Ahh, the simplest things.  You need the patient’s name, date of birth,  and social security number if possible.  The name is most important.  If the name is John Smith or Juan Martinez, the date of birth helps.

I was a brand new spanking EMT and we had a patient in classic CHF — I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum.  We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out.  No name, no DOB, no social, just the address we picked him up at.  Chalk that one up to two excited rookies.

On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you.  In the past, I didn’t often bother with this information if the patient was talking to me.  I figured I could get it out in the ambulance.  I look at the elderly patient and say  “You know your date of birth and social security number?”   The patient looks me right in the eye and says “yes, sir.”  Very good.

On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth.  “Yes, sir!”  he says.  Same answer to social security number.  I ask him his name.  “Yes, sir!”

Always get the name and social.

I am in the nursing home and the nurse hands me the envelope.  I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it.  Check.  Check.  The patient is unresponsive.  Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition.  I notice then that patient’s name is Mary Wilson.  The problem is the patient is a man.  I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.

Here’s one.  Nursing home patient is unresponsive.  Ambulance crew takes patient and paperwork.  Patient’s blood sugar turns out to be 29, but he is not a diabetic.  They give him D50, and he comes around, but is still somewhat confused.  At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic.  Plus he is still confused.  He won’t answer to his name.  Later that night, the hospital gets a call from the nursing home to check on the patient.  Who?  The hospital says, we have no one by that name here.  Later the hospital calls the nursing home back.  We do have someone here from your facility named Edward Thomas.  Ahh, no you don’t.  Edward is right here next to me in his wheelchair.  Whoops.  No wonder the man in the hospital bed won’t answer to his name.  Turns out the patient is a diabetic after all.

You have to check the name.  If the patient can’t confirm it, check for a name bracelet.  No bracelet?  Get a nurse to verify the patient and paperwork are one and the same.

You’d think it would be easy, but it’s not.  The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder’s previous patient, and not this current one.  The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper.  Not the  patient in front of me.

I try hard now.  I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name.  Mistaken identity can lead to serious errors, and those we always want to avoid.

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In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments.  Simple enough.  If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag.  Some might say you should also be bringing in your suction –anything you might need.  You never know what you are walking into.  But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you.  (At least in cases A-D). Here’s where the problems begin.

Problem A 

Both batteries are dead.  You checked them this morning and you swear they both had four bars.  Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead.  What happened?  Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down.  I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.”  What do you do?  If you are still in the truck when the battery is beeping, you change the batteries out.  Simple enough.  But let’s say they are both dead and you don’t notice until you are in the house.  You take the spare battery out of the back.  How do you know you have a spare battery?  Because this has happened to you before, so you always keep a spare battery in the back now.  Always.

Problem B

The batteries are good, but when you attach the electrodes, nothing reads on the screen.  You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change.  Still nothing.  You take the electrodes off and apply some new ones from the same open bag, and still nothing.  You blame the monitor.  Is it the monitor?  No, some of you may have guessed from your experience or from what I have written that reveals the clue.  The problem is the electrodes are from an open bag and they are dried out.  You were smart enough to switch electrodes, but you took the new ones out of the same open bag.  Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem.  I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this — from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.

Problem C

You need to do a 12-Lead.  Whoops, you have the regular cable, but the 12-lead attachment cable is missing.  It fell out and no one noticed or you forgot to check carefully this morning.  Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic.  What do you do?  A modified 9-Lead.  This is how we did 12-leads before we had Life-Pack 12s.  Take the left leg lead — the red lead, and move it to the V1 position.  Run Lead III in diagnostic mode.  Repeat with V2, V3, V4, V5 and V6.  Label each lead as follows:  McL (modified chest Lead)1, McL2, McL3, etc…  While not exact replicas, they do passably well.  You do this and see hyperacute T waves in McL3 and McL4 and McL5.  Call in a STEMI Alert.

Problem D

This time you have your 12-Lead cables, but that is all you have.  You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables.  Your patient is alert, but very clammy and you can’t feel a pulse.  What do you do?  Take out the defib pads, and apply them to the chest.  Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set.  If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print.  If it is a sinus, well at least you know that.

Problem E

Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor.  D’oh!  What happened?  Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh!  I was lucky enough that my call was not a chest pain, but a BLS call.  Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept.  Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed.  Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.

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I am introducing a new series. I am calling it Street Lessons, but I could just as well call it any of the following:

Things They Didn’t Teach Me in Paramedic School

Things They Might have Taught Me in Paramedic School, but I Was on a Bathroom Break.

Oh Shit!

Things I Learned The Hard Way

Trial and Error

Eureka! or Light Bulb Moments

***

Street Lesson # 1

Don’t Carry Hypotensive Patients in a Stair Chair

Over the years, I have had five patients go into cardiac arrest while I carried them in a stair chair. What does that tell me? It could mean that I carry a lot of patients in stair chairs. It could mean there are not very many elevators in the city I work in. It could mean I have done a ton of calls in my twenty plus years in the field. All would be true. And I can say I have never had an ambulatory patient go into cardiac arrest on me — at least not while I have been ambulating them. My first words to my partner on arriving at patient bedside are usually, “Get the stair chair.” The old saying “ABCs – Ambulate Before Carry” – it is not in my book of sayings.

Still five patients coding on the stair chair seems like a lot — certainly enough for me to wonder whether their coding was in any way related to their being on the stair chair.

So why might they code on a stair chair?

They are sick and dying and called 911, and if we hadn’t arrived as soon as we did, they would have gone into cardiac arrest at that precise moment anyway.

They are sick and dying and the fact that they were being carried down steep creaky stairs scared the last bit of life out of them.

Or maybe they were hypotensive and when we sat them up, their weak hearts couldn’t compensate, and that little extra bit of stress was enough to push them into the void.

I cannot remember the details of all five cases. But I can remember each of them dropping their head back or dropping it forward in a manner that indicated they no longer had muscle control. Sometimes they took a last gasp or two, sometimes not. I am a big believer in working a cardiac arrest right where they code, not losing a precious second in poor or absent CPR. Still it is hard to just stop carrying someone mid-stair case and start rescusitation.

“You know what just happened?” I will say to my partner.

“What?

“The patient just coded.”

So what is the lesson in all of this (Besides, expect if you do enough calls and carry enough people some will code on the stair chair)?

My lesson is — if the patient is hypotensive while supine or borderline hypotensive and they are sick, consider carrying them in a scoop stretcher.

A 20-year-old with a pressure of 80 due to vomiting may be less at risk that an 80-year-old cancer patient with altered mental status, tachycardia and a pressure of 100. If a patient gets dizzy sitting up, then don’t use the stair chair. It may not spare you having them arrest on you during extrication, but it will be less likely to cause harm.

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Last week, I spent a fascinating hour and a half with two members of Physio-Control’s technical team going over the 12-Leads I discussed in a recent post. I was extremely impressed with their knowledge, their desire to improve the computer’s algorithms, and their commitment to patient care.

I went back over each of the charts to determine the discharge diagnoses of each case and any other relevant data, and was also able at their suggestion to obtain the 12-lead’s PCO file, which is available through CODE-Stat software, that provides a far more detailed look at what the computer is actually seeing when it makes its call. Unfortunately, I only had access to the PCO files to the most recent third of the transmissions.

From the original 58 transmissions, I excluded 9 -12-leads due to the following reasons, 3-patients went to other hospitals and had unconfirmable diagnoses, 3-12-leads from 1 patient who was a patient 4 times (all 4 times, his 12-lead triggered a false Acute MI reading), 1 patient who was a DNR and may not have been considered for the cath lab, 1 -12 lead from a patient who had a second 12-lead recorded several minutes later, but who had been listed as two separate patients, and one due to clear arm lead reversal that was later corrected in untransmitted 12-leads. I also recategorized one of the missed STEMIs as a confirmed STEMI when the PCO file revealed, all arm motion in the transmitted ECG and all three subsequent, but nontransmitted ECGs correctly called the ECG as a STEMI. And I recategorized another inappropriately labeled STEMI as a correct STEMI when I discovered a coding area in the chart.

