At the nursing home I get a quick report from the nurse (who is running the other way down the hall when we come in) which makes me think the difficulty breathing we have been called for is a patient with pneumonia or sepsis. The vitals she tells me are BP 83/34, Sats in the 80's on a cannula, and a temp of 102.8, on a patient with increasing confusion.
The patient’s family is in the way and are rude to my partner when she drops a woman’s sunglasses while trying to hand her her bag off the patient’s bed, so we can get the patient -- a 55 year old female -- onto our stretcher. There is an overall bad vibe with the family. I decide to just get the patient out to the ambulance and do everything en route.
In the ambulance, reading the W10, I discover the patient is on renal dialysis, but now I don't have the answer to the question I am later asked -- When did the patient have dialysis last? I see the patient has some communicable diseases and since we are going to a hospital that doesn't take our blood draws I am thinking I may just BLS the call in. Then I decide that would lazy and irresponsible.
Our SAT won't read, and then it comes up in the 70’s. The patient's fingers are in poor condition so I don't know how reliable the SAT is. Still I put the patient on a nonrebreather to be safe and also put on the ETCO2. I'm concerns when I see it is 53, which indicates the patient is hypoventilating(or possibly it could be due to the fever and increased metabolism). Regardless, it is not a sign of pristine health.
I see what looks like a dialysis catheter under the patient's sweater as I attach electrodes to her chest. I listen for lung sounds. I hear no rhonci, no rales or wheezes, but it is hard to get the patient to follow commands enough to take deep breaths. I check her sweatered arms for a shunt and then put an IV in her left wrist and start some fluid.
At the hospital when I try to convey my sense of the patient’s level of sickness -- she doesn’t know where she is, her SAT is low and her ETCO2 is up, she's hypotensive, although our reading at 100/50 wasn't as bad as the nursing home's, tachycardic at 112. The nurse then asks the patient how she’s doing. The patient answers in gibberish, which doesn't seem to register on the nurse. Over the phone, the triage nurse tells the room nurse who will get the patient that the patient is not tachypnic and responds to her. She apparently didn't hear me say or understand about the hypoventilating.
In the room I give an admittedly meandering report to a young doctor I have never seen before, making a poor impression for myself. I'm caught a little off guard because she has come into the room while we are trying to move the patient over, so I am talking and moving the patient at the same time sort of like walking and chewiing gum -- hard for some people, particuarly me today. I am unable to answer what the patient’s normal mental status is nor what their daily activity is. All I say is, "I don't believe this is the norm. they said increasing confusion today."
I am feeling slow and stupid -- like my four days off have robbed me of any sharpness. The new doctor now recognizes the patient as someone she has treated before and declares this is, in fact, her norm. In the EMS room, I finally see written on the W10, the patient is normally alert and oriented and ambulatory. Do I feel dumb. I wish I pointed that out to the doctor, who apparently was mistaken.
When I return to the room with my written report, the nurse announces that I have put an IV in the arm with a shunt in it. I apologize and say I didn’t feel it there, plus she gets her dialysis through her chest catheter anyway. You can feel it, she says, squeezing the patient's arm. Sorry, if I’d known it was there, I wouldn’t have put it there, I say. I’m kicking myself for not undressing the patient at the home, taking her thick sweater off and putting on a Johnny. I almost always do it, and then I don't, it bites me. Dumb. Lazy.
Another young doctor I have never seen before asks the nurse what were the patient’s SATs. I don’t know, I'd have to check the notes, the nurse says. I pipe up then, “They were in the 80s in the nursing home – we were getting in the 70’s.” The doctor is not looking at me, but continues talking to the nurse. I feel like saying what am I invisible? I continue, “In triage after she’d been on the nonrebreather for about twenty minutes, her SAT was 97. But we were also monitoring her ETCO2 and we were getting 53 for a reading, which is high. She may be hypoventilating.”
The doctor turns to me then and snaps, “Well, she doesn’t need to be on a nonrebreather then.”
I don’t say anything. A look of puzzlement comes over me. ???? There is no COPD here. No question of a hypoxic drive. Her SATs were in the 70-80 range before the non-rebreather. Her ETCO2 is 53. Besides she looks really sick.
I want to point this out to the new doctor -- and say if she is hypoventilating and has low SATs off the mask, and doesn't have COPD, she really needs the oxygen -- but when you do poorly on a call – meandering through it, and even putting an IV in a shunt arm -- when you appear so stupid yourself -- what do you say when someone says something so stupid to you.
I just turn and leave the room.
Maybe she knows something I don't know. Maybe I know something she doesn't. They’ll come to the right answer soon enough.
The thing about medicine is – you can be great on one call, and then the next be an idiot – paramedics and nurses and doctors, all of us. You have to prove yourself patient by patient. You won't bat 100, but you need to try.
In the coming year I resolve to try to do my best on each call and not to judge anyone, high or low.
Sunday, December 31, 2006
Friday, December 29, 2006
No Work Today
I feel like I am unemployed. Everyday I check the pager. No shifts. Years ago when I lived in the Midwest and was a day laborer, I used to go down to the work office every morning. When things were good it was unloading trucks, roofing, or working in an plant – making frozen fast food sandwiches or assembling door knob packages. When it was slow, it was no work today. Come back tomorrow. Or maybe next week, we may have some new contracts. No work today. No work today.
Not so long ago, I could work everyday. Call in, make your own hours. I’m hoping this is just a convergence of a big class of new hires and the winter holidays. What I’ll need to do is start putting in my availability in advance. The good thing with that is, you’ll get the extra shifts. The bad thing is it ties you in to the shift. Once my name is in the book, I work it. I never book off.
Last year I made more in extra pay than in regular pay. I swore years ago, I would never get in a position where I had to work overtime, but that is a laugh now. Like just about everyone with any kind of time in EMS, I need the OT to survive.
Years ago, when I started, there was hardly any OT. The man who ran our company was an old fashion businessman, an original ambulance man, who hated to give up even a nickel to overtime. Everyone worked 3-12’s, so you had four hours a week of being held late before you qualified for OT, and he somehow attracted enough employees that there were very few extra shifts – the ones that were there went to part-timers and per-diems. Another thing was medics got to pick their partners back then, so everyone who worked together liked working with each other. No one would book-off because they couldn’t deal with their partner getting mad at them for sticking them with a new partner. If you were sick you sucked it out because you didn’t want to let your partner down, and you didn’t want him to let you down when he was sick.
There was an OT list you signed up for once a month. If you got your name first on the list, you were the first one called for any OT in each week of the month. That could mean four cake suburban OT shifts for the coming month. The list went up at seven in the morning. One guy used to get there at 5, and then someone came in at 4:30, and you know how it went. Those of ue who lined up were called overtime whores. The guy who always got there first waltzed in at 2:30 one morning thinking he had beaten us all. Two of us were sitting there already. Top o’ the morning to you. You all are crazy, he said.
Most people worked second jobs for other ambulance companies, of which there were many.
Then we were taken over by the big company that was buying up some of the other companies. The shifts went to 40 hours (5-8s or 4-10s or 2-12s and 2 8s) plus being assigned a partner not of your choosing ever six months. Things started to change. People took days off. They didn’t like their partners. There was more turnover. While the same company bought up most of the other companies, and then prevented its employees from working for the dwindling competition (some medics had worked for three different companies who were now all one), the lack of a second job was more than made up for by the available open shifts – overtime that paid time and a half.
It’s been a gravy train of overtime pretty much since. Sure there are dry periods -- hopefully this is one of them -- but the inevitable EMS turnover keeps us all in the bountiful slop. People leave for greener pastures, people get hurt, but mostly new people find out this isn’t always the easiest or best job -- that not anyone can do this work. I’d have to look at our company’s seniority list to verify, but once you get to a certain number -- a certain length of service, it is hard to get much higher. Anyone who has been here as long as I have – I'm starting my 12th year -- isn’t going anywhere unless they break down physically. I think I’m actually also number 12 on the paramedic seniority list, and I am lucky to go up one notch a year.
It feels strange being off so much, growing a four-day beard, sleeping late, playing Mr. Mom – the girls and I went swimming again today -- I kind of like it. I’m enjoying it while I can.
Because I need the work hours.
Not so long ago, I could work everyday. Call in, make your own hours. I’m hoping this is just a convergence of a big class of new hires and the winter holidays. What I’ll need to do is start putting in my availability in advance. The good thing with that is, you’ll get the extra shifts. The bad thing is it ties you in to the shift. Once my name is in the book, I work it. I never book off.
Last year I made more in extra pay than in regular pay. I swore years ago, I would never get in a position where I had to work overtime, but that is a laugh now. Like just about everyone with any kind of time in EMS, I need the OT to survive.
Years ago, when I started, there was hardly any OT. The man who ran our company was an old fashion businessman, an original ambulance man, who hated to give up even a nickel to overtime. Everyone worked 3-12’s, so you had four hours a week of being held late before you qualified for OT, and he somehow attracted enough employees that there were very few extra shifts – the ones that were there went to part-timers and per-diems. Another thing was medics got to pick their partners back then, so everyone who worked together liked working with each other. No one would book-off because they couldn’t deal with their partner getting mad at them for sticking them with a new partner. If you were sick you sucked it out because you didn’t want to let your partner down, and you didn’t want him to let you down when he was sick.
There was an OT list you signed up for once a month. If you got your name first on the list, you were the first one called for any OT in each week of the month. That could mean four cake suburban OT shifts for the coming month. The list went up at seven in the morning. One guy used to get there at 5, and then someone came in at 4:30, and you know how it went. Those of ue who lined up were called overtime whores. The guy who always got there first waltzed in at 2:30 one morning thinking he had beaten us all. Two of us were sitting there already. Top o’ the morning to you. You all are crazy, he said.
Most people worked second jobs for other ambulance companies, of which there were many.
Then we were taken over by the big company that was buying up some of the other companies. The shifts went to 40 hours (5-8s or 4-10s or 2-12s and 2 8s) plus being assigned a partner not of your choosing ever six months. Things started to change. People took days off. They didn’t like their partners. There was more turnover. While the same company bought up most of the other companies, and then prevented its employees from working for the dwindling competition (some medics had worked for three different companies who were now all one), the lack of a second job was more than made up for by the available open shifts – overtime that paid time and a half.
