A woman calls 911 and says “my baby is sick!”  You get dispatched for a sick baby.   You think if it is a sick baby, what do you need equipment for?  Most likely the baby is not really sick, but if the baby is really sick then you can, as my preceptor once said to me, “O.J. it.”  This of course was when O.J. Simpson was known for running and leaping faster than any other human and not known for slashing throats.  “O.J it” meant grab the baby and run for the ambulance.

Many times in my early years as a medic I “OJed” it with sick kids, sometimes doing CPR and tiny breaths as I went, hurtling toward the ambulance, my office where the gear that made me a medic was stowed.  Aside from that clearly not being the ultimate way to resucitate a baby or anyone for that matter, the “sick baby” call doesn’t always turn out to be a sick baby.  The sick baby can be anything from a 300-pound fifty-two-year old son in cardiac arrest to a vomiting parrot.  The 300-pound son you clearly wish you had your gear for.  The vomiting parrot?  Well,  that’s another story.

When I started there was one paramedic who always carried all his equipment in on every call.  Back then we had a black hard suitcase called a biotech for the meds and IV supplies.  We had an intubation kit, we had a large house bag with the oxygen and bandaging supplies, and we had the Life Pack 5 and then the Life Pack 10 monitor.  We also had an orange tackle pedi-box.

Now this medic didn’t bring the pedi-box in on every call unless it sounded like it might be a pedi.  For the sick baby that turned out to be the 300-pound fifty-two-year-old son, he would have had the pedi box there along with everything else where other medics would have had to send their partners running back down to the truck.

He also– and this is what impressed me the most — he always carried the portable battery-operated suction machine in.  Every call.  Me, I only bring it in to a known cardiac arrest, and I can tell you to my embarrassment, two of the last three difficulty breathings I’ve been too have turned out to be cardiac arrests where my preceptee has said, “I need suction!” when he has put the larengyscope in and seen nothing but murky waters.  “I need suction now!”  On its way. but not here yet.

We had a paramedic here who was fired for not bringing equipment in.  She sometimes brought equipment in.  Say it was a known cardiac arrest, she would put a larengyscope, a tube and a 10 cc syringe in her pocket.  I kid you not.  She also downgraded a stabbing because the hole in the chest was “just a little hole.”  Lazy paramedic.  Bad paramedic.

I carry in the house bag and the monitor, and the 02 if the fire department hasn’t gotten there yet, although there have been times when I have climbed up three flights of stairs only to find the fire department also didn’t bring in their 02.  I hate not being prepared.

I carry my controlled substances on me when I go into a call.  While there is some lack of clarity as to what exactly the rules are in our state governing the securing of controlled substances — it ranges from they must always be secured doubled locked in the ambulance unless you have the intention to use them to its okay to secure them on yourself as long as you are on the clock and capable of being dispatched to a call where you might need them.  The issue here is:  what if you respond for a person vomiting and after wheeling your stretcher down many halls and up a couple different banks of elevators in a big insurance company, you find your patient is actually seizing?  You can either 1) Put the patient on your stretcher and wheel them seizing all the way back out to the ambulance.  2)  Give the controlled substances keys to your BLS partner and tell him to get the kit and hurry.  3) Or you can take the controlled substances kit out of your own pocket and stop the seizure now.  I hate being without my gear when I need it.

Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched — the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, “he’s up on the 2nd floor.” We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with gurgling respirations and an ever growing pool of blood around his head. “He got the shit kicked out of him,” the cop says — “steel toed boots.”  ”Uh-o,” Steve says to me. “Go get the gear,” I say to Steve.

We work together the next week. No “uh-o” moments we both agree. We’ll bring the gear in on every call. First call of the night is for a “woman drunk wants to go to rehab.” This is a call we do all the time too. We walk in, meet the patient, who says, “I want to go to rehab.” And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door — also up on the second floor. “My daughter is an alcoholic,” he says. “She needs to get cleaned up. I don’t think she’s breathing.” Uh-o. Go get the gear.

I know the gear is heavy, but look at it this way, you are in physical training.  Carrying all that gear up and down stairs will get keep you in shape and keep you young.  Do enough calls, walk up and down enough staircases and you can skip the gym after work and spend the time with your family.

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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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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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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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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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