So here then is the revised bottom line:

49 Transmitted ECGs (49 Patients that were either machine called STEMIs or clinical STEMIs not called by the machine. Patients who had nondiagnostic 12-leads were excluded).

Of the 42 called STEMI by the machine, 21 went to cath lab (50%), 19 were classified STEMI (45%), two had clean arteries.

23 ECGS incorrectly called STEMI (55%), 21 that did not go to cath lab (50%).

Of the 26 confirmed clinical STEMIs in the batch, 7 were missed by the machine interpretation (27%). The machine correctly captured captured 19 (73%).

If this small back of the envelope sample holds true, then you could say the computer will identify 73% of STEMIs, but miss 27%.

Likewise, if it were to hold true, if the machine does call a 12-lead a STEMI, there is a 50% chance they will go to the cath lab, and a 45% chance that it is actually a STEMI.

These are better figures than what I first reported, but still concerning if the computer interpretation’s limitations are not properly understood and accounted for in patient care algorithms.

Had we been able to view the PCO files from all the 12-leads, other small adjustments may have been made.

Keep in mind that this was not a rigorous scientific study. Such a study could and should be done, preferably at an institution with a high volume of transmitted ECGs.

That aside, here then are the lessons we should take from this.

1. Systems that require the computer to interpret the 12-Lead as a STEMI for activation put patients at risk. If the computer interpretation alone buys you a trip to the cath lab, some people will be cathed unneccessarily.

Also, if you can only preactivate the cath lab if the machine calls it a STEMI, many people having obvious STEMIs will have their care delayed.

2. The machine is only as good as the quality of the data. Failure to put the electrodes in the right place, to see that they are well affixed and that patient is not moving can lead to a false reading.

The fact that many paramedics I have talked to, have recognized this, and then redone a 12-lead suggests an even higher computer miscall rate, but it also suggests that vigilance to this, and perhaps requiring a 2nd 12-lead of high data quality, might lower the miscall rate substantially.

Paramedics should be very careful when acquiring 12-leads and if they distrust the result, should consider getting a 2nd 12-lead of higher quality after trouble-shooting any movement issues. Systems likewise should consider the 12-lead they are receiving may not reflect pristine positioning and lack of movement and may be treated with some skepticism.

3. There are two well defined examples that appear to mislead the machine – aflutter (which has been recognized by Tom Bouthillet at EMS 12-Lead and hyperactute T waves in the anterior leads. Of the 7 missed STEMIs in this small survey 5 had hyperactute T waves in the anterior leads. Of the 23 inaccurately called STEMIs, 4 had atrial flutter as an underlying rhythm.

Here are some examples of some of the hyperacute T wave misses.

4. Physio-control is committed to providing the best product possible. They will be sending many of the PCO files I shared with them to Glascow, which produces the algorithm, for analysis.

5. Ultimately, no computer will be perfect. The software should always just be used as an adjunct, a valuable adjunct, but not a requirement replacing human consideration.

On a final note, I think EMS has an obligation to do more than complain about the computer error. We should

a. Insisit on proper ECG placement and data quality
b. Identify patterns of errors and share this information with the developers of the algorithms so they can improve on them for our mutual goal of improved patient care and outcomes.

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In previous posts, I wrote about paramedics’ ability to identify STEMIs and about the computer’s ability to identify STEMIs. My conclusions were that unless 12-lead interpretation is a major and continual focus of paramedic education and qualify assurance, paramedics’ ability to recognize STEMI will not be optimal. While most paramedics can easily identify an inferior STEMI, lateral and anterior can at times be more difficult, the lateral because it is often subtler and the anterior because it is often confused by the STEMI mimics. As far as the computer’s interpretation ability, while it can be used as an interpretation assist, and is constantly being improved, I don’t feel it is yet ready for prime-time. The software misses too many STEMIs and inaccurately calls too many nonSTEMIs as STEMIs. While the computer companies are working hard to improve their algorithm, they are just not there yet. Today I address the question of transmitting 12-leads. Should all paramedic services be required to have 12-lead transmission capability?

I admit I have had a small bias against transmission. The services I have worked for have not had the transmission capability (We are getting it very soon). In our area there are three hospitals that allow paramedics to activate the cath lab based on recognition, one that requires transmission for the hospital to preactivate the cath lab. Unless, the patient absolutely insists, I go to the other hospitals because I know I can get the patient to the cath lab quicker because those hospitals will activate in advance of our arrival at the ED based on my interpretation alone. I do also work for a hospital where half the STEMIs that come in are from services that transmit and the other half do not. Our best times are from the service that does not transmit, but just barely.

Transmission is not necessary for the obvious big I can see it from across the room STEMIs if you have a paramedic who can give a good patch and a doctor at the other end willing to trust the interpretation. Two hospitals in our state that have excellent door to balloon times (their medics go right to the cath lab) do not rely on transmission at all. But here is the question I wonder about. If you rely on paramedics alone, are paramedics more apt to only call in the obvious STEMIs? What happens to the patients with the more subtler STEMIs? Are they missed? I would like to see a study asking this question. I wonder about this because we have had an occasional hard time just getting paramedics to call in on obvious STEMIs. In hospitals that have 100% of their services transmitting, do they have fewer missed STEMIs than those hospitals where none of their services transmit? By missed STEMI I mean a STEMI that is not recognized until the hospital that shows the same morphology on the prehospital 12-lead as opposed to the ECG evolving into a STEMI after ED arrival. My guess is that the all transmission system, where paramedics are encouraged to send in borderline 12-Leads capture a greater percentage of STEMIs. But this is just a hypothesis. I await a study for verification.

What do I feel is the ideal system? Here it is:

1. Include 12-lead competency in all paramedic education and QA
2. Encourage medics to consider but not rely on computer interpretation.
3. Tell medics to call in not just definite STEMIs but possible STEMIs. There is no shame in being wrong.
4. Add transmission capability.

With these four components in place, no STEMI should fall through the cracks.

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On Tuesday, our region voted to adopt a spinal board policy similar to the Yale-New Haven Sponsor Hospital document that came out a few months back as a first step toward eliminating the use of the long backboard for anything but extrication and movement. Today, the state EMS medical advisory committee (CEMSMAC) is expected to begin reviewing a guideline based on the National EMS Physician’s October draft that recommended eliminating long boards for spinal immobilization. Earlier, the state committee voted to develop guidelines based on that position paper.

At the meeting on Tuesday we debated a stronger document, but ultimately decided it would cause too many problems to be out of whack with what CEMSMAC might develop, so we decided to go in unison with New Haven, and then adopt the more comprehensive state document when it is ready. Hopefully, the state document will be ready for implementation soon.

Our limited policy will start on April 22. We again debated an implementation time ranging from waiting for the textbooks to be rewritten to opening up the window of the committee room and shouting. “Free at Last! Free at Last! Unboard My People Now!” Or perhaps, immediately adjourning the meeting, joining arms and skipping down Blue Hills Avenue, arm in arm, singing “Ding Dong! The board is dead! The wicked board is dead!” In the end we went with a two week notice to give the EDs and first responders time to be advised in order to prevent conflict, shouting, rioting and chaos.

Stay tuned.