It’s been a gravy train of overtime pretty much since. Sure there are dry periods -- hopefully this is one of them -- but the inevitable EMS turnover keeps us all in the bountiful slop. People leave for greener pastures, people get hurt, but mostly new people find out this isn’t always the easiest or best job -- that not anyone can do this work. I’d have to look at our company’s seniority list to verify, but once you get to a certain number -- a certain length of service, it is hard to get much higher. Anyone who has been here as long as I have – I'm starting my 12th year -- isn’t going anywhere unless they break down physically. I think I’m actually also number 12 on the paramedic seniority list, and I am lucky to go up one notch a year.
It feels strange being off so much, growing a four-day beard, sleeping late, playing Mr. Mom – the girls and I went swimming again today -- I kind of like it. I’m enjoying it while I can.
Because I need the work hours.
Thursday, December 28, 2006
Vomiting
The three days I worked over Christmas, I did a lot of vomiting calls.
Here's a question: When you ask how many times have you vomitted, what are you really looking for? The number of times you have vomited or the number of vomitting episodes?
I woke up yesterday not feeling too well. Soon in a race to the bathroom.
I hardly ever throw up -- I go years and years without vomiting. Yesterday I found myself pondering that question -- episodes versus times. My final tally was five episodes, 18 times. The vomiting started shortly after my breakfast of a power bar and lasted till five in the evening. Only then did I finally get some nourishmant down -- gatorade, rye crisp, two jellybeans, green tea and a slice of apple.
When I get sick I always feel like I am never going to be well again in my life. I guess its a good lesson for a paramedic. It helps teach compassion -- to understand how miserable a sick person can feel.
Still I didn't call 911.
Not this time.
Here's a question: When you ask how many times have you vomitted, what are you really looking for? The number of times you have vomited or the number of vomitting episodes?
I woke up yesterday not feeling too well. Soon in a race to the bathroom.
I hardly ever throw up -- I go years and years without vomiting. Yesterday I found myself pondering that question -- episodes versus times. My final tally was five episodes, 18 times. The vomiting started shortly after my breakfast of a power bar and lasted till five in the evening. Only then did I finally get some nourishmant down -- gatorade, rye crisp, two jellybeans, green tea and a slice of apple.
When I get sick I always feel like I am never going to be well again in my life. I guess its a good lesson for a paramedic. It helps teach compassion -- to understand how miserable a sick person can feel.
Still I didn't call 911.
Not this time.
Sunday, December 24, 2006
Christmas Eve: Fifteen on the Scale
It's Christmas eve. We get called to one of the local nursing homes for rib pain. The room number sounds familiar. The nurse hands me the paperwork. "Mr. Ryder," she says. "He says he needs more Percocets. He's requesting transport."
Mr. Ryder is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can't weigh more than a hundred pounds. He sits in his wheel chair, wearing his motorcycle jacket and oxygen cannula.
"I'm in real bad pain," he tells me in his whisper of a voice. "Fifteen on the scale." He nods as if to say it is the truth.
"Well, we'll take you down to the hospital and maybe they can help you."
It seems he fell a couple weeks ago and cracked a rib.
I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always real bad, he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted.
While I don't like to categorize patients in this way, he does fall into the "pain in the ass" category.
I see him nearly everytime we go into the nursing home. He is always sitting out in his wheelchair in the main TV area. He sees me and his eyes light up. I say "Hey Jimmy! How'ya doing?" as I push the stretcher past going for someone else on the wing.
He lights up and says, "Not too bad, hanging in there."
That's the jist of our relationship.
Today in the ambulance, I have an EMT student do vitals as we start toward the hospital. I'm not going to do anything for the patient -- no IV, no monitor -- just keep him on his normal 2 liters of oxygen. His color is good and he doesn't appear in any distress. He, in fact, seems rather lively.
She chit chats with him.
"You've got all your Christmas shopping done?"
"Yeah, I just bought stuff for myself," he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.
"I buy presents for myself sometimes," she says. "How about you?" she asks me.
"I'm pretty much done."
"Well, unless you're going to the drug store when you get off, you're out of luck. Time's run out."
"I'm in good shape," I say. I think to myself if I get out in time, I'll probably make a quick stop at the liquor store where I'll buy myself some Christmas beer -- a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I'd get it myself. There is a liquor store that doesn't close till eight on my way home. I'll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I'll buy other beer during the year, but this case -- my Christmas beer -- I'll stretch out.
The patient looks up at the EMT student and says, "This guy over here, me and him go back a long way."
"He's taken care of you before?" she says.
"Yeah." He nods at me and then says, "He's probably one of my best friends in the world."
I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies -- Hoss and Mongo and Big Steve -- and wonder if they are partying at the Iron Hog without him tonight or if maybe they are all either in the ground or solitary in nursing homes themselves.
He looks up at me now, his eyes locking on mine. "I'm in real bad pain," he whispers urgently. "Fifteen on the scale."
Mr. Ryder is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can't weigh more than a hundred pounds. He sits in his wheel chair, wearing his motorcycle jacket and oxygen cannula.
"I'm in real bad pain," he tells me in his whisper of a voice. "Fifteen on the scale." He nods as if to say it is the truth.
"Well, we'll take you down to the hospital and maybe they can help you."
It seems he fell a couple weeks ago and cracked a rib.
I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always real bad, he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted.
While I don't like to categorize patients in this way, he does fall into the "pain in the ass" category.
I see him nearly everytime we go into the nursing home. He is always sitting out in his wheelchair in the main TV area. He sees me and his eyes light up. I say "Hey Jimmy! How'ya doing?" as I push the stretcher past going for someone else on the wing.
He lights up and says, "Not too bad, hanging in there."
That's the jist of our relationship.
Today in the ambulance, I have an EMT student do vitals as we start toward the hospital. I'm not going to do anything for the patient -- no IV, no monitor -- just keep him on his normal 2 liters of oxygen. His color is good and he doesn't appear in any distress. He, in fact, seems rather lively.
She chit chats with him.
"You've got all your Christmas shopping done?"
"Yeah, I just bought stuff for myself," he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.
"I buy presents for myself sometimes," she says. "How about you?" she asks me.
"I'm pretty much done."
"Well, unless you're going to the drug store when you get off, you're out of luck. Time's run out."
"I'm in good shape," I say. I think to myself if I get out in time, I'll probably make a quick stop at the liquor store where I'll buy myself some Christmas beer -- a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I'd get it myself. There is a liquor store that doesn't close till eight on my way home. I'll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I'll buy other beer during the year, but this case -- my Christmas beer -- I'll stretch out.
The patient looks up at the EMT student and says, "This guy over here, me and him go back a long way."
"He's taken care of you before?" she says.
"Yeah." He nods at me and then says, "He's probably one of my best friends in the world."
I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies -- Hoss and Mongo and Big Steve -- and wonder if they are partying at the Iron Hog without him tonight or if maybe they are all either in the ground or solitary in nursing homes themselves.
He looks up at me now, his eyes locking on mine. "I'm in real bad pain," he whispers urgently. "Fifteen on the scale."
Saturday, December 23, 2006
Best Day Ever
I haven't worked since Tuesday. No open shifts, which is rare. I guess a lot of part-timers are home from school and looking to make some Christmas or school money. They get priority on the open shifts. I've been spending the week driving my girlfriend's kids around. I've been carrying my pager with me hoping to jump on any shift that gets paged out, but nothing comes over. The kids were asking me yesterday if I was working today. Not yet, I said. Will we have fun then? the six-year-old asked. If I'm not working, I suppose we can do some fun things, I told her.
Last night I made everyone spaghetti and then we had ice cream and watched ELF
, which I thought was really funny. When it was over, only the six-year old and me were still awake. The eleven-year old and mom were dead asleep. We nudged them awake and sleep-walked them to bed.
This morning a page came over while I sat at the computer. I quickly checked it, hoping for a shift. (I really need some extra money myself. Christmas time I have been spending entirely too much money. I feel like I am walking around with my wallet open, saying here, rob me.)
No shift. Just a page for one of the crews to call operations.
About ten minutes later, the six-year-old comes in, wiping the sleep out of her eyes.
Are you working today?
Not yet.
"So we're going to have some fun today then?
"Yeah, I guess. It's looking that way."
I make breakfast. Bacon and waffles and cut up some bannanas. Pour some juice.
Their mother goes off to work.
We go duckpin bowling.
The six-year old wins the first round with an 85. I roll a 74. The eleven-year old wins the next one with a 101. I get a 100, ending strong with a spare and my first strike. She needs five pins to beat me. She knocks down five. Not one less, not one more.
Then its off to Chucky Cheese. We get 100 tokens and a large pizza, half pepperoni, half cheese. I eat the pepperoni half and watch as they run around from machine to machine. The little one jumps up and down four times when she hits a fifty ticket bonus on the dinosaur spinning machine. She runs back to the table, holding the connected tickets high in the air, streaming behind her like a kite.
I try one ride - the jet ski race. I wipe out a couple times and come in 10th out of 10. I have never finished better than 10th. One trip to the Cheese's place I tried eight times. Now I only try once, then walk back to the table and the last slice of pepperoni. I shake some red pepper flakes on it to make it edible.
Before we go, we have our pictures taken at the Chuck E. Cheese studio booth. Then the kids cash in their tickets and get cotton candy, a Chucky Cheese lollipop, a Captain Hook hand and a lizard. Oh, and they get me a couple Smarties candies, which they know I like. Thank you, I say.
Driving back, the six-year old says, "This is the best day ever!" She uses that line a lot, but I always like to here it.
Later we go to the library where I help them get their first library cards. They take out a book and a movie each. We stop at the supermarket and buy sugar cookie dough and make some Christmas cookies. We unknowingly make the dough a little too thick so the molds of a candle, bells and a wreath all produce shapeless blobs of cookies, which the kids shrug about and then eat rapidly before I take the rest away for later.
Around seven I drive them to their grandmother's house, where an aunt and cousins have arrived today. They are excited to see them.
I'm here alone now, drinking a beer after cleaning the house, and doing some last minute wrapping.
Tomorrow morning I am back at work. I'm working 6-6. We'll have dinner and open presents in the evening. Christmas day I'm working 6-6 again. Their mom is working all day too.
I got them some good stuff.
Have a safe and Happy Holiday, everyone!
