***

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

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

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

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

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

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

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

“Okay,” she says.

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

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

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

“We’ll get you a smoke.”

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

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

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

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

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

“I ain’t pregnant,” she says.

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

“You’re wasting a cup on me.”

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

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

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

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

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

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

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

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

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

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

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

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

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

LMA Manual

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

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

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

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

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

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

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

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

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

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

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

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

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

Are Fentanyl and Morphine Equals?

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

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

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

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

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

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

***

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

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

Life is short.

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

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

Acute pain protocol for moderate/severe pain

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

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

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

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

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

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

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

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

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

I am with him on that all the way.

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