***

Text of North Central position:

“Effective April 22, 2013, long backboards will no longer be utilized for spinal immobilization of ambulatory patients. Patients who are ambulatory at the scene, but who require cervical immobilization based on our regional spinal immobilization guidelines, will be placed in the position of comfort, limiting movement of the neck during the process. This change in procedure is the first step toward eventually using long boards only when needed to facilitate extrication, and not during transport.”

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Several years ago I told a group of paramedics that while not relaying on the computer interpretation in the case of STEMI, they should consider it as a fellow paramedic offering his opinion. I told them that the studies showed a 60% sensitivity and a 90% specificity in identifying STEMI. In other words, the computer would only identify 60% of the STEMIs, but if it identified a STEMI, it was going to be right about 90% of the time. I based this on several older studies I had read.

I can tell you as a paramedic when I suspect a patient may be having a STEMI and the computer agrees and the tracing meets criteria, I feel much better about calling a STEMI alert. I confess once when I had a patient with an ECG suggesting a small elevation in I and AVL. I did 9 ECGs en route to the hospital, and finally on the 5th one, the computer came around and agreed with my suspicion that the patient was possibly having a STEMI, giving me the maniless to call in the alert (I know I was being a wimp). Though the computer reversed course again on the 6th and 9th ECG, the patient was in fact having a lateral STEMI. He coded in the ED, was revived and successfully had his 100% occlusion in his circumflex artery stented.

Conversely when the computer calls it a STEMI, but I disagree with the reading, I recheck my lead placement and do another. Some make me doubt my reading ability, others make me want to put a dunce cap on the monitor and put in the corner of the ambulance facing the wall. You weren’t paying attention in paramedic school obviously, bad monitor!

A new study in the April-June 2013 Prehospital Emergency Care, Prehospital Electrocardiographic Computer Identification of ST-segment Elevation Myocardial Infarction, reports a 58% sensitivity and a 100% specificity for computer interpretation.

They reviewed the transmitted 12-leads of a 100 consecutive STEMIs and found 58 of them had the interpretation “Acute MI Suspected” on the 12-lead. Then to determine specificity, they analyzed 100 random 12-leads from non STEMI patients and found none of them incorrectly said “Acute MI Suspected.”

I must ask: Does this high specificity match anyone’s experience? Or even come close?

How often do you do a 12-lead and it says ***Acute MI Suspected*** or “Consider Acute MI” depending on the monitor you use, and you can look at the 12-lead and say No. Not even close.

In my hospital I receive an email each time a 12-lead is transmitted. I enjoy reading the strip. Our medical director and I play a STEMI game where we immediately email each other with our vote STEMI or no STEMI assuming the patient always to be symptomatic. I can tell you the number of 12-leads transmitted that say “Consider Acute MI” is way more than the number that actually are STEMIs.

Consider these:

The computer seems particularly inaccurate in wide complex and tachycardic strips.

I have had to go back to the medics and say the studies are wrong. Don’t put as much stock in the computer interpretation as I suggested you should. It is not close to 90% accurate.

An informal tally using the same criteria as the 2012 study for sensitivity shows the Life Pack 15 is about 60%. It properly identifies 60% of STEMIs, but misses 40%.

But then when I analyze specificity, I admittedly use a different criteria, which will yield a markedly different, but more telling conclusion. I ask, what percentage of the time when the computer reads “Meets ST Elevation Criteria” and “Consider Acute Infarct,” is it actually a STEMI? And the answer in this small sample (50 cases) is 32%. Not 100%.

Note: The published study cited above used the Life Pack 12, my figures are for the LifePack 15, which uses a different software.

The computer seems to consistently misread tachycardic rhythms and wide complex rhythms.

These, in my mind, are the proper questions we should be asking if we are going to incorporate the machine reading into our decisions:

What percent of the time is it a STEMI and the machine missed it? Seems to run about 60%

When the machine does call it a STEMI, what percentage of the time is it right? That answer is clearly not 100%, or even close.

Obviously, this should be confirmed in formal studies, which can be easily done at any PCI facility.

Does this mean I would be in favor of removing the interpretation from the machines? No, I think they can be valuable. I am just saying we shouldn’t be misleading others and ourselves by claiming the machines are better than they are.

When making policy that incorporates the computer reading into the decision making, we need to understand its limitations.

We need to make certain that paramedics are not relaying on the computer alone to call, and that if the machine does read STEMI, the medic makes agrees with the interpretation.

And we need to continue to work to improve basic paramedic interpretation, as well as proper placement and technique of ECG aquisition.

This will help limit false activations for services that cannot transmit.

Note: In our state we use the following to help determine diversion to a PCI center:

c. ***ACUTE MI*** or equivalent prints on 12-lead ECG; paramedic agrees

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If I show this 12-lead to a group of paramedics, I would wager close to 100% would accurately identify it as an inferior MI and call in a STEMI alert if the 50 year old male patient in front of them was clutching his chest.

Now, if I have the same patient and the 12-lead shows this;

How many paramedics are going to say this is a STEMI?

It is not a STEMI, it is a Left Ventricular Hypertrophy.

In a recent  study published in the April 2013 issue of Prehospital Emergenncy Care, 63.3% of paramedics identified this ECG as a STEMI.

The study, PARAMEDIC ABILITY TO RECOGNIZE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION ON PREHOSPITAL ELECTROCARDIOGRAMS, by Mencl, et al, goes against the findings of prior studies that have shown paramedics can identify STEMIs with a high degree of accuracy. The limitations of the other studies have been that they have used paramedics right after training classes and in many cases had them evaluate only a small number of relatively obvious ECGs. The 12-leads used in this study I believe offer a more realistic test of a paramedic’s interpretation abilities.

In this study they had 472 paramedics from 30 different EMS services in five counties with 15 different medical directors read 10 different ECGs and were asked to either identify the strip as a STEMI or not.

Here’s how they did:

The number indicates the percentage of paramedics who correctly identified the rythm as a STEMI or not a STEMI.

Inferior STEMI 96.0%, Anterior STEMI 78.0%, Lateral STEMI 51.1%

Normal 1 97.3%, Normal 2 100%

RBBB 79.2%, LBBB 39.0%, Ventricular pacing 52.8%, LVH 36.7% , SVT 65.3%

The study concludes: “Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics’ low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training.”

I took the 10 ECGs from this study and gave them as a test to a large group of paramedics ranging from twenty-year veterans to new paramedics and found similar results.  These results square with my observations of paramedics bringing possible STEMI patients into our hospital.

Here’s what I take from it:

Paramedics can identify inferior STEMIs with a high degree of reliability.  Lateral and Anterior STEMIs can be more difficult.  Left bundle branch and LVH can particularly cause confusion in some paramedics.

My experience with field STEMI alerts is that paramedics tend to by shy about calling for STEMI alerts, and thus have fewer false activations than this study, if extrapolated,  would suggest.  In other words, if a paramedic is sure it is a STEMI, such as an inferior, the paramedic will call in a STEMI alert.  But while the paramedic might guess a 12-lead is a STEMI such as the LVH ECG above, the paramedic might be less likely to call in a STEMI alert with it. 

Despite this well done study, I continue to support field activation of the cath lab through paramedic interpretation alone, but I do believe we need to increase our 12-lead training efforts.

I believe that with frequent training and regular competency checking, paramedics can indeed identify STEMIs with a high degree of reliability.  But if you don’t do the training and keep it up, the results will not be as high.

In a future post – What about computer interpretation?

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In a recent post((These Go to Eleven), I made fun of some of my patients’ uses of pain scales. While I am big advocate for pain management, I am occasionally stumped by the pain scale declarations of 10. This last week in reading the report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, I read a section on pain scales that I thought was interesting.