Last night I made everyone spaghetti and then we had ice cream and watched ELF
, which I thought was really funny. When it was over, only the six-year old and me were still awake. The eleven-year old and mom were dead asleep. We nudged them awake and sleep-walked them to bed.This morning a page came over while I sat at the computer. I quickly checked it, hoping for a shift. (I really need some extra money myself. Christmas time I have been spending entirely too much money. I feel like I am walking around with my wallet open, saying here, rob me.)
No shift. Just a page for one of the crews to call operations.
About ten minutes later, the six-year-old comes in, wiping the sleep out of her eyes.
Are you working today?
Not yet.
"So we're going to have some fun today then?
"Yeah, I guess. It's looking that way."
I make breakfast. Bacon and waffles and cut up some bannanas. Pour some juice.
Their mother goes off to work.
We go duckpin bowling.
The six-year old wins the first round with an 85. I roll a 74. The eleven-year old wins the next one with a 101. I get a 100, ending strong with a spare and my first strike. She needs five pins to beat me. She knocks down five. Not one less, not one more.
Then its off to Chucky Cheese. We get 100 tokens and a large pizza, half pepperoni, half cheese. I eat the pepperoni half and watch as they run around from machine to machine. The little one jumps up and down four times when she hits a fifty ticket bonus on the dinosaur spinning machine. She runs back to the table, holding the connected tickets high in the air, streaming behind her like a kite.
I try one ride - the jet ski race. I wipe out a couple times and come in 10th out of 10. I have never finished better than 10th. One trip to the Cheese's place I tried eight times. Now I only try once, then walk back to the table and the last slice of pepperoni. I shake some red pepper flakes on it to make it edible.
Before we go, we have our pictures taken at the Chuck E. Cheese studio booth. Then the kids cash in their tickets and get cotton candy, a Chucky Cheese lollipop, a Captain Hook hand and a lizard. Oh, and they get me a couple Smarties candies, which they know I like. Thank you, I say.
Driving back, the six-year old says, "This is the best day ever!" She uses that line a lot, but I always like to here it.
Later we go to the library where I help them get their first library cards. They take out a book and a movie each. We stop at the supermarket and buy sugar cookie dough and make some Christmas cookies. We unknowingly make the dough a little too thick so the molds of a candle, bells and a wreath all produce shapeless blobs of cookies, which the kids shrug about and then eat rapidly before I take the rest away for later.
Around seven I drive them to their grandmother's house, where an aunt and cousins have arrived today. They are excited to see them.
I'm here alone now, drinking a beer after cleaning the house, and doing some last minute wrapping.
Tomorrow morning I am back at work. I'm working 6-6. We'll have dinner and open presents in the evening. Christmas day I'm working 6-6 again. Their mom is working all day too.
I got them some good stuff.
Have a safe and Happy Holiday, everyone!
Thursday, December 21, 2006
The Sealed Envelope
The last post on interfacility transfers sparked quite a number of comments, including several on the "sealed envelope" which plagues us. For those not in EMS, the sealed envelope is what the nurse hands you containing the patient's medical records.
Sometimes "Confidential" is written on it. Sometimes they hand you the sealed envelope "for the hospital" and an unsealed demographic sheet "for you." The demographics are the patient date of birth, address and billing information. Sometimes when you start to open the sealed envelope, the nurse or administrator scolds you -- that's confidential.
The sealed envelope can come in other forms. Sometimes it is a medical binder that the patient's aide (when the patient is a ward of the state) won't let you carry -- she insists on keeping it in the car in which she is following. Sometimes the binder is taped shut with confidential written on it.
Sometimes the sealed envelope is just a doctor or a nurse saying -- they have her records at the hospital, I've called them already. They don't want to tell us anything because they see as as ambulance drivers, not professionals.
In any form, the sealed envelope is a silent slap in our faces.
What do we do when confronted with the sealed envelope? Here are some of my stories.
When I was a new paramedic, around seven in the morning I was sent to do a transfer out of the ED. I think it was a pschyiatric patient who had an IV in. All I remmber is the nurse handed me a envelope with confidential written on it, and when I started to open it, she told me I couldn't. I told her I was going to open it. She told me I couldn't open -- at least not in front of her. It was a new policy -- the information was confidential. I'm going to open it, I said. Right now. I need to know what's on it. You can't, she said. It's not allowed. Then I'm not taking the patient. What I didn't know was she has had a really long shift, and was just doing what some nurse manager who had been riding the staff all night had told her. Are you going to tell me everything that's on it? I said. You can't f--ing open it here, she said, then turned her back and walked away. I opened it there. She didn't look back.
When I complained to the ED doctor who was our medical control about it later, he said, she had a bad night, you could have just taken it and opened it a minute later when you were out of her sight. But....I said.
The but... is the crux of it.
But I'm a professional -- apart of the health care system -- a crucial link in the chain.
I can't tell you how many times this sealed envelope situation occurs. In just about every situation all you have to do is smile, nod and then go ahead and open it later.
But...
There could always been information you need to know, although there usually isn't.
But...
I'm somebody.
Maybe a better man can take it. It seems almost everytime I insist on opening it. Am I insecure? Do I need to prove that I am a professional on a par or greater than my tormentor?
I need to read those papers, I insist. I need to know what's going on with the patient. That book stays with the patient, and the patient is with me. Your phone call to the ED is a scrawl on a scrap of paper in a pile by the tirage desk that no one is going to read, I need the story. I'm responsibile for the patient. I will not eat your shit.
I hate conflict. I don't like anyone to be angry or ruffled, but the sealed envelope pushes my buttons.
Obviously sometimes -- like with the alert and oriented psych patients, as one commenter stated, you might not really need to read their whole case history -- and I admit on long transfers I enjoy reading as much as I can about a patient's history -- the story of their lives -- how they came to this mental state, how they were treated as children, did their families love them or abandon them, how f---ed up are they? Maybe I am invading their privacy the deeper I go into the binder.
But when it is medical -- I absolutely need to know. I will sit there and interview the obstiniate nurse for a half hour asking every question I can think of if she won't turn over the medical records. I will do a full body assessment, vitals, hook the patient up to the monitor, and put in an IV right there, instead of waiting to do it in the ambulance. Look at me I'm an F---ing paramedic.
Is it about the patient or is it about me and my need for respect? Maybe its both.
I've had doctors refuse to tell me their medical history -- he's just dehydrated -- only to find at the hospital the patient has AIDS. If a patient is a psych, I'd like to know if he's violent -- am I transporting Hannibal Lector? I want to know what drugs a patient has just been given? Is the patient allergic to Latex? Do they have a cardiac history? Is that why their left shoulder and arm hurts. Are they a diabetic? Maybe that's why they are acting so wierd today -- their sugar is 800 plus.
In this job we can come into someone's house -- someone who is very sick or dying -- and people look at us like we are the hands of their god -- we can walk onto an accident scene and move men and machines with our words -- or we can walk into an office or onto a ward and be treated like poop on shoes. It creates an indentity crisis. You want to say to the nonbelievers I'm not poop on shoes, I'm a hero, I'm a lifesaver, I'm the man, the MAN -- I'm not an errand boy.
I've mellowed a little over the years. I try to be nice about opening the envelope or asking for more information. I try to do it without an attitude. I don't need to prove anything to anyone -- I am a paramedic. I'll go find the doctor and I'll say hate to bother you, but there's a few things I need to know and I'll talk the lingo. Most of the time it works.
"I just need to make certain everything's in order," I'll say to a nurse, smiling, pretending to be deaf to their objections. "Make certain everything's there we'll need for our report. Gotta keep those CQI stats up or You know how attendings can be if you don't have the answers ready when they ask. Or gotta keep the lawyers happy. Or those damn state regulators happy. Or it accredidation time again."
Many times they smile and commiserate. We are comrades in the health care bureacracy. Nothing personal, just doing our jobs.
With my luck, my next call I'm going to get the sealed envelope and a battleax handing it to me.
I don't like conflict.
I don't like sealed envelopes.
I'll try to handle it calmly, professionaly.
But...
Sometimes "Confidential" is written on it. Sometimes they hand you the sealed envelope "for the hospital" and an unsealed demographic sheet "for you." The demographics are the patient date of birth, address and billing information. Sometimes when you start to open the sealed envelope, the nurse or administrator scolds you -- that's confidential.
The sealed envelope can come in other forms. Sometimes it is a medical binder that the patient's aide (when the patient is a ward of the state) won't let you carry -- she insists on keeping it in the car in which she is following. Sometimes the binder is taped shut with confidential written on it.
Sometimes the sealed envelope is just a doctor or a nurse saying -- they have her records at the hospital, I've called them already. They don't want to tell us anything because they see as as ambulance drivers, not professionals.
In any form, the sealed envelope is a silent slap in our faces.
What do we do when confronted with the sealed envelope? Here are some of my stories.
When I was a new paramedic, around seven in the morning I was sent to do a transfer out of the ED. I think it was a pschyiatric patient who had an IV in. All I remmber is the nurse handed me a envelope with confidential written on it, and when I started to open it, she told me I couldn't. I told her I was going to open it. She told me I couldn't open -- at least not in front of her. It was a new policy -- the information was confidential. I'm going to open it, I said. Right now. I need to know what's on it. You can't, she said. It's not allowed. Then I'm not taking the patient. What I didn't know was she has had a really long shift, and was just doing what some nurse manager who had been riding the staff all night had told her. Are you going to tell me everything that's on it? I said. You can't f--ing open it here, she said, then turned her back and walked away. I opened it there. She didn't look back.
When I complained to the ED doctor who was our medical control about it later, he said, she had a bad night, you could have just taken it and opened it a minute later when you were out of her sight. But....I said.
The but... is the crux of it.
But I'm a professional -- apart of the health care system -- a crucial link in the chain.
I can't tell you how many times this sealed envelope situation occurs. In just about every situation all you have to do is smile, nod and then go ahead and open it later.
But...
There could always been information you need to know, although there usually isn't.
But...
I'm somebody.
Maybe a better man can take it. It seems almost everytime I insist on opening it. Am I insecure? Do I need to prove that I am a professional on a par or greater than my tormentor?
I need to read those papers, I insist. I need to know what's going on with the patient. That book stays with the patient, and the patient is with me. Your phone call to the ED is a scrawl on a scrap of paper in a pile by the tirage desk that no one is going to read, I need the story. I'm responsibile for the patient. I will not eat your shit.
I hate conflict. I don't like anyone to be angry or ruffled, but the sealed envelope pushes my buttons.
