have all recently instituted various procedures for prehospital folks to activate the cath lab from the field. One hospital requires EMS to transmit a 12-lead, others ask us to contact medical control, and say, “I have a STEMI alert.” I mention that the EMS coordinator of one of the hospitals told me the other day that EMS crews are welcome to come up into the cath lab and watch the procedure if they bring a STEMI in.

balloon

The cath lab procedure involves passing a catheter into a patient’s groin(the femotal artery) and then snaking it up through the circulatory system and into the patient’s heart. The cardiologist injects dye to find the blockages and then inflates a balloon in the artery to clear the blockage. He then inserts a stent, a small drug-coated metal tunnel to keep the artery open. The sooner the artery is opened (and blood flow is restored), the less damage is done to the heart.

Door-to-Balloon Time

Hospitals judge themselves on their door-to-balloon time, meaning the time the patient enters the hospital to the moment the balloon is inflated in the heart restoring blood flow. The goal is 90 minutes. Nationwide less than half of all patients with STEMIs have this time met.

It used to be only cardiologists could activate the cath lab. (Activating the lab means clearing a table, getting the staff in place to begin the procedure). If someone came into the ED with chest pain, they would get triaged and worked up by a nurse. A 12-Lead ECG would be done, which would be presented to a doctor. The doctor who would look at it, and if it was concerning, he would evaluate the patient. If he thought the patient was having a STEMI, he would then call the cardiologist and describe the patient and the ECG. The cardiologist would then decide whether to come down and see the patient for himself or not.

Then the ED docs got so they could make the decision to activate the cath lab themselves. ECG and story in hand, they would call the cardiologist at home in the middle of the night and tell him they had a STEMI in the ED who needed to go to the cath lab. The cardiologist would throw on some scrubs and race out of the house, and head in to the hospital as his staff prepared the lab.

Now EMS can call the ED doc and ask for field activation. I radio in on Sunday afternoon that I have a STEMI coming in, a cardiologist on a golf course gets a page, and his foursome is suddenly a threesome minus a golf cart. Or on a regular day, in the case of my partner’s neighbor, the cardiogist has to tell the patient he has just put on his table and started prepping for a routine procedure (an investigative look at coronary artery health) that a more important patient is on the way in. The neighbor will have to wait.

With earlier activations, door-to-balloon times have drastically decreased. Years ago, cardiologists had no idea about EMS. Now we are their new best friends because they recognize if we do our jobs in the field right, the door-to-balloon time will significantly decrease. It will improve their performance times, and most important of all, it will improve outcomes.

I spoke with a paramedic in Carolina recently who said their system is so far advanced, a person calling 911 with a complaint of chest pain will get a quicker door-to-balloon time then a person walking into the same hospital with a complaint of chest pain.

Some systems have an EMS-to-balloon benchmark of 120 minutes, while others try for 90 minutes with the goal being 30 minutes prehospital, 30 minutes in the ED and 30 minutes in the cath lab.

Thank You Letters

I tell my partner the last two STEMIs I did, I got wonderful letters from the patients, thanking me for saving their lives. The letters were so similar; it made me believe the cardiologists must have made a point of telling them that EMS had been crucial to their care. The last one I did, a man and his wife, a week to the day after they’d traveled lights and sirens in our ambulance to the hospital, stopped by the ambulance bay and brought cookies the wife had baked as well as the thank you letter she wrote. The man couldn’t stop shaking my hand, and thanking me.

“So anyways,” I finally conclude, “STEMIs are great paramedic calls.”

“Interesting,” my partner says. “I’m glad I asked.”

911 Call

That afternoon we get a call for a thirty-year-old man at work short of breath with tingling in his arms.

So I’m thinking sounds like anxiety, hyperventilation, BS.

We arrive at the office building, and on entering, find a crowd of people standing around a cubicle. A young man lies on the ground by his desk. He is shivering. He is covered up to the neck with winter coats. He is ghostly pale. There is vomit in the waste basket. I touch his forehead and it is as soggy as a sponge. I ask him how he is doing, he answers in a forced whisper which I can’t understand. My plan is to just get him out to the ambulance and out of the sight of others and try to figure out what is going on. I am wondering if maybe he doesn’t have a stomach bug or something. He looks perfectly fit – a spitting image of Lance Armstrong, except he is so pale.

In the ambulance, I help sit him up so I can get his shirt off, which is soaked through with sweat. We put him on a cannula and I attach the monitor while my partner tries to get a quick blood pressure. The young man tells me he has been feeling weak with pains in his arms for about forty minutes. He says he vomited twice.

“I can’t get a pressure,” my partner says.

I glance at the monitor.

32mi

I don’t need strong ECG skills to recognize this one. It’s hitting me in the face. Game On.

I tell my partner to get in front and drive. Code three. He snaps to attention as we almost never go lights and sirens.

I do the 12-lead while I am asking the patient about his medical history. He has none, except he says his father had a heart attack at age thirty-eight.

mi32b

“Am I having a heart attack?” he asks.

“Yes,” I say, “but we are going to take care of you.”

I get right on the radio. “I have a STEMI alert,” I say. While the age – 30 might make the listener balk – my description of the ECG, ST elevation in II, III and AVF with reciprocal changes in I and AVL, along with the patient’s presentation, cold, clammy, ghost pale, and the clincher – his father had an MI at 38 bring me the response, “Do you need anything besides the cath lab activated?”

On the ride in, the patient gets aspirin, two IVs, and Zofran for his nausea. When he complains the oxygen isn’t working, I switch him up to a nonrebreather. I apply the defib pads just in case.

The cardiologist meets us in the ED. He takes one glance at our ECG and starts explaining the procedure to the patient to get his consent.

And then it is off to the cath lab.

Cath Lab

Not just the patient, but my partner and I. Standing behind glass we get to watch everything. A cardiology nurse directs our attention to two computer monitors, one that shows the patient’s beating heart, the other his ECG. We watch as dye is injected in each of the coronary arteries. When they try to inject it in the RCA – the right coronary artery, it goes no where. 100% occlusion.

Next we see the balloon inflated and then on the ECG monitor after a brief period of the heart slowing down, suddenly the ST elevation disappears and moves down to the baseline as blood flow is restored.

cathcath

(Note: Not my patient’s image)

The cardiologist asks for the time. Door-to -balloon – 35 minutes. I calculate back to our end. 911-call to balloon – 62 minutes.

Activation Time – 1 minute
Response Time – 4 minutes
Scene Time – 8 minutes
Transport time – 12 minutes
Ambulance Bay to ED – 2 Minutes
ED/CathLab – 35 Minutes

The cardiologist inserts a stent, and then does an echocardiogram that shows the patient still has a strong functioning heart.

We have to clear to get back in service. We thank the cardiology nurse for letting us observe. As we leave ,the doctor calls to us, “Great job!”

Another Question

Walking down the hall, there is a definite bounce in my step.

Then my partner says to me, “Now that I know what a STEMI is, ‘What’s a ruptured esophageal varices?’”

I stop and look at him. He didn’t just hex us, did he?

“I’m just messing with you,” he says. “I guess I’ll learn to be quiet from now on.”

***

Here’s two old posts on STEMIs that show the changes over time:

ECG Changes 2006

Cath Lab 2004

***

Disclaimer: As always some details and characteristics have been changed to protect patient confidentiality.

Posted by on November 16, 2009 • Filed under: ems-health-safety, ems-topics • Tagged: , , ,

Ambassador of Love

7 comments

emergency

In emergency medicine, field and hospital come together when the EMT/paramedic hands over patient care to the nurse. This transfer is almost always professional and courteous. The good feelings demonstrated on the job between paramedic and nurse are not limited to working hours. After we punch out for the shift, we often meet in restaurants, bars and at parties large and small. Paramedics and emergency nurses love to eat, drink and be merry together. Many end up spending their lives with one another.

At one of the trauma centers in our city, a pretty young nurse chatted with four medics as we waited to get room assignments for our patients. We were discussing the routine “wait” of the triage line when the nurse smiled and said, “Well, at least the nurses at (our) hospital are the friendliest.” She was met with silence and bemused grins — a reaction she clearly hadn’t expected. “We are the friendliest?…Aren’t we?”

While none of us would complain about the friendliness of the nurses at her hospital, the truth was all four of us were either married to or living with nurses at the other hospital in addition to being the fathers of their children.

My point is the much discussed conflict between nurses and paramedics is more often the exception that the rule. At work and at play, we love and respect each other. Still there is no hiding the fact that there can be conflicts. It usually arises when the nurse and EMT/paramedic are unfamiliar with each other. A rude or misunderstood remark takes on a larger significance. Instead of nurse and paramedic, it’s Hatfields and McCoy’s.

Sly Hero

Each confrontation is retold and enhanced with the paramedic always being the sly hero and nurse being an archetype moron or villian. I wrote about this a couple years ago in Left Lateral Condoyle, Paramedic as Sly Hero and Stud or Idiot?

Dumb nurse and sly paramedic stories are quite common in EMS rooms or any place where ambulance crews gather to swap the day’s tales. I suspect nurses may tell their own version of dumb paramedic and sly nurse stories when they are among their own kind in their own clubhouses.

Threat to Public Health?

Years ago I went before the legislature to testify about a bill enabling paramedics to give controlled substances on standing orders. (Connecticut had an antiquated law that required controlled substances be given only by “simultaneous communication” with an ED physician.) A few months before the state had passed a law changing paramedics from certified to licensed status, which meant instead of paying $35 every two years, medics now owed the state $75 every year. A certain interest group was concerned that giving license status to paramedics would enable them to work as paramedics in doctors’ offices, walk-in clinics and nursing homes. So in response, they cajoled the legislature into writing a bill specifying that paramedics could only practice as paramedics within the confines of the emergency medical services system. This legal language change was lumped together with the proposal enabling us to use controlled substances on standing order.

My lowest day as a paramedic came from watching the representatives from the Nurse’s Association and the Emergency Nurses Association testify that it would be unsafe to have paramedics working in doctors’ offices because paramedics were not as well trained as nurses and thus would be a danger to the public health, blah, blah, blah. A lone ER doc then got up and said completely without irony that in addition to being untrained, if we let paramedics work in doctor’s offices, there would be no one left to take care of the truly sick people in the field.

While the doctor was allowed to go on for 11 minutes, any paramedic that wished to speak was gaveled into silence after three. The one bright spot of the day was when a hospital clinical coordinator who was also a paramedic made the savvy point of speaking about first aid stations at a large area boat show that were manned by nurses. If a visitor needs an ice pack or a Band-Aid, he said, then the nurse takes care of them, but if they go into cardiac arrest, the nurse’s first action is to call for paramedics.

Mutual Respect

I do not hold the actions of the nursing organizations (that were successful in limiting our area of practice and who slandered our profession) against the ED nurses who take over care of the sick patients we bring in to the hospital or against the sweet ED nurse who gets up in the middle of the night to comfort my crying daughter, while I get up to warm a fresh bottle of milk. We have a mutual respect.

But still there are those rare, but telling moments when an unfamiliar nurse lets me know that SHE is a nurse and her actions imply I don’t know anything. This happened just the other day at one of the local nursing homes. A COPD patient, who I have been caring for for many, many years, was again having an exacerbation. While I questioned “Frank” about how he was feeling this time and assessed his lungs and breathing, the nurse tried to tell me how much oxygen to give and how to position the patient. Frankly, she was in my way.

I attempted to explain to her that I knew Frank well and had learned to trust him to tell me what he needed. Also, I told her we had capnography and could thus monitor his ventilatory status. She clearly didn’t want to listen nor do I think she had any idea what I was talking about. “I know what you can monitor,” she said, “but you can’t give him too much oxygen.”

I told her we had it in hand – a cue for her to leave. I wanted to say, not only have I been a paramedic for almost two decades, I am also a registered nurse, but I couldn’t say it because my nurse status was still listed as pending on the official state license verification site.

Paramedic, R.N.

That’s right.

dixie

For the last couple years I have (off and on) pursued a nursing degree, and I recently completed the final step of the process by successfully passing the NCLEX exam. Yesterday morning, I received an official letter from the state addressing me as Peter Canning, R.N. and including a copy of my new license. I am now a dual citizen.

In addition to pledgeing to uphold the fine and honored nurse traditions and standards of caring for my patients, I really want to meet Dixie McCall. I want her to teach me the nurses’s secret handshake and to formally invite me to the Nurses Annual Hotenanny at the local Moose Lodge.

Ambassador of Peace and Love

I will save a future post for a detailed look at how I got my nursing degree – what I think about the educational experience I had and what I plan to do with my nurse education (besides being an ambassador for peace and love among the clans).

I can say definitively, I have no intention of leaving the paramedic streets as long as I am healthy and able-bodied.

gage

As far as credentials, I intend to be listed as Paramedic, R.N.

Posted by on November 10, 2009 • Filed under: ems-topics • Tagged: , ,