Pain scales were widely introduced into the health care system in 2001 due to the efforts of the Joint Commission of Health Care Organizations which made pain the “5th Vital Sign” and a requirement for hospital accreditation. Health care personnel were now required to document a pain scale in a patient’s record right next to the more traditional vital signs of pulse, blood pressure, respiratory rate and temperature. It wasn’t long after that EMS began to require pain scales as well. In our region every patient requires a documented pain scale whether or not they are complaining of pain.

Here is what I read in the Relieving Pain book:

The full impact of the fifth vital sign approach is not entirely clear, however, as studies have indicated effects ranging from beneficial and limited outcomes to negative consequences. While adherence to the standard has improved satisfaction with pain management, adverse drug reactions have increased (Vila et al., 2005). In selected trauma care centers, overmedication with opioids and sedatives—attributed by the researchers to compliance with the new standard—reportedly contributed to higher mortality rates, usually resulting from too great a reduction in blood pressure or compression of the airway (Lucas et al., 2007). In a veterans’ outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006). Similarly, in a study of eight veterans’ facilities in the Los Angeles area, documentation of pain—necessary for pain care planning—was frequently absent from the medical records of patients with moderate and severe pain (Zubkoff et al., 2010). Taken together, these studies suggest the need to exercise careful clinical judgment based on a comprehensive patient assessment instead of merely monitoring pain (meeting, in a sense, the letter of the law and not the spirit), using opioids to the exclusion of other treatment approaches, or routinely using these powerful medications when their use is not clinically indicated.

What I take from this is we need to exercise “careful clinical judgment” when evaluating pain. Every patient should get a pain scale, but we should not relay entirely on that scale to guide our treatment. I am not suggesting we revert back to the “I can judge your pain” mentality, when studies have clearly shown people are incapable of accurately judging another’s pain. What I mean by clinical judgment, is that paramedics need to decide, based on a number of factors, what is the most appropriate method of treating someone’s pain. Automatically giving a narcotic analgesic to any patient who says his pain is a 10 is no more right than automatically refusing to give narcotic analgesics because a patient doesn’t look like he is in pain.

It comes down to the old cookbook analogy. Paramedics should never blindly follow a protocol. Instead paramedics should assess, evaluate, consider, and then act in the best interests of the patient. And, of course, document why you reach the clinical course you do.

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I have written much about pain management and find it one of the most gratifying aspects of being a care-giver. I feel a little bad that in my last post I made fun of some of my patient’s pain scales – something I will address further in my next post, but I wanted today to reclaim the high road and talk about a book –Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research – I highly recommend to all.

The book is largely about chronic pain, but it does mention acute pain and the need to treat it promptly. Unfortunately there is no mention of the EMS role in the book, but there are still many lessons for us in it.

I am going to quote and comment on the opening paragraph of the book, which I think is beautifully written and drives home much of what I have come to learn and feel about the importance of pain management.

“Protection from and relief of pain and suffering are a fundamental feature of the human contract we make as parents, partners, children, family, friends, and community members, as well as a cardinal underpinning of the art and science of healing.”

The very first role of ancient healers was to treat pain. In the mix of our learning of various diseases and the skills to combat them, we often neglect the very patient in front of us. William Osler, the father of modern medicine said, “Care more for the individual patient than for the special features of the disease.”

“Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences.”

I have been giving my pain management talks for a long time and, at times, have been nearly hooted out of the room by old guard medics who followed the “I have to hurt looking at you for me to give you pain meds” philosophy and others who see a drug-seeker behind every person in pain. Over time many of these paramedics have come back to me and apologized, and said they had no idea of what pain was until they tore their shoulder or had a kidney stone themselves, and now they treat patients much more liberally and compassionately, understanding what it is like to be in real pain.

“While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying cause to become a disease in its own domains and dimensions.”

Untreated acute pain can rewire a patient’s body making them more susceptible to pain in the future. For people who think pain is a simple message from the injured part to the brain that goes away when the injury heals should think about amputees who still feel pain in their missing limbs to understand the complexity of our neurons and physiology. We need to think of pain as a disease that attacks the body right from the outset and pain management as a time sensitive intervention that in cases of acute pain, can affect the outcome of patient’s lives. As Dr. R McKenzie writes “The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”

“We all may share common accountings of pain, but in reality, our experiences with pain are deeply personal, filtered through the lens of our unique biology, the society and community in which we were born and live, the personalities and styles of coping we have developed, and the manner in which our life journey has been enjoined with health and disease.”

Who are we to sit in judgment of others, not having walked in their shoes? Should the judgment of Drug Seeker! and Faker! be gaveled down in the court of the back of the ambulance? I am uncomfortable with that. I would rather err on the side of the patient and let the rest be sorted out in the hospital. How many times can we be wrong about a drug seeker to justify withholding drugs from someone truly in pain? And we must remember often people seek drugs because of their pain. They aren’t all just bored and looking to get a quick high.

“The personal experience of pain is often difficult to describe, and the words we choose to describe pain rarely capture its personal impact, whether it is sudden and limited or persists over time.”

Pain scales I realize are imperfect and better techniques of assessing pain need to be developed. But more about pain scales and their pros and cons in the next post.

“Severe or chronic pain can overtake our lives, having an impact on us as individuals as well as on our family, friends, and community.”

People as young children didn’t dream of growing up to become dependent on pain medicince. The suicide rate for people with chronic pain is much higher than the national norm. 100 million Americans suffer from chronic pain. Many of us will suffer chronic pain at some point in our lives. Let’s hope our care-givers are compassionate with us.

“Through the ages, pain and suffering have been the substrates for great works of fiction, but the reality of the experience, especially when persistent, has little redeeming or romantic quality.”

For most of history people believed that the mind and the body were separate — that people could just soldier on without damage. But we have learned now that mind and body are interlinked by physiology. Pain can destroy both body and mind.

“The personal story of pain can be transformative or can blunt the human values of joy, happiness, and even human connectedness.”

No one should have to sit before another and have to beg to be treated as a fellow human. In EMS we are caregivers. We are the door to compassion – to human connectedness. Open 24/7.

***

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research is a publication of the National Institute of Medicine that came out in 2011 and is available for free PDF download at this site:

Relieving Pain in America

Here is the description of the report:

Chronic pain costs the nation up to $635 billion each year in medical treatment and lost productivity. The 2010 Patient Protection and Affordable Care Act required the Department of Health and Human Services (HHS) to enlist the IOM in examining pain as a public health problem. In this report, the IOM offers a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America. To reach the vast multitude of people with various types of pain, the nation must adopt a population-level prevention and management strategy. The IOM recommends that HHS develop a comprehensive plan with specific goals, actions, and timeframes. Better data are needed to help shape efforts, especially on the groups of people currently underdiagnosed and undertreated, and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. Because pain varies from patient to patient, healthcare providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted. In addition, because there are major gaps in knowledge about pain across health care and society alike, the IOM recommends that federal agencies and other stakeholders redesign education programs to bridge these gaps. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

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I recently ran across a fairly new blog that has made my regular read list. Mill Hill Ave Command is written by Brooks Walsh, an EMS medical control Doc in Bridgeport, Connecticut who comes from an EMS background (former EMT and paramedic). His posts center around recent research or interesting calls his medics have brought in. The posts are intelligent, easy to read and may change the way you practice or at least how you think about calls you are on. Recent posts tackle the issues of spinal immobilization, pain management, STEMI, cardiac arrest resuscitation and NTG in CHF and ACS. Walsh is also the coauthor of a recent study published in Prehospital Emergency Care about paramedic attitudes toward pain management that is quite eye-opening.

Paramedic attitudes regarding prehospital analgesia.