Obviously sometimes -- like with the alert and oriented psych patients, as one commenter stated, you might not really need to read their whole case history -- and I admit on long transfers I enjoy reading as much as I can about a patient's history -- the story of their lives -- how they came to this mental state, how they were treated as children, did their families love them or abandon them, how f---ed up are they? Maybe I am invading their privacy the deeper I go into the binder.
But when it is medical -- I absolutely need to know. I will sit there and interview the obstiniate nurse for a half hour asking every question I can think of if she won't turn over the medical records. I will do a full body assessment, vitals, hook the patient up to the monitor, and put in an IV right there, instead of waiting to do it in the ambulance. Look at me I'm an F---ing paramedic.
Is it about the patient or is it about me and my need for respect? Maybe its both.
I've had doctors refuse to tell me their medical history -- he's just dehydrated -- only to find at the hospital the patient has AIDS. If a patient is a psych, I'd like to know if he's violent -- am I transporting Hannibal Lector? I want to know what drugs a patient has just been given? Is the patient allergic to Latex? Do they have a cardiac history? Is that why their left shoulder and arm hurts. Are they a diabetic? Maybe that's why they are acting so wierd today -- their sugar is 800 plus.
In this job we can come into someone's house -- someone who is very sick or dying -- and people look at us like we are the hands of their god -- we can walk onto an accident scene and move men and machines with our words -- or we can walk into an office or onto a ward and be treated like poop on shoes. It creates an indentity crisis. You want to say to the nonbelievers I'm not poop on shoes, I'm a hero, I'm a lifesaver, I'm the man, the MAN -- I'm not an errand boy.
I've mellowed a little over the years. I try to be nice about opening the envelope or asking for more information. I try to do it without an attitude. I don't need to prove anything to anyone -- I am a paramedic. I'll go find the doctor and I'll say hate to bother you, but there's a few things I need to know and I'll talk the lingo. Most of the time it works.
"I just need to make certain everything's in order," I'll say to a nurse, smiling, pretending to be deaf to their objections. "Make certain everything's there we'll need for our report. Gotta keep those CQI stats up or You know how attendings can be if you don't have the answers ready when they ask. Or gotta keep the lawyers happy. Or those damn state regulators happy. Or it accredidation time again."
Many times they smile and commiserate. We are comrades in the health care bureacracy. Nothing personal, just doing our jobs.
With my luck, my next call I'm going to get the sealed envelope and a battleax handing it to me.
I don't like conflict.
I don't like sealed envelopes.
I'll try to handle it calmly, professionaly.
But...
Wednesday, December 20, 2006
Interfacility Transfers, DNRs, Choices
I recently recieved an email from Jamie Davis, The Pod Medic, about a dilemna one of his listeners faced on a recent call. Here is the story he recieved:
This happened to me last month and I've been asking around trying to get other people's opinions about what they would have done, so let me know what you think and feel free to put it on the show...
The EMS I'm working for (Hospital Name Removed) also does non-emergency transportation for the hospital. We had a patient about two weeks ago that we were to transport to hospice after being discharged off of a treatment floor. We transferred the patient to our stretcher and began the transport to hospice when the patient began to exhibit signs of respiratory distress.
Now, herein lies the ethical dilemma:
1. The patient's file contained a DNR, but not with a signature from a responsible party. The DNR was "confirmed" by an RN talking to someone over the phone. It was also not co-signed by another RN or MD.
2. The patient was exhibiting moderate to severe distress, including multiple brief periods of apnea, but was not in a resuscitation situation.
3. I made a judgement call to return to the hospital's ER to have the patient re-evaluated, per our protocols, which was agreed to by both my partner and our supervisor after talking to him on the phone for on-line control.
4. The ER sent us right back up to the treatment floor without any other treatment, and that began an argument between the nursing staff on the treatment floor and my crew. The nurses on the treatment floor said that the MD attending the case has expressly instructed that the patient was to "leave and leave now" for undisclosed reasons, and that they ensured she was stable before we left. My partner and I felt that this patient was not dynamically stable and needed to be re-evaluated before transport. We then transferred the patient back to a room on the treatment floor and left the floor. Our supervisor informed us about 10 minutes later that we were to meet him on the floor and we would re-evaluate the patient's condition to determine transport options. We met our supervisor and completed a re-eval of this patient, only now being told by the RN attending that the respiratory condition of this patient was normal and not an anomaly. Our supervisor then indicated that he was okay with the patient being transported if we were. My partner and I agreed that
we would again attempt transport, but if the patient's condition worsened, that we were going to return to the ER for stabilization per our protocols and NOT attempt a third transfer.
The nurse was hesitant to agree to this, but eventually did and we were lucky enough to make it to the hospice center without an incident. My partner and I were both very relieved that the patient did not die in the back of the ambulance, but we were at a loss as to why a transfer would be scheduled the day before Thanksgiving in the
evening, which is prime rush hour in our primary service area. The lack of concern for the patient's well being was a little unsettling as well.
I couldn't help wondering if there was a better way to handle this situation
and I'm curious to see what you think. Thanks for taking the time to read this and please let me know if there's anything that isn't clear.
***
Warning: My answer is rambling and full of tangents.
Interfacility transfers are a true grey area in EMS. Here in our state we are finally developing a program with regulations to address some of this, although final approval and enactment may be some time away. But all EMS systems should have these issues addressed to prevent the field medics from being put in situations like the above. Without regulations, hospitals will continue to ship people out without the "t's" crossed and the "i's" dotted just to clear up beds.
Anyway, I probably would have done just what the medic above did. On the unsigned DNR issue, the interfacility transfer gives you less leeway to do the "right" thing than maybe a scene call does. I have, rightly or wrongly, on scene calls accepted DNR paperwork that might not have had all the i's dotted because I felt the intention was clear. While the paperwork may have been ambiguous, there was nothing ambiguous about the scene -- a terminal patient who was asystole, a family in agreement with a loved one that he die in peace. The fact that the physician signature wasn't fully dated became a detail noticed and then forgotten. When I wrote my paperwork up, I wrote the scene up "blacker than greyer," if you know what I mean. I'm not saying I didn't write it up accurately. What I am saying is that paperwork is black and white, while the decisions we make are often grey. You can't write the patient had a hint of rigor mortis in their jaw, in the paperwork, they had rigor mortis. An "i" that is not dotted might become a detail not noted in the paperwork if you chose to accept the paperwork.
A newer medic, told me the other day about responding to a deceased patient with a DNR that was not properly signed, he chose not to initiate CPR, but to call medical control to ask permission to presume, thinking it would be a forgone conclusion, only to be told to implement full ACLS resuscitation and bring the patient to the ED. This happened just days after he was castigated by another physician for putting CPAP on a patient in respiratory distress, who was a DNR. Seeking counsel from supervisors and older medics, he recieved answers ranging from you have to work the patient to you shouldn't have called medical control, you should have just called the patient dead.
It is ethically grey. When you are the lone medic, you can chose where to draw the lines by yourself, but once others are involved, the line tends to be drawn more legally than ethically. People act out of legal concern rather than ethical concern -- they are forced too.
Medics are constantly being put in these dilemnas.
Here's a case that happened a few years ago. An experienced medic is doing an interfacility transport of an MI patient, taking him from a small hospital to a hospital capable of doing an angioplasty. En route to the hospital, the patient arrests. The medic is faced with the choice -- do I bring the patient back to a small hospital or do a continue on to the larger hospital? The distance is grey. It is wherever your line is in making the decision. It might be a little closer to the small hospital, but the big hospital has the angioplasty. What do you do? He went to the big hospital and caught massive shit and was suspended. I would have probably done just what he did. He was put in the situation, not me or any other medic. He got suspended for his choice.
When I was a new medic I responded to a child hit by a car in front of a trauma center. My choice was take him to the trauma center or go another five minutes more in another direction to the farther trauma center which had pediatric specialists. I went to the closer center. When the farther trauma center called my supervisor to give him hell, I was lucky he defended me. Had I gone to that trauma center, no doubt the closer center would have been on the phone. When a patient dies, you are in a no-win situation. We can always be second guessed.
Before we get to the case outlined above, here are two interfacility cases I was involved with that raise somewhat similar issues -- doing what you think is right versus what is allowed under the technical rules.
A small hospital calls to transfer a shooting victim to the trauma center down the street. They stabilize the patient by putting in IVs, a chest tube and intubating. I arrive, and not being trained in chest tubes, request a nurse to accompany us. They are overwhelmed, understaffed and don't have anyone who can go. The man needs the OR. They give me a quick lesson on the chest tube and I transport the patient hoping nothing happenes to the tube. I'm putting myself on the line. Why should I do that? Maybe because there is a man dying in front of me, and somebody has to think about him. He didn't have time for us to sort out the rules.
Another call, we are called to take a 16 year old patient home to die(although curiously she wasn't a DNR). The patient has two chest tubes and is on some wierd kind of ventilator that sucks oxygen like crazy. While she is going home, there will be two private critical care nurses there. Her heart rate is in the 160s. This is normal for her -- in her state. I'm not real comfortable with this transfer, even though I have a nurse going with me. The nurse, who is a respiratory specialist who works for the company that makes this almost one of a kind ventilator, says he knows a little something about chest tubes. It is rush hour. I ask my partner to do the transfer with easy lights and sirens. I am worried we will run out of oxygen. When he makes this request, the dispatcher goes nuts. You can't go lights and sirens on a transfer home! she screams over the air. If you are uncomfortable, bring the patient back into the hospital. The dispatcher knows nothing about the specifics of the call. I can't explain to her over the radio because the family is right there and the mother is already upset about everything. How is it going to make her feel if I tell the dispatcher the woman's daughter is dying and it is the family and the hospital's wish that she spend her last days at home and not in the hospital where she has spent the last six months. I can't bring her back to the hospital because she is in the state they know she is in. (This is her norm.) What a mess for everyone that will cause. Okay, just go, I say to my partner. I catch shit from everyone about wanting to go lights and sirens on a transfer home. I don't even bother to explain. Like the case above, fortunately the patient doesn't die on us or run out of oxygen.
As a newer medic at that time, I didn't want to rock the boat. I didn't want to make the company look bad, upset the family or appear inadequate. Maybe in retrospect on arrival now, I would be on the line with a supervisor before I put the patient on my stretcher.
