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IO on Living Person

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The patient is morbidly obese and obtunded. I look at him with his tongue protruding from his mouth and think, if he stops breathing he is going to be impossible to tube. We try to stimulate him, but barely get any response from a deep sternal run.

On our way to the hospital, we look for an IV. Nothing. Then I remember we carry the EZ-IO.

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I have used the EZ-IO about eight or nine times, but always on cardiac arrests — patients who were more or less not feeling any pain. We can use it on living, and even awake patients in extremis, and while I know of medics who have done so, I have not encountered the situation yet, but this I am thinking may be that time.

Now I was very skeptical of the EZ-IO when it first came out. I have always been very proud of my IV skills and felt that people might jump to do an EZ-IO and neglect a findable peripheral vein. Surely, the IO had to be more harmful to the patient. Then two things happened. One, I read that infection rates for IOs were far less than they were for peripheral veins, and two, I used it during a code for the first time — on a one legged diabetic — and was astonished about how quick and easy it was to put in. While I still look for peripheral veins on codes, if I can’t find one right off the back, I have no hesitation about going for the drill.

But drilling an IO on a live person – that is a barrier that is tougher to cross.

My preceptee and I discuss the possibility and decide to go for it. My preceptee picks his landmark on the proximal tibia (just below the knee) and starts drilling. While EZ-IO makes a larger bariatric needle for large patients, we don’t carry them yet. This needle is just spinning in the man’s fat. Fortunately I have had this situation before. We reposition the angle and lean in hard on the drill. By applying pressure we find the bone. The needle drills in and finds anchor. My preceptee asks if he should give the lidocaine dose before hand. The lidocaine dose is a pain-control measure for conscious patients. While the drill itself causes only minor pain, they say it is the fluids being pushed that really hurts. This guy reacted to the drill with only the faintest of groans. “Not necessary,” I say. “He’s unconscious.”

I prepare a saline flush while my partner spikes a bag. I push the 10 ccs of fluid and from out of the depths of unconsciousness, the patient screams and nearly comes off the stretcher. I keep pushing and he keeps screaming. It is a good thing it only takes four or five seconds to push the saline. As soon as I am done pushing, he drops back to unconsciousness.

I think maybe we should have given him the lidocaine (Although that likely would have hurt just as much pushing the saline in). Maybe next time.

We hang the bag of Saline and wrap a blood pressure cuff around it to get the fluid flowing. It drips in a slow, steady rate. We call the hospital and let them know what we are bringing in.

In the ED, they are pleased we have IV access. There is no “What?! You drilled a live person?!” reaction. So I guess they have seen it before.

Still I am thinking as far as IOs on living people, if it caused an unconscious person that much pain, I can’t imagine how painful if might be to an awake patient. If I have to drill another living person, I will certainly use the lidocaine, and will likely search just a little bit longer for a useable vein.

As an aside, this all raises the issue of pain relief for the unconscious. Our guidelines, while quite liberal for pain control, don’t allow pain relief for anyone with a GCS of 12 or less. When patients go the OR and are operated on, they are not just knocked out; they are medicated with analgesics before hand because even though unconscious, they continue to feel pain and pain can be quite harmful to the body. What about the groaning patient with multiple fractures? A topic for another day.

***

Here are our regional IO Guidelines:

INTRAOSSEOUS INFUSION
The following guideline is to be utilized for FDA approved intraosseous access devices only. You should follow the specific manufacturer’s guidelines for the insertion rocedure.
INDICATIONS: May be inserted on standing order for the following:
Adult (> 40 kg) & Pediatric (3 – 39 kg)
1. Intravenous fluids or medications needed and a peripheral IV cannot be established in
2 attempts or 90 seconds AND the patient exhibits any of the following:
a. An altered mental status
b. Respiratory compromise
c. Hemodynamic instability
d. Status Epilepticus unresponsive to IM or rectal medication
2. IO access may be considered PRIOR to peripheral IV attempts in the following
situations:
a. Cardiac arrest (medical or traumatic).
b. Profound hypovolemia (Shock) with altered mental status.
c. Patient in extremis with immediate need for delivery of medications and or fluids.
CONTRAINDICATIONS:
• Fracture of the tibia or femur
• Previous orthopedic procedure (knee replacement) or IO within 24 hours
• Infection over insertion site
• Inability to locate landmarks due to either significant edema or excessive tissue
Note: If contraindication exists, utilize an alternate insertion site.
PROCEDURE:
1. If the patient is conscious, explain the procedure and provide the rationale for it.
2. Use appropriate body substance isolation equipment.
3. If the patient is conscious, prime the extension set with 2%, preservative-free Lidocaine* and leave the syringe attached (up to 50 mg Lidocaine total).
4. Identify the insertion site.
5. Prep the site with betadine** or alcohol.
6. Prepare the IO needle.
7. Stabilize, insert the IO needle and remove the stylet.
8. Confirm proper placement (aspiration of marrow; flushes freely without extravasation).
9. Connect the extension set and flush with 2% preservative-free Lidocaine*:
a. Adults 20-50 mg
b. Pediatric 0.5 mg/kg
10. Rapidly flush with 0.9% NaCl:
a. Adults 10cc
b. Pediatric 5cc
11. Start infusion utilizing a pressure bag or BP cuff (if pressure bag unavailable).
12. Secure the catheter and tubing.
13. Attach identification wrist band, notify receiving facility staff and deliver removal instruction form to treating physician or nurse.
14. Frequently monitor IO catheter site and patient condition.

