My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

I always had a problem with it. The patient was dead. Everyone knew he was dead. He hadn’t been seen since the night before when he’d asked for a cool glass of water. They found him in the morning in his bed, still as can be. He wasn’t breathing and he had no pulse. He looked peacefully there, his head on the pillow, the half-drunk glass of water on the bed stand. He was eighty-nine years old with inoperable cancer. He’d refused hospitalization just two days before. The problem was while there was a little bit of rigor in his jaw, there was no lividity. The room was warm – how he liked it. The family knew he didn’t want any extra measures done to save his life, but they called us because they didn’t know what else to do.

How many times did this or similar scenes play out? The patient ripped from the bed, laid on the hard floor, compressions breaking the chest, tube down the throat, IV, drugs, strapped to a board, carried out of the house to the ambulance in the rain, raced lights and sirens to the hospital, only to be dismissively called dead on the stretcher on entry to the code room. And then later, unseen to us the family received bills for ambulance transport and for ED care.

Everyone was worked and everyone was transported unless they had a DNR bracelet or met the criteria of rigor mortis in the major joints with dependent lividity.

We finally instituted some changes in our system. Medics were encouraged to use their judgment and call medical control, explain a situation and get permission not to intervene. If they did work the code and the patient was asystole, we could work a patient for 20 minutes, and then cease the resuscitation at home, call the patient dead, remove the tube, lift the person back up, put them back in bed, pull the sheet up to the neck, and have the family come in to say goodbye.

For a number of years, we could presume the patient on our own, but then once we developed statewide guidelines on termination, in the interests of solidarity with the other regions, we agreed to require our medics to call a physician for permission to cease. I have never yet had a doctor disagree with my request to cease. I am somewhat bothered by the requirement that we have to initiate CPR until the doctor gives the final concurrence, although I suppose that protects us if the doctor were ever to say, no, I want you to work the patient and bring him in. It has happened to others.

Sometimes, I have the family come into the room while we were still doing CPR, and have them say goodbye before we stop. What a sight that can be. A family one by one saying good bye to the 100-year old aunt in the room where she has lived the last ten years of her life. The love you see, the things they say, the tenderness. “Auntie Mae, I’m going to look out for Junior, for you, you know that.” “Auntie Mae, I love you, I love you my whole life.” “You going to rest now, Auntie Mae, you going where the fields are green.” Sometimes, they just give a kiss, and whisper something into the ear. A husband says, we’ll be together again. Wait for me.

I have seen this scene play out a number of times and I have always considered myself privileged to be there to witness it.

We do all we can. The families know when a loved one’s time has come. Their spouce, or mother or father or sister or brother, grandparent, aunt or uncle, dies at home, surrounded with their love and thoughts in their last moments, with some kind of dignity.

The National Association of Emergency Medical Physicians has termination of resuscitation rules that have a 100% predictive value for determining death. A study done at Yale showed that 54% of cardiac arrests brought into their ED met national guidelines for being called at home. They were all declared dead in the ED.

I understand that sometimes there may be reasons to transport dead people and that every scene is different. But as the American Heart Association said in its 2005 Guidelines:
“Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable.”

Termination of Resuscitation Protocols is # 6 on my list of best treatment changes in the last 20 years.

***

Here are our regional guidelines on termination on nontraumatic cardiac arrests:

TERMINATION OF RESUSCITATIVE EFFORTS (PARAMEDIC LEVEL ONLY):

NONTRAUMATIC CARDIAC ARREST

Discontinuation of CPR and ALS intervention may be implemented after contact with medical
direction if all of the following criteria have been met.
1. Patient must be least 18 years of age.
2. Patient is in cardiac arrest at the time of arrival of advanced life support, no pulse, no
respirations, and no heart sounds.
3. ACLS is administered for at least twenty (20) minutes, according to AHA/ACLS Guidelines
4. There is no return of spontaneous pulse and no evidence of neurological function (nonreactive pupils, no response to pain, no spontaneous movement).
5. Patient is asystolic in two (2) leads
6. No evidence or suspicion of any of the following: drug/toxin overdose, hypothermia,
active internal bleeding, preceding trauma.
7. All Paramedic personnel involved in the patient’s care agree that discontinuation of the
resuscitation is appropriate.

All seven items must be clearly documented in the ambulance patient care report
(PCR).

DMO should be established prior to termination of resuscitation in the field. The final decision to terminate resuscitative efforts should be a consensus between the on-scene paramedic and the DMO physician.

CONTACT DMO for confirmation of terminating resuscitation efforts.

If any of the above criteria are not met and there are special circumstances whereby
discontinuation of pre-hospital resuscitation is desired, contact DMO.

Logistical factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. Examples: Inability to extricate the patient, significant physical environmental barriers, unified family wishes with presence of a living will.

All patients who are found in ventricular fibrillation or whose rhythm changes to ventricular
fibrillation should in general have full resuscitation continued and be transported.

Patients who arrest after arrival of EMS should be transported.

***

Here is a link to a blog post detailing a call where the decision to resucitate was complicated:

Here is a link to a survey on this issue I conducted a couple years back:

Here is a link to the NAEMP’s position paper.

TERMINATION OF RESUSCITATION OF NONTRAUMATIC CARDIOPULMONARY
ARREST: RESOURCE DOCUMENT FOR THE NATIONAL ASSOCIATION OF EMS
PHYSICIANS POSITION STATEMENT

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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On Thursday May 17, I will be participating as a speaker in the EMS Web Summit.

I will be speaking from 7:15-7:45 EST.

My Topic is EMS Changes: A Personal Journey.

I will be speaking about why I got into EMS, what care was like when I started, how it has changed over the last twenty or so years, and how it has changed me. I’ll also take a stab at where it may go in the future. I hope you will join me.

Check out the link below for more information on this great event. Live registration is free.

Here is a list of topics: EMS WEB FORUM TOPICS

EMS Web Summit Registration

I believe this link will get you into the chat/viewing room once the forum starts:

EMS Web Forum Viewing

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There is a profile of me over at Greg Friese’s Everyday EMS Athletes, a feature of Everydayemstips.com.

Peter Canning Profile

Check it out!

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

7.  Decreased Use of Lights and Sirens

Ambulances in this area drove faster twenty years ago than they do today.  We had some wrecks.  People were killed, other injured.  It happened.  The longer I worked, the more unnecessary it seemed. Drive half way across the city lights and sirens only to wait half the day in the triage line with the same patient.  What was the point?

The worst drivers were young men in their early twenties, all full of testosterone and invincibility, wearing bullet proof vets, but not using seat belts, much less wearing crash helmets.

In time we got mandatory seat belts and were required to come to complete stops at all intersections when responding lights and sirens, and we had the black box technology to enforce it.  You “fob” in to drive so the computer knows you are driving.  If you don’t wear a seatbelt, drive too fast, take a corner too sharply, or stop too suddenly, you lose points and have to listen to the ambulance beep when it happens.  I resisted the black boxes at first (not the seat belts, which I always wore), and in time, I came to think they were great.  People definitely drive better now.

 The role of lights and sirens is much less now.  EMD, which I am not a big fan of, has at least, contributed to the downgrading of some responses. 

 We even have a statewide policy now to help limit the use of lights and sirens.  The general rule of thumb now is only go lights and sirens to a hospital if the hospital can do something for the patient that you can’t in the amount of time you would save going lights and sirens over flow of traffic that will make a difference in the patient’s outcome.

 I rarely even go lights and sirens to the hospital now.  Despite this, I think lights and sirens are still overemphasized.  Too many town and municipal contracts are based on on-time performance as well as outcomes.  All these contracts measure is what time the ambulance arrives, not whether a medic is there or not or how good the care is.  How about these for performance measures instead of response times?  Percentage of patients 55 and over with hip fractures, who receive pain meds, % of STEMI patients who get ASA and have their 12-lead done and successfully interpreted or transmitted to the ED, CHF patient who receive CPAP and nitro?

 When I started, the Golden Hour ruled, but it has been discredited over time.  Quality Care and Safe Transportation are the new watchwords.  I hope this trend continues.

***

Here’s a post I wrote about the debunking of the Golden Hour.

And here’s a post I wrote several years ago called My Death, which deals with my thoughts about overuse of lights and sirens.

***

Lights and Sirens Use Policy
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
OFFICE OF EMERGENCY MEDICAL SERVICES
RESPONSE AND TRANSPORTATION GUIDELINES FOR AUTHORIZED EMERGENCY MEDICAL
VEHICLES (INCLUDING LIGHTS AND SIREN USE)

Due to the inherent risk of operating with lights and siren. Department of Public Health Authorized Emergency Medical Vehicles (AEMV),
(specifically ambulances and EMS non-transport vehicles) should use emergency lights and siren only when responding to calls involving or
transporting patients believed to need immediate life or limb threatening medical intervention. The mode of transport is a patient care medical
decision.

Preparation

EMS personnel must use patient compartment vehicle occupant restraints whenever practical based upon patient critical needs. EMS personnel
must use occupant restraints when driving. Front seat and patient compartment passengers/patients must use occupant restraints. EMS employers
must ensure that EMS personnel who operate AEMVs are qualified and trained appropriately. Consideration should be given to the use of
electronic behavior modifying instant feedback systems as a skills improvement and coaching tool.

The Department of Public Health should strongly encourage and financially support;

1. Emergency Vehicle Operators Training for all EMS Providers and,
2. The use of vehicle monitoring systems that encourage coaching and provide operators with immediate driving
technique feedback and organizations with data for system improvement.

System Status

Connecticut Statute 14-283 must be adhered to.

Patient Response

Authorized Emergency Medical Vehicles should respond lights and siren only when directed by their dispatch center based on EMD criteria.
Should additional information be received from public safety personnel suggesting that a response no longer merits a lights and siren mode while
the AEMV is en route to the scene, the AEMV response should be downgraded to non-lights and siren mode. Similarly, should additional
information be received from public safety personnel suggesting that a non lights and siren response merits a lights and siren mode while the
AEMV is en route to the scene, the response should be upgraded to a lights and siren mode.

Patient Transport

The highest level certified/licensed EMS provider responsible for the patient’s care will advise the driver of the appropriate mode of
transportation based upon the medical condition of the patient.

When transporting the patient utilizing lights and sirens, the need for immediate medical intervention should be beyond the capabilities of the
ambulance crew using available supplies and equipment and be documented on the patient care report.

The mode of transport for emergency interfacility transfers should be based upon the directions of the referring physician and on the condition of
the patient unless the patient’s condition has deteriorated en route.

Exceptions to these policies can be made under extraordinary circumstances.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

8. Selective Spinal Immobilization Guidelines

I remember this scene from a hospital triage line vividly.  It is eight-thirty in the morning.  A woman in her middle thirties in a nice business suit is on a backboard with a tightly applied neck collar, two body straps, and her head is immobilized with thick duct tape going from the top ends of the board, down around her collar, cranking her neck back. Her problem, besides the poor job of spinal immobilization is she needs to pee.  She has been drinking coffee since she woke up and got her kids off to school, and was drinking it on the way into work when she was rear ended in traffic.  She has some minor back pain.  “Please,” she says for the third time to the crew and triage nurse, Let me off this board!  I need to use the bathroom.  Please, I can’t hold it any longer!”

The triage nurse snaps at her.  “Hold still, unless you want to be paralyzed.  You have to stay on that board until the doctor exams you!”

 I have seen similar scenes.  Triage nurses,EMS, even doctors shouting at people that they could be paralyzed unless they submit to being immobilized.

Come on, people!  What about the patient?  Does anyone really think that letting this lady get up to pee is going to paralyze her.  Does anyone think that her jerking around on the board is good for her supposedly injured spine?

 If we really cared about keeping patients still, everyone we immobilized, we would also sedate.  Got neck or back pain from a minor MVA?  You get spinally immobilized, and then given 5 of Versed and 100 of Fentanyl.  Hell, why not RSI them all?

 Actually, this is probably a bad idea because most alert people with spinal injuries have their muscles tense up, which helps them self-splint the injury to limit movement.

 I remember once I was called for a motor vehicle victim in a Chinese restaurant.  The patient had been in an MVA on the highway, fled the scene and finally called from the Chinese restaurant.  I tried to immobilize him.  He wanted no part of it.  I had two cops with me.  Somehow they ended up wrestling with him to try to get him to submit to being immobilized.  One cop had him in a head lock.  It occurred to me then that maybe it would be better for his spine if we didn’t try to force him into the collar.

We used to immobilize everyone.  Every motor vehicle, every fall over three feet, every shooting.  We immobilized to protect the spine based on mechanism of injury, not based on assessment.  There was no science behind it; just the conjecture that keeping people with possible spinal fractures still would prevent them from suddenly becoming paraplegics with the slightest movement.  In our state basics continue to c-spine everyone.  Paramedics are able to follow criteria to selectively omit spinal immobilization.  There is a plan that is slowly progressing through the channels to extend this to basics.

 The science of spinal immobilization is more extensive than I can cover.  While there is evidence that spinal immobilization causes back and neck pain, leads to decubitis in elderly and can hinder breathing, and delays transport of critical patients increasing their risk of death, to date, there is no evidence that it does what it claims to do – protect the spine.  It may, in fact, make it worse.

The study I like to cite the most is the one where they studied all spinal fractures in New Mexico brought in by EMS immobilized and all those from Malaysia who were thrown into the back of a donkey cart (I am joking here) without immobilization and taken to the hospital .  The patients in New Mexico did worse.  Did the study prove spinal immobilization was bad?  No, but it clearly did not provide any evidence that spinal immobilization was beneficial.  No study ever has.

Out-of-hospital spinal immobilization: its effect on neurologic injury.

 As a clinical coordinator, both at my hospital and in conversation with other coordinators, I do know of many cases where patients with cervical fractures were not immobilized (usually elderly victims of low falls), but I know of no cases where harm was done to the patient from not being immobilized.  I have had several patients with cervical fractures who I did immobilize.  Every one of them had significant neck pain.

Since we were able to omit spinal immobilization, countless people have been spared torture.  I am unawre of any patient who suffered neurological injury from not being immobilized in our system.  I would like to see the current guidelines extended to basics and I would like tto see the guidelines rewritten for paramedics to make spinal immobilization indicated only for suspicion based on assessment.  If in your clinical judgment, the patient may have a spinal injury, then immobilize, and immobilize fully and properly.  If you don’t believe they do, based on your assessment and judgment, don’t immobilize.

Here is our current spinal immobilization guideline:

OMITTING SPINAL IMMOBILIZATION

Paramedics shall make spinal immobilization decisions based on mechanism of injury and clinical
criteria. The decision to not immobilize a patient is the responsibility of the paramedic.
Indications for Spinal Immobilization:

1. Any patient who has sustained a significant mechanism of injury (includes windshield spider,
dash deformity, ejection, rollover, fall from > 10 feet, and vehicle space invasion > 1 foot).
2. Any patient with positive or questionable mechanism of injury and who has one of the following
clinical findings:
a. Altered mental status
b. Hemodynamic instability
c. Evidence of intoxication or unreliability
d. A significantly distracting painful injury
e. Neurological Deficit
f. Spinal Pain or tenderness

Procedure:
1. Determine Mechanism of Injury
Significant mechanism (including windshield spider, dash deformity, ejection, rollover, fall from >
10 feet, and vehicle space invasion > 1 foot) immobilize patient.
Positive Mechanism or questionable mechanism (including patients with trauma above the clavicle,
falls, MVAs, trauma to the spine head or neck, abrupt accelerating, decelerating or rotational forces)
maintain stabilization and proceed with spinal assessment.
2. Assess Patients
Assess mental status. If patient is not alert and oriented, immobilize.
Assess hemodynamic stability. If patient is hemodynamically unstable, immobilize.
Assess for intoxication and reliability. If patient has evidence of intoxication, mental impairment, or
gives unreliable answers, immobilize.

Assess for distracting injury. If patient has an injury, which may distract from patient’s awareness to
pain, immobilize.
Assess neurological function. If patient has neurological deficit, immobilize.
Assess spine. If patient has pain on palpation of spinous process of cervical, thoracic or lumbosacral
spine, immobilize.
If the above are negative then:
Assess range of motion. Direct patient to touch their chin to their chest, look up extending their neck,
and then turn head from side to side. If patient has any neck pain during their normal active range of
motion, immobilize.

Decision:

Patients, who pass the above assessment, may have immobilization omitted at the discretion of the
paramedic.
Extra caution must be used in pediatric and geriatric patients. When in doubt, immobilize.
All pertinent exam and history findings must be included in run form.
In cases where the paramedic does not accompany the patient to the hospital, the paramedic needs to
provide their name to the transporting BLS provider for documentation purposes.

Remember: The decision to not immobilize a patient is the responsibility of the paramedic.
 

***
16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

9. Alternative Airways

When I started as a paramedic – all we had was the ET tube. You brought in a code, the first question you were asked in the EMS room was “Did you get the tube?” If you got the tube, you got an approving nod. You didn’t, after you left, the other medics would shake their head. Of course, if you got the tube, nobody asked how many tries it took you to get the tube. You might hear the medic’s EMT partner later commenting it was a “hard tube,” which meant there were multiple tries. Familiar with the term “A Pass the Larengyscope Code?” I have been at a few of those and heard of many more.

Nowdays, we have alternative airways – The LMA and the Combi-tube. We may soon get the King LT. And we have limits on the number of times a paramedic or any combination of paramedics can attempt an ET.  Two tries for the first medic and one for the second.  No more than three tries total.  And, most importantly, you don’t have to try at all.  You can just go to the alternative airway to start if you think it gives you the best chance to quickly secure the airway.

Here are some old posts describing my first LMA and my first Combi-tube, as well as a post called “The Battle” describing my beginning mindset when contemplating what airway to use.

LMA

Combi-tube

The Battle

I can tell you this now, based on the medical literature, and on my experiences with the LMA and Combi-tube, I no longer hesitate to use an alternative airway as my first line airway.

The goal is not to impress other medics, but to effectively ventilate the patient, and in cases of cardiac arrest, not to interrupt compressions. I can do both of those quite well with an alternative airway.

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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On Thursday May 17, I will be participating as a speaker in the EMS Web Summit. Check out the link below for more information on this great event. Live registration is free. More information will follow.

Here is a list of topics: EMS WEB FORUM TOPICS

EMS Web Summit Registration

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

10. Chemical Restraint

I pride myself on my ability to talk to psychs. I saw a movie once about a hostage negotiator called “The Voice.” I would flatter myself that I, too, was “The Voice.” I could talk anyone down, make any madman set down his hammer, sword and WWF delusions, and come peacefully. Once I was trying to talk down a kid on angel dust. I am very patient, but other responders there were not so much so. While I was talking this guy down and making what I thought was steady progress, a medic from another division, who was up helping us handle a particular rowdy concert, had had enough and jumped the guy wrestled him to the stretcher and with his partner roughly four-pointed the boy, who fought and spit and screamed all the way to the hospital. I was torqued. It seemed there was a certain class of responder who got into restraining/beating up people. I’m not saying I was always able to talk them down, but most of the time I could. If I couldn’t, sure I’d end up using the physical restraints, but I have never liked that part of the job.

Then we got Ativan and Haldol. Things are different. No more driving to the hospital with four people fighting a patient all the way to the ED. If I can’t talk them down, sure we may have to hold them down for five minutes, but I load’em up and they sleep baby dreams to the hospital.

***

This is my favorite Ativan/Haldol story – Sleepy Boy or Fetch My Dart Gun:

We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.

A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal’s office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.

When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.

I am not.

Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.

Six people, I think, right. Talk about overkill.

I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.

“You’re just one crew?” the cop asks. “You have restraints?”

***

Now when I first took my EMT class many years ago, I wasn’t too keen on the section of the course where we practiced restraining patients. I mean I wasn’t certain I wasn’t going to vomit at the first sight of gore, and I wasn’t certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.

I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouldn’t get called for the big guy who wanted to kick my ass.

I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn’t work on. That’s why we have cops, but cops don’t like to get worked up any more than paramedics.

In recent years, restraining patients has also gone somewhat out of favor due to some tragedies — patients dying of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title “Chemical Restraint.”

***

“We’re going to sedate him,” I say. (If this was movie, I would have said to my partner, “Fetch my dart gun.”)

2 mg Ativan and 5 mg Haldol IM.

He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.

Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.

Ten minutes go by. He is still angry and yelling.

I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. “By all means,” he says.

Andy nearly throws everyone off him when I hit him in the other thigh.

I sit back down in a chair and wait.

A staffer asks what the plan is now.

“I’m going to sit here until he’s asleep,” I say.

Five minutes later, he starts to snore.

One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.

He snores all the way to the ER.

***

Here is our restraint guideline:

North Central EMS Behavioral Emergency Guidelines

EMS providers may use physical and/or chemical restraints on patients who pose a danger to themselves or others.

Providers should make every effort to ensure that law enforcement and adequate assistance are present when attempting to restrain a violent or combative patient.

Only the minimum amount of restraint necessary to protect providers and the patient should be used.

Providers should first attempt to verbally calm the patient down. If the patient does not comply, physical restraint may be attempted.

Providers should assess the patient for medical conditions that could be contributing to the patient’s behavior. If an assessment cannot be performed prior to physical restraint, it should occur as soon as possible after restraint is applied when it is safe and feasible.

Physical restraints must be soft in nature and pose no threat to the patient’s safety.

Only the extremities shall be restrained and these restraints must be assessed every five minutes.

Patients must never be hog-tied, restrained in a prone position with hands tied behind their backs or placed between backboards or mattresses. No restraint shall ever be tied around the head, neck or chest. A surgical mask, spit shield, or an oxygen mask may be placed loosely on the patient to prevent spitting.

Handcuffs may only be used by law enforcement or correction officials on patients in their custody. If the law enforcement officer insists that the patient remain handcuffed during transport, they must either accompany the patient or provide a key to EMS personnel.

Chemical restraint may be used per guideline following unsuccessful attempts at verbal and/or physical restraint or when a patient continues to forcibly struggle against physical restraints.

All restrained patients must have continual reassessment of vital signs and neurovascular status of distal extremities. In chemically restrained patients (safety permitting) this should include ECG, pulse oximetry, and capnography if the patient is no longer alert.

Documentation must include justification for restraint, type of restraint used, restraint procedure, results of continual reassessment, medications administered, the indications for the administration, and any other care rendered.

Do not hesitate to involve medical direction in any call involving restraint.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

In our 2012 Regional Protocols, Lasix has been removed from our med kits. I stopped using it several years ago — even when I was reasonablely sure my patient had CHF. I had CPAP and I had nitro and I relied on them, as I do now.

The first rule of medicine is “Do No Harm.” Lacking chest x-rays and the ability to do BNPs in the field, time and again, EMS (myself included) has done harm to our patients by giving patients we thought we in CHF, Lasix when in truth they had sepsis or pneumonia.

Below is excerpted from a 2010 post about Lasix.

Dear EMS Medical Control-

I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. “Stop the Horror! Ban Lasix!” I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.

Respectively
Patient X.

***

As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services’s trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and won’t be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We don’t want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.

In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.

Evaluation of prehospital use of furosemide in patients with respiratory distress.

For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.

Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school don’t always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didn’t have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.

I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. D’oh!

When I was a newer medic in the last 1990’s, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didn’t give Lasix at all.

Several years back, we added the following caution to our regional protocols:

CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.

Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient’s respiratory distress is severe.

With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.

That seems to be the clear direction EMS is headed in. Check out this article from JEMS.

Meds Under Scrutiny

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

The first time I put an IO in a small child, there was no choice between an IV and an IO. The child was in arrest. I had already dropped a tube and I now needed access. I couldn’t picture myself strapping on a tourniquet and probing for a tiny vein. I reached for the Jamshidi, found my landmark on the proximal tibia, and screwed it in. Pop! Just like that I was in. I amazed myself. The fluid ran fine. Some epi, some atropine, some CPR, and some lights and sirens, and two days later the kid’s name was in the obits. We did our best.

Not a week later, I did my second IO in a kid. Another arrest, although this was a little less traumatic – a kid with congenital disease, on feeding tubes, expected to die, died. The family still freaked and called 911. The fire department got there first and freaked and carried the kid out to us as we pulled into the curb. I get him on a small board in the back. Dropped the tube, reached for the old Jamshidi IO needle, and screwed it in. Only this time, something happened. When I tried to take the needle out, it wouldn’t budge. I had bent it when I screwed it in. All the short four minutes to the hospital I spend trying to yank the dam thing out while a firefighter did CPR, and my rider squeezed the ambu-bag, and the mother wailed from the front seat.

I put in a few more over the years, two successful and another one that bent. Since we got the EZ-IO, I thankfully haven’t had to use it yet on a child. I have done quite a number of EZ-IOs, usually almost all on elderly cardiac arrest patients with poor IV access. It’s great. Just drill and you are in. No misses. Every one has been in the proximal tibia. I’ve done two on living people, although both were in deep comas. I haven’t yet done one on an alert person and hope I never have to.

I am picking the EZ-IO as my twelfth biggest treatment change since I started as a medic because it has taken much of the anxiety out of what can be stressful situations.  Now admittedly the research shows that IV meds make no difference in cardiac arrest. Still, as a single medic it is nice to be able to get the skills done. Whether it is getting ROSC or simply fulfilling the requirements necessary to cease resuscitation on scene – an advanced airway, an IV or IO, 20 minutes of ACLS, — having the EZ-IO in the kit as an IV backup is a big help.

While on the subject of the EZ-IO, there was an interesting study in the Annals of Emergency Medicine that came out last year comparing a tibial EZ-IO with a humeral EZ-IO with a peripheral IV during cardiac arrest. The tibial EZ-IO had the highest first attempt success rate (91%) with the lowest dislodgement rate, but the peripheral IV was capable of delievering twice the amount of fluid as the IOs.

Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial.

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

13. Permissive Hypotension

In the mid 1990s and before then, you were a stud if you could swoop down on a shooting victim, toss him on a board, get him in the back of the ambulance, and take off before the mobile TV news crews arrived (even better if you were gone before the PD arrived).  Then in the three or four minutes you were in the back of the ambulance as your partner flew (we’re taking airborne on the rises) to the Level one trauma Center, you slammed in two large bore IVs and had the fluid running fast and wide.  Two 14’s was an A plus.  A 14 and a 16 was good.  Two 16’s was border line.  Anything less was not worthy of the patch on your shoulder.  You were a god if the 1000 liter bags had less than 100 cc by the time you hit the trauma room.

It really sucked if your victim had bad veins.  A 20?  That was all you could get?  A 20?  But in most cases your shooting victims were young strong males with bulging pipes, who just happened to be on the wrong street corner doing nothing at the wrong time.

I remember one time I put a 14 in a man’s AC and the fluid ran like Niagara Falls.  I noticed then the cot was soaking wet under his upper arm.  He had another huge bullet hole there that had completely taken out the vein. The fluid entered the AC, run upstream for four inches and then ran right out tinged with pink.  Pink was often the color on the sheets after we’d unloaded the patient.  And back then, we didn’t just run the fluid when the BP was low.  We ran the fluid regardless of the BP.  We were medics and aggressive and taught to stay ahead of the game.  We ran fluid in anticipation of the BP dropping.

Many medics started the day by hanging and prespiking two 1000 cc bags of fluid.  One of Saline; one of Ringers.  Some medics hung the bags, but just taped the drip sets unspiked to them.  I usually just laid two bags on the bench seat, ready to open and spike.  A few medics may have just left the fluid in the cabinets until needed.  I guess it all depended on what degree of spark you were.

Of course we know better today. Aggresive fluid resucitation in absence of controlled bleeding can damage the body’s ability to clot off the bleed, create hypothermia, and impair the delievery of oxygen. While there is still some discussion about just how much fluids trauma patients should get prehospitally, permissive hypotension seems to rule the day.  Our regional protocols calls for blood pressure to be titrated to 100 systolic.  I know some would argue that blood pressure limit should be much lower – just enough to produce a pulse and no more.

Here is a link to Trauma.org that has a good editorial and summary of the permissive hypotension debate:

Permissive Hypotension

Bibliography

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.  Expanded Medication Routes, Less IV Emphasis

When I was going through paramedic school (1982), another student told me, if you can’t get an IV, you can’t be a paramedic. If your IV skills are not second nature, you will spend too much time worrying about getting an IV, he said, and not be calm enough to keep the big picture in mind. Plus, he said, if you can’t get the IV, you can’t fully treat the patient or give most of the medications you carry.

I worked hard on my IVs during school, taking many extra shifts on the IV rotation where I accompanied the IV nurse around the hospital and jumping to do every IV I could on my ED rotations. I was already an EMT-Intermediate, but I worked for a small volunteer service and was lucky to get three IVs a month. When I was cut loose as a paramedic (now working for a city 911 ambulance company), I was assigned an EMT-Intermediate as a partner for my first six months as a condition of my medical control. On my calls, I insisted on doing most of the IVs and I put IVs in most of my patients. My reasoning was if the person was going to get an IV in the hospital, I was going to give them an IV in the field. At the time, we also drew four tubes of blood for the hospitals, so bringing in a patient with an IV and labs drawn was a great way to earn nurses’ favors.

Back then, if a patient was in status epilepticus, we had to have an IV to give them Valium. If a patient was in CHF or having an MI, we had to have an IV to give them nitro. If they were in pain, we had to have an IV to give them morphine. Even most heroin ODs got an IV. True, if you had a patient in cardiac arrest, you could give drugs down the tube if you didn’t have an IV, but even then, we did not think that was the most effective way to deliver the drugs. And, of course, trauma patients didn’t just need an IV, they needed two large bore IVs so you could run the fluids wide open.

Things are very different today in 2012. You still need to be good at IV to be an effective paramedic, but there are more drug delievery options, which is better for the paramedic and, most importantly, better for the patient.  Also, the IV has less importance in cardiac arrest and trauma as studies have shown IV meds don’t improve and may worsen outcomes in cardiac arrest and the old practice of pouring fluids into trauma patients was, in fac,t helping kill some of them.

Today with a patient in status epilepticus, we can give Versed not just intramuscularly (IM), but intranasally (IN). Same with patients in pain. IM, or even better IN with Fentanyl. Heroin ODs get Narcan IM or IN as well. We can give patients with chest pain NTG without an IV as long as we use caution. Someone sick and vomiting, we can give Zofran IM, and very soon, we may be able to give it sublingually. With Benadryl we now have a PO option. And for those patients who absolutely need an IV, no more sweating and shaking hands, the eyes of everyone on you as you poke and poke and fail to get an IV on a critical person who continues to deteriorate or who may already be dead, you now have the EZ-IO drill to fall back on.

I want to thank all the thousands of patients who let me put IVs in them over the last twenty years and who helped give me the confidence I have today in my IV skills. I no longer follow the rule that if a patient is going to get an IV in the hospital, they will get one from me in the field. I still do my fair share of IVs – but I now appreciate there may be times when it may be necessary in the ED, but it is not as necessary for us prehospitally to do it. There is also that factor that some hospitals routinely either DC prehospital IVs or put in their own. Some have said it is for infection control reasons, others have said it allows the hospital to add another charge to the bill. I don’t know, but when transporting a patient to a hospital following such a policy, I tend to be more selective about when I establish IV access.

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.Expanded Medication Routes, Less IV Emphasis

 15. Narrower Use of Narcan
16. Increased Standing Orders

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15. Narrower Use of Narcan

When I started we used narcan for opiate overdose and coma of unknown etiology. Today we only use narcan for respiratory depression or inadequate ventilation associated with opiate overdose.

The following is excerpted from a post “That Narcan Shit” from December of 2008.

When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie’s IV, and slamming the Narcan as they’d go through the ED door so the junkie would sit up and puke all over the medic’s nemesis — the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.

I did, however, slam Narcan into lots of junkies and wake them up. When I say slam, I’m not taking about pushing the Narcan in like I push Adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.

I’d slam it. They’d puke, curse, rip their IV out and stalk off. One guy I found in an abandoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the Narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push Narcan. I’d had no idea.

Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the Narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.

Slamming a full dose of Narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.

It used to be if I was called for an OD and the patient had used Heroin, they got Narcan even if they were breathing okay. As long as they were slightly altered, I’d hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.

“Did you do drugs?”

“No.”

“Then why do you keep dropping asleep?”

“I didn’t do drugs.”

I’d push the Narcan. They are wide awake and puking. Stupid. Them and me.

“Did you do drugs?”

“No.”

“Then why are you wide awake now and puking?”

I don’t give narcan now as much as I used too because I don’t work in the city nearly as much, plus now, like I said, I only give Narcan if I suspect an opiate overdose and the patient’s respirations are extremely depressed. Sometimes I bring Heroin users in to the hospital and the first thing the hospital staff does is give the patient Narcan. Wake them up and make them puke. I shake my head. That’s just no way to treat people. Put them in a hallway and let them sleep it off — as long as they are breathing okay.

We also used to give Narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.

Here’s two cases where I gave narcan to coma of unknown origin with bad consequences.

1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did — living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills — opiates — I zapped him with Narcan. So now I went from a patient in a semi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I’d just zapped all the pain medicine he needed to tolerate living into the ether. My bad.

2. Called for a possible stroke, I found an 80-year-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her Narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn’t find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Strange. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her Narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.

Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of Narcan.

Narcan Solves the Riddle, Part I

More Rogue Medic Narcan Posts

Ambulance Driver Article “Naloxone: The Most Abused Drug in EMS”

I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:

“Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic

Rogue Medic sites an excellent study done years ago in LA.

The empiric use of naloxone in patients with altered mental status: a reappraisal.

The study asked the following questions:

# 1 – Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?

# 2 – Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?

-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52

730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period

Only 25 patients (3.4%) demonstrated a complete response to narcan

32 (4.4%) manifested a partial or equivocal response.

673 (92%) had no response.

19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed

2 of 26 partial responders (8%) (with known final diagnosis)

4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.

Of the 25 complete responders to Narcan

19 had opiate overdose

6 had seizure or closed head injury.

Their conclusion was:

“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”

“In addition, response to naloxone created a substantial amount of diagnostic confusion…”
-Ann Emerg Med. 1991 Mar;20(3):246-52

That study came out when I was still as EMT.

Good lessons, as I had learned the hard way.

The bottom line:

Just because they woke up after you gave them narcan doesn’t mean they woke up because you gave them narcan.

In the last month I have responded to three calls of a person passed out in a car in the middle of the road. All three had pinpoint pupils and only seemed to be breathing on prodding. All three had just done opiates (two heroin and one had swallowed a 20 mg Morphine pill). I thought about giving one of them a slight squirt of intranasal Narcan (We can do this now), but as soon as he saw me go fro my yellow medical kit, he snapped awake. (So how unresponsive was he even though he was breathing at 6 a minute?) Don’t, he said. I won’t as long as you keep breathing, I said. Deal?

I so much prefer the new approach. I am for love and happiness and as long as someone can support their own ventilations, I am oppossed to being a buzz-kill or for practicing bad medicine for that matter.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic
15. Narrower use of Narcan
16. Increased Standing orders

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I had yesterday off and was going to run the Greater Hartford Quarter Marathon, for which I had already paid my entry fee, but I ended up spending the day in bed. Just two weeks before I ran in the O’Hartford 5K and set my personal best 5K mark of 26:58, good for 764th place out of 2567 runners, a good ten minutes behind the winner, but over four minutes faster than I ran my first 5K five years ago. I was feeling pretty good that day (the picture of health and fitness), but I likely overextended myself and instead of taking a couple days to rest, kept up my regular exercise routine and soon found myself battling a raging respiratory infection. I had actually thought I had made it through the winter without my annual sickness. I slugged it out for over a week, but it beat me down completely. By yesterday I could barely rise from bed. I hoped the day long sojourn under the covers would enable me to report fresh for work this morning, but by 5:30 last night, I knew it would be rough. I hesitantly picked up the phone and called out. Today has been for sleeping, reading, some writing, some more sleeping, some more sleeping, a little more reading and writing, and I have just now cooked a small steak, which I am actually eating with gusto. I will be ready for work tomorrow. Hopefully, with enough vim, vigor and vitality to make it though the day.

My annual cold reports:

Called in Sick 2011

2009/10: Dueling Coughs

2008: Medicine For Paramedics

2007: Sick

2006: Hacking

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I have made my list of the 16 biggest EMS treatment changes over my twenty-year career as a paramedic. I will be posting my list in reverse order over the coming weeks.

16. Increased Standing Orders

When I started as a paramedic 20 years ago, we had to call medical control for permission to give medications far more than we do today, including anytime we wanted to give controlled substances. If a patient was in status epilepticus or had bones sticking out of their leg, we had to call to talk to a doctor for permission to give Valium for the seizure or morphine for the broken leg. What doctor would say no? We did this because at the time in Connecticut there was a law requiring “simultaneous communication” with a physician for a paramedic to give controlled substances.

We had also had to call in many other situations. often whether you got permission or not depended on which doctor answered the phone. Some moonlighters or new doctors didn’t even know our guidelines or would tell us to give drugs we didn’t carry. Recently we had torodol as a medical control option. The problem was some doctors said no to torodol no matter the scenario, while others thought ti was a great drug and always said yes. There was little consistency. In the end, we decided to remove the drug altogether and just up the amount of fentanyl and morphine would could give instead.

We hardly ever have to call for anything now. Our region has decided that if our guidelines are reasonable, we ought to be able to lay out situations where paramedics can do what they need to do on standing orders. For instance, if a medic needs to call in for permission to give a drug like dopamine, he likely has a patient sick enough to demand his full attention and requiring him to get on the phone to talk a doctor, who likely is busy himself, is not an ideal situation. While medics are always encouraged to call if they have any question, as long as they are within our general guidelines they are free to follow them on their own. The only two major situations we call for now are for STEMI alerts to get the doctor to activate the cath lab and on cardiac arrests if we want permission to cease a resuscitation on scene. Overall, the standing order system works great and is a vast improvement over the old “Mother, May I?” days.

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I pride myself on my assessment skills, my finely tuned senses — the ability to see, hear, touch, smell, taste, and whatever the sixth sense is – I do that one well too. But lately, I must confess I have been having some issues with the hearing. I auscultate the patient’s lungs and hear nothing. I say to my partner, “You listen. Tell me what you hear.”

“Fine rales,” he says.

“Ah, precisely,” I say as fine rales squares with my other senses that this patient seems to present with mild CHF. “But a bit decreased?” I add, trying not to sound too questioning.

I have noticed in recent years more and more of my patients have decreased lung sounds and I think this is more because of my hearing than their conditions. Twenty years of sirens have taken their toll. I find myself out at dinner or other functions having to say, “What? Speak up.” It is even worse with patients. “You have to speak up,” I say. “It’s hard to hear over the engine.” Oh, how I hate patients who whisper because they are too sick in their minds to talk at a normal level. I try to be polite. “Speak up,” I say. “Use your full voice. I can’t help you, if I can’t hear what you are saying.” I am beginning to sound like a crotchety old man. I remind myself of my old partner Arthur who was always scolding people to speak up. There have been days when I have put the stethoscope in my ears and held it out to the patient and said, “If you can’t speak up, talk to this.”

But I must confess in the last week, even that trick was failing me. Every lung sound I listened to was decreased. I thought it might be the stethoscope itself. I tapped against the diaphragm with my finger to make certain I didn’t have it turned off. It was on. But then I would listen and hardly hear a thing. “Decreased,” I would say to the nurse. “But my hearing isn’t so great.”

So anyway, the other day, I go into the hospital and approach a particularly attractive nurse. I stand over her in my paramedic uniform with my stethoscope dangling around my neck. “Hey there, beautiful,” I say. “You are looking fine today. How about you come home with me tonight?” The other nurses laugh. The nurse I am talking to of course in the mother of my daughters. All the nurses know this except for a new one who appears astonished by my confidence, my forwardness. She has heard (been warned perhaps) about paramedics and here she is witnessing one of this bold breed in action.

The mother of my daughters looks up at me and smiles. “Your stethoscope is broken,” she says.

“Huh,” I say as it look at it. “I’ll be.” The plastic diaphragm covering and rim are missing.

“Here,” she says, pulling another stethoscope out of drawer. “I have an extra.”

Later that day.

“How were the lung sounds?” The doctor asks as I give my report. “Fine rales,” I say. “with a slight expiratory wheeze.”

He listens as well. “Yes, yes,” he says. “Precisely.”

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I am working with a young man who I have mentored since his first day as a volunteer at my old suburban post. I have tried to teach him the right way to do the job – to be thorough, to be considerate, to be empathetic, to be professional. We have done many calls together over the years, and he has made great strides from his first tentative days. I work with him now occasionally in the city.

I come in to work this morning and am glad to see he is my partner. They post us in a location straddling two towns. We stop at a doughnut shop for breakfast. And then we are dispatched to a cardiac arrest at a nursing home in one of the towns. My partner fires up the lights and sirens. Depending on who your partner is a cardiac arrest call can cause a little bit of anxiety. I have no anxiety this morning. I can depend on my partner. He is the EMT is in the old saying. Paramedics Save Lives, EMTs save paramedics. I am very proud of him. I flatter myself that he will carry on in my fine tradition long after I have left the streets.

We are not three minutes into our response when we get shut down as a closer unit is now available. My partner shuts off the lights, and then turns suddenly into the Dunkin’ Doughnuts just ahead.

“What you didn’t get enough to eat?” I ask.

“No,” he says. “Isn’t that what you taught me?”

“What?”

“Whenever you get canceled from a lights and sirens response, pull into the next doughnut shop you see so people will think you were using lights and sirens just to get doughnuts.”

“I said that?”

“Yeah, you said it makes you laugh so hard you nearly pee yourself every time you do it.”

“You sure that was me?”

“Yes, you said the thought that someone thought you were using lights and sirens to get doughnuts cracked you up. You would innocently say to the person if they followed you into the doughnut shop, “Oh, no sir, we were on our way to a cardiac arrest and we just got canceled. I’m just trying to grab a quick bite to eat before the next call. We would never use lights and sirens to get doughnuts.”

I have to admit it does sound vaguely familiar. I suppose I might have taught him that.

“You said you need humor in this job to keep you sane. You’ve got to have your laughs, you said.”

“Okay, well,” I say. “Well done then.”

What the young remember.

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I don’t get to read other blogs as much I would like. There are a few that I check in on periodically. I read Ambulance Driver when looking for a chuckle, I read Rescuing Providence when I want to read a quality vignette of an EMS scene call. I check out EMS 12-Lead to improve my cardiology education. But for me, the one indispensible blog is Rogue Medic. This guy slays it. He takes on EMS myth and bad science always on behalf of the patient. If I want to learn something new, this is where I go. And even when he is writing about studies I am familiar with, his take on them is always insightful.

Check out his thoughts on the new JAMA paper on epi in cardiac arrest, as well as his thoughts on the recent RAMPART study comparing IM midalzolam to IV atin in status epilepticus.

Rogue Medic is an EMS hero.

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Yesterday the American Medical Association published a landmark study (nonrandomized, observational) challenging conventional wisdom and possibly tolling the death knell for the use of epinephrine in cardiac arrest. In a study encompassing over 400,000 out-of-hospital cardiac arrests in Japan from 2005-2008, researchers are declaring that epinephrine in cardiac arrest may lead to worse survival and neurological outcomes than no drug at all. While their study also shows epinephrine leads to increased rates of return of spontaneous circulation (18% to 5%), despite this seemingly positive link to return of circulation, they are suggesting the longer term deleterious effects of the epinephrine may outweigh the short term positive effects. This study now clears the way for what previously would have been an unethical (because epi has been the standard of care) study – a randomized, blinded trial of epinephrine versus placebo.

The article and accompanying editorial are available to be read at the following links.

Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest

Questioning the Use of Epinephrine to Treat Cardiac Arrest

Twenty years in the field have taught me that getting pulses back with epi, particularly on a patient with asystole or PEA, does not mean the patient is going to walk out of the hospital. It feels great to get pulses and pressure back and have the patient start to breathe on their own, but in most cases, their name shows up in the obituaries within a week or two. They either die or their family faced with confirmed brain death agrees to pull the plug. I did a call a week ago – a patient in asystole who with a quick combitube, good CPR, and two doses of epi had pulses back. Some dopamine, normal saline, a fourth floor carry down and transport with no loss of circulation, had us all shaking each other’s hands. Yet each day, I check the obits looking for the patient’s name, just as I did a month ago for another patient who came back from asystole with a single dose of epi only to show up in the death pages a week later. Epi seems to jump start their hearts, but its effect on the brain may be a different story. Most of my true saves have been people who have dropped in public, gotten bystander CPR and come back with defibrillation. Years ago they said high-dose epi was bad for the patient, today it looks like any epi at all may be bad.

Now I am on a new death watch. As I have checked the obits for the names of my patients, in 2015, I will check the new AHA guidelines checking for epinephrine’s demise.

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I was in a parking garage over the weekend when my exit was held up by a woman in a SUV who took about five minutes to make all he turns necessary to back into a parking space. I was thinking why not just drive in straight? Why do you have to be parked for the quick getaway? It can’t be harder to back out then it is to back in.

While watching this and shaking my head, I was reminded of many times over the years, I have been driven lights and sirens hurtling through traffic to provide light-saving care (or not) to people who called 911 in distress, only to have to wait while my partner executed the same multiple turns to back into the driveway for the planned getaway.

This has never made sense to me. We drive lights and sirens for one reason — to get to the patient more quickly. We drive to the call with lights and sirens far more than we drive away lights and sirens. So why do we delay arriving in order to park the car for the getaway when we seldom need the quick departure? Why not just drive in straight and back out later after the emergency is over?

I have wanted to write about this for awhile and since now I am either in a fly car or have partner du jour, I run no risk of offending any current partner.

I am mild-mannered and easy-going. If something bothers me, I tend to not let it show. But now after all these years, here it is: Park the damn ambulance already!

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It never ceases to amaze me when it happens. When routine saves you.

I was talking with another EMS Clinical Coordinator recently, and he said he did not understand why some medics seem to check the blood sugar on virtually everyone. Why don’t they do it only when it is indicated? I argued that medics don’t do it on everyone, just likely everyone within a very wide net. Almost any medical patient who gets an IV and some trauma get their blood sugar checked by many of us. Why? Well, the hospital often asks what the patient’s blood sugar is, and you look like you are on top of your game when you can fire back a number. And two, and more importantly, it is just prudent care. Now when I speak of checking the blood sugar, what usually happens after I get an IV, is I take the catheter and using my pen push against the back of it, causing a small drop of blood to come out the front, and I press that against the glucometer strip. What I am testing is not the capillary blood from the finger tip, but venous blood, which is often slightly less than the capillary blood. I am not too concerned with 10 points here and there. I am looking to see if there is a big issue. Is the sugar abnormally high or abnormally low?

The other day, I had a patient with weakness, who’s caregivers said she was not herself, and had been deteriorating, and was much worse this morning. They mentioned her blood sugar was 150. In my head, I ruled out hypoglycemia. I did my assessment. We carried her out to the ambulance in a stair chair. In the ambulance I did a 12-lead and put in an IV. I checked the sugar almost as an afterthought, and there was the number – 43. I now rechecked it with capillary blood just to make sure – 37. Okay, now I understoodd. She was hypoglycemic and her glucometer was not working properly. Some D10 (we are trying not to use the concentrated D50 now) and she was now chatting with me. How stupid would I have looked if I hadn’t checked it? In my almost 20 years as a paramedic, when expecting a normal result, I have gotten a surprising diagnostic result probably 20 or 30 times. You are not thinking hypoglycemia and bingo, there it is. I don’t have to face the “You know that lady you called the stroke alert for? Her sugar was 20 ” from a know-it-all ED staffer. I have caught hypoglycemia as late as the ED parking lot. “You know the stroke alert I called in,” I tell the triage nurse, “Never mind.”

I get called for a seizure. Patient history of seizures, not taking her meds, had a seizure last night and another one this morning. They are described as nonconvulsive seizures with altered mental status. A BLS crew is on scene with patient. The address is not more than a mile from the hospital. The BLS crew will likely be fine to take her in, but I decide to ride it in, just as a precaution. With seizures, you never know, and I am by nature, cautious. My routine with seizures is I ride in with them and I do them ALS. Again, I put in an IV just as a precaution. The lady is a hard stick, but the IV gods are with me, and I snake in a 22 in her forearm.

We go on a non-priority. Then just as we get to the ED, the patient’s eye starts twitching. By the time we have her in the room, she is now full blown, tonic-clonic, earth-quaking, bed shaking seizure. They thank me for the IV, through which they push Ativan to control the seizure.

Why did I ride it in? Why the IV? Did I know she was going to seize again, and this time have a full-blown seizure. I did not. I did it because it was my routine. It’s what I have taught myself to do.

I get called for a man with weakness. He is diabetic and has been feeling light-headed this morning. He has trouble walking, no strength in his legs. I follow my routine. I pop him on the monitor, put in an IV, check his sugar – its 187. I do a 12-lead. The machine spits it out. If the ST elevations by themselves aren’t enough to open my eyes, the machine is screaming it out as well — ***ACUTE MI SUSPECTED***. Oh, my gosh. I radio ahead. Get the cath lab ready.

There are some medics who can walk in a room and in one glance tell you what is going on. I can do this sometimes, but I am not always right. Nor do I need to be. I just need to not tunnel vision on my first impression. I need to keep an open mind and follow my routine, which casts a wide net for all possibilities – hypoglycemia, recurrent seizure, STEMI.

There was no brilliance involved on these calls, just following a day to day routine. You never know when it will save you.

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Our regional guidelines say in status epilepticus, we can give Ativan IV or Midazolam IM when there is no IV access.

I have used both, and my anecdotal experience has been the Ativan resolves the seizure most of the time, and Midazalom only some of the time.

I have often given Midazolam to a seizing patient with poor access, and then once that dose was on board, looked for and found an IV, administered Ativan IV, and stopped the seizure.

So based on that anecdotal experience, if I thought I could get an IV, I went right for the IV, and once I got it, I pushed Ativan. I only tried Midazolam if I thought I was not going to get an IV or if I failed repeatedly to get an IV.

Now we have some evidence. A new study has just come out in The New England Journal of Medicine.

Citing both the need to get an IV in difficult patients to effectively give Ativan and Ativan’s limited shelf life when not kept refrigerated, the researchers asked the simple question, “Is IM Midazolam noninferior to IV Ativan in terminating seizures in the prehospital environment?”

To do this, they conducted a very interesting study. Medics were given a sealed kit containing either 10 mg Midazolam in an injectable syringe (think Epi-Pen) and an IV placebo or an injectable placebo and 4 mg Ativan for IV injection. When they opened the kit, a voice recorder was activated. They announced when they had given the IM dose, when they had obtained IV access, when they had pushed the IV dose and when the seizure stopped.

Included in the study were all patients over 13 kg, who were still seizing on EMS arrival and who received the study medication. Exclusions included patients with major trauma, bradycardia < 40, hypoglycemia, and pregnancy.

The study utilized over 4000 paramedics from 33 EMS agencies, and 79 hospitals.

Here’s what they found:

IM Midazolam stopped 329 of 448 (73.4%) seizures; IV Ativan stopped 282 of 445 (63.4%).

It took 1.2 minutes to administer the Midazolam and 4.8 minutes to administer the Ativan.

The IM Midazolam took 3.3 minutes to stop the seizure; the IV Ativan took 1.6 minutes.

For total time(includes getting access), it took Midazolam 4.5 minutes and IV Ativan 6.8 minutes to stop the seizure.

Between the two drugs, there was no difference in the need for intubation, no difference in repeat seizures or in hypotension.

Patients who received IM Midazolam were less likely to be admitted or go to the ICU.

The authors concluded that “the intramuscular administration of Midazolam by EMS is a practical, safe, and effective alternative to the intravenous route for treating prolonged convulsive seizures in the prehospital setting.”

In an accompanying editorial, Laurence Hirsch, M.D. wrote: “the findings in this study should lead to a systematic change in the way patients in status epilepticus are treated en route to the hospital.”

Shortly after this study came out, I responded to a call of a man down. On a third walkup apartment, I found a man face down in a pool of blood seizing. I do not know if the patient was beaten or if he seized and fell cutting himself on furniture before hitting the ground (I did find out later he had an intrcerebral hemorrhage). I was by myself, but I had my controlled substances in my pocket. The patient was fully clothed and the light in the apartment was dim. My thought was to try to get an IV and give him some Ativan. But getting an IV in that apartment was troublesome. My house bag was on the bed by the door, I needed to get his shirt and sweater off and lay out my IV kit. But the blood pool was quite large. Instead, I just opted to draw up some Midazolam and give him an IM injection. 5 mg stopped the seizure – at least temporarily. Enough to enable us to board and carry the patient out to the ambulance, where he started seizing again. Another 5 of Midazolam and he again stopped. On the way, we got IV access, and when the patient started seizing again, we gave Ativan. The patient did not seize again in our presence.

Had I not read the study I might have concluded Ativan was the drug that finally ended the patient’s ceasing based on anecdote, but having read it, my anecdotal case also supports the ability of Midazolam to stop at least temporarily a fairly significant seizure. I was satisfied with the way Midazolam worked on this call, and now that there is solid evidence of Midazolam’s effectiveness in relation to Ativan, I will definitely alter my practice to consider going right to the Midazolam IM to stop any seizure in the future. My take away from reading I have done on this is that the sooner you can gain control of a seizure, the better. With IM Midazolam you don’t have the risk of missing the IV, and further delaying treatment.

I wonder in how many of my anecdotal cases where I gave IM Midazolam in the past, the seizure would have stopped on its own anyway if I held off the Ativan IV, or in how many cases a larger dose of Midazolam would have done the trick.

The doses used in the study are worth noting: 10 mg of Midazolam and 4 mg of Ativan. Our current protocols call for 5 mg of Midazolam or 2 mg of Ativan, repeated in 5 minutes.

Maybe our doses need to be raised when we next review our guidelines.

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The Annual Gathering of Eagles Conference is over and the presentations are now posted on-line.

The “Eagles” Coalition, also known as The U.S. Metropolitan Municipalities EMS Medical Directors Consortium includes most of the EMS Medical Directors for the nation’s largest cities 9-1-1 systems. The conference highlights “the most cutting edge information on EMS research, management issues, lessons learned and newly-proposed advanced patient care techniques.”

Gathering of Eagles 2012 Presentations

Check out these two presentations in particular:

The Pentagon Papers: The Five Most Important Publications of the Past Year – Corey M. Slovis, MD (Nashville)

Epileptic Fix: Hot-Off-the-Press Results from the RAMPART Trial Jason T. McMullan, MD (Cincinnati)

If you want to stay on top of the latest trends and research in EMS, you have to know what the Eagles are talking about.

***

Gathering of Eagles 2010

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A couple years I was interviewed by Greg Friese for a podcast in a series he was starting about EMS writers. I enjoyed chatting with him at the time, but it wasn’t until the other night that I really checked out his collection of author interviews. He now has a stand alone blog site called Medical Author Chat. I listened to three of the interviews last night – the ones with fellow fireemsblogs.com bloggers, Michael Morse and Kelly Grayson, and another with Maggie Dubris, a little known, but excellent writer, who has produced two of the best works of EMS writing I know (the poem “Willie World” and the short story from “Weep Not, My Wanton” about the birth of a premature infant in Times Square.

I was fascinated to hear Greg Friese’s interviews of writers and look forward to listening to the rest of his series, including interviews with several authors of EMS books I had been unaware of. I would encourage you to check these out.

Medical Author Chat

Michael Morse

Kelly Grayson

Maggie Dubris

And here’s the one he did with me:

Peter Canning

EMS writing records the way we live. Not only do people who are unfamiliar with our world get a glimpse of it through our works, but years from now, it will serve as a historical record, primary sources of what life was like in our worlds. Greg has done a valuable service by recording the thoughts of the writers behind these works.

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I’m sitting in my ambulance posted in the North end of Hartford. Thankfully it has been a quiet morning so far and that has enabled me to finish Responding, Michael Morse’s great sequel to his first book Rescuing Providence. Michael is an excellent writer and one of the best EMS bloggers around.

Responding chronicles a 38 hour shift, but it also has flashbacks to earlier calls, and at the end has many of the short stand alone stories that for me are the reason for reading Morse’s blog.

What I like about this book, as well, as his first one, is that I found at several points, I was reminded of what I like most about EMS – the view of others’ lives and the quiet moments where you just stop and feel the whole universe around you, and sad or joyful, tragic or miraculous in that moment you feel that you are a witness to life and the human condition that is laid bare before you, and even if that moment hurts, you feel honored to be allowed to see and feel it and to be present. Three moments in particular in this book stand out for me, Morse on scene over time with a Cambodian woman, whose history he has learned, the brutal childhood and the spiral into alcohol, ending with him present to call the time on her now cold and stiff body; a scene where Morse visits his own mother in a nursing home and brushes her hair while she sleeps; and then on a transport to pick up a child with severe disabilities, and witness the love of his caregivers, as they brush the boy’s hair who they have cared for his whole life and say good bye. We as EMS are there in moments where we see life in its barest truth, and we also have the gift of touch that the single most powerful gesture we possess to affirm that we, as an individual and as a collective, are human.

And by recording these moments, Morse brings our world to life and does the job of the writer that of bearing witness to our humanity.

I think this is what William Faulkner was getting at in hisNobel Prize address, where he described the job of a writer. Man, he wrote, “is immortal, not because he alone among creatures has an inexhaustible voice, but because he has a soul, a spirit capable of compassion and sacrifice and endurance. The poet’s, the writer’s, duty is to write about these things. It is his privilege to help man endure by lifting his heart, by reminding him of the courage and honor and hope and pride and compassion and pity and sacrifice which have been the glory of his past. The poet’s voice need not merely be the record of man, it can be one of the props, the pillars to help him endure and prevail.”

Before I became an EMT I read EMS books for accounts of the calls. Now the calls themselves are less interesting to me that the writer’s ability to chronicle what our lives in EMS are really like. While this book has war stories, more important for me is the view of what Morse’s life and world is like as an emergency responder and how he has come to his place in it.

Responding is welcome addition to our growing body of EMS literature.

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