Enough rambling. The bottom line is this -- Prehospital people need to be protected by clear interfacility guidelines. Hospitals probably never will, but need to work within the rules of the system. As medics or EMTs we should make certain all the paperwork is in order before we put the patient on our stretcher. Still though, there will probably still be grey situations when the interests of the patient clash with the contrictions of the system, and we will be left with doing the best we can, and always wondering how we could have done it better.
***
The Medic Cast
This happened to me last month and I've been asking around trying to get other people's opinions about what they would have done, so let me know what you think and feel free to put it on the show...
The EMS I'm working for (Hospital Name Removed) also does non-emergency transportation for the hospital. We had a patient about two weeks ago that we were to transport to hospice after being discharged off of a treatment floor. We transferred the patient to our stretcher and began the transport to hospice when the patient began to exhibit signs of respiratory distress.
Now, herein lies the ethical dilemma:
1. The patient's file contained a DNR, but not with a signature from a responsible party. The DNR was "confirmed" by an RN talking to someone over the phone. It was also not co-signed by another RN or MD.
2. The patient was exhibiting moderate to severe distress, including multiple brief periods of apnea, but was not in a resuscitation situation.
3. I made a judgement call to return to the hospital's ER to have the patient re-evaluated, per our protocols, which was agreed to by both my partner and our supervisor after talking to him on the phone for on-line control.
4. The ER sent us right back up to the treatment floor without any other treatment, and that began an argument between the nursing staff on the treatment floor and my crew. The nurses on the treatment floor said that the MD attending the case has expressly instructed that the patient was to "leave and leave now" for undisclosed reasons, and that they ensured she was stable before we left. My partner and I felt that this patient was not dynamically stable and needed to be re-evaluated before transport. We then transferred the patient back to a room on the treatment floor and left the floor. Our supervisor informed us about 10 minutes later that we were to meet him on the floor and we would re-evaluate the patient's condition to determine transport options. We met our supervisor and completed a re-eval of this patient, only now being told by the RN attending that the respiratory condition of this patient was normal and not an anomaly. Our supervisor then indicated that he was okay with the patient being transported if we were. My partner and I agreed that
we would again attempt transport, but if the patient's condition worsened, that we were going to return to the ER for stabilization per our protocols and NOT attempt a third transfer.
The nurse was hesitant to agree to this, but eventually did and we were lucky enough to make it to the hospice center without an incident. My partner and I were both very relieved that the patient did not die in the back of the ambulance, but we were at a loss as to why a transfer would be scheduled the day before Thanksgiving in the
evening, which is prime rush hour in our primary service area. The lack of concern for the patient's well being was a little unsettling as well.
I couldn't help wondering if there was a better way to handle this situation
and I'm curious to see what you think. Thanks for taking the time to read this and please let me know if there's anything that isn't clear.
***
Warning: My answer is rambling and full of tangents.
Interfacility transfers are a true grey area in EMS. Here in our state we are finally developing a program with regulations to address some of this, although final approval and enactment may be some time away. But all EMS systems should have these issues addressed to prevent the field medics from being put in situations like the above. Without regulations, hospitals will continue to ship people out without the "t's" crossed and the "i's" dotted just to clear up beds.
Anyway, I probably would have done just what the medic above did. On the unsigned DNR issue, the interfacility transfer gives you less leeway to do the "right" thing than maybe a scene call does. I have, rightly or wrongly, on scene calls accepted DNR paperwork that might not have had all the i's dotted because I felt the intention was clear. While the paperwork may have been ambiguous, there was nothing ambiguous about the scene -- a terminal patient who was asystole, a family in agreement with a loved one that he die in peace. The fact that the physician signature wasn't fully dated became a detail noticed and then forgotten. When I wrote my paperwork up, I wrote the scene up "blacker than greyer," if you know what I mean. I'm not saying I didn't write it up accurately. What I am saying is that paperwork is black and white, while the decisions we make are often grey. You can't write the patient had a hint of rigor mortis in their jaw, in the paperwork, they had rigor mortis. An "i" that is not dotted might become a detail not noted in the paperwork if you chose to accept the paperwork.
A newer medic, told me the other day about responding to a deceased patient with a DNR that was not properly signed, he chose not to initiate CPR, but to call medical control to ask permission to presume, thinking it would be a forgone conclusion, only to be told to implement full ACLS resuscitation and bring the patient to the ED. This happened just days after he was castigated by another physician for putting CPAP on a patient in respiratory distress, who was a DNR. Seeking counsel from supervisors and older medics, he recieved answers ranging from you have to work the patient to you shouldn't have called medical control, you should have just called the patient dead.
It is ethically grey. When you are the lone medic, you can chose where to draw the lines by yourself, but once others are involved, the line tends to be drawn more legally than ethically. People act out of legal concern rather than ethical concern -- they are forced too.
Medics are constantly being put in these dilemnas.
Here's a case that happened a few years ago. An experienced medic is doing an interfacility transport of an MI patient, taking him from a small hospital to a hospital capable of doing an angioplasty. En route to the hospital, the patient arrests. The medic is faced with the choice -- do I bring the patient back to a small hospital or do a continue on to the larger hospital? The distance is grey. It is wherever your line is in making the decision. It might be a little closer to the small hospital, but the big hospital has the angioplasty. What do you do? He went to the big hospital and caught massive shit and was suspended. I would have probably done just what he did. He was put in the situation, not me or any other medic. He got suspended for his choice.
When I was a new medic I responded to a child hit by a car in front of a trauma center. My choice was take him to the trauma center or go another five minutes more in another direction to the farther trauma center which had pediatric specialists. I went to the closer center. When the farther trauma center called my supervisor to give him hell, I was lucky he defended me. Had I gone to that trauma center, no doubt the closer center would have been on the phone. When a patient dies, you are in a no-win situation. We can always be second guessed.
Before we get to the case outlined above, here are two interfacility cases I was involved with that raise somewhat similar issues -- doing what you think is right versus what is allowed under the technical rules.
A small hospital calls to transfer a shooting victim to the trauma center down the street. They stabilize the patient by putting in IVs, a chest tube and intubating. I arrive, and not being trained in chest tubes, request a nurse to accompany us. They are overwhelmed, understaffed and don't have anyone who can go. The man needs the OR. They give me a quick lesson on the chest tube and I transport the patient hoping nothing happenes to the tube. I'm putting myself on the line. Why should I do that? Maybe because there is a man dying in front of me, and somebody has to think about him. He didn't have time for us to sort out the rules.
Another call, we are called to take a 16 year old patient home to die(although curiously she wasn't a DNR). The patient has two chest tubes and is on some wierd kind of ventilator that sucks oxygen like crazy. While she is going home, there will be two private critical care nurses there. Her heart rate is in the 160s. This is normal for her -- in her state. I'm not real comfortable with this transfer, even though I have a nurse going with me. The nurse, who is a respiratory specialist who works for the company that makes this almost one of a kind ventilator, says he knows a little something about chest tubes. It is rush hour. I ask my partner to do the transfer with easy lights and sirens. I am worried we will run out of oxygen. When he makes this request, the dispatcher goes nuts. You can't go lights and sirens on a transfer home! she screams over the air. If you are uncomfortable, bring the patient back into the hospital. The dispatcher knows nothing about the specifics of the call. I can't explain to her over the radio because the family is right there and the mother is already upset about everything. How is it going to make her feel if I tell the dispatcher the woman's daughter is dying and it is the family and the hospital's wish that she spend her last days at home and not in the hospital where she has spent the last six months. I can't bring her back to the hospital because she is in the state they know she is in. (This is her norm.) What a mess for everyone that will cause. Okay, just go, I say to my partner. I catch shit from everyone about wanting to go lights and sirens on a transfer home. I don't even bother to explain. Like the case above, fortunately the patient doesn't die on us or run out of oxygen.
As a newer medic at that time, I didn't want to rock the boat. I didn't want to make the company look bad, upset the family or appear inadequate. Maybe in retrospect on arrival now, I would be on the line with a supervisor before I put the patient on my stretcher.
Enough rambling. The bottom line is this -- Prehospital people need to be protected by clear interfacility guidelines. Hospitals probably never will, but need to work within the rules of the system. As medics or EMTs we should make certain all the paperwork is in order before we put the patient on our stretcher. Still though, there will probably still be grey situations when the interests of the patient clash with the contrictions of the system, and we will be left with doing the best we can, and always wondering how we could have done it better.
***
The Medic Cast
Tuesday, December 19, 2006
Back
Back from vacation. It will be the last one for quite awhile. I sort of overdid it this year with travel. The only reason I went this time was I had some tickets I had to use or they would expire this month.
Vacation is great, but there are always difficult decisions to make.
Do I workout and eat healthy?
Or do I gorge at the buffet?
Do I sit by the pool and drink? and if so
Do I drink beer or umbrella drinks?
I walked a reasonable line, I guess. I weighed myself when I got in last night at two. .8 lb gain. Not bad.
Maybe it was all the late nights at the disco.
I only had three hours sleep, and am back at work, limping slightly.
I'm tanned, but not particuarly rested.
First call was for an old man with Parkinsons who fell and couldn't get up. His wife didn't look in much better shape. I hope they took plenty of vacations together in their day. Enjoyed their time in the sun.
I didn't think about work much at all while away. I brought a small notebook and made some notes about the things I want to accomplish in the job and in EMS over the next year. I wrote in it for about ten minutes by the pool and then put it away. I'll relook at the list soon and write something at the end of the year.
I hope today is quiet as I need the rest.
Vacation is great, but there are always difficult decisions to make.
Do I workout and eat healthy?
Or do I gorge at the buffet?
Do I sit by the pool and drink? and if so
Do I drink beer or umbrella drinks?
I walked a reasonable line, I guess. I weighed myself when I got in last night at two. .8 lb gain. Not bad.
Maybe it was all the late nights at the disco.
I only had three hours sleep, and am back at work, limping slightly.
I'm tanned, but not particuarly rested.
First call was for an old man with Parkinsons who fell and couldn't get up. His wife didn't look in much better shape. I hope they took plenty of vacations together in their day. Enjoyed their time in the sun.
I didn't think about work much at all while away. I brought a small notebook and made some notes about the things I want to accomplish in the job and in EMS over the next year. I wrote in it for about ten minutes by the pool and then put it away. I'll relook at the list soon and write something at the end of the year.