One of the best things about EMS I have seen over the years is the influx of motivated young EMS doctors who came from the streets themselves, who respect the work we do and are actively working to improve our systems and the care we provide. Brooks Walsh is one of these docs. You won’t be disappointed when you check his blog out.

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I am all for pain management, and in just about all cases I give my patients the full benefit of the doubt. Still, sometimes I am confounded by the answers I get to the pain scale question. “That’s be a 10.” “Oh, I’d say definately an 10.” “Five thousand. On the scale, mine is a five thousand.”

The other day my preceptee asked a patient his pain scale, and the man calmly said, “That’d be a 10.”

Now I don’t even remember what the patient’s presentation was it was such an unremarkable call.

“I don’t think you understand,” my preceptee said. “Zero is no pain, 10 is like an alligator biting your leg off pain.”

I about drove off the road I was laughing so hard.

Unphased, the man said, “Yeah, mine’s a ten.”

Later in the day, another woman said her pain was an 11.

It made me recall the famous scene from the movie, This is Spinal Tap, where the guitarist describes his amplifiers that go to 11.

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A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster–is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

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I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student’s own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service’s medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again.

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I had an interesting discussion with an EMS coordinator friend of mine on the issue of enhanced BLS. He conceded that while, it was true BLS could easily be taught to give IN Narcan or put on CPAP, his worry was that allowing Basic EMTs to do so many things, their towns or services would feel they did not have to upgrade to the paramedic level. He then showed me an email he had received from another medic arguing for enhanced BLS in his area because that area could not economically support more paramedics. The phrase “could not economically support” was what upset him. He felt that if a town could support police and fire, they ought to be able to support paramedic level EMS services.

I agreed with him. Most EMS budgets are absolutely paltry in comparision to police and fire budgets. It is shameful. All towns should support paramedic level EMS. But, unfortunately, they haven’t and they don’t, and as unfortunately, in these economic times when town, state and federal budgets are being cut, it is unlikely that additional monies will be found for EMS. And hard economic times are not going away. Taxes are being raised, schools are being closed. Health care funding, particularly for hospitals, is being slashed. Where is the money to support more paramedics? Not around here.

EMS, if it wants to even continue its current level of funding, has to show its worth to the community and to the budget makers. Unfortunately, it can currently be argued that ALS doesn’t improve outcomes in such major areas as cardiac arrest survival and in major trauma. Some would say, and there are studies to back it up, that ALS actually contributes to increased mortality in these areas.

On the other hand, BLS can hardly shine when you consider, in many cases, when BLS shows up at your house, they can’t help you any more than throwing you on the stretcher and taking you to the hospital. If your tib and fib bones are sticking through your skin, ice packs and pillows aren’t much help. If your mother is vomiting profusely, an emesis basin and a kind pat on the back don’t quite cut it. Your daughter, in first time anaphylaxis from eating nuts, is dying in front of your eyes, you better hope the ambulance has an epi-pen. Having chest pain? The cath lab is not going to be activated and ready for you when you arrive at the hospital if BLS brings you in. A visiting neighbor in insulin shock? Sorry EMTs can’t pour oral glucose down his throat. And the list goes on. But we can all, ALS and BLS, drive ambulances.

The day is going to come where EMS like hospitals will have to prove positive outcomes or we won’t be reimbursed. I believe we can prove positive outcomes, but it may require a reinvention of the way we do business. I don’t think the answer is a paramedic in every ambulance and on every street corner. Paramedics are part of the solution, but they need to be used differently than perhaps most systems currently use them. The answer may in fact be fewer, but more experienced paramedics, and more, but better equipped EMTs.

Traditionally in medicine, individual interests groups, whether doctors, nurses, or paramedics fight to maintain their territories and their jobs. They do this by putting down their competition. As I got angered years ago when nurses in our state fought to limit paramedics from working outside the realm of emergency medical services because, according to them, we were not qualified to take care of patients in clean well lit rooms (only in rainy ditches), so I would be angered if I were an EMT and was told by a paramedic I was not qualified to do something simple with such a high benefit as giving a vomiting patient oral Zofran or giving an Epi-pen injection to someone in anaphylaxis, while either waiting for a paramedic to arrive or driving to the hospital because there is no paramedic coming.

If my family member is in need of medical assistance, I don’t care if the person coming through the door went to paramedic school or not, if what my family member needs is something that EMS person can safely give them, then I want them to get it. If the EMT can’t safely give it to them, then I would like to have a paramedic available to respond. The trick is finding out what EMTs can and cannot be giving safely. That alone should be the distinction. Safety and risk benefit should triumph over artificial barriers such as EMTs can’t give any medicine or do any “invasive” procedures.

It has already been proven that BLS can safely save lives with AEDs and defibrillation. I am not familiar with the studies, but I think it is safe to say the same holds true with BLS and Epi-pens. I contend there is more out there for them to do that will benefit our communities and enhance respect and support for EMS, while still maintaing patient safety.

Stay tuned for discussion of this.

***

Note:In previous posts, I have expressed support for the following BLS medications provided the services have approval of their medical director who has overseen proper training: PO Benadryl, PO Tylenol, Zofran ODT, IN Narcan, IM Glucagon. I will address Combivents, NTG SL, IM Versed, and IN Fentanyl in future posts (note saying yet if I will support these.) I will also be posting about other possible BLS enhancements such as CPAP, supraglotic airways, 12-lead transmission, and discussing their risk/reward ratios.

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In a recent post, I praised CEMSMAC, the state EMS Medical Advisory Committee made up of the medical directors from each of Connecticut’s five EMS regions. I have been in EMS over twenty years, and I can tell you, I grow more and more optimistic about the future of EMS thanks to the growing maturation of emergency medeical physicans. Whether individual and working together on committees and in organizations, they are demonstrating a committment to patients, to evidence, and to making a better system.

If there was any place I could be this weekend, besides sitting here at home playing with my five-year old daughter (and working the ambulance tomorrow), it would be in Dallas for the annual “Gathering of the Eagles” conference.

Here is the description of the conference from the Gathering of Eagles website:

The EMS State of the Sciences Conference (dubbed by media as “A Gathering of Eagles”) has become one of the most progressive and important EMS conferences worldwide.

Beyond the faculty, this unique global EMS conference is also famous for having pioneered the 10 minute bullet plenary presentation, “lightning rounds” and other innovative educational advances which have not only provided the attendees with 40 or so plenary presentations over 2 days but, according to conference evaluations, have also changed nationwide medical practices almost overnight. Accordingly, the consortium has become extraordinarily influential in shaping future EMS practice trends, medical aspects of disasters and homeland security — not to mention day-to-day 9-1-1 responses and resuscitations worldwide.

One day I will go. In the meantime I await their posting the PDFs of their presentations on their web site. They truly are the cutting edge, and I am anxious to learn where they believe we are going.

Old Posts on the Eagles

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I have been writing about medications or interventions I believe BLS could be doing safely with approval of their medical oversight. To date, in the approve category, I have Epi-pen, ASA, Zofran ODT, and IN Narcan.

Today, I am adding Benadryl and Tylenol PO. These are over the counter meds that unfortunately many people don’t have access to either because of money or circumstance and having an EMT there to start making a kid with a fever or someone with a rash start to feel better on their way to a likely hospital waiting room, I think it is a good thing. These are low risk medications with the reward of making people feel better. It doesn’t take a lot of training to be able to understand when to give these meds. Many of us give them to our kids at home.

I am also adding to the list Glucagon IM in the form of a preloaded syringe. I would make the indication for confirmed hypoglycemia with inability to protect the airway. There has been talk recently of IN glucagon, but I do not favor this favor. IN absorption is not as reliable as IM, and it requires double the dose. At $80-$100 a pop, I don’t see the utility of IN glucagon. If someone is in insulin shock, they need as reliable a method of administration as there is. Absent an IV for Dextrose administration, that would be IM Glucagon.

Now some say EMTs should not be doing invasive procedures, and an IM med is invasive. I think the invasive procedure distinction is artificial. The sole distinction should be risk versus benefit. If the risk is minimal and benefit is large, then I am for it. I think that is true in this case. The fact of the matter is whether in a big city or a rural township, unless there is a paramedic in every ambulance, BLS is going to walk into calls where patients are in insulin shock, and without glucagon, they have little choice but to bag and drag and call for a medic who may not be available.

BLS in many areas can give Epi-pens. Epi-pens are invasive, but they are also life-saving. Preloaded Glucagon syringes may not be as dramatic as Epi-pens when it comes to saving less, but they are also considerably less harmful if given to the wrong patient.

Writing this series is helping me shape my thinking on this issue of “What BLS Should Be Doing Now.” In one of my next posts I will address an interesting conversation I had about the unintended consequences of enhancing BLS. Other posts will address the remaining medication options – pain and anti-seizure meds, breathing treatments, and NTG SL for BLS, and I will also later be addressing interventions for BLS. I will wrap it up with an EMS vision for the future.

Stay tuned.

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We have a longstanding issue in our region with EMS not leaving run forms at the hospital. It has been going on for as long as I have been in EMS, but it has gotten much worse since the transition to electronic PCRs.

I have perhaps the most unique view of the issue here as I am a full time paramedic who has to write the run forms, a 70% clinical coordinator who has to chase down paramedics for their run forms as well as QA them, and I am also the trauma registrar, which means I have to access the forms weeks later to gather and enter data from trauma patients.

First, the good news, the EPCRs are legible and from the clinical coordinator position, they are great for QA as they are easy to access once they have been submitted. Now, the bad news. The electronic PCRs take too long to finish, and paramedics are left with the choice of finishing the run form or responding to another call. And sometimes when they do finish them, the printer is not working or the computer freezes and the form can’t be run off.

As a paramedic, I do my best to leave a completed run form at the hospital before I leave for the next call. I often start the PCR on the way to the call, entering as much information as I can. Then, I enter information during the call. You can’t really do this during a cardiac arrest, but it can be done on most EMS calls. I ask the patient, a question, I type the answer into the computer. Name, date of birth, social security number, insurance info, meds, allergies, medical history. I’ll enter the vitals and any interventions I do, along with which hospital we are going to and why, etc. Sometimes I can even do the narrative on longer or less complicated trips.

Occasionally there is talk of installing video cameras in the back of ambulances, and people have speculated what it will show. My guess is there will be lots of footage of EMTs and paramedics looking at their keyboards, instead of at their patients.

In triage, I keep writing, and will get the receiving hospital signature, along with the patient’s if I have not already gotten it. Even with all that, though, on most calls, I still need to sit down in the EMS room and finish entering info. I enter only the bare minimum, but I do try to write as full a narrative as possible. I used to never leave until I finished the report, but that was largely when I was working as a contracted medic for the volunteer service. They didn’t care how long I took at the hospital. Now that I am back in the city, I am usually the one being called out of the hospital to do the call in the volunteer town while the volunteer medic pecks away at her run form. Or I am being called out to a call in the city of another town.

Some argue you should never leave the hospital without leaving a complete PCR. The PCR is essential to the patient’s continuing care. Others would argue the lady having a stroke in the aisle at Wal-Mart is more important than finishing the run form for the patient sitting in the waiting room with cold and flu symptoms, who you picked up three blocks from the hospital. I am clearly on the side of helping the lady stroking out.

We talk a lot about getting more funding for EMS. I know of one cheap way to help EMS. Allow medics to leave the hospital before completing their run forms provided they are able to fax it or deliver it to the hospital in a timely manner. If I do 8 transports in a 12 hour shift and it takes me 30 minutes to do each run form, that means 33% of my time is spent sitting in an EMS room. If I can cut that 4 hours down to one hour sitting in the hospital, then I have increased my productivity by 25%.
I don’t hesitate to clear the hospital now and I am doing more calls because of it. However, there are still some calls where I always leave the run form — cardiac arrests, strokes, unresponsive patients – any call where I feel there is valuable information for the patient’s continuing care that no one else can provide. But there have been times when I have received a status zero, holding priority ones page when I have cleared even those calls.

I am in favor (and it is being worked on) of having a required short form that can be filled out by hand and left on turnover. But I think the best way to fix the issue is to improve the reporting at patient handover. Too often, we give an oral report to a busy nurse, who may or may not remember the details when it is time to focus on the patient. And unless, the patient is critical, we hardly ever give a report to the doctor. A better more attentive oral report structure might lessen the need for the doctor or nurse to reference the written report later.

One final thought. I understand that the PCR is important to continuing care, and while it may seem like it is not read by the ED nurse or doctor, it is very valuable to other people in the hospital as well in the ICU or cardiology or orthopedic floors. But I would like to raise a question.

There is a statistic known as number needed to treat. For instance, with CPAP, the number is 6. What that means is for every 6 people, you treat with CPAP, you save one of their lives. What is the number needed to treat for leaving a run form before leaving the hospital? In other words, how many run forms need to be left before one left run form will save a patient’s life or affect a certain outcome. Now let’s look at the number needed to treat for ambulances being allowed to leave the hospital immediately following patient turnover and oral report as opposed to being required in all cases to stay at the hospital until the PCR is finished. How many people are being helped by having an ambulance available or a closer ambulance available? I don’t know these numbers, but I would wager heavily that as far as patient outcomes, having the ambulances available far outweighs having the PCRs completed prior to leaving the hospital.

Here is our current regional PCR policy:

Documentation of Prehospital Care

Documentation of assessments and patient care shall be done on all patients evaluated including, but not limited to: emergency, transfer, patient refusals, downgrades and stand by circumstances.

Documentation of patient care shall be done immediately upon completion of patient care, and/or transfer of care. The only exceptions to this practice are personal safety issues.

The EMS Patient Care Report (PCR) is a medical record and the primary source of information for continuous quality improvement review. Prehospital care personnel shall be responsible for providing clear, concise, complete and accurate documentation. The prehospital provider who authors the report must include his/her name and signature on the report.

When a patient is transported, the PCR will be delivered with the patient to the hospital. Vital information should also be immediately communicated to the Emergency Department staff for efficient and safe transfer of care.

The PCR shall be left at the receiving emergency department. Every effort shall be made to be certain that the nurse/and or physician responsible for care receive the record. In the event the crew is called out of the hospital to respond to an emergency call, the run form must either be faxed to the facility immediately following the call, or hand-delivered. All PCRs must be left within eight hours.

Failure to leave a run form is considered to be just cause for disciplinary action.

Each emergency department shall prominently post in their EMS area their procedure for leaving PCRs. Copy machines will be made available to EMS. Hospitals may require a second copy of the PCR be left in a designated box for review by the hospital’s EMS Clinical Coordinator.

One last note on PCRs. Most services have electronic logins available for hospitals so the hospital clinical coordinator can look up any call at his desk and have access to the run form. No paramedic leaves at the end of the shift without finishing all his PCRs for the day. The PCRs get written, the question is more about timely delivery to the hospital.

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I work Sunday, Monday and Tuesday, 12-hour city shifts. I took the day off today (Tuesday) to go to the monthly regional EMS meetings for my clinical coordinator job that fall on the 2nd Tuesday of every month. I was excited for the meeting because we were going to be voting of our new spinal immobilization guideline to limit the use of long boackboards for certain patients, but the meetings were cancelled due to the storm we had this past weekend. Friday night we were hit with a blizzard that dumped anywhere from two to three and a half feet on towns in the area. The storm plus the nightmare of cleanup stressed enough of us with backlogged work and still messy road conditions that the meeting was put on hold.

I woke up Saturday morning to this site in my driveway:

Fortunately, I had a good helper with the shoveling.

Sunday and Monday at work were challenging as many of the streets in the city had yet to be plowed. We got as close to the call locations as possible and then either hiked in or had the patients meet us on street corners. The mother with the sick kid and the woman with the full body rash met us on the corners, the unresponsive hypoglycemic and the weakened dialysis patients who missed their scheduled appointments we had to go get.

Monday was complicated by people trying to drive to work and by a cold rain that turned the streets to slosh and ice. We dealt with more blocked streets, and cars that were stuck on ice with skidding wheels that we had to get out and help push out of the way. All day long, it seemed I was stepping out into snowbanks and doing crazy arm whirling balance dances when my own boots failed to grip the ice.

So a part of me was relieved that instead of dealing with more of the mess today, I was in my warm office at my computer, weating a comfortable sweater and reading run forms on the computer instead of doing the actual calls myself.

…instead of doing calls myself!

I do like my office job with the nice state benefits and great boss and chance to work on systems issues, but I also like doing calls myself. Really there’s nothing like it.

I found myself daydreaming, remembering the day before, how on one call to keep from blocking the road completely and leaving room for the arriving fire truck, I was wedged up against a giant snowbank. I squeezed out of the passenger door, and started climbing. I climbed to the very top of that snow bank. I was up higher than the ambulance roof, higher than the big fire truck. I was higher than everyone on the street. I could look all the way down the avenue, at all the life of the winter city digging out. I stood on the snowbank a moment, and pounded my chest like old King Kong. I was the King of the World! Then I climbed down to follow my paramedic preceptee and our EMT partner into the apartment house where on the third floor we took care of an old man with swollen legs, carried him down in a stair chair, and out through the snow and into our warm ambulance and transported him safely to the hospital.

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When I was working on a presentation last year called from Ativan to Zofran, a Review of EMS Medications for ALS and BLS, I composed a list of drugs that I felt BLS could easily use with minimal risk. At that time, I had IN (Intranasal) Narcan at the top of the list. If in some areas of the country we can give first responders like police officers and common citizens such as relatives of known opiate users IN Narcan, certainly we can give it to BLS EMTs.

Later I had a conversation with a fellow EMS coordinator asked me what I felt about giving IN or IM Narcan to BLS in our state. He expressed some initial opposition to the concept that we should let BLS responders do things just because they can. He wanted more reasoning behind any decision — was there a true need. I told him I thought it was generally a good idea in certain areas particuarly and send him the following link, which quite possibly may gather everything known about IN Narcan:

Intranasal Narcan

I did think about his caution and believe he does have a point. We should not let people do medical things just because they can. We have to always weigh the risk/benefit as well as the need. I can actually more easily understand giving police officers and family members Narcan than EMTS. Why? Because police officers and family members don’t have BVMs nor are they trained to use them. Their delievery of the drug while awaiting EMS response can be life-saving.

An opiate overdose, including one involving respiratory arrest, should be able to be effectively managed by BLS. Those addicts who are simply on the nod, can be treated with stimulation, a good shake or prodding every few minutes. This usually works like a charm. They can be kept ventilating then either with the BVM or with more prodding – all the way to the hospital, where often unfortunately the hospital may choose to shoot the patient up with Narcan and often put them in withdrawal because they don’t want to have a sitter, sitting with them, and shaking them every time they go apneic.

Still, in the end, I believe it is reasonable for allow BLS providers in areas of high opiate usage to administer intranasal Narcan with the approval of their services’ medical director. Sometimes there are just two in the crew and the patient is three hundred pounds and on the third floor of an abandoned building with no ALS available. And sometimes, there are more than one patient on scene who need arousal. The record for me was three – unfortunately one in cardiac arrest who was beyond the benefit of Narcan. Some IM Narcan for his buddies enabled us to concentrate on reviving (unsuccessfully) the fellow in cardiac arrest without having to worry about the other two joining him in dead junkie land.

I am also in support of Narcan for BLS because of the advent of IN Narcan. As a paramedic I have used intranasal Narcan four times now, and the first two of those times, I ended up supplementing the IN Narcan with IM in one case and IV in another (I rarely ever give Narcan IV, but while waiting for the patient in respiratory arrest to respond to the IN, and while bagging the patient with the aid of the fire department first responders, I put in an IV, and then gave 0.8 IV (should have used 0.4), which woke her up and she vomited and had the shakes). In both cases, I wasn’t patient enough with the IN Narcan, and in both cases, I put the patient into a touch of withdrawal. My bad. From my third and fourth use and from talking with other medics, and from a review of the capnography strips from my first two cases, I have learned the following about IN Narcan (at least my anecdotal impression, which on further reading of the above listed link suggests my experiences are quite common).

IN Narcan works much more slowly and mildly than IN or IV. It takes longer to wake a person up (one medic I spoke with reported 15 minutes for a response! A patient man, indeed), and wakes them up much more gently. From review of the capnography strips, the patient’s hypoventilation is corrected much sooner than the patient’s actually awakening. Even though the patient still appears unresponsive, the RR came up steadily and the ETCO2 dropped. In an ideal situation, when used artfully, that is exactly what we want from Narcan – a sleepy, happy, but now normoventilating patient. None of this slam the Narcan as you are coming in the ED door so the patient vomits on the triage nurse bullshit that was being promoted many years ago among burned out street medics who apparently missed the DO No Harm lecture in medic school.

If I were to allow BLS to use IN Narcan, I would insist on narrowly defined criteria. Respiratory rate of <8 and or signs of hypoventilation and not arousable from stimulation. Not just giving someone Narcan because they took heroin, which I have seen many medics do. I suppose ideally I would want the BLS providers to carry portable capnometers, as since I have had capnography, which I put on all my opiate overdoses, patients can have respiratory rates less than 8 and be effectively ventilating and they can have respiratory rates greater than 8 and be hypoventilating if their volume is low. Patients should also have evidence of opiate use. Using Narcan for coma of unknown etiology can often lead you down the wrong diagnostic path if the patient wakes up, not because of the Narcan, but because they are waking up.

Thus in the end, not a simple decision, but I feel a reasonable one provided proper training and oversight.

Agree? Disagree? Let me know your thoughts on this one.

Thoughts on Tntranasal Narcan

Narrower Use of Narcan

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I believe there are several medications that BLS could give patients with very little risk and much gain to patient care (if they were allowed to by their states and/or their service’s medical directors). I do not subscribe to the notion that only paramedics should be able to give medicine. In my state – Connecticut – BLS can give ASA and epinephrine in the form of an epi-pen, but only with the approval of their service’s medical director. When I was first an EMT in Connecticut, we could not even have given these two medications. BLS is also allowed to assist a patient with their own nitro or breathing inhaler.

If there is one medication I would give to BLS services aside from the epi-pen, it would be Zofran (Ondansetron) ODT. Zofran is not life-saving like the epi-pen, but it can significantly ease a patient’s comfort. As EMS struggles to define itself and prove its worth, the one area that we can do well in if we focus on it is comfort care. Nausea and vomiting is one of the most common patient presentations, and one of its most unpleasant. And it is something we can if not fix, than at least moderate with a simple dissolvable pill.

While it has not been studied at the BLS level, it has proven safe and effective at the paramedic level for both adults and pediatrics with nausea and vomiting.(1, 2) The patient population who can benefit from it is large (it is the most administered drug by many paramedic services), and the contraindications (hypersentsitivity) are small. I am not advocating making nausea and vomiting a routine BLS call. Paramedics should still be dispatched for nausea and vomiting because they are often symptoms of very serious illness. I am saying if paramedics are not available or if the presenting case is a clear cut case of an otherwise healthy person with the flu or a GI bug, then it is something BLS can safely handle, provided the service’s medical director agrees and is comfortable with the education and training of the BLS providers he oversees. (Instead of spending so much time practicing spinal immobilization, we can teach our BLS about Zofran, Tylenol and Benadryl, and perhaps other meds I will be discussing in subsequent posts that I believe can make a difference in patient’s health and comfort, and satisfaction with the health care system, including EMS).

(1) Warden , prospective evaluation of ondansetron for undifferentiated nausea and vomiting in the prehospital setting – Prehosptal Emergency Care, January-March 2008.

(2) Salvucci, ondansetron is safe and effective for prehospital treatment of nausea and vomiting by paramedics. Prehospital Emergency Care Jan-March 2011

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In the coming weeks I will be unveiling What BLS Should Be Doing Now. I am not talking about doing a better job of assessment, treatment and documentation. We all should be doing a better job of that, or most of us. I am talking about procedures or skills or medication administration that may not be in the BLS scope of practice in many states.

Now let me state, I am a firm believer in paramedics and believe all communities should have paramedic protection. What I will be proposing for BLS is not meant to give communities an excuse not to implement, upgrade or enhance their own paramedic coverage. I make these recommendations because I believe they will be better for patients, that they will do more good with minimal risk of harm. And again, while I am a firm supporter of paramedics, I do not believe, as a profession, we should act as doctors and nurses have sometimes acted in not allowing others to do skills that were previously only in their own domains. I like to think we should always put self-interest aside and put the patient first.

In the first part of the series, I will address Medications for BLS, before moving on to New Skills and Procedures for BLS. I have developed a list of medications that I believe are safe for BLS to give, and I have another list that I am on the fence about or am opposed to.

Now in Connecticut, there are already some medications BLS can administer, provided they have approval of their services medical director. These include ASA for suspected acute coronary syndrome, epinephrine in the form of an epi-pen for anaphylaxis, and they may also assist a patient with the patient’s own nitro and inhaler.

I have no issues with ASA and the epi-pen, and find them reasonable, and in the case of anaphylaxis certainly, life-saving. I am on the fence about assisting them with their inhaler and nitro, leaning toward not objecting. In general, I think it is a good idea. The patients have been prescribed these meds by their physicians and are presumably taking them as directed for diagnosed conditions. I think assisting them is fine, and will mostly doing more benefit than harm. The danger of course is if the patient is having a right ventricle infarction or in the case of the treatment is not having asthma/COPD, but is in CHF.

I am not familiar with the training of the BLS in regards to this, but as long as they are cautioned to take a BP before allowing the patient to take the nitro or listen to the lungs before assisting them with the inhaler, I think this is okay. In our systems, paramedics can only give nitro after doing a 12-lead in cases of suspected ACS, and are forbidden to give nitro in cases of right ventricle infarct, but I have found that most patients who are already prescribed nitro and take it regularly are less affected than previously healthy people who have never taken nitro and are being given it for the first time.

Medication List for BLS
1. Epi-Pen (Yes)
2. ASA (Yes)
3. Inhaler (assist with patients) (A Conditional Yes)
4. NTG SL (assist with patients) (A conditional Yes)
5. To be continued

Here then are the meds, I will be discussing and voting either Yes-safe for BLS, Maybe – on the fence, or No -Not ready for it yet. And of course, any yes is conditional on the approval of the service’s medical director and the implementation of appropriate training, documentation and oversight.

Zofran ODT
Benadryl PO
Tylenol PO
Combivent
Glucagon IM
Versed IM (in autoinjector)
Fentanyl IN
NTG SL
Activated Charcoal (removed from our Regional BLS)

Stay tuned, and in the meantime, please feel free to comment with your thoughts on these drugs or drugs not on the list you think should be considered suitable for BLS administration.

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Bag-Valve-Mask is better than ET Intubation or even supraglottic airways in cardiac arrest. Or at least that is the conclusion of an important new study, Association of Prehospital Advanced Airway Management With Neurologic Outcome and Survival in Patients With Out-of-Hospital Cardiac Arrest, just published in the January 16. 2013 issue of the Journal of the American Medical Association.

Abstract Available Here

The article again raises questions about the importance of ALS interventions in cardiac arrest, and makes us wonder if we are doing more harm than good with aggressive airway intervention.

I need to take a statistics class someday so I can better understand studies or at least make more sense of them, so I will leave others to comment on the technical points. Here are the results as I understand them:

The researchers looked at 649,654 consecutive out of hospital cardiac arrests in Japan over a six-year period (2005-2010). The primary end point was favorable neurological status one month after the arrest.

57% had bag-valve mask, 6% had endotracheal intubation and 37% had supraglottic airways.

Here is the outcome:

Neurologically Favorable Status
Overall 2.2%
Bag Valve – 2.9%
Supraglottic – 1.1%
ET – 1.0%

An accompanying editorial by noted airway researcher Hanry Wang and Donald Yealy called the study “large, methodically rigorous and compelling.”

The authors write:

“Recent studies have questioned the wisdom of the wide use of out-of-hospital endotracheal intubation in many severely ill or injured patients. Out-of-hospital endotracheal intubation adverse events include unrecognized esophageal placement, tube dislodgement, iatrogenic hypoxia and bradycardia, and frequent need for multiple tube insertion attempts. Endotracheal intubation during cardiac arrest can interfere with cardiopulmonary resuscitation continuity of chest compression or facilitate inadvertent hyperventilation, both of which can adversely influence cardiac arrest survival.”

I eagerly await responses more educated than mine to this study. At this point all I can do is speculate as to the reasons for this outcome based on commentary in the studies and my own thoughts.

Perhaps, while ET and supraglottic may be better airways the time taken to get them may come at the cost of effective CPR in the critical spare seconds patients have to be brought back from the precipice of permanent harm.

Perhaps while ET and supraglottic airways may save some patients, poor insertion may kill others who might have been saved.

Perhaps the supraglottic airways were more likely to be used in patients with a difficult airway (I don’t think this is true, but I was surprised and disappointed at the poor results of the supraglottic airways).

Perhaps, as the authors suggest, advanced airways may give the responders the avenue to kill the patients through hyperventilation and hyperoxemia.

I thought that perhaps the advanced airways were also accompanied by epinephrine, which has been shown to increase mortality, but then I saw in the study the use of epinephrine was evenly divided among the groups. The baseline characteristics of propensity-matched patients (whatever that means) were quite similar according to a large chart in the article.

I also thought that perhaps the bag value mask survivors included all those patients who were brought back by defibrillation before an advanced airway could even be inserted.

(I believe the paper says this is not the case due to statistical adjustments, but I don’t quite understand that. From the article: “endotracheal intubation and supraglottic airways were similarly associated with a decreased chance of favorable neurological outcome. The observed associations were large and persisted across different analytic assumptions.”)

The answers to some of these questions may lay in the study, but I await others to explain them to me.

In the meantime, I agree with the editorial writers conclusion that:

“The study by Hasegawa et al sends a clear message. Emergency medical services professionals across the world must engage in the scientific process. A large, well-designed research effort is needed to define the benefit from endotracheal intubation, supraglottic airway insertion, or more simple actions during resuscitation after cardiac arrest. Absent this investment, the emergency medical services community risks turning a blind eye and embracing ineffective or harmful airway interventions. Patients with cardiac arrest and the out-of-hospital rescuers who care for them deserve to know what is best.”

What do you think?

***

See Vince D’s excellent comments below. He also provided this link to the first expert commentary on the study:

MedPage Today Commentary

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