* If the patient is unconscious or allergic to Lidocaine, prime the extension set with 5-10 mL 0.9% NaCl.
** Betadine is preferred (if patient is not allergic to iodine). If time permits, swab three separate times in an outward, circular motion utilizing a fresh applicator each time.
Note: Paramedics must have attended a medical control approved, device-specific in-service and demonstrated competency prior to utilizing an IO device in clinical practice.

COMPLICATIONS:
• Infection
• Compartment syndrome
• Subcutaneous extravasation
• Clotting of marrow in needle
• Osteomyelitis/cellulitis

PEARLS
Sites:
Should be used on sites in accordance with manufacturer recommendations and guidance from local medical control.
Introsseous,
• Complications are infrequent (0.6%) and consist mostly of pain and extravasation.
• IO flow rates are typically slower than with IV catheters. Use a pressure bag or pump.
• Insertion of IO needles in conscious patients causes mild-moderate discomfort and is usually no more painful than a large bore IV.
• Infusion through an IO line may cause severe discomfort for conscious patients and preservative-free lidocaine should be administered.
• Onset of analgesia with lidocaine typically takes approximately 1 minute and lasts 40 minutes to 1 hr.
• The most common side effect of lidocaine toxicity is seizures.

Posted by medicscribe on December 28, 2009 • Filed under: ems-topics • Tagged: ,

The Handover – Holiday Edition

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The Handover – Holiday Edition, a collection of blog posts from multiple contributors, is being hosted this month by Ambulance Driver at A Day in the Life of an Ambulance Driver.

My contribution Winter’s Fuel is included, along with many great posts by other bloggers.

Check it out!

Happy (and Safe) Holidays for all!

Posted by medicscribe on December 24, 2009 • Filed under: ems-topics

PSVT-Adenosine

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“She’s a little light-headed and her heart’s going really fast,” the officer says. “She needs you to run a tape on it.”

The woman, sitting on the couch, is pale and looks uncomfortable.

Her pulse is very rapid. Too fast for me to count.

She says this has been going on for twenty minutes. She had an episode that lasted fifteen minutes a few days ago, and just one episode a month before that lasted almost a half an hour. She made it to the doctor’s office. He felt her pulse and discovering it to be very rapid, ordered an ECG. The nurse at the patient’s request brought in a glass of cold water, which the patient drank while she put the electrodes on. When they did the 12-lead her heart was back to normal. Without the printout, the doctor said he couldn’t tell what was wrong.

“Well, let’s not give you a cold glass of water before we record you then,” I say. It is quite likely the cold water triggered the patient’s vagus nerve, which sent a signal to the heart, slowing it down, and giving it a chance to reset in a normal rhythm.

PSVT

I attach the limb leads, and glance at the monitor.

PSVT5

A PSVT. Paroxysmal Supraventricular Tachycardia. I hit print.

“Consider yourself recorded.”

“You’re going to give me that recording so I can show the doctor?”

“Better than that,” I say, as I attach electrodes to my 12-lead cables. I’m going to take a more detailed picture of your heart, and then I’m going to fix you.”

“Are you going to give me a cold drink of water?”

“Perhaps, but let’s try a couple other things first.”

I instruct her to cough a couple times. No change in the rhythm. I have her bear down like she is going to the bathroom, “but don’t go,” I caution. No change. Both these maneuvers also activate the vagus nerve, which can sometimes slow the heart and help break the rhythm.

We try the cold water.

No change.

“I guess we’ll have to go the medicine route.”

The patient immediately reaches for her medication list to show me what she is already on, but I explain the medicine I am giving her — adenosine — will be IV.

Paramedic Favorite

Years ago I had two patients who were in PSVTs convert before I could give them the adenosine. One self-converted when we were carrying her down the stairs, another when we hit a bump in the road when I was drawing up the medicine. I was a younger medic then and deeply disappointed that I didn’t get to give the drug — a paramedic favorite because of its quick response in the patient condition when it works. Not only did I not give the drug, I failed to record a strip, thinking I had plenty of time. That started me recording a strip as soon as possible and also giving the drug on the spot. That worked well until the day I gave it to a patient sitting at his desk. Five seconds after I pushed the adenosine, the patient then slumped over on the desk in sudden ventricular tachycardia. Opps. A little known, but documented side effect. Now not only do I always get a 12-lead before I try to convert a patient, but I make certain the patient is on the stretcher first. If they are going to go out, I don’t want to have to worry about picking them up.

This woman has nice veins, which is great. Ideally, you want the biggest catheter you can get into the biggest vein you can find closest to the heart. I’m not talking a 12 in the jugular (a neck vein), but if you can put an 18 in the AC — the vein in the crook of the elbow, that is great. IV catheter sizes get bigger as the number gets smaller. Most medics just carry a selection from the tiny 24 to the large bore 14. (Some carry a 12 for needle decompressions.) You want the big vein close to the heart because the drug lasts for such a short time (adenosine’s half life is 10 seconds), you need to get it to the heart before it is deanimated.

I have at times had to settle for hand veins, and a couple times have done it successfully with a 24 in the hand, but ideally the 18 in the AC is what you want. Out in the ambulance, I sink the IV and attach a saline lock. I then draw up the 6 mg (2 cc) dose of Adenosine in a 5 cc syringe (I use a 5 cc in case the drug doesn’t work, then I can use the same syringe for the second dose, which is 12 mg (4 cc) )and 10 cc of normal saline in another syringe. I stick both needles in the saline lock.

P1030068

I push the adenosine and then rapidly fire the saline a split second later. Think of it as the 10 cc of saline being a rocket booster to hurtle the adenosine payload through the veins up through the vena cava and into the heart where it works its magic. (Be careful when you do this to hold the stopper down after you have fired the first syringe. If you don’t, when you fire the saline it may back up into the first syringe decreasing the pressure of the thrust.)

Uncomfortable Feeling

I still love giving the drug, but for the patient’s sake, I always try the vagal maneuvers first. If the vagal maneuvers don’t work, I hope the patient self-converts. Some people take to adenosine better than others. It can be very uncomfortable. The drug itself only lasts in the body about 15 seconds, but what it does is basically produce asystole -– flat line — until the heart can reset itself. The asystole usually only lasts a few seconds, but it can seem much longer.

“You may feel uncomfortable — it affects everyone differently — but keep in mind it only lasts for a few seconds — ten at most — and then is gone.”

“What do you mean by uncomfortable?” the woman asks.

“Some people feel chest pain, other just anxiety. It is different for everyone.”

What I don’t tell her is I have had people who have been treated both by being shocked without sedation and who have received adenosine on the other, and who would prefer I shock them they found the adenosine so unsettling. A patient once told me he they felt like he had died and left his body after I gave him the adenosine, and I have seen patients grab at the chest in sheer terror. I am hoping this one will go easier.

The terror can go both ways. The paramedic has to go through the experience of watching his patient flat line, praying for a beat, and then watching a whole bunch of funky beats and waiting for them to organize into a nice sustained sinus. The years and number of times I have given the drug have somewhat moderated my fear. And I will say it is much less scary for us now that we have the LP 12 monitors. When I started we had LP 5s and 10s which had a much smaller and shorter screen, so you really did see nothing but asystole. Now it is rare because the screen shows several seconds worth of time all at once as opposed to maybe only a second or two, so you never really see just a complete flat line on the screen anymore.

It’ll Pass

“Ready, here goes,” I say, as I fire first the five cc syringe and then the ten.”

I watch the monitor and see the sudden break in the rhythm, and say, “You should be feeling it now.”

PSVT3

“I’m feeling it,” she says.

“It’ll pass, it’ll pass, and you should be feeling better.”

“Let’s hope so.” She looks like it starting to bother her.

“How about now?”

PSVT4

The rhythm is back to sinus.

“I am. That wasn’t too bad.”

“I’m glad for both of us.”

Explanation

I do a repeat 12-lead, and spend the rest of the ride chatting with the patient. Sometimes I explain in advance what a drug does, but with adenosine, I wait until after to fully explain. I show them the strip and tell them how the drug temporarily stopped their heart.

The heart is very electrical. Each beat originates with an electrical spark in the SA node. The electricity causes the atrium, the top chambers of the heart to contract, pumping blood to the ventricles below. The electricity has to go through a gate called the AV node, where it is delayed temporarily to allow the ventricles to fill with blood, and then the electricity continues down into the ventricles, causing them to contract and pump blood throughout the body. If there wasn’t a delay in the AV node, there ventricles would contract with no blood in them, and that would not be good at all.

In a PSVT, the AV node, instead of acting like a one-way door, suddenly becomes a revolving door. The electricity whirls around causing both chambers of the heart to fire very rapidly — I’ve seen it as high as 240. Because the heart is no longer pumping effectively, this can cause the patient to feel very light-headed and uncomfortable. The body of course cannot tolerate this indefinitely.

Adenosine acts like a stake in the whirling door. Stopping it cold From 170 beats a minute in this woman’s case; it is suddenly not beating at all. The heart then starts back on its own, and after a few funky beats, should resume its regular activity.

The dose of 6 mg, if properly flushed rapidly up to the heart, corrects the rhythm about 60% of the time. I have had several patients who I have had to give 12 mgs to. That I understand is effective a cumulative 92% of the time. If that doesn’t work, you can give a second 12 mg dose. Fail again, and it is time to consider shocking the patient. Adenosine won’t work if the patient has a rapid atrial fibrillation or another problem that originates above the AV node.

I always hope that six works, because if the patient has had a bad experience, I don’t have to try to convince them to let me do it again.

Six is the charm this time. At the hospital I make copies of the 12-leads and conversion strip, leaving one in the patient’s chart and handing her another so she can show it to her cardiologist if the other copy gets lost. The patient says she is not looking forward to spending the night in the hospital, but I tell her while it will be up to the doctor, in many cases, I have observed patients with resolved PSVTs simply be told to follow-up with their cardiologist and sent home. Sometimes they may be put on a beta blocker in the interim.

The next day I get a phone call that the patient stopped by the ambulance headquarters and left a thank you note and an assortment of Christmas cookies for my partner and me.

Here’s some more information on Adenosine

Posted by medicscribe on December 22, 2009 • Filed under: ems-topics • Tagged: , ,

Winter’s Fuel

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3093514020_127a858ef0_t[1]
As my contribution to the Handover’s forthcoming Christmas issue, I have combined two old Christmas posts.

***

Fifteen on the Scale

It’s Christmas eve. We get called to one of the local nursing homes for rib pain. The room number sounds familiar. As we wheel our stretcher through the lobby, “Good King Wencelous” plays through the speakers.

Gently shone the moon that night, thou the frost was cruel.
When a poor man came in sight, gathering winter’s fuel.

In the East Wing, the nurse hands me the paperwork. “Mr. Ryder says he needs more Percocets. He’s requesting transport.”

Mr. Ryder is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can’t weigh more than a hundred pounds. He sits in his wheel chair, in his Rebels motorcycle jacket, wearing an oxygen cannula.

“I’m in real bad pain,” he tells me in his whisper of a voice. “Fifteen on the scale.” He nods as if to say it is the truth.

“Well, we’ll check you out when we get you out in the ambulance,” I say.

It seems he fell a couple weeks ago and cracked a rib.

I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always “real bad,” he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted, and in those cases it is usually for a COPD exacerbation.

While I don’t like to categorize patients in this way, he does fall into the “pain in the ass” category. But a patient is a patient, and none of my paychecks has ever bounced, so I’m not really complaining. They’ll be turkey with all its fixings on my feast table tomorrow. And besides, there is always something to be said for the familiar.

I see Jimmy nearly everytime we go into the nursing home. He is usually sitting out in his wheelchair in the main TV area. I say “Hey Jimmy! How’ya doing?” as I push the stretcher past going for someone else on the wing.

He lights up and says, “Not too bad, hanging in there.”

That’s the jist of our relationship.

Today in the ambulance, I have an EMT student do vitals as we start toward the hospital.

She chit chats with him.

“You’ve got all your Christmas shopping done?”

“Yeah, I just bought stuff for myself,” he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.

“I buy presents for myself sometimes,” she says. “How about you?” she asks me.

“I’m pretty much done.”

“Well, unless you’re going to the drug store when you get off, you’re out of luck. Time’s run out.”

“I’m in good shape,” I say. I think to myself if I get out in time, I’ll probably make a quick stop at the liquor store where I’ll buy myself some Christmas beer — a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I’d get it myself. There is a liquor store that doesn’t close till eight on my way home. I’ll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I’ll buy other beer during the year, but this case — my Christmas beer — I’ll stretch out.

The patient looks up at the EMT student and says, “This guy over here, me and him go back a long way.”

“He’s taken care of you before?” she says.

“Yeah.” He nods at me and then says, “He’s probably one of my best friends in the world.”

I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies — Hoss and Snake and Big Steve — and wonder if they are enjoying their winter’s fuel at the Iron Hog without him tonight or if maybe they are all either in the cold ground or solitary in nursing homes themselves.

Jimmy looks up at me now, his eyes locking on mine. “I’m in real bad pain,” he whispers urgently. “Fifteen on the scale.”

-Christmas 2006-

***
Christmas

Last night I watched Scrooged, the Bill Murray version of “A Christmas Carrol,” where Murray is the bah humbug head of a big TV network. Bill Murray is a very funny actor, and Scrooged always chokes me up at the end, when the little mute kid speaks for the first time and says “God Bless us Everyone.” Then they all start singing “Put a Little Love in Your Heart” with Murray singing like his old Saturday Night Live lounge singer character.

Sometimes I feel like I am a Scrooge. I am always working on Christmas. My brother invited me to go to New Jersey and have Christmas with him and his family this year. Of course I couldn’t go — I had to work.

What kind of a bah humbug am I? Working on Christmas all the time. But working in EMS on Christmas is different than working a regular job on Christmas. I have always been proud that when my name is written in the book, I can be counted on to be there. It is not like we can just close up shop on Christmas. Christmas falls on my day to work, I work it. I like being reliable.

I read an interesting article — “Will Words Fail Her?” — about a young Chinese fiction writer, Yiyun Li, who wrote a great collection of short stories called A Thousand Years of Good Prayers. One of her teachers, James Alan McPherson, who was also a teacher of mine many years ago, was quoted in the article as saying in American fiction, we have lost the community voice. It is all about the self, but that community voice still exists in writers in Japan and China, writers like Li.

In this job over time you can lose yourself. You become a part of the community, the blanket of watchfulless over the cities and towns that you cover, and that becomes more important than who you are as an individual. People say it is bad to lose yourself in your job, and I don’t disagree — you need balance in your own life. But at the same time, I don’t think it is neccessarily all bad.

In Scrooged, Murray’s ex-boss, who comes back as the dead Jacob Marley, says his work, his life should have been that of mankind, not TV ratings. While I am not knocking the fact that today I am getting paid double time and a half holiday pay, I think you can make the arguement that our work in EMS is not the work of material advancement, but the work of mankind. There is a certain privledge in looking out over the community, in being its protector, particularly on Christmas Day.

There are some sacrifices in this job, and I am not advocating putting it before everything else in your life, but if you find meaning, even redemption in your work, that is no small thing.

-Christmas 2005

***

This year 2009, Christmas falls on Friday so I am off work. I will spend it gratefully with my family.

Posted by medicscribe on December 14, 2009 • Filed under: ems-topics • Tagged: , ,

Paramedic to Nurse Program

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Nurse

I promised in an earlier post, Ambassador of Love, to talk about how I got my nursing degree.

I started the program with the intention of using it as a insurance both against injury and against overtime drying up. Before I finished the program I got my current second job as an EMS coordinator. Now, working 68 hours a week, I don’t have an hour left ito use my nursing degree. I won’t quit my medic job, and won’t quit the coordinator job, which is a state job with a pension if I manage to stay at it long enough.

Still, it is nice to have the R.N. in my pocket.

Here’s the deal on how I got it, and how you, as a paramedic, have a similar opportunity.

Excelsior College

If you are a paramedic, an LPN, a respiratory therapist or work in a few other select categories of health care, you are eligible to get a nursing degree from Excelsior College (the old Regents College).

Excelsior College

Excelsior is a fully accredited nursing program that utilizes the self-study educational model.

You do not have to go to a physical class.

You study on your own and take exams via computer at a Pearson testing center when you are ready. You pick the date and time from the many openings they have.

There are no clinicals.

You must however pass an extremely tough 3-day clinical Exam. (60% national pass rate).

If you have some college behind you, you may receive credit for the courses you have already taken.

I had to take the following 11 exams to get my degree.

Early Childhood Development
Geriatrics

Microbiology
Anatomy and Physiology

Nursing Concepts 1-7

I also had to take a one credit information literacy course that took less than 1 day to complete.

In general when I was committed to studying I could knock off an exam a month. A&P took 2 months. I did most of my studying on duty, either sitting in the ambulance when posted on the street or at the ambulance bay when working in the contract town. I know people who have completed an exam every two weeks with intense studying.

People have passed the whole program in six months, most are expected to finish in less than two years. You must finish within seven. With two lengthy interruptions, it took me four years from first test to R.N. license. The beauty of the program is you can go at your own pace. If an interruption comes up in your life, you are not forced to drop out like you may be in a more traditional program.

Each exam costs (or did when I took them) from $225 to $290.

The exams require studying. I tried taking one exam without studying at all and I failed it. (I had already paid for the exam, but had lost interest for a time in the program. I received notice if I didn’t take the exam by a certain date (you have six months to take an exam after you pay for it), I would forfeit the exam fee, so I went down and took it with no success.

One nice thing about the exams is you get your grade as soon as you are done. Each exam is 160 multiple choice questions and you are given 3 hours to take it. I never needed more than 2. You hit the done button and your grade pops up. I love to see an A, but a C earns the same amount of credit.

I bought most of my textbooks used on Amazon. Some people pay upwards of $400 per course for study guides from various services such as the College Network. A friend lent me her study guide for one course and it was much easier and quicker studying from their guide than going through the texts myself.

When you finish all 7 nursing courses (I believe there are now 8 nursing courses), you are then eligible to take the CPNE (The Clinical Performance in Nursing Exam).

After you pass the CPNE, and have completed any other requirements, you get your degree and are eligible to take the NCLEX – the national nursing exam, which can range from 75 questions to 265. The exam cuts off when the computer decides you know the material. Once you pass the NCLEX, you are then eligible to be licensed in your state. In Connecticut, that meant filling out a form and paying the state $180.

Most states accept Excelsior College degrees. There are just a few that don’t or who have additional requirements. Check with the College before enrolling.

The Excelsior Program is for you if you work full-time and are a self-motivated student.

(All told the degree and associated costs (fees, books, exams, travel, seminar) totaled about $8,000.)

The CPNE

The CPNE (Clinical Performance in Nursing Exam) is a three day practical test held at various testing sites (hospitals) across the county. On the first day, you are tested on four lab stations (IV push, IM/SQ Injection, IV Drip Medications, and Wound Care). If you fail any or all, you get a chance to retake them the following afternoon. Fail one station twice, and they send you home.

On the second day, you have two PCSs (patient care situations). You have 2 ½ hours during which you receive your Kardex with assigned areas of care, get a report on the patient, review the patient’s chart, write a nursing care plan, implement it, and then write an evaluation and complete your documentation. You go over 2 1/2 hours you fail.

You will have to do vital signs, assist with mobility, record all intake and output, as well as demonstrate you are a caring person, and that you know all about hand-washing and asepsis. You will have to give medicine and perform several assigned areas of care and assessment (Neurovascular, Respiratory, Musculoskeletal, Skin, etc.). Throughout it you are judged by an impartial CA (Clinical Associate) who shadows you while constantly writing on her clipboard.

If at any point, you don’t meet a critical element, you fail the PCS. I failed one of my PCSs because they didn’t like my care plan, so I never even got to meet the patient.

You must pass two adults and one pediatric. If they don’t have suitable pediatrics in the hospital, you get a substitute adult. You get one chance to repeat an adult failure and one chance to repeat a pediatric failure. On the last day, you do your PCS # 3 and then if necessary, PCS # 4 and # 5.

The exam costs $1900 not counting travel, lodging and missed work. If you fail an exam, you can retake it at a later date up to two more times, each at a cost of $1900. If you fail the third time, they boot you from the program. If you still want to be a nurse at that point, you need to look elsewhere.

This is a high stress test. You can be just fairly prepared and sneak through or you can be highly prepared and fail. It has a 60% pass rate nationally (I am guessing that means each time taken). Look at it this way. If you have average preparation then you have to reach into a box of ping-pong balls. Six are marked pass, four are marked fail. The better prepared you are, the more ping pong balls that say pass on it. But due to the nature of the exam with so many automatic failures, the best you can probably hope for is 9 Pass balls and one fail.

I spent three months studying for the exam, including traveling to Atlanta for an excellent three day seminar on how to pass the exam.

I went though all my course work without having to miss a day of work, and because I do well on written and multiple choice tests, it was pretty easy for me. The CPNE is the one drawback to this program. I have worked as a full time paramedic for 16 years. I have vast clinical experience. For that, they credit me so I didn’t have to do any clinicals, but I had to do the CPNE. They make the CPNE so rigid because they have to certify that you know what you are doing. They don’t want the guy who slept at the Holiday Inn Express last night to have to easy a chance to slip through without being exposed.

I was lucky and got through on my first try. I would hate to go through the program and then fail the CPNE on all three attempts, which happens to some people.

Had I known how hard I would have to study for the CPNE and how stressful it would be, I might have thought twice about the entire program.

But in the end, it worked out for me, so I am glad I did it. I now have some degree of injury and future employment protection. As I said, I hope to keep working as a paramedic, although there are days when I feel the aches of age and wonder how long I can stay at this.

Good luck to anyone taking the Excelsior program. If you have any questions, please feel free to contact me.

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

Interview

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I did an interview with Greg Friese of Everyday EMS Tips as part of his EMS Author Chat series. We discuss my first two books, Paramedic: On the Front Lines of Medicine and Resuce 471: A Paramedic’s Stories, as well as blogging and my thoughts on doing a new EMS book. You can listen to the interview here:

Paramedic and Rescue 471: Medical Author Chat with Peter Canning

Posted by medicscribe on December 3, 2009 • Filed under: ems-topics • Tagged: ,

Koolatron

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iceman

Every morning I come to work, I switch the medic gear out of the night paramedic’s ambulance and put it into my assigned ambulance. Life Pack 12 monitor, Stat-Pack house bag, pedi box, spare drug case and two narc kits. Lately, more items have been added to the switch list – a digital camera, a laptop Toughbook computer, a battery powered hydraulic stretcher, and our cooler.

Koolatron

The cooler or Koolatron isn’t very heavy, but it is quite bulky, and I have to wedge it into the space between the front and the back of the ambulance where it partially blocks the door to the narcotics cabinet. The Koolatron’s power chord connects to the cigarette lighter in the dash. If the power chord detaches in the middle, you have to be careful to reattach it with the blue dot facing the arrow and not the red dot. Initially unknown to us, the Koolatron also has a Heatatron feature. We opened the Koolatron one day to find steam rising out of it. Not good for the contents, which fortunately we had no need for on that particular day.

We use the Koolarton occasionally to keep our groceries cool. My daughter’s grandmother is Jamaican and I often buy five pound bags of oxtail or goat meat from a local grocer to bring home for her to cook. The rumor that we use the cooler to keep beer in is simply not true. No EMS TV series will be based on our zany or depraved escapades as we are all too old or boring or busy doing the real work of EMS to think of such activity.

The primary purpose of the Koolatron is to carry two 1000 cc chilled bags of Normal Saline, two 10 cc drip sets, four commercial ice packs ready to be popped, and a piece of paper detailing all the steps in our new Induced Hypothermia protocol. We really could get by with a smaller Koolatron, but hey, this one was on sale for $79.

CPR in Progress

On a recent afternoon, we are called for difficulty breathing at one of the homes up in the hills at the far end of town. We’re updated by the EMD dispatcher that the patient is unconscious and the caller is uncertain if he is breathing. We hear the police arrive on scene and then the tell-tale message is relayed, “CPR in progress.”

It has been a couple months since I’ve done a cardiac arrest. After we arrive on scene, I find myself standing over the patient, a large man laying by the open car door having his chest pounded upon by the police officer, wondering what I should do first. It is probably only a five second delay, but it seems like I am standing there for ten minutes.

I’m trying to decide whether I should attach him to the monitor or break open my intubation kit. And whether I should get him on a board and get him on the stretcher and into the ambulance where I can start working him or work him right here where he was pulled out of the car.

Since he is already on the officers defib and it has announced “no shock advised,” I see no immediate need to slap him on mine. So I decide, and I think correctly, to intubate and work him right here.

You can say I am doing this all to give the patient the best chance to live, but the truth is I have been doing this long enough to know his odds of living are so long that our response is more faithfully carrying out a role than actually being life-savers. What I mean by that is I have no expectations for a successful resuscitation. The man looks to be in his eighties. His head is blue (thus my decision to intubate instead of continuing to bag). The 911 call came in 15 minutes before our arrival and it was a good seven or eight minutes before the police officer got there and found him not breathing. The man’s elderly wife sits on the front steps of their house, watching us silently. She doesn’t seem to have an appreciation for the direness of his situation.

I drop the tube in and am surprised to see an initial ETCO2 of 50, which soon drops to the 20s as we begin to ventilate. My partner has attached my monitor now and when we stop CPR briefly, the rhythm is flat line. I have the IV kit out, and am pleased to see some big blue veins in his hand, so with no need to stop CPR again to roll him to get his snow jacket off (it is unzipped but he is a big man and both arms are still in the jacket), I pop a twenty in his hand and slam in a quick epi and atropine.

ROSC (Return of Spontaneous Circulation)

And then just like that the ETC02 jumps back to the 50’s. “Check for pulses,” I say. My partner feels the man’s neck and announces, “I got one. Nice and strong.”

Wow. I always think that when I get pulses back. Not a big tremendous wow, but a small appreciative wow.

No time to rest however. We get him on a board and keeping a close eye on the ETCO2, get him up on the stretcher and into the back of the ambulance. We roll him enough to get his left arm out of this snow jacket where we take a blood pressure and find it to be 110/50. I get my scissors out to cut the jacket off his right arm, but right before I cut, I sense that the jacket is perhaps down, and cutting it may not be a great idea, so I leave the jacket on the arm and the coat under him.

Induced Hypothermia

It has already occurred to me that I am going to get to use the induced hypothermia protocol for the first time. I am lucky that one of the officers is also a paramedic, so I enlist him to accompany us to the hospital. I work one paramedic all the time and can handle a code by myself, but having another medic there is great. He manages the airway and keeps an eye on the monitor, where we have a nice narrow complex rhythm going. I pop in another IV and spike the two bags of chilled saline and get them running. We have a rider with us today and she breaks open the ice packs and stuffs them in the man’s arm pits and groin. I fish the protocol out of the cooler to see what else I am supposed to do and find it all soaking wet and stuck together, but the print is still legible.

My question concerns how much Versed to give the patient. We use the Versed to keep the patient from shivering. It says 2-5 mg slow IV push if the blood pressure is over 90 mm HG. I get the controlled substance kit out, which is hard because the Koolatron partially blocks the door, but after giving the cooler a good shove and reaching in I am able to get the kit out. I recheck the patient’s blood pressure. 65/30. Scotch the Versed. I get out the premixed dopamine, which I attach piggybacked to one of the lines.

The patient has pinked up quite nicely and the officer says he can feel the patient trying to breathe on his own. I call the hospital and tell them we are bring in a ROSC with the induced hypothermia protocol running. I try to get a 12-lead, but get way too much artifact to be able to make anything out of it.

My next pressure is 94/60, but since we are just now pulling into the ED, I hold off on the Versed.

In the code room, an anxious group of nurses, techs and residents descend on the patient, and I do my best to protect the tube and lines when the patient is yanked onto the hospital’s bed. I repeatedly say “this is the hypothermia protocol.”

Feathers

I turn briefly turn my back on patient to address the attending who has just walked into the room. When I turn back I see snapping scissors, the air filled with feathers, the patient naked, and the four ice packs thrown on the floor instead of packed in the groin and arm pits.

There is much confusion as this is a new protocol. It seems some of the staff are under the impression I have brought in a hypothermic patient who needs rewarming. I have to explain, I am instead trying to cool the patient. The attending understands this and orders new ice packs applied and the warmed blankets and arriving Bear Hugger not attached. (Although eventually the Bear Hugger will be used to try to keep the patient at just the right moderate cooled temperature).

The man, who has an extensive medical history, gets admitted to the Intensive Care Unit (ICU) where he lives for a week. I eventually see his name in the morning paper on the obits page.

It would have been nice to report he walked out of the hospital on his own steam and that he and his wife brought us a huge hot apple cobbler pie, but it is what it is. There are few survivors of cardiac arrest, particularly at such an advanced age with such an extended medical history and being without CPR for so long.

But that may change. There is a great deal of promise in this induced hypothermia, which is making its way into EMS systems across the country, based on quite promising evidence from clinical field trials and experiences of those systems who have tried it.

Some History

Hippocrates advocated packing wounded soldiers in snow and ice. Napoleonic surgeon Baron Dominque Larrey observed that wounded officers, who were kept closer to the fire, died more frequently than the infantrymen who slept in the snow. By 2003, based on recent research, the American Heart Association endorsed therapeutic hypothermia post cardiac arrest for the first time.

The Study

The landmark study, Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. was published in 2002 in the New England Journal of Medicine. Researchers studied patients resuscitated from v-fib arrests. Patients were randomly assigned hypothermia or not. The outcomes were 1) favorable neurological outcome within 6 months, 2) mortality within six months. There were 136 patients in hypothermia group, 137 patients in normothermia group.

These are the results:

Favorable Neurological outcome at 6 months:
Hypothermia group – 75 patients
Normothermic group – 54 patients

Mortality at 6 months:
Hypothermia group – 41 percent
Normothermic group – 55 percent

The study’s conclusion: “In patients who have been successfully resuscitated after cardiac arrest due to ventricular fibrillation, therapeutic mild hypothermia increased the rate of a favorable neurologic outcome and reduced mortality.”

Physiology

The idea behind cooling seems to be that cooling functions as a neuroprotectant that helps maintain cell membrane stability, limits intracranial pressure, limits inflammatory response and keeps out destructive free radicals that can be unleashed when the brain is reperfused following injury.

Regional Guidelines

Our regional guidelines call for inducing hypothermia in any ROSC patient after cardiac arrest not related to trauma or hemmorage provided the patient is over 18, not obviously pregnant, and with no signs of hypothermia. The patient has to be intubated (An LMA or combitube will suffice, and the patient has to have no purposeful response to pain.

Hypothermia is induced by exposing the patient; applying ice packs to Axilla & Groin, giving Midazolam 2-5 mg (0.1 mg/kg) if systolic pressure is over 90 mmHG Slow IV Push, and a cold Saline Bolus 30mL/kg to max of 2 liters. If the SBP is below 90mmHg, we can administer Dopamine 5-20mcg/kg/min IV titrated to SBP of 90mmHg.

Our protocols include the following Pearls:
If no advanced airway in place, do NOT INDUCE HYPOTHERMIA

AT ANY TIME Loss of Spontaneous Circulation: Discontinue cooling and go to appropriate protocol

Monitor ETCO2 Target 40 mmHg DO NOT HYPERVENTILATE

During Neuro Exam, look for purposeful movements.

Cold Saline should be chilled to about 4 C. (39.2 F)

Blood Pressure of less than 90 mmHg, is not a contraindication for the administration of hypothermia.

When exposing patient for purpose of cooling undergarments may remain in place. Be mindful of your environment and take steps to preserve the patients modesty.

Do not delay transport for the purpose of cooling.

Perform a 12-lead EKG with ROSC if time and staffing permit,

Reassess airway frequently and with every patient move.

Patients develop metabolic alkalosis with cooling. Do not hyperventilate.

Links:

Here are some links JEMS has about hypothermic cooling:

JEMS Links

Posted by medicscribe on December 1, 2009 • Filed under: ems-topics • Tagged: , ,