I hope today is quiet as I need the rest.
Thursday, December 14, 2006
Give Your Life Meaning
No posts until next Tuesday. I'm taking a little vacation. In the meantime I will leave this article I read today. While it is about retirement, I think even if you are in your early twenties it is still something to consider. Every now and then I get opportunities to try something with a little more security, but I haven't found anything in work that gives me more meaning than being a paramedic. Not that that is enough to sustain a person. You need meaning in more than just your work. I'll be thinking about that this week while I'm having a beer with my feet up. I'll let you know what I come up with.
Give Your Life Meaning
***
PAUL B. FARRELL
'New Retirement' asks: 'Got dreams?'
Discover the meaning of life, or nothing matters, not even money
By Paul B. Farrell, MarketWatch
Last Update: 7:24 PM ET Dec 11, 2006
ARROYO GRANDE, Calif. (MarketWatch) -- What's the only thing you really need to get "right" in retirement? Get right, or nothing matters? This message isn't just for retirees. It's for boomers, young investors starting a career and family, folks in midlife crisis. Some day we all stop and ask: What's really, really important?
What's the big question mark in retirement? Health? Maybe family? Security? Money? I'll bet Wall Street's got you convinced that all your fears boil down to one thing, money. Got money? Got no problems! Right? Wrong!
So what really, really matters in retirement? OK, so it's not money or security. Nor health, a loving spouse, teaching the kids right. Don't get me wrong, they're all important. But none of them will ever matter much if you don't get this one thing right.
To understand it, let's put it in context: Look at the old versus "new retirement," compare 1969 to today. Not Vietnam versus Iraq; I'm talking "Easy Rider!"
Dennis Hopper is a great pitchman: He's come a long way from his get-rich-quick days chasing the great American Dream in "Easy Rider." Remember the night before Hopper's character gets killed. After a big score, he's telling his buddy Peter Fonda: "We did it. We're rich, man. We're retiring in Florida. You go for the big money, man, and then you're free."
Except he didn't get "it." The price of his dream was too high, it cost him his soul. And he didn't even know why. His friend did: "We blew it, good night man." Next day, he was blown off his chopper by an angry shotgun-totting redneck in a beat-up truck. He went to his grave oblivious. He didn't "get it."
Money isn't "it." Get-rich-quick isn't it. Neither is getting rich slowly: All that stuff Wall Street and Corporate America want you to believe about working 30 or 40 years, saving regularly, piling up a hundred thousand, maybe a million or whatever, in IRAs, 401(k)s and lots of retirement accounts. Not it.
Flash forward from 1969: Today Hopper's got it. And it's not hard to miss his exuberant reincarnation in the new Ameriprise Financial ads: No more empty dreams of getting rich quick and playing shuffleboard in Florida:
"You still have things to do, right?" Hopper says to new retirees. These ads replace the old "rocking-chair dream" with relaxing beaches, rolling hills of wildflowers, yoga, traveling, stuff you've always wanted to do. "You have dreams. And there is no age limit on dreams. The thing about dreams is, they don't retire."
You gotta love it! But, there's a catch: Sure, everybody gets a second chance, but lots don't take it. Too many are still like Hopper'69, oblivious, never quite getting "it."
Why? You'll get a glimpse of the answer in Thomas Stanley's classic, "The Millionaire Mind:" "Why is it that only a minority of our population love their work?" That's right, the vast majority of people don't like what they're doing before retirement, and they're not prepared for the second chance, second career, second act.
Then, when it finally happens, you may even retire one of the few who've saved enough to announce like Hopper: "I did it. I got the big money. I'm rich, man, I'm free!" Then it'll hit you, you'll come face to face with the one and only thing that really matters in retirement ... and it's not money.
Case in point: I was in the career-planning business years ago. I've been around miserable megamillionaires. And around people who are broke yet happy, doing what they love in retirement, and before. I'll bet you know some of both.
A "new retirement" begins with a new attitude. It's not about money. And it's also not about being "happy." Being happy is a by-product of something else.
You must find the "meaning" of life, the meaning of your life. Years ago I was in a midlife crisis, got my first glimpse of the answer in Tony Robbins' "Unlimited Power:" "Nothing has any meaning except the meaning we give it." Psychiatrist and Holocaust survivor Viktor Frankl elaborates in "Man's Search for Meaning:"
"We needed a fundamental change in our attitude toward life. We had to learn ourselves and, furthermore, we had to teach the despairing men, that it did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead to think of ourselves as those who were being questioned by life -- daily and hourly. Our answer must consist, not in talk and meditation, but in right action and right conduct. Life ultimately means taking the responsibility to find the right answers to its problems and to fulfill the tasks which it constantly sets for each individual."
You can have health, friends, family, total security and all the money you'll ever need, but unless your life has "meaning," nothing matters. And no one can give "meaning" to your life except you. Not a million-dollar portfolio, not being debt-free, nor tight abs, low cholesterol, nor a famous guru, evangelist or yoga instructor. All that's irrelevant if you don't know deep in your soul the meaning of your life.
Only you can ever know whether you're living a meaningful life or one of quiet desperation. So let's assume you're already more like the new rather than the old Hopper. But you're searching. And let's forget all the new-age nonsense about "life's not a rehearsal" and "you only go around once."
Everyone gets a second chance. We never stop getting chances because "dreams never retire." When I was helping plan careers, I'd have people spend time covering a wall with a montage of magazine clippings, whatever turned them on (fishing, fashion, golf, travel, music, art, hobbies, you name it), then we'd explore the pattern.
In "The Power Years," retirement guru Ken Dychtwald suggests making three lists. Go buy a big journal. Write in it every day: First, a list of every job you've ever had and what you loved about it. Next, go through your annual budgets, list where you spend your discretionary income. Third, review the key turning points of your life. Get real: Where did your secret dreams take a back seat to your commitments to others, like the kids' college.
Go on a retreat, to seminars, maybe a spiritual pilgrimage, maybe get the advice of a career counselor. Read about other's second-act dreams. Take your time. You're on a journey, explore. Review the lists. Look inside. Trust me, the answers are already in there.
Rediscover your dreams, tap into the meaning of your life. You'll get all the chances you want this time around because dreams never retire! It's your life, make it a meaningful life. And when you get it, go for it with passion.
Give Your Life Meaning
***
PAUL B. FARRELL
'New Retirement' asks: 'Got dreams?'
Discover the meaning of life, or nothing matters, not even money
By Paul B. Farrell, MarketWatch
Last Update: 7:24 PM ET Dec 11, 2006
ARROYO GRANDE, Calif. (MarketWatch) -- What's the only thing you really need to get "right" in retirement? Get right, or nothing matters? This message isn't just for retirees. It's for boomers, young investors starting a career and family, folks in midlife crisis. Some day we all stop and ask: What's really, really important?
What's the big question mark in retirement? Health? Maybe family? Security? Money? I'll bet Wall Street's got you convinced that all your fears boil down to one thing, money. Got money? Got no problems! Right? Wrong!
So what really, really matters in retirement? OK, so it's not money or security. Nor health, a loving spouse, teaching the kids right. Don't get me wrong, they're all important. But none of them will ever matter much if you don't get this one thing right.
To understand it, let's put it in context: Look at the old versus "new retirement," compare 1969 to today. Not Vietnam versus Iraq; I'm talking "Easy Rider!"
Dennis Hopper is a great pitchman: He's come a long way from his get-rich-quick days chasing the great American Dream in "Easy Rider." Remember the night before Hopper's character gets killed. After a big score, he's telling his buddy Peter Fonda: "We did it. We're rich, man. We're retiring in Florida. You go for the big money, man, and then you're free."
Except he didn't get "it." The price of his dream was too high, it cost him his soul. And he didn't even know why. His friend did: "We blew it, good night man." Next day, he was blown off his chopper by an angry shotgun-totting redneck in a beat-up truck. He went to his grave oblivious. He didn't "get it."
Money isn't "it." Get-rich-quick isn't it. Neither is getting rich slowly: All that stuff Wall Street and Corporate America want you to believe about working 30 or 40 years, saving regularly, piling up a hundred thousand, maybe a million or whatever, in IRAs, 401(k)s and lots of retirement accounts. Not it.
Flash forward from 1969: Today Hopper's got it. And it's not hard to miss his exuberant reincarnation in the new Ameriprise Financial ads: No more empty dreams of getting rich quick and playing shuffleboard in Florida:
"You still have things to do, right?" Hopper says to new retirees. These ads replace the old "rocking-chair dream" with relaxing beaches, rolling hills of wildflowers, yoga, traveling, stuff you've always wanted to do. "You have dreams. And there is no age limit on dreams. The thing about dreams is, they don't retire."
You gotta love it! But, there's a catch: Sure, everybody gets a second chance, but lots don't take it. Too many are still like Hopper'69, oblivious, never quite getting "it."
Why? You'll get a glimpse of the answer in Thomas Stanley's classic, "The Millionaire Mind:" "Why is it that only a minority of our population love their work?" That's right, the vast majority of people don't like what they're doing before retirement, and they're not prepared for the second chance, second career, second act.
Then, when it finally happens, you may even retire one of the few who've saved enough to announce like Hopper: "I did it. I got the big money. I'm rich, man, I'm free!" Then it'll hit you, you'll come face to face with the one and only thing that really matters in retirement ... and it's not money.
Case in point: I was in the career-planning business years ago. I've been around miserable megamillionaires. And around people who are broke yet happy, doing what they love in retirement, and before. I'll bet you know some of both.
A "new retirement" begins with a new attitude. It's not about money. And it's also not about being "happy." Being happy is a by-product of something else.
You must find the "meaning" of life, the meaning of your life. Years ago I was in a midlife crisis, got my first glimpse of the answer in Tony Robbins' "Unlimited Power:" "Nothing has any meaning except the meaning we give it." Psychiatrist and Holocaust survivor Viktor Frankl elaborates in "Man's Search for Meaning:"
"We needed a fundamental change in our attitude toward life. We had to learn ourselves and, furthermore, we had to teach the despairing men, that it did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead to think of ourselves as those who were being questioned by life -- daily and hourly. Our answer must consist, not in talk and meditation, but in right action and right conduct. Life ultimately means taking the responsibility to find the right answers to its problems and to fulfill the tasks which it constantly sets for each individual."
You can have health, friends, family, total security and all the money you'll ever need, but unless your life has "meaning," nothing matters. And no one can give "meaning" to your life except you. Not a million-dollar portfolio, not being debt-free, nor tight abs, low cholesterol, nor a famous guru, evangelist or yoga instructor. All that's irrelevant if you don't know deep in your soul the meaning of your life.
Only you can ever know whether you're living a meaningful life or one of quiet desperation. So let's assume you're already more like the new rather than the old Hopper. But you're searching. And let's forget all the new-age nonsense about "life's not a rehearsal" and "you only go around once."
Everyone gets a second chance. We never stop getting chances because "dreams never retire." When I was helping plan careers, I'd have people spend time covering a wall with a montage of magazine clippings, whatever turned them on (fishing, fashion, golf, travel, music, art, hobbies, you name it), then we'd explore the pattern.
In "The Power Years," retirement guru Ken Dychtwald suggests making three lists. Go buy a big journal. Write in it every day: First, a list of every job you've ever had and what you loved about it. Next, go through your annual budgets, list where you spend your discretionary income. Third, review the key turning points of your life. Get real: Where did your secret dreams take a back seat to your commitments to others, like the kids' college.
Go on a retreat, to seminars, maybe a spiritual pilgrimage, maybe get the advice of a career counselor. Read about other's second-act dreams. Take your time. You're on a journey, explore. Review the lists. Look inside. Trust me, the answers are already in there.
Rediscover your dreams, tap into the meaning of your life. You'll get all the chances you want this time around because dreams never retire! It's your life, make it a meaningful life. And when you get it, go for it with passion.
Sunday, December 10, 2006
Listening
We get called to a nursing home for abdominal pain and possible kidney or gallstones. We find an 88 year old man, alert and oriented, in no pain. The nurse explains he had an unresponsive episode earlier in the day. They did an ultrasound which revealed he had an Abdominal Aortic Aneurysm, multiple gallstones and a cyst on his kidney. Now almost ten hours later, the doctor has told them he should go to the ED to be evaluated. The nurse says she has just gotten off the phone with the emergency room. They are expecting him.
His blood pressure is 92/62. His SAT on room air is 99%. His respiratory rate is 18. His End Tidal CO2 is 35. His belly is soft and nontender. He said it was bothering him earlier in the day, but okay now. There are no pulsing masses. His distal pulses are all equal. The only abnormal finding is his pulse. It is 32. He is not on any beta blockers. I do a twelve lead. He is in 3rd Degree Heart Block. Looking through his paperwork, I see he is a DNR.
Since he is asymptomatic, we go to the hospital on a non-priority. We have a very nice conversation. His last name is the same as a man who used to play for the New York Giants. I ask if he is related to the football player. He says the man is his brother.
At the hospital, the triage nurse, who I believe is new, asks “Is this the AAA?
“Well, sort of,” I say. “There is more to the story. I try to explain everything that is going on, but she doesn’t appear to be listening. “When was he unresponsive? This morning! Why did they wait to call?”’ The hospital’s automatic cuff come sup then with a BP 50/30. “Look at his pressure,” she says.
“That’s not his pressure,” I say. “It’s much higher. It’s been very steady at 90/60. His problem is...”
“They’re waiting for him in room C,” she says impatiently.
“...he has a low pulse rate.” I say. But she isn’t listening.
We take him to room C where we are met by a doctor and two nurses. Before I can even tell the story, I hear the triage nurse say she is alerting the OR that the Triple A is here and needs to go right up. Then I tell the story. This is Mr.____, I say. He was unresponsive earlier, I say, they did an ultra sound that showed the AAA, gallstones and a cyst. He is now alert, no pain, mentating, good capillary refill, good pulse saturation. His pulse is 32. He is in a third degree heart block. Oh, and by the way, he is a DNR.
As I am giving the report, his BP on their machine comes up 90/60. The doctor, who has been listening to me the whole time, tells a nurse. “Call the OR back.” He shakes his head.
***
What is going on? Well for one, they probably didn’t know he was a DNR and that makes it less likely they would undertake a major surgery. But that aside, the question I am asking is while he may have a Triple A, is it dissecting right now or even close to bursting? A triple A is one thing a dissection Triple A is another – that’s the real emergency. My guess is the man simply needs a pacemaker. Why was he unresponsive earlier? From past experience dealing with nursing homes it could be anything from he was tired and sleeping to he had a small stroke or seizure, or he vagaled or had an arrhythmia. So because he said his stomach had been bothering him, they did an ultrasound and discovered all these problems that he may well have had for years that no one knew about. He’s 88 years old, for goodness sake. People hear AAA and think someone is dying. So his heart rate is 32. It may have been that for sometime and they only now noticed it. Sitting in bed, he may be able to get by on 32 because he doesn’t exert himself. The odds are he is probably an old athlete like his brother so he has a strong heart. Time has eroded his electrical pathways, but he’s still pumping well enough to perfuse his brain. A pacemaker will definitely perk him up, but I don’t think he needs to be rushed to the ED to have his belly cut open.
“Mr. _____,” the doctor says. “Any relation to ______, the old football player?” He smiles when the man says yes. “I saw him play at the old Yankee stadium back in the 60’s,” the doctor says, leaning forward against the bed railing. “Hell of a player, your brother.”
The two talk.
His blood pressure is 92/62. His SAT on room air is 99%. His respiratory rate is 18. His End Tidal CO2 is 35. His belly is soft and nontender. He said it was bothering him earlier in the day, but okay now. There are no pulsing masses. His distal pulses are all equal. The only abnormal finding is his pulse. It is 32. He is not on any beta blockers. I do a twelve lead. He is in 3rd Degree Heart Block. Looking through his paperwork, I see he is a DNR.
Since he is asymptomatic, we go to the hospital on a non-priority. We have a very nice conversation. His last name is the same as a man who used to play for the New York Giants. I ask if he is related to the football player. He says the man is his brother.
At the hospital, the triage nurse, who I believe is new, asks “Is this the AAA?
“Well, sort of,” I say. “There is more to the story. I try to explain everything that is going on, but she doesn’t appear to be listening. “When was he unresponsive? This morning! Why did they wait to call?”’ The hospital’s automatic cuff come sup then with a BP 50/30. “Look at his pressure,” she says.
“That’s not his pressure,” I say. “It’s much higher. It’s been very steady at 90/60. His problem is...”
“They’re waiting for him in room C,” she says impatiently.
“...he has a low pulse rate.” I say. But she isn’t listening.
We take him to room C where we are met by a doctor and two nurses. Before I can even tell the story, I hear the triage nurse say she is alerting the OR that the Triple A is here and needs to go right up. Then I tell the story. This is Mr.____, I say. He was unresponsive earlier, I say, they did an ultra sound that showed the AAA, gallstones and a cyst. He is now alert, no pain, mentating, good capillary refill, good pulse saturation. His pulse is 32. He is in a third degree heart block. Oh, and by the way, he is a DNR.
As I am giving the report, his BP on their machine comes up 90/60. The doctor, who has been listening to me the whole time, tells a nurse. “Call the OR back.” He shakes his head.
***
What is going on? Well for one, they probably didn’t know he was a DNR and that makes it less likely they would undertake a major surgery. But that aside, the question I am asking is while he may have a Triple A, is it dissecting right now or even close to bursting? A triple A is one thing a dissection Triple A is another – that’s the real emergency. My guess is the man simply needs a pacemaker. Why was he unresponsive earlier? From past experience dealing with nursing homes it could be anything from he was tired and sleeping to he had a small stroke or seizure, or he vagaled or had an arrhythmia. So because he said his stomach had been bothering him, they did an ultrasound and discovered all these problems that he may well have had for years that no one knew about. He’s 88 years old, for goodness sake. People hear AAA and think someone is dying. So his heart rate is 32. It may have been that for sometime and they only now noticed it. Sitting in bed, he may be able to get by on 32 because he doesn’t exert himself. The odds are he is probably an old athlete like his brother so he has a strong heart. Time has eroded his electrical pathways, but he’s still pumping well enough to perfuse his brain. A pacemaker will definitely perk him up, but I don’t think he needs to be rushed to the ED to have his belly cut open.
“Mr. _____,” the doctor says. “Any relation to ______, the old football player?” He smiles when the man says yes. “I saw him play at the old Yankee stadium back in the 60’s,” the doctor says, leaning forward against the bed railing. “Hell of a player, your brother.”
The two talk.
Saturday, December 09, 2006
Speaking of DNRs
Speaking of....
Called for difficulty breathing to a nursing home. Second time in same day called to the same nursing home for same complaint, had same nurse, asked the same question. What is the patient’s norm? The nurse shrugs and turns to an aide who says, she don’t speak, but she converse. Does she have any history of respiratory problems? The nurse shrugs. I’ll have to look in her chart. All I know is she has dementia.
The woman is in her 80’s and breathing rapidly and shallowly. They have her on a non-rebreather at 4 lpm. They say they can’t get her SAT above 80. They can’t tell me how long this has been going on, but they seem to think it all started this afternoon. Her lungs are very junky. She looks like she is getting very tired. Her daughter is in the room, holding the woman’s hand. We have to ask the daughter to move so we can get the stretcher in. We move the patient, quickly to our stretcher, attach at nonrebreather at 15 lpm, and head out down the hall. I stop at the nurses’s desk and ask for the paperwork. The nurse is very flustered, but finally has the papers together and hands them to me. I scan them quickly. Name, DOB (which I hadn’t noticed was missing from the first patient I had taken in earlier), Social Security number, history, meds. No respiratory history? I ask again. Again all it says is severe dementia.
Let me check the chart, the nurse says. No, no respiratory history she says. We speed down the hall and out to the ambulance. The patient’s daughter is still holding the woman’s hand, walking rapidly beside us. She wants to ride with us. I say it will have to be in the front. She says she’ll take her own car then. I tell her we are going to do a few things in the back before we leave.
While she stands outside the ambulance and looks in through the side window, my partner tries to get a blood pressure and I hook the patient up to the ETCO2, pulse oximeter and try to get a line. Her respiratory rate is in the 30’s. It seems a little slower than it was initially. Her ETCO2 is in the low 20’s. I can’t get a SAT and my partner can’t get a pressure. He tries to hook her to the monitor. I think I am in with my IV, but get no flash at all. I try again and again no flash, but am sure I am in. The leads won’t stick to the patient and I can’t get a reading. I flush the IV and it is good. I am conscious of the time on scene and the woman watching us. And my patient’s tiring breaths. Let’s just get out of here, I say to my partner, as I try again to get the electrodes to stick. I start to get a rhythm, but loose it almost immediately.
We go lights and sirens. I get out my intubation kit. Her resps are almost agonal now. I shout to my partner to patch to the hospital and tell her the patient is in respiratory distress and that I am intubating. What! He calls. We shout at each other as I disconnect her nasal cannula ETCO2 monitor and hook the ET capnography filter to end of the ET tube and slip in a thin stylet. Just patch for me, I shout.
I see her chords and pass the tube. I look at the monitor I have no wave form. I must have missed I think. I pull back a little, and then again go through the chords. I have no wave form, but I am not certain now she is breathing. I grab the ambu bag and give it a squeeze and up pops a wave form. I’m in. I secure the tube and start bagging. Her End tidal is 30, but then it soon drops to 17.
My partner is having the following conversation with the hospital:
Partner: “I have a patient unresponsive, respiratory distress, my partner is intubating.”
Hospital: “What are the vitals?
Partner: “I’m driving.”
Hospital: “What is her history?
Partner: “I’m driving the ambulance! My partner is intubating. We’re almost there.’
Hospital: “What’s her rhythm?”
I can feel the bump of the hospital driveway. I’m looking at my patient. The monitor is still not reading the leads. She looks like she is dead. The end tidal is very low. I reach over and do some compressions. I shout to my partner, but he is already out of the ambulance.
He opens the back door. Standing behind him are the patient’s daughter and another family member. His eyes widen when he sees I am doing CPR. He turns and waves to the crew of an ambulance parked in the lot. With their help we get the patient on a board, slaps some pads on – the patient is asystole -- I can check my lung sounds – equal right and left, nothing in the belly, and get a round of drugs in, one epi and one atropine, and then we are wheeling her in.
"You have paperwork?" the triage nurse asks.
In my pocket," I say and nod to my front pocket.
He plucks the papers as I pass.
In the room, I tell the story. Dementia only history, sudden onset dsypnea, agonal breathing. “She just coded as we pulled in,” I say.
“What’s her code status?” the doctor asks.
I stop for a moment. “I don’t know. I’m assuming full code they didn’t give me any DNR papers or say anything.”
He calls for another round of epi and atropine.
The triage nurse sticks his head into the curtain, and hands the doctor the papers he took from me. The doctor studies them. His eyebrows go up. In the small box labeled code status, it says
DNR.
Ooops.
"Sorry," I say. "They didn't give me any other paperwork or say anything."
“Its not valid without the proper papers anyway,” the doctor says. “You had to work her.”
He has the tech stop compressions. The patient is asystole. I walk out of the room.
When I go to drop my paperwork off, I make certain I go the long way so that I don’t have to pass the family room where the patient’s relatives are waiting.
***
Here’s the trend summary I printed out after the call, which pretty much tells the story of her declining respirations.
The period of apnea includes my taking her off the end-tidal cannula, attaching an end-tidal ET filter to the tube, and then intubating.
Called for difficulty breathing to a nursing home. Second time in same day called to the same nursing home for same complaint, had same nurse, asked the same question. What is the patient’s norm? The nurse shrugs and turns to an aide who says, she don’t speak, but she converse. Does she have any history of respiratory problems? The nurse shrugs. I’ll have to look in her chart. All I know is she has dementia.
The woman is in her 80’s and breathing rapidly and shallowly. They have her on a non-rebreather at 4 lpm. They say they can’t get her SAT above 80. They can’t tell me how long this has been going on, but they seem to think it all started this afternoon. Her lungs are very junky. She looks like she is getting very tired. Her daughter is in the room, holding the woman’s hand. We have to ask the daughter to move so we can get the stretcher in. We move the patient, quickly to our stretcher, attach at nonrebreather at 15 lpm, and head out down the hall. I stop at the nurses’s desk and ask for the paperwork. The nurse is very flustered, but finally has the papers together and hands them to me. I scan them quickly. Name, DOB (which I hadn’t noticed was missing from the first patient I had taken in earlier), Social Security number, history, meds. No respiratory history? I ask again. Again all it says is severe dementia.
Let me check the chart, the nurse says. No, no respiratory history she says. We speed down the hall and out to the ambulance. The patient’s daughter is still holding the woman’s hand, walking rapidly beside us. She wants to ride with us. I say it will have to be in the front. She says she’ll take her own car then. I tell her we are going to do a few things in the back before we leave.
While she stands outside the ambulance and looks in through the side window, my partner tries to get a blood pressure and I hook the patient up to the ETCO2, pulse oximeter and try to get a line. Her respiratory rate is in the 30’s. It seems a little slower than it was initially. Her ETCO2 is in the low 20’s. I can’t get a SAT and my partner can’t get a pressure. He tries to hook her to the monitor. I think I am in with my IV, but get no flash at all. I try again and again no flash, but am sure I am in. The leads won’t stick to the patient and I can’t get a reading. I flush the IV and it is good. I am conscious of the time on scene and the woman watching us. And my patient’s tiring breaths. Let’s just get out of here, I say to my partner, as I try again to get the electrodes to stick. I start to get a rhythm, but loose it almost immediately.
We go lights and sirens. I get out my intubation kit. Her resps are almost agonal now. I shout to my partner to patch to the hospital and tell her the patient is in respiratory distress and that I am intubating. What! He calls. We shout at each other as I disconnect her nasal cannula ETCO2 monitor and hook the ET capnography filter to end of the ET tube and slip in a thin stylet. Just patch for me, I shout.
I see her chords and pass the tube. I look at the monitor I have no wave form. I must have missed I think. I pull back a little, and then again go through the chords. I have no wave form, but I am not certain now she is breathing. I grab the ambu bag and give it a squeeze and up pops a wave form. I’m in. I secure the tube and start bagging. Her End tidal is 30, but then it soon drops to 17.
My partner is having the following conversation with the hospital:
Partner: “I have a patient unresponsive, respiratory distress, my partner is intubating.”
Hospital: “What are the vitals?
Partner: “I’m driving.”
Hospital: “What is her history?
Partner: “I’m driving the ambulance! My partner is intubating. We’re almost there.’
Hospital: “What’s her rhythm?”
I can feel the bump of the hospital driveway. I’m looking at my patient. The monitor is still not reading the leads. She looks like she is dead. The end tidal is very low. I reach over and do some compressions. I shout to my partner, but he is already out of the ambulance.
He opens the back door. Standing behind him are the patient’s daughter and another family member. His eyes widen when he sees I am doing CPR. He turns and waves to the crew of an ambulance parked in the lot. With their help we get the patient on a board, slaps some pads on – the patient is asystole -- I can check my lung sounds – equal right and left, nothing in the belly, and get a round of drugs in, one epi and one atropine, and then we are wheeling her in.
"You have paperwork?" the triage nurse asks.
In my pocket," I say and nod to my front pocket.
He plucks the papers as I pass.
In the room, I tell the story. Dementia only history, sudden onset dsypnea, agonal breathing. “She just coded as we pulled in,” I say.
“What’s her code status?” the doctor asks.
I stop for a moment. “I don’t know. I’m assuming full code they didn’t give me any DNR papers or say anything.”
He calls for another round of epi and atropine.
The triage nurse sticks his head into the curtain, and hands the doctor the papers he took from me. The doctor studies them. His eyebrows go up. In the small box labeled code status, it says
DNR.
Ooops.
"Sorry," I say. "They didn't give me any other paperwork or say anything."
“Its not valid without the proper papers anyway,” the doctor says. “You had to work her.”
He has the tech stop compressions. The patient is asystole. I walk out of the room.
When I go to drop my paperwork off, I make certain I go the long way so that I don’t have to pass the family room where the patient’s relatives are waiting.
***
Here’s the trend summary I printed out after the call, which pretty much tells the story of her declining respirations.
The period of apnea includes my taking her off the end-tidal cannula, attaching an end-tidal ET filter to the tube, and then intubating.
Thursday, December 07, 2006
DNR Study Results
As many readers of this blog know I am very interested in prehospital research. I have been talking with one of my medical control doctors and the leader of our research journal club about actually initiating our own research projects. It is not as easy as just going out and doing a project. If your goal is to actually publish your research in a respected journal, you have to follow a process known as getting approval from an IRB - Institutional Research Board - before beginning research, which involves quite a number of hoops.
A potential problem for us is the possible opinion of the IRB that the project if it involves prehospital people should be sponsored not by the hospital IRB, but by the ambulance service's IRB. Our service doesn't have one -- at least not yet. I recently corresponded with the national medical director of our company, and was quite encouraged by his plans and commitment to prehospital research utilizing the company's resources, which probably will ultimately include a company IRB.
Yesterday we had our regional paramedic skill sessions, which presented an opportunity to question over a 100 paramedics about their attitudes. We decided to go ahead with a questionnaire, even though we have not yet gained IRB approval for this particular questionnaire, as a test run for future projects, and with luck we may be able to get this project approved as well.
I have been reading a book called An Introduction to EMS Research, which is informative on the subject.
Questionnaires are one of the easist forms of research, although as the book warns, they are not as simple as they might seem. The questions need to be carefully worded. It was interesting watching the medics answer the questions, and hearing their concerns about some of the questions. I realized how I could improve the questionannaire in the future.
The goal behind this particular questionnaire was to gauge paramedic attitudes toward the DNR issue, particuarly the issue of enabling a paramedic to accept a family's verbal request not to begin resucitation on a terminally ill family member in absence of DNR papers.
King County in Washington state recently changed their protocols to allow this option and they found a large reduction in rescusitations in those services that chose to adopt the new protocol.
Futile Rescusitations
I modeled the particular scenario after one I had encountered and described in Understand.
***
Paramedic DNR Study
Hypothesis: Paramedics will not deviate from state guidelines to consider a family’s verbal requests not to initiate resuscitation on a terminal patient.
Results:
Hypothesis partially disproved. 27% of paramedics when confronted with family verbal request not to implement resuscitation on a terminal patient deviate from state guidelines by not implementing at least Basic CPR prior to receiving approval from Medical Control to withhold resuscitation.
80% of paramedics favor changing protocols to honor verbal family wishes in cases of terminal patients. This may be related to years experience as a paramedic but doesn’t appear to be related to experiences initiating resuscitation against family wