Skip to content


Archives for

See all posts in the network tagged with

A Cigarette

No comments

As my entry for this month’s The Handover (This month’s theme – Crisis patient’s) hosted at EMS in the New Decade I am submitting a post I wrote back in 2006.

***

The mental health team meets us outside. “We should wait for the police,” the clinician says. “She’s a big woman. When we went back up there she had a knife near her that wasn’t there the first time we were up with her. She’s very anxious today. When she’s off her meds, she can be volatile. I’ve seen her tear a door off its hinges.”

“Okay,” I say. “We’ll wait for the PD.”

When the first officer arrives, she repeats the story to him. He calls for backup.

Once backup arrives, we walk up the three flights of outdoors stairs and then force the door open because she will not come to it. Inside we find a completely bare apartment. I am always surprised when I walk into what is actually a fairly common occurrence — a psychiatric patient living in an empty apartment. In the kitchen there is a bare table with no chair and in the living room, there is no furniture, except the single folding chair in which the woman sits facing the window sill, smoking a cigarette. She wears a dirty flowered robe and slippers. She is about two hundred and ninety pounds and built solid like a rhinoceros. When the officer starts talking to her, she turns her head around slowly and says, “Don’t you be talking to me in my house. I don’t give a good god damned about any of you, so for all I care, you can all go ahead and kiss my ass. I ain’t getting up, and I ain’t going anywhere.” She goes back to looking out the window and slowly smoking her cigarette

One at a time we try to talk to her, but she just gets more agitated. When it is my turn, I say in a soft monotone, “We’re just to give you a nice easy ride down to the hospital where you can get something to eat and talk with a doctor and nice nurse about all that’s going on.” She turns full on me, and even though I am several feet away, I can feel hot breath coming out of her flaring nostrils. I just let her rant, and whenever she stops to catch her breath, I start talking again in a real quiet, slow voice. It doesn’t get me far, but at least it wears her down some.

Our efforts to talk her into going having failed, the lead cop and I discuss various game plans. He wants us to get restraints. I offer chemical as an alternative, but suggest we just try to get her to walk first. They stand her up and she starts yelling, but once they cuff her she calms down. We walk down the stairs with her, and she yells again at the top of her voice about what motherfuckers we are and how the world is corrupt. “You think you can just go in and take a woman out of her house, you all a bunch of god damned honkey ass motherfuckers! I have my mind set to take you all out, and I will leave nothing, nothing in my wake. Do you hear me? I said do you hear me! Make no mistake. You all can kiss my black ass cause I’m going to take you all down, treating a poor black woman like this. You should be ashamed of your punk asses, motherfuckers!”

When we get her down on the stretcher, she says, “My wrists hurt.” I start talking soft to her again, “I’m sorry they hurt. I’ll ask the officers to take them off if you agree to not fight us.” I nod to my preceptee who is probably about six-four and close to three hundred pounds himself. “The two of us will ride in the back with you. We’ll just take a nice easy ride to the hospital, where you can talk to a doctor. You don’t even have to say anything to us.” She seems to be listening. “And we’ll let you have a cigarette outside the hospital before we go in if don’t fight us.”

“Okay,” she says.

The cops seem a little dubious. “You’re going to have to ride with her.” I nod at my partner. “We can handle her.” They look at the two of us, and they have to admit, she’s big, but the two of us are not likely to be easily handled even by an enraged rhino, and I do have the Haldol and Ativan at the ready. “It’s your choice.”

“She’ll be good,” I say. “We’ll let her have a smoke.”

“You best not be tricking me,” the woman says.

“We’ll get you a smoke.”

They uncuff her and she is quiet on the way in. She even lets us take her pulse and blood pressure. While we are still in the ambulance, I have a vision of us pulling her out on the stretcher and letting her smoke while still on the stretcher, and a newspaper reporter taking a picture of us “ambulance attendants” standing around letting our patient have a cigarette, and what a storm of controversy it might cause. When we get to the hospital, I ask her is she wants to walk in or go in on the stretcher. “I’ll walk,” she says. We’re supposed to keep everyone on the stretcher and while there is no policy about not letting them smoke, I think that is only because no probably imagined crews would let their patients smoke.

We have her step out of the back of the ambulance, and so she is standing when he give her the cigarette. If a photographer were there, it wouldn’t be apparent that she is our patient. She looks like your typical weary two hundred and ninety pound late fifty year old lady in a dirty flowered robe and slippers, smoking a cigarette on a cold grey day. And that’s good, because if she were on the stretcher people seeing a photo in a newspaper might not understand the power of a cigarette. It often works better than brute force, better than pepper spray, handcuffs, Haldol and Ativan. It’s a simple acknowledgement that a person is having a difficult day and needs a break, a chance to have a smoke and collect yourself before heading on into another tough day.

In the ER, she says she has to use the bathroom. The nurse tells her she has to pee into a cup.

“I’m going to need a bigger cup,” she says. “And why can’t I just go in the bathroom?”

The nurse says all females have to pee into a cup to see if they are pregnant.

“I ain’t pregnant,” she says.

“We require this of all females,” the nurse said.

“You’re wasting a cup on me.”

Still she takes the cup and shaking her head, waddles over toward the bathroom.

The Battle

7 comments

A couple of months ago I posted at the end of ET Interruptions about the battle I would engage in the next time I had a patient with a witnessed cardiac arrest. The battle between getting a quick airway via an LMA or fulfilling my paramedic I am an intubator ego. Finally, after a long dry spell, the challenge presented. Here’s how it went down.

The call was for a man on the ground. The caller wasn’t certain why. I am pretty good at sniffing out a code from the dispatch, but this one sounded like a lift assist. I figured we would likely encounter an elderly man who had fallen and his neighbor couldn’t get him up. As we approached the scene, I saw the man was not inside his apartment but was actually in the parking lot by a car. There were two bystanders kneeling over him. Since it was a hot day, I said to my crew, “Take the gear off the stretcher. He’s outside. We’ll just get him on the stretcher, get him in the back and see what’s going on with him.”

I stepped out, while they went around to pull the stretcher. I could see one of the bystanders was holding a tube of glucose and squeezing it into the patient’s mouth. “He’s a diabetic,” the other bystander said. I could only see part of the patient, but the patient looked a little too still to be getting oral glucose. I shouted at the woman to stop. “He’s got to be able to protect his airway for you to do that. We can’t have him vomiting and aspirating.”

Just then a woman called down from a porch apartment. “He was just at the doctor. He’s hasn’t been feeling well lately. They gave him some new medicine. Do you hear me! Are you listening to me! He was just at the doctor! He got new medicine! New medicine! Are you listening to me!”

“Okay thanks” I said, thinking I’m a little busy here.

I was noticing then the patient was awfully still. His skin was warm and diaphoretic, but he did not seem to be moving one lick. he wasn’t just unresponsive. I wasn’t even certain if he was breathing. The stretcher was beside the patient now and in low position. I tried to sit him up and he was dead weight. Oh shit! This is a code.

I had my gear in the truck. It was drop him and work him in the 100 degree heat or lift him on to the stretcher, and get him in back, which is what we did, with some compressions thrown in on the way.

He was in a PEA in the 40′s. With one partner doing compressions (we shoved a short board under him) and the other reaching for the ambu-bag, I went — hooray for me –right for the LMA — a #5. I love to tube, but I promised myself, no interruptions in CPR, no dicking around, just toss in a quick LMA. Which I did. It went in easy. I got a continuous wave form with an ETCO2 of 15 that remained fairly constant for the next 10-15 minutes despite our interventions.

The man was short but obese. I tried for an IV in the hand with no luck so I went for the IO. He had elephant legs all the way down to the ankles which had tiny toes sticking out from underneath them. His shoulder was also huge. I ran my hand down the length of his tibia and finally felt some bone about midshaft. I shifted some of his fat and drilled right in. We don’t carry the bariatric needle so I was pleased to get the regular needle in. Some epi, some atropine, continuous compressions, but no change in result. I started to prepare the patient for packaging. When I went to secure the LMA, I noticed the LMA looked like it was sticking out a little far, so I gave it a push in and went to secure it and suddenly I started having some compliance problems. What I realized later, was giving it that shove had doubled the mask over, which I understand is a common problem. As soon as my partner said it was getting harder to bag, I, to my shame, felt the approach of a little bit of joy. Maybe I’ll just pop the LMA out and tube him for the ride in. I was thinking, the LMA worked great for the time I needed it to. We did our best – fifteen good minutes of CPR and drugs — the patient is unlikely not coming back. I did the right thing by putting the LMA in and now I still get my tube. Hot Dog! I did try to see if I could fix the LMA. I stuck the laryngoscope in and tried to move the tongue out of the way to see if that would fix the problem, but as I did the whole LMA popped back at me. I just took it out then, had my partner give a few bags while I prepared to intubate.

The patient of course had an enormous tongue. I tried to move it out of the way, and it slipped off the blade. I swept it over again with success this time, but then when I went to look for the chords, all I could see was blood in the airway, which puzzled me. I wondered if maybe I had been too rough with my first sweep or if maybe something else was going on with the patient’s arrest. I finally saw the bottom half of the chords and tried to pass the tube, but quickly pulled it out on seeing I had no wave form. The tube was covered with a very sticky blood. Screw this, I thought. I reached for a second LMA (a #4 this time) and popped it in. It worked great. ETCO2 back to 15.

We worked the patient all the way in, but couldn’t get the ETC02 above 15. The PEA continued throughout. With epi i could get it up to the 90′s but it would slow back to the 40′s then 30′s. The complexes had deep Q-waves, and made me think the patient likely had been having a massive MI all day until he finally just keeled over. They called him dead at the hospital. It wasn’t until the next day — Duh! — it finally dawned on me that the sticky red blood in the airway was just sticky red oral glucose.

What lessons did I learn? The good (get an airway that works quick and avoid any CPR interruptions) medic hasn’t completely defeated the bad (I gotta get my tube) medic but there is hope for me. After sitting idly in my box for a few years, I am learning more about the LMA with each use. After this call I reviewed the manual and picked up a few more tips on its use. I think I clearly would have been better off going for the #4 to start. The other point that I had missed entirely was lubricating the posterior side of the cuff prior to insertion. I now have a package of lubricating gel at the ready.

As for the battle between the LMA and the ET, stay tuned.

LMA Manual

Morphine and Fentanyl

4 comments

A research article entitled “Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia” by Fleischman RJ, Frazer DG, Daya M, et al. appeared in the latest issue of Prehospital Emergency Care.

The bottom line of the study was there was little difference between the two drugs, (as used under the study protocol). There were very few side effects and both decreased pain by an average of three points on the 0-10 scale.

under the study protocol, the paramedics were able to give pain meds on standing orders for isolated extremity injuries, burns, and chest pain unrelieved by nitroglycerin. Morphine was given as an IV dose of 2–5 mg, repeated every 5 minutes to a maximum of 20 mg. Fentanyl was given as a 50-μg IV dose, with repeated doses of 25–50 μg every 3–5 minutes to a maximum of 200 μg. Any additional dosing required on-line medical control.

The drugs were judged to have adverse effects if any of the following happened:

Respiratory rate under 12 breaths/min
Systolic blood pressure under 90 mmHg
02 oxygen saturation (SpO2) below 92% and 5% below baseline
Any decrease in the Glasgow Coma Scale (GCS)
Nausea or vomiting
Intubation

718 patients aged 13–99 years received opiates under the study protocol, 355 received morphine, 363 received fentanyl. Fentanyl patients received a higher narcotic equivalent (7.7 mg morphine equivalents for morphine, 9.2 mg for fentanyl; but the same number of doses.)

The mean initial pain scores were 8.1 for morphine and 8.3 for fentanyl. Morphine decreased pain by 2.9 points. Fentanyl decreased pain by 3.1 points. In the ED morphine patients experienced an increase in their pain scores of 0.9. The fentanyl patients experienced an increase in their pain of 0.8. The authors of the study point out that, given the size of the study sample, this small difference is not statistically significant.

5.6% of the fentanyl patients experienced an adverse effect. 9.9% of the morphine patients did. Most of the adverse effects were related to nausea. (3.8% fentanyl, 7.0% for morphine). Ten patients had their systolic blood pressures go under 90 mmHg. All resolved either spontaneously or with a fluid bolus. Ten patients had drops in their oxygen saturation or declines in their respiratory rate below 12 breaths/min, but none required anything beyond supplemental oxygen. No patients required intubation.

More significant to me than there being little difference between the two drugs (I think there are differences such as time of onset that a differently designed study would have showcased) was the documentation of very little side effects, which has been my observation with the use of morphine (The service where I work as a paramedic is still awaiting the arrival of Fentanyl), and the documentation of both the average dose and average decline in pain scales.

I did a similar (but much smaller) study of pain meds by a group of medics I oversee, and found an average morphine dose of 5.6 mg of MS and 75 ug of fentanyl with an average drop in pain scale of 2 points for morphine and 3.1 for fentanyl. My on the back of an envelope stats based on far fewer cases is hardly scientifically rigid, but seems in-line with the published study. The only documented side effects from the run forms I reviewed was occasional nausea for which zofran was given. While the dose of the drugs these medics have given seems modest, it represents a great improvement over recent years. Their use of analgesia is up almost 500% from two years ago.

I next reviewed the times I have given morpine over the last 21 months (as far as our electronic records go back). I have given morphine 69 times during this period, but I had to exclude 15 records due to the patient being unable to articulate a pain scale (some elderly with low grade dementia, pediatrics, and non-English speakers unable to understand the pain sclale). Of the 54 I was able to include, the average initial pain scale was 9.2. The average dose of morphine I gave was 7.8, and the average final pain scale was 5.4 for a 3.8 point drop in pain or 41%. My intial guess was that I would have dropped their pain scale by a greater amount, but on review there were many patients who the pain meds barely touched. 11 of my 10 of 10 pains never dropped below an 8. I only had two patients complain of nausea, and one complain of itching. No incidents of hypotension, declining mental status or desaturation.

The take home message for me is when used to treat prehospital pain morphine and fentanyl are safe. Do not be afraid to treat your patients out of fear of causing adverse effects.

There is a nice little recap of this study on jems.com by Dr. Keith Wesley, one of my EMS heroes, and Marshall Washick, an experienced paramedic.

Are Fentanyl and Morphine Equals?

I agree whole-heartedly with Marshall Washick that medics should try to drop a patient’s pain scale by at least 50%.

As i stated earlier, I was surprised to learn that despite my efforts, I am only dropping pain by about 40%.

Codzilla (Or why I haven’t been blogging lately)

3 comments

I was off a week ago Saturday. I took my ten-year old to Boston for the day. We went for a ride on Codzilla, a speed boat out on Boston Harbor. They said we would get wet. We got soaked.

Good times. 85 degrees out. Sunny. Walked around in the sun, went to Quincy Market, had pizza and shared a cannoli, and then headed over to Fenway Park where the Sawx topped the Dodgers with a walk-off two-out bottom-of-the-ninth win.

Sunday was Father’s Day. It was busy at work. I had promised myself I’d write a blog post, but I got side-tracked when I got home.


I have been in EMS for over 20 years. It was long my pride that I never missed a day of work. If my name was in the book, I was there, fifteen minutes early ready to work. This past year I have finally slowed down. On more than one occasion I have called up operations and said, hey, take me off the schedule for Saturday, my daughter’s got a softball championship I want to see, or I’m going to run in a race, or I’m taking the kids to the big city.

***

The same with blogging. I like to keep at it, but sometimes you need a break.

This summer I’m putting in for quite a few days off.

Life is short.

Would You Like More Pain Medicine?

6 comments

Another paramedic tipped me off to a great podcast called Patient Controlled Analgesia by Dr. Edward Gentile.

The bottom line is this physician has come up with an interesting and bias-free pain management protocol.

You apply the same protocol to anyone in acute pain. Young, old, black, white, male, female, rich, poor.

Acute pain protocol for moderate/severe pain

• Administer morphine 0.1 mg/kg IVP (If pt is > 55 y/o, substitute morphine 0.05 mg/kg IVP for this 1st dose) + diphenhydramine 0.5 mg/kg IVP
• 7 minutes later the patient is asked, “Would you like more pain medicine?”
• If the answer is yes, give a 2nd dose of morphine 0.05 mg/kg IVP
• 7 minutes later, the patient is asked again, “Would you like more pain medicine?”
• If the answer is yes, give a 3rd dose of morphine 0.05 mg/kg IVP
• This continues every 7 minutes until the patient answers “no” to the question or the patient is asleep.

This guy is my new hero. His podcast is wildly entertaining and in my opinion, right on.

I have modified his ED protocol to fit the prehospital guidelines we operate under.

If someone is in acute pain, I now simply ask: Would you like pain medicine?

For severe unquestionable pain, I give the first dose 0.1 mg/kg dose spread out over 3-4 minutes. For moderate pain, I may break the first dose down in half, then give the second half fif needed five minutes later. The next 0.05 mg/kg dose, I give ten minutes after the first dose is complete. I dose until I have reached my allowable max which is 0.15 mg/kg up to 15 mg. If they need more, I will call for orders if I am not already at the hospital.

Due to our protocols, I only give the Benadryl if they itch, but I have it on standby as well as zofran if their only complaint is nausea.

I really love this phrase, “Would you like pain medicine?” as well as “Would you like more pain medicine?” I am required to do the pain number scale, but I only ask that after they have answered the pain medicine question. The other day I had a lady who was still a “7’ tell me she was all set as far as the pain medicine after one dose.

I have used the protocol three times now with great success and patient satisfaction.

Dr. Gentile modifies the old slogan “Commit random acts of kindness and senseless acts of grace and beauty,’ to “Commit systematic acts of kindness and sensible acts of grace and beauty.”

I am with him on that all the way.

Had This Call Before

Comments Off

Obese septic patient from SNF
29 diagnoses including dementia
labored breathing, gurgley rhonchi throughout
Diaphoretic, temp of 104.1
Doesn’t fit on stretcher, keeps falling to the side
Yankeur suctioning thick brown sputum
Gloves rip
Electrodes won’t stay stuck
Can’t get an IV.
Can’t read the writing on the W10
CMED radio on fritz
“We didn’t copy your patch, you keep cutting out.”
Not regular partner hitting every bump on the road
Driving too fast
AC not working either.
Getting jostled
I throw a roll of cloth tape at the front.
Slow down!

Had this call before, but not for awhile
Will have it again.

I just want to throw my hands up in the air and quit.

but I have to suction again.

Chronicles of EMS Contest

Comments Off

Chronicles of EMS has an exciting contest to rename the show, check out this link: Chance of a Lifetime

Latest Edition of The Handover

Comments Off

Read the latest edition of the Handover, And That’s When it Came Together…” hosted at The EMT Spot.

It is an excellent compilation of stories of medics talking about when they first realized they knew what they were doing.

Check it out!

D’oh!

1 comment

homerMedication safety is a topic I am focusing on these days. How to prevent errors and keep our patients safe.

Since I am a clinical coordinator responsible for overseeing medication safety, and as someone writing about it, and as a paramedic responsible for my own patients, I need to live up to the standard.

It is with regret that I must describe the following;

We have three ambulances at the base I report to each morning I work. Only one is on-line. The second and third are available for call-in crews. We have four regular medics with one set of medical gear. Each medic is assigned to an ambulance, two of the medics share the same ambulance.

When I come in at quarter to six, I move the ambulances around so my ambulance is in one of the front positions in bay. I then move the medic gear from the night ambulance into mine.

Here is what I move each morning;

Lifepack 12 monitor
Medic House bag
Pedi-bag
Spare meds kits
2 controlled substances kits
Crick kit
Digital camera
Toughbook computer
Power stretcher

I also have to check my ambulance out for supplies, 02, linens, boards, etc.

No big deal. Been doing it for years.

Other morning I come in, move the gear, check the ambulance. All seems well.

Couple hours later, we get a call for back pain. Take off, arrive at the scene. Go to pull the stretcher, something seems not right.

“Where’s the monitor?!”

D’oh!

Not funny at the time.

Fortunately, the patient’s problem was pretty straight forward muscular. Nevertheless, I asked the patient and their family member if they minded if we took a two minute detour to swing by our headquarters to pick up a piece of equipment we would need to stay in service at the hospital. They were cool about it.
We picked up the monitor (left in the night ambulance) and I breathed some relief that the scenario was not different. I don’t want to think about what might have happened.

So how do I prevent this from happening again, once the memory of the near disaster starts to fade? I need to improve my personal system. A checklist perhaps. Long ago I went from a checklist to visual checking. Maybe I need to return to that system.

The other thing that I could do more stringently, which I do periodically, is always glance in the back prior to leaving on any call.

That has saved me before. I instituted that change after this famous call:

The Stretcher

The Years

1 comment

emergencyIf I ever had a call – a double shooting or a status seizure — where I could look back and say here is where it all came together, then I have forgotten it.

What I remember from my earlier years as a medic is not so much one specific call, but rather gradual realizations over a series of calls that I was getting better at my job. Becoming a better paramedic is about reaching a series of plateaus where your realize you are doing something fairly well on a regular basis that you once had anxiety about. You give a quality report at the hospital and think, you know, I’m getting pretty good at that. You manage a cardiac arrest, coordinating the compressions, securing the airway, calling out the drugs, and getting pulses back, and you realize that not only do you know what you’re doing, but you doing it like it is supposed to be done.

There are so many areas a paramedic has to master – from assessment and all its areas to the wide variety of our mechanical skills to other talents like scene management. –that it is hard for any of us to reach true expertise in all facets. There are some areas I became good at quickly — like patient repore or IVs — and others that have taken years to master — like splinting or respiratory care (particularly suctioning) — though mastery is often an illusion.

What I like about EMS is there is no resting on laurels. You truly have to prove yourself every day and on every call. Getting twenty tubes in a row doesn’t help you when you’re looking down the throat of someone you can’t for the life of you get the tube in, or being the nicest, most compassionate paramedic doesn’t cut it when you are in bad mood and set off either your patient or one of their family members with an ill-thought remark. This job is all about the present.

The only difference between now and my younger years is it is easier now to pick myself up when I fall. If I miss an IV or am off base in my assessment, it doesn’t crush me like it used to. Learn and move on. And when I do a really good job, well, I’ve been humbled too much to stick my chest out too far.

Medication Errors – Epinephrine

2 comments

epiA number of years ago a young woman was driving along the road when a bee flew through her open window and stung her on the knee. She panicked. She was allergic to bees and she had left her epi-pen at home. She immediately pulled to the side of the road and dialed 911. A police officer arrived first and found her very anxious, but with no visible signs of a reaction. He helped her into the ambulance that arrived shortly thereafter, and then retuned to his cruiser to make arrangements for her car to be taken off the road. When he returned to the ambulance to give her the information about where to locate her car, he was startled to find the ambulance crew doing CPR on the young woman who within an hour would be pronounced dead at the hospital.

In medic school we are taught about medication safety. I personally don’t remember being taught about it, but don’t doubt that I was. It was after all almost twenty years ago. Maybe they didn’t have the 5 R’s then. Last year I graduated from nursing school, and I can tell you I had to know the 5 R’s. On my clinical exam if I did not do all and repeat them precisely, I would been sent home on the spot. Automatic failure.

The 5 R’s
Right patient
Right drug
Right dose
Right route
Right time.

With lots of verify and reverifying thrown in. Not to mention asking about allergies.

I can tell you, shame on me, that I don’t have a foolproof medication routine for the ambulance. Generally I reach for the drug I am going to give, look at the label, draw up the drug, and then give it.

Here are the drug mistakes I have made over the years (not counting errors of assessment);

I once gave Dramamine (Dimenhydrinate) when I meant to give Benadryl (diphenhydramine). (Both vials were the same size and color,and both had long names that began with D and both were right next to each other in the kit.

I have more than once in cardiac arrest situations, given epi when I meant to give atropine and vice versa. A fairly harmless mistake as I would be giving both drugs in multiple quantities during most arrests. (We break our boxes down so just the vials are next to each other all in a row. Eight epis and four atropines — the only way to tell them apart is to hold them up to your eyes and read them.) A mistake, nonetheless.

I gave 0.08 mg of narcan when I thought I had given 0.4 mg. Brain farted that my 1 cc syringe was a 3 cc. I ended up intubating a patient who soon thereafter yanked his own tube tube.

I gave ASA to someone allergic to Salisylates. I glanced at the W10 and not seeing ASA, went ahead and gave it to them. Only shortly thereafter did my brain realize I had seen Salisylates in the Allergy line. At the same time of my realization, the patient started to itch. Opps. I had to give them Benadryl.

I have never given Sodium Bicarb when I meant to give D50, but I have come close quite a number of times. Right next to each other, same size and color, just different print on the glass.

I have also, on very rare occasion, given expired drugs and hung expired fluids. That’s plain embarrassing. Not just plain emarrasing, truly embarrasing.

Granted a very small number of mistakes over 20 years of calls, but I and my patients have been lucky that I have not made more serious errors. Neither I nor my kit have been error-proofed.

People make mistakes and have brain farts. A good personal system can help you catch yourself when you fail. With a good external system can help you avoid even being in a position to make some errors.

Over the years the airline industry has become quite proficient at recognizing errors and then designing their systems to prevent them. EMS needs to do the same.

One of the most common and deadly errors is giving epi 1:1000 IV. This is what happened in the opening true life case. You can blame it all on the medic, but the system bears some responsibility. The medic did not seem to know that epi 1:1000 could be fatal when given IV. the medic did not seem to know that epi was not indicated if the patient was not showing any severe symptoms much less any symptoms. And the medic apparently did not know that the dose was 0.3 mg (SQ) rather than 1 mg. Perhaps in his mind, he thought. Patient allergic to bees, stung by a bee, doesn’t have epi-pen. I’m a medic. I have epi and I can get an IV so why don’t I just give it IV which is a quicker route than IM. And heck, why not just give a full milligram. I’m feeling generous. Clearly, the medic probably shouldn’t have even been practicing in the first place (tell me your system doesn’t have a few of these medics), and I believe he lost his medical control over this case, although I have heard that he is working somewhere else now as a medic.

Here is another case:

Young woman having a severe allergic reaction bordering on anaphylaxis, wheezing, itching hives. Medic draws up 50 mg of benadryl and 0.3 mg epi in separate 1 cc syringes. The medic is momentarily distracted by a family member. He picks up the syringe and injects the benadryl into the IV, no wait, he injected the epi. Oh shit. The patient grabs at her chest. “What did you give me!’” she screams. She has a run of VT, but it subsides. The medic reports the error, and the woman eventually is discharged without a problem.

These are not the only two times epi 1:1000 has been given IV. It is, in fact, a not uncommon error. Whether the medic is a fool or an excellent medic badly screwing up, the fact is the drug is right there in the kit waiting not just to save a life, but to take one.

A local clinic recently had a patient suffer an allergic reaction to bactrim. The doctor prescribed 0.3 mg epi. The nurse gave 0.3 mg epi 1:1000 IV. The patient went into cardiac arrest, but fortunately was revived and discharged from the hospital a few days later.

Hospitals are somewhat more advanced than EMS in how they deal with errors. Many enlightened hospitals try to adopt an approach similar to the airline industry. One local hospital, in response to nationwide errors, has removed epi 1:1000 from most areas of the hospital to be replaced by epi-pens. They are not the first hospital to do this.

epi-penThese actions are now filtering down to EMS, and we are considering requiring medics to use epi-pens as their first line approach to anaphylaxis. We will likely keep epi 1:1000 available on the rigs in a separate location so that it may be utilized in special circumstances (nebulized for croup, for bariatric patients, for infants too small for epi-pen juniors, for epi-pen failure, for epi ET if unable to get IO or IV).

Again, we would not be the first EMS service to do this.

The Use of Epinephrine in the Prehospital Setting

Along with this move, it is perhaps time to do some CMEs on medication safety as well as looking at our kits to see what possible errors could be made when a medic’s has a temporary lapse.

It’s all about risk versus benefit.

Remain Vigilant.

Do no harm.

And take care of the patient.

Nurse Jackie

3 comments

nurse jackie

I recently watched Season One of Nurse Jackie – a Showtime TV series now available on DVD. Nurse Jackie stars Carmello Soprano (real name – Edie Falco) as Nurse Jackie, a veteran no-bullshit inner city ER nurse with a bad back, who has become addicted to pain medicine, which she gets from the pharmacist who she is banging during her breaks. Oh, yeah, and she is happily married with two kids, that the devoted pharmacist knows nothing about.

I’ll say right from the onset, the show has its moments – where anyone with any emergency medicine background can point out the errors or how something like that would never happen. But much about the spirit of the show feels real.

I watched all the episodes with an ER nurse who loved it. The show won her over in the opening minutes when the nurse administrator admonished the nurse for taking overtime against policy and then in the next breath asked her if she could do a double.

I enjoyed the show even though I ultimately disliked the lead character. Nurse Jackie is self absorbed with a dubious ethical sense, but that ethical sense aside, she knows what is going on with her patients and she knows the system. She reminds me in her actions and demeanor of some nurses I have known — tough exterior, a mean streak, but with some true Florence Nightingale thrown in. Like real people, she is a complicated character, and thus doesn’t fall into the good or bad category. While I may not like her, I have empathy for her.

I feel bad that she has to work so much to get the bills paid, that her back hurts so bad, and that her nice husband, who you can see she loves, doesn’t quench her soul.

Besides feeling true in spirit if not in all deeds, the show works for me because it often makes me laugh. It is a dark comedy, which I think is the most successful way to write about emergency medicine.

In reading the Nurse Jackie Wikipedia entry on the show I see that the New York State Nursing Association protested the show’s portrayal of nurses, citing Nurse Jackie’s constant violation of nursing’s code of ethics. I can understand that, and as a paramedic, I am somewhat offended that so many paramedic shows and books portraying medics show us as unshaven burnouts with deep psychological scars. Ironically, my favorite EMS movie is Broken Vessels, in which the two primary medics do heroin and other drugs on the job and one of them, steals from patients. Obviously, enjoying the movie and understanding its message doesn’t mean I endorse its characters’ behaviors.

Cold Justice

1 comment

ColdJustice

Australian author and former paramedic Katherine Howell has written her third EMS-related crime thriller, Cold Justice.

Like her first two thrillers, Frantic and the Darkest Hour, it is a great read. The books have a constant character in police detective Ella Marconi, who teams with a different paramedic in each book to solve the crime.

Her books, which are best-sellers in Australia, have also been published internationally. Her first two novels can be purchased on Amazon USA and Amazon UK.

Cold Justice won’t be published internationally until 2011. A fourth book will also be published soon and Howell has contracts for a fifth and sixth book.

Katherine Howell Books

Paramedic Awareness

1 comment

I recieved email this week from a Denver paramedic working to promote paramedic awareness and recruitment, asking me to post the following Youtube link:

Denver Health

On it there are a number of excellent videos promoting our profession.

I will note that the paramedic who wrote is Rocky Mountain Medic an EMS blogger so good I have kept him on my blog roll even though he stopped posting over two years ago. Check his blog out.

Door-to-Balloon

10 comments

balloon

When I started in EMS, it was drilled into me. I had ten minutes on scene for trauma and 20 minutes for medicals. If I took longer, I had to explain why. If I did it quicker, all was good.

Evidence – based medicine wasn’t in our vocabulary then. We believed whole-heartedly in the golden hour of trauma. Times have changed. For trauma, studies have shown the golden hour has no scientific basis and that EMS time intervals have little to no effect on outcomes in trauma.

But what about medicals, and in particular what about ST-elevation myocardial infarctions(STEMIs)? The American Heart Association says that for patients having ST-Elevation MIs, who go to the cath lab to have their occlusions cleared, the systems goal should be a first medical contact–to-balloon time within 90 minutes.*

So 90 minutes is the goal? But is there anything magic about the 90 minute time? And how much better or worse does someone do if they get to the cath lab earlier or later than the 90 minutes?

A recent study in the British Medical Journal, Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study., asks: Is mortality higher with successively longer times to treatment? And does mortality plateau after two or more hours of delay?

To answer this, the investigators analyzed the National Cardiovascular Data Bank, sponsored by the American College of Cardiology, which collects standardized data from 600 participating cath labs.

They hypothesized that any increase in door-to-balloon time would be associated with increased mortality and that this mortality risk would persist irrespective of the length of the delay in treatment.

For a study sample they looked at the records for 2005-2006, counting the patients presenting within 12 hours of symptom onset, who had lab and ECG evidence of STEMI, and who underwent the cath procedure.

They excluded transferred patients, patients who received fibrinolytic therapy first, patients under 18 or over 99, and patients at facilities that did less than 5 procedures a year.

They further excluded patients who had missing times, who had door-to-balloon times of less than 15 minutes (excluded due to possible incorrectly coded times) and excluded patients with door-to-balloon times of > 6 Hours (excluded because PCI was presumably not the primary reperfusion strategy). This left a total of 43,801 patients.

In the study the median door-to-balloon time was 83 Minutes. 57.9% were treated within 90 Minutes.

Women, nonwhites, older patients, and patients with comorbidities had proportionally longer door-to-balloon times. Patients with shorter door-to-balloon times were treated between 8AM and 4 PM, at urban hospitals, and had lower incidences of cardiogenic shock.

Mortality was 4.6%. Patients who died had a 14 minute longer median door-to-balloon time. Mortality was 2.8% for patients with 30 minutes, 9.8% for door-to-balloon times of 240. When patients with shock were excluded, longer door-to-balloon times continued to be associated with mortality.

When plotted out on a graph, there was a steadily rising minute by minute mortality curve.

The results are pretty easily explained: Patients with longer door-to-balloon times will experience longer periods of ischemia and more necrosis than patients with shorter time to treatment.

The clinical implications are also clear:

“Any minute of delay is associated with an increased risk of mortality.”

“There is no ‘floor’ to the mortality reduction that can be achieved by reducing time to treatment.”

Reducing D2B from 90 to 60 minutes could reduce mortality from 4.3% to 3.5%.

Rather than settling for 90 minutes as the standard, the standard should be “As soon as possible.”

As far as limitations, the study did not assess time from onset of symptoms to arrival at hospital, nor did the study assess door-to-balloon and subsequent mortality at 30 days, 1 year. It did not examine morbidity.

The bottom line:

Door-to-balloon time is associated with mortality.

Any delay in door-to-balloon time is associated with increased mortality.

My thoughts;

This is an excellent study with a large patient sample. I cannot help but think if mortality can be improved by such a great percent, the morbity improvement must be even more substantial.

Here’s what I will try to do and what I will tell other medics to do:

Cast a wide net with your 12-lead. Get a clear 12-lead as soon as possible.

Once you recognize a STEMI, call the hospital right away so they have all the necessary equipment and personnel ready to go as you hit the doors.

Get going. Don’t dawdle on scene. Don’t wait for the patient’s daughter to arrive. Don’t let the patient take his time going about gathering his toothbrush and pajamas. Get on your way. Lights and sirens if needed for traffic, but drive safely.

Do serial 12-leads.

Don’t forget the Aspirin.

* 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

Community

6 comments

community

Last week I had the privilege of attending a ceremony in which a town received a Heart Safe Community designation, which goes to towns who meet certain criteria in terms of their EMS systems and availability of training, education and public access defibrillators and other factors affecting the Chain of Survival.

At this particular ceremony there were three cardiac arrest survivors who all got up and told their stories — of their lives on the day they went into arrest, of who saved them, and what they have done with their lives since. All three suffered their cardiac arrests in public places, recieved bystander CPR, were defibrillated within minutes, and had rapid response from EMS. All three returned to productive lives.

Watching them speak, for a moment, I pictured a dead version of them besides themselves. Cool, lifeless blue heads, bloated bellies, vomit strewn down their mouths, unending flat lines – a version that could easily have been a reality if the Chain of Survival had not held strong on their day.

Those grim images faded and were replaced again by the living, by the human warmth, smiles, and by their grateful tears as they recounted seeing a daughter graduate, being present for the birth of a grandchild, going on a trip to Paris with a wife of fifty years.

Every ambulance company president, every hospital CEO, fire chief, municipal elected official, EMS medical director, state and regional EMS representative, right on down to front line paramedic, EMT and first responder ought to attend one of these ceremonies every year.

Turf wars are too common in EMS. Over the years I have seen it in many forms. EMS versus fire, first responder versus ambulance, intercept medic versus transport medic, ground versus helicopter, commercial versus municipal, volunteer versus career. Field versus hospital. Big hospital versus small hospital. Town versus region, region versus state. While we all say we are for the patient, we all have our own agendas. And that can cause our eyes to drift from the prize. A badly put together conflicted system can kill.

It is so easy to forget what EMS is about. It is not about us. EMS is about our communitites. It is about those three living souls and their families who still have them.

EMS is about designing the best system possible, not necessarily for our service’s or hospital’s needs, but for the patient’s needs. We need to check personal and institutional egos at the door. We need science based protocols, system benchmarks, quality improvement/assurance programs, and out-of the box thinking that is never afraid to change the status quo if it is the right thing to do for the patient. And we need to each prepare personally, so we are always ready to do our best.

This is not frivolous work we do. Those three survivors are a testament to that.

Unresponsive

5 comments

LP12The last couple weeks have been pretty mundane – the typical pneumonia, hip fracture, lift assist, nausea, minor MVA stuff.

Yesterday we got called for the unconscious. Updated CPR has been started with the patient having agonal breathing. It is in an elderly housing complex. I’ve got a good crew with me so I have no anxiety about the call. I am actually pumped. While I feel bad for anyone falling ill, a CPR in progress call is a chance for me to perform.

We beat the first responders to the scene. While my crew takes the elevator up with the stretcher, I grab the LP 12 and bolt up the stairs two at a time. I’m thinking okay, freshly down, maybe in V-fib – for the first couple minutes it’s going to be all about the electricity and the compressions. I am on it.

I am excited. This will be my first code since I challenged myself to delay intubation and not be afraid to just pop in an LMA. Who will win the battle for my soul — the clinical coordinator who wants the quick LMA or the medic who demands his right to tube?

I burst through the door, through the kitchen. I see a woman standing looking at me, and for a moment I think I am in the wrong apartment – but then I see another woman laying on the couch – and while no one is doing CPR, the woman is still, her skin almost waxen. Instinctively I reach for her jaw to check for pliability. If it is loose, I will in one swooping motion lift her and set her down on the floor, and slap the pads on. My hand touches her jaw and pulls it down, it comes easily followed quickly by a biting motion as the startled woman opens her eyes and the startled paramedic jumps back.

The electricity and compressions will have to wait for another day…

The story: She and her friend were watching the soaps. She closed her eyes, shook a little, and then didn’t move, so her friend called 911. I don’t know where the part of the CPR came in. Maybe the EMD dispatchers told her to start CPR, but she never did. The patient either had a syncopal episode, a TIA, a seizure or more likely, just a bad story line that caused her to drop deeply asleep.

0.5 MG Morphine

6 comments

cryingI have written much about pain management in the last several years. Most of the time when I deal with pain it is for broken bones from falls or motor vehicle accidents. Between snow blowers, lawnmowers and all the machine industry we have in our town, I do several digitit amputations a year – all of which I offer morphine. They may not all be in immediate pain and they are usually tough guys, but all who refuse are in pain by the time they reach the hospital. Since our guidelines changed, I give morphine quite frequently to abdominal pain. I am quite liberal with pain relief and have never yet had a bad outcome beside an occasional nauseous patient that I then treated successfully with an anti-emetic. I admit to having delivered my share of sleeping patients as well as patients singing “The Farmer in the Dell.” All good in my book.

It is fair to say I have become quite comfortable with giving patients pain relief.

Even giving pain meds to kids causes few qualms for me. I say this because I sit on the regional medical advisory committee and the physician from the Children’s Hospital has repeatedly backed our pain initiatives and has made it clear that pain management is great for kids and that they tolerate it quite well.

We used to have to call to give pain meds to kids, but for the last couple years it has been on standing orders. Sometimes I have found parents do not like the idea of “an ambulance driver” giving their child morphine (perhaps they think it is similar to an ice cream truck driver selling them heroin) so I have on occasion called medical control with the parent at my side to have the physician reassure the parent that morphine would be a good medication for their screaming child with the fractured arm. Other parents, of course, have nodded agreeablely when I have told them I am planning to give their child morphine. Anything to ease their child’s suffering is agreeable to them. So pleased were they that I could have been offered honorary unclehood on the spot.

I carry 40 milligrams of morphine. The most I have ever given is 20 milligrams – for a 400 pound patient with a painful back who could not get out of bed and who we could not manage to move. Twenty milligrams and he not only got out of bed, but walked down the stairs. Thank You Jesus, thanks you, Lord. I have often given 15, which is the maximum I can give to a patient of 100 kgs or more on standing orders.

This past month I gave my lowest dose ever.

My Tuesday night partner and I had a rough two weeks. A two month old cardiac arrest and then at the exact same time of the week (just as American Idol was starting) we were called for severe burns for another two month old.

She was screaming like a banshee when we got there. I am not even going to get into what happened or who said what about whose fault it was or whether or not the story made any sense or what I thought about the caregivers.

The bottom line was the baby had severe burns, around her midsection. If you are a parent or know anyone who has a small small child go down right now to your hot water heater and turn the temperature down low. Put it on the vacation setting if you have to. I’ll take a warm shower everyday to protect my daughter from ever getting scalded.

This baby girl weighed 18 pounds. The initial morphine dose is 0.1 mg/kg, which is 0.81 mgs for her weight. Following our protocols I could give up to 1.22 mg without having to call for orders. And while I could give that amount on standing orders I still called the kid’s hospital for medical control. I wanted to make certain it was okay to transport there and not the trauma center across the street or have the child flown to a burn center (it was raining so I didn’t think that was a possibility) and I wanted to tell them how I planned to treat the burns – moist sterile dressings. The burn area was about 15%, but burns have a habit of growing beyond what they first look like. And so while I had them on the phone, I told them I was planning to give the child one milligram of morphine. I rounded up due to the pain. The doctor came back and told me to just give 0.5 mg, as well as agreeing to my treatment plan and agreeing to accept the patient.

I was a little perturbed that by rounding up or even calling I had cost the child some needed pain med, but I went ahead and gave the 0.5 IM.

How did it work?

The screaming banshee was sound asleep by arrival at the hospital.

Good stuff.

***

Here’s a recent article about how giving adequate morphine to young burn patients helps prevent posttraumatic stress disorder:

Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns.
J Burn Care Res. 2009 Sep-Oct;30(5):836-43.

Abstract
This study tested the hypothesis that very young children who received more morphine for acute burns would have larger decreases in posttraumatic symptoms 3 to 6 months later. This has never before been studied in very young children, despite the high frequency of burns and trauma in this age group. Seventy 12- to 48-month-old nonvented children with acute burns admitted to a major pediatric burn center and their parents participated. Parents were interviewed at three time points: during their child’s hospitalization, 1 month, and 3 to 6 months after discharge. Measures included the Child Stress Disorders Checklist – Burn Version (CSDC-B). Chart reviews were conducted to obtain children’s morphine dosages during hospitalization. Mean equivalency dosages of morphine (mg/kg/d) were calculated to combine oral and intravenous administrations. Eleven participants had complete 3 to 6-month data on the CSDC. The correlation between average morphine dose and amount of decrease in posttraumatic stress disorder symptoms on the CSDC (r = -0.32) was similar to that found in studies with older children. The correlation between morphine dose and amount of decrease in symptoms on the arousal cluster of the CSDC was significant (r = -0.63, P < .05). Findings from the current study suggest that, for young children, management of pain with higher doses of morphine may be associated with a decreasing number of posttraumatic stress disorder symptoms, especially those of arousal, in the months after major trauma. This extends, with very young children, the previous findings with 6- to 16-year olds.

Trauma Data Collector

10 comments

scroogeWhen I was hired as the EMS coordinator at the hospital there wasn’t much mention about one small part of my job – that of being the hospital’s trauma data collector.

All of the hospitals in our state, like those in most states, are required to participate in their state’s trauma data registry. The trauma data registry collects information about all victims of trauma who are either admitted to the hospital, die in the ED or are transferred from the ED to another acute care hospital.

The collected information includes: patient demographics (age, race, zip code, etc), type of injury, mechanism of injury, and when injury occurred, method of arrival (ambulance, private vehicle, police, etc.), prehospital information (times, vitals, interventions),* ED treatment (times, interventions, vitals), and hospital treatment (length of stay, procedures performed, and discharge status (alive, dead, level of functioning).

*This is the reason why in our state, EMS is required by law to leave a copy of their prehospital run form for a trauma patient before leaving the hospital.

While the hospital specific information collected by the state is kept privileged, some general information is released to the public and researchers can apply for access to the data.

Since we are not a trauma center, I only have to input a basic set of information. Trauma center data collectors have a much more intensive number of data points to enter.

The inputting itself is extremely tedious. Fortunately, our medical records are now computerized so I can access them from my desk rather than dragging my laptop down to the medical records office and then having to page through thick binders for the information I am looking for as I did when I first started the job. Still, it can make for a long day (although some days I don’t mind having mindless work to do).

Think about it: if you arrived on scene at 11:54, I have to type in 11:54. If the BP was really 140 systolic, but you wrote down 142, I have to type in 142. If you c-spined a patient, I check that the patient was c-spined. If you didn’t, I don’t check it. If you didn’t describe how the accident happened, then I have to hope it is described in the Ed chart or else I have to type in unknown. And if you didn’t leave a run form and I can’t track it down, I have to check run form unavailable. Then I have to check the ED chart to see if they listed your interventions. I would get another job if this was all my job was about. Fortunately, it is just 20% of my job.

Once a year the data I collect is downloaded to the state, which means I could theoretically ignore my inputting for months at a time, but believe me, if you delay, you pay for it later. I try to keep up. Sometimes I get caught up, and then the next thing I know two months have gone by and I am behind again. I would like to manage my time so I do it weekly.

This past week, with my monthly CME presentation done and out of the way, I devoted two full days to catching up.

The experience, as it always does, left me frustrated and upset.

80% of all our trauma patients are fall victims, 70% are falls of less than 3 feet. The average age of our all of our trauma patients is in the high 60’s. We see many hip fractures, mostly in patients in their 80’s.

sufferingAs many of you may have heard, hip fractures have a 15-20% mortality rate within a year of injury. I see this all the time. Occasionally a patient will come in with a hip fracture, and expire in the hospital from other medical causes. But more often, in reviewing EMS run forms throughout the year I will see familiar names. The medics bring in a patient with pneumonia. The patient had a hip fracture three months earlier. The medics bring in someone with sepsis. Hip fracture two months before. They presume someone on scene. A familiar name. Entered her as a hip fracture six months before. Hip fractures are tough on old people. They don’t heal well, fear limits their mobility, immobility makes them susceptible to illness. While some recover to lead full engaged lives, for others, a hip fracture is the beginning of the end. Farewell to independent living, hello skilled nursing facility, hello dark and lonely descent to death.

Most of our hip fractures are females, maybe 35% are men. While I stay fit which lowers my risk factors for an eventual hip fracture, I am of tall stature, which is a risk factor. I’m only 51, but it still worries me. It will be just my luck thirty years from now, another bored trauma collector will be typing in my demographic information and reading another paramedic’s run form about how they treated me on scene.

Here are two things that bother me:

One is the never-ending nature of the hip fractures. Every month, there are sure to be seven of eight new patients to enter into the data base just with hip fractures alone. I wish I had their names in advance, so I could warn them. Please be careful.

The other thing that bothers me is reading the patient’s EMS run forms. Here is what I see. Pain scale 10 of 10. Patient cries when ambulance hits bump. BLS transport. It really bothers me in a deep personal way. I get upset about Wall Street and the banks screwing the little guy. I get upset about all the chemicals and pollutants in our air and water and food. And I get upset about the way we treat hip fractures in EMS.

While pain scales are not recorded in the trauma data base, I have been keeping my separate Excell spread sheets on pain. I am tracking everything, compiling the data.

Here are some of the nuggets I can release:

1 out of 10 hip fractures gets prehospital analgesia. While this is horrible, statewide only 1 out of 20 gets it. Almost 90% of these patients will get analgesia in the ED.

When medics give pain meds they give it an average of 15 minutes into the call. This also works out to be 22 minutes before arrival at hospital triage.

While I am not at liberty to give out our hospital’s time to medication, it is better than national studies and we are working to improve it. But it is fair to say time to hospital triage is rarely time to immediate pain relief.

A paramedic on scene can medicate a patient far quicker than a nurse can medicate a patient rolling into the ED. At least in the ED, they get a more comfortable bed and an end to the jostling of potholes on the road.

While I would like to see a greater improvement in prehospital pain management – like 100% for patients with 4 or more on the pain scale and no contraindications, there are numerous problems that need to be overcome.

Our area is not one EMS system, but virtually a different system in each town. Consequently the hip fracture treatment rates vary widely from town to town. My statistics show towns that have all medic ambulances provide more pain relief than towns that have BLS ambulances and medic flycars. The reasons for this are that medics are not dispatched for low falls, basic EMTs are reluctant to call for pain management for hip fractures and when they do, fly medics are reluctant to commit themselves to riding in on a hip fracture when it means they are leaving their town without medic coverage (they might be missing a “more serious” call).

While there are benefits to both systems, I don’t want my grandmother living in a town that will not treat her hip fracture with analgesia. I don’t want her living in a town that will strap her unmedicated soul to a board and bounce her over the bleeding roads to the hospital. No sir.

So today, I am still depressed after two days of reading through run forms of seeing patients in pain, and seeing their pain go untreated.

I continue to collect my data, continue to build my case.

In the meantime, frail old people, be careful.

It’s a mean world out there.

Up the Stairs

4 comments

stairs
Saturday night. 9:30. A half an hour before I get off after a 16 hour shift. It’s the worst time to get a call. Another fifteen minutes later and my relief would be in and he’d take it, but at 9:30, no such luck. I am definitely getting off late.

The call is for a fall, a man in his thirties, tumbled down the stairs and has back pain. No loss of consciousness. My partner and I discuss what it is likely to be.

“I just know it,” I say. “It’s going to be a large person. And he’s going to be at the bottom of the basement stairs, and we’re going to have to board him and carry him up the stairs.”

“Maybe he’ll have already walked up the stairs for us.”

“Please, please let that be the case,” I say.

We park in the road and wheel the stretcher up the driveway, and then leave the stretcher out front and walk up the four granite steps. The front door is partway open. I am so hoping to see someone sitting on the bottom step or in the chair by the door. No one. Damn!

I look for the basement stairs, but then hear a voice. “Up here!”

Upstairs?

We walk on up and find our patient sitting on the bed, holding his back and grimacing.

“Let me get this straight,” I say after hearing the patient’s description of the event. “You fell all the way down the stairs, lay there in pain for twenty minutes, and then got up and walked all the way back upstairs to call us.”

He nods, not getting the irony. “That’s right.”

I palpate his spine. He winces as I touch the thoracic area.

No way around this. I explain what we are going to do, and then leave, and then come back with the board, collar, straps and head bed.

The patient is six-four, two hundred and forty pounds. Fortunately my partner Josh is strong and the two of us manage. With a police officer keeping his hand on my back, I also balance myself by leaning my left shoulder against the side wall, as I step backwards down the stairs. I grit my teeth and repeat the mantra, don’t let go, don’t let go. We carry him all the way down, and out the door and down the four granite steps, to the stretcher.

When I do these carrydowns, as my arms start to tremble and my back strains, I always wonder how smaller crews manage, and I also think how easy it would be to lose your balance or let go from the strain, and with all the improvements over the years with slide sheets and tractor wheel stair chairs and power stretchers, there has to be a better way to carry people up and down stairs on backboards.

I end up giving him 5 mg of morphine for the pain ( I probably should have done it in the house) — at least it seems to take the edge off for him. So now in addition to writing up my run form, I have go to the pharmacy and exchange controlled substances kits.

On the way back to the base, my partner says, “Maybe he’ll walk up the stairs. Your prayers are answered.”

“Don’t even start,” I say.

I punch out at 11:10.

Youth

5 comments

The mat outside the apartment door says “Coors Country.” Inside the door there are two empty cases of beer; Bud Light and Heinekin. There are two plastic garbage bags tied up and ready to be taken down to the parking lot dumpster. Straight ahead there is an open kitchen with a bar counter. Lined up on the bar are at least ten bottles of booze – all 5ths. Captain Morgan, Bacardi, Jack Daniels, something Mojito. There is also a very large mug, three quarters full with stale beer. There are more bottles lined up on top of the kitchen cabinet – all empty, along with several other 24 packs of beer, which appear full — ready for another party.

There is a movie poster on the wall – Scarface.

To the right is the living room, which is quite spare. There is a giant plasma TV on the wall, a coffee table and a long couch. There is also an idle vacuum cleaner on the plush white carpet. A police officer stands facing the couch where a young man sits, head in arms, crying.

Another police officer directs me to the bedroom. The roommate is on the bed. The story seems to be, he crashed last night after some heavy drinking. Flopped face down on his pillow, his right arm hanging off the bedside, his knuckles on the floor. His friend let him sleep through the day, and then when the sun went down, the friend finally shook him to get him to wake up, and when he wouldn’t wake up, he rolled him over.

The roommate lays on his back now, his right arm sticking straight up to the ceiling.

I copy down the information from the driver’s license the officer gives me. Out-of-state student. Handsome young man.

One phone call I wouldn’t want to have to answer.

Gathering of Eagles

6 comments

Eagle1If there is one EMS conference I go to next year, I would like to go to the annual EMS state of the Science Conference — better known as the Gathering of Eagles — held in Dallas each February.

The Eagles are the EMS Medical Directors of the largest 911 systems in the country, and some of the most forward progressive thinkers in EMS.

The conference is open to anyone interested in EMS.

The presentations from their 2010 conference are available online and make great reading.

Gathering of Eagles Presentations 2010

Here is a sample of two presentations about the future of intubation:

The Great Debate: Why Medics Should Not Be Trained in Intubation
- Raymond L. Fowler, MD (Dallas)

The Great Debate: Should Paramedics Intubate?
- Corey M. Slovis, MD (Nashville)

I’ve heard both of these men speak before at JEMS Conferences and they are both outstanding speakers.

Other topics discussed at the conference included medics using biomarker saliva testing to identify NSTEMI patients, induced hypothermia not just post ROSC, but during arrest, RSI using a King LT instead of ET, return of tourniquets for uncontrolled hemmorage, and new ways to treat excited delerium.

Check it out.

***

For more on the Eagles work, here is an informative post by Firegeezer:

ALS Response Times; Never Mind.

ET Interruptions

10 comments

ET2The November 2009 issue of the Annals of Emergency Medicine has a new study called Interruptions in Cardiopulmonary Resuscitation from Paramedic Endotracheal Intubation.

With all the science showing the benefits of uninterrupted cardiac compressions, the investigators asked the question: Since nearly every out-of-hospital cardiac arrest patient gets an intubation attempt, how do intubation attempts affect the CPR?

Using a prospective observational study design, they looked at two Pittsburgh EMS Agencies, both participants in the Resuscitation Outcomes Consortium: an urban service – 14 – 2 medic ambulances – 65,000 calls per year and a a county rural based agency with 27 single paramedic ambulances doing 60,000 calls per year. Both top flight, well-trained services with strong involved medical direction.

They recorded consecutive out of hospital cardiac arrests receiving EMS resuscitation and endotracheal intubation attempts from November 1, 2006 to June 20, 2007. They excluded pediatric patients (<18 years), major trauma, and patients where an advanced airway was not attempted.

They used cardiac monitors that continuously recorded ECG rhythm, ventilations, ETCO2, and chest compressions. They were also equipped with audio recorders.

They identified all CPR interruptions (CPR stops for 5 seconds or more). The interruptions were not just ET attempts, but also tube confirmations, adjustments, securing the tube, etc. They combined digital information with audio to determine what was going on.

Their outcome measures were the number of CPR interruptions and the duration of the CPR interruptions.

Of 182 arrests, they excluded 82 for the following reasons: 4 pediatric, 15 intubated before start of CPR recording, 18 no advanced airway, 6 No resuscitation attempted, 1 not cardiac arrest, 38 incomplete data.

The 100 patients broke down as follows: 61 male, 39 female, 42 witnessed arrests, 36 bystander CPR, 6 EMS witnessed arrests, 21 VF/VT, 100 intubation attempted, 79 ET tube, 8 combi, 5 King LT, 5 bag-valve, 73 transported and 24 ROSC.

Here are the results: median of 2 CPR interruptions, range from 1-9 interruptions, and median time to first ET attempt was 246 seconds.

Median duration of 1st ET attempt was 45 seconds (range from 7 to 221 seconds), 30% of cases 1st ET attempt exceeded one minute, some cases have interruptions lasting 4 minutes.

Subsequent interruptions broke down as follows; median duration was 35 seconds per CPR interruption, median total interruptions was 109.5 seconds per patient, 25% of patients had more than 3 minutes of interruption, some cases had 7 minutes of interruptions.

Interruptions associated with intubation had a median duration was 35 seconds per CPR interruption, median total interruptions was 109.5 seconds per patient, 25% of patients had more than 3 minutes of interruption, some cases had seven minutes of ET interruptions.

Limitations to the study were as follows: excluded patients may have altered data, using well-trained, high-acuity systems may show fewer interruptions than in less well-trained systems, study did not examine effect of number of rescuers on scene, and the study could not determine if ET attempts occurred during CPR.

The bottom line: paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

In an accompanying editorial, Do Not Pardon the Interruptions the authors made the following points;

1. Many aspects of current out-of-hospital cardiac arrest management lead to detrimental loss of circulation during CPR.

2. Interruption intervals, although significant, actually underestimate, the amount of time that circulation is compromised because of the “ramp-up” period required to restore adequate circulation on resumption of compressions.

3. There is no evidence that tracheal intubation contributes to survival in out-of-hospital cardiac arrest.

Their conclusion:

“For at least the first 5 to 10 minutes of resuscitation providers should prevent interruptions of chest compressions for anything other than single defibrillatory attempts and intentionally delay tracheal intubation before return of spontaneous circulation.”

***

The 2005 American Heart Association Guidelines had much to say out about what was once considered the gold standard of airway protection:

Rescuers must be aware of the risks and benefits of insertion of an advanced airway during a resuscitation attempt.

Because insertion of an advanced airway may require interruption of chest compressions for many seconds, the rescuer should weigh the need for compressions against the need for insertion of an advanced airway.

Rescuers may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation

It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of prehospital cardiac arrest.

Interruptions needed for intubation can be minimized if the intubating rescuer is prepared to begin the intubation attempt (ie, insert the laryngoscope blade with the tube ready at hand) as soon as the compressing rescuer pauses compressions.

The compressions should be interrupted only as long as the intubating rescuer needs to visualize the vocal cords and insert the tube.

The compressing rescuer should be prepared to resume chest compressions immediately after the tube is passed through the vocal cords.

***

There are some services in the country who are now forbidding their medics to intubate v-fib arrests in the first ten minutes or more of resuscitation.

Some are arguing the medics should simply forgoe ET intubation altogether for the immediate insertion of a supraglottic airway.

What will the 2010 AHA Guidelines have to say on this issue? Will the march away from intubation continue? We’ll have to wait and see.

***

In the meantime how will this study effect my practice?

First, let me say, I love intubating. For some childish hubristic reason every time I intubate I feel like I am more of a medic. When someone asks I want to have an impressive number of tubes to tell them.

But given all the years I have been intubating and reading this and similar studies, I have to say that my going for the tube early on in the call may not have always been in the best interests of the patient. I am a decent intubator, not a great one. I went seven years once without missing a tube (70 plus tubes). Well, to clarify, I went almost seven years where every patient I tried to intubate (who did not have a gag reflex) arrived at the hospital with an ET tube in the trachea, but that doesn’t mean I got them all quickly and on the first attempt, and it doesn’t mean there weren’t delays in CPR.

I have placed three LMAs in the last two years now after not getting an initial ET (our ET attempts have been limited to 2 now with an attempt being classified as inserting the blade in the mouth, not necessarily trying to pass the tube). I have always been bothered by how long it takes me just to get my intubation kit out and unzipped and get all the gear ready to intubate. An LMA is pretty dam quick in comparison. And then add on top of that, all the tube confirmation, securing time that is much longer with an ET than with an LMA.

And while I have intubated many patients quickly without stopping CPR for a single compression, I have had to tell people to stop on other occasions. How long have those interruptions been? I can’t say, but certainly they weren’t optimal for the patient.

Here’s what my game plan is now:

On VT/VF arrests, my mantra will be compressions and defibrillations take priority over anything else. I will delay ET. I will utilize two person bag-valve if I have enough help. I will be quicker to consider an LMA as my first line airway. If I have to intubate, I will try not to interrupt compressions at all. I will also take every attempt to practice all of my airway skills so I will best able to help my patient.

As a medic I respect recently said to someone who was questioning why she dropped a combitube in a large patient as her first airway, “I don’t have to intubate a patient to prove I am a good paramedic.”

I want to live up to that in word and in practice.

.

Katherine Ann

5 comments

Down the corridor
Jason straddles the gurney,
thumbs on her sternum.

babcpr

Only these fingertips
hold the mask against her skin,
her head in my hands.

Let’s Go to the Tape

6 comments

bow

Mark Glencourse at 999Medic has an interesting post, Real or Fake about patients seizing or pretending to seize.

I had two calls recently involving seizures of curious origin. One, which deserves its own blog post at a later time (after the complaints are resolved), involved a young churchgoer who was “with the spirit.” The other was a school child who was arching her back and shaking her arms and rolling her eyes quite violently and quite at random.

Every Jerk and Twitch

Were they faking? I have learned in my reports to be as nonjudgmental as possible, simply writing a lengthy narrative notating each jerk and twitch as I saw it. I will say I saw no immediate medical need to give either patient Ativan.*

Still, these were difficult calls. Both performances were in front of large gatherings of concerned onlookers, including a nurse at both scenes as well as top authority figures, a pastor at one and a principal at the other. Each call required an extended extrication, one from the front row of the church balcony, the other out of a school auditorium. None of the onlookers were well experienced in or even aware of the art form of psuedoseizing. On both calls my partner had to leave me for a longer than comfortable period, one to get a stair chair, the other to move the ambulance to the back side of the building. I was left with “seizing” patients, large audiences and nothing to do. Yawning, doing my daily stretches or practicing tap dancing would hardly have been appropriate.

Demons! Be Gone!

If you are in the back of an ambulance with someone faking a seizure, it is one thing to say “Knock it off!” It is a bit more delicate to do so in front of an uncomprehending crowd. In the case of the church seizure, I considered and rejected, placing my hand on his forehead and commanding “Demons! Demons Be Gone!” The problem here was he was not in fact communing with a demon, but, according to the onlookers, with a higher spirit. I did attempt to talk to them (patient and spirit), placing my hands on the patient’s temples and asking if the two of them could find it in their hearts in the interests of safety as long as I wasn’t interrupting anything important, if they could adjourn so we could help him stand, and walk up to the corridor where our stretcher, a clean sheet upon it, lay awaiting his rest. To no avail.

The Tape

These episodes did remind me later, as I wrote my extended narratives chronicling every jerk, shimmy and coco-bop that a few years ago I had written a post suggesting that we be allowed to videotape our patients as they seized for later broadcast, not on You Tube, but for the patient’s ED doctor and consulting neurologist.

camera

“Let’s go to the tape…”

I feel more strongly today than I did back in 2006 when I posted New Frontier that if we can use digital cameras to capture pictures of crashed cars to show the trauma team, we can use video cameras to record our patient’s busted moves.

***

On a cautionary note, several years ago I attended an excellent presentation on seizures called a “Whole Lotta Shaking Going On” by noted EMS lecturer Bob Page that revealed to me that seizures are far more complex and varied than I had realized and that I had, in fact, on an occasion or two, mistaken a real seizure for an act. Here are my notes from that lecture;

Seizure Notes

* While neither patient got Ativan because I felt neither patient was seizing, in retrospect, a couple milligrams of Ativan for each would have made my life much easier and been more pleasing to the audiences (in addition to placating their howls) than simply allowing the patients to continue to perform.

In both cases, I should add, their “seizures” ended once they had been removed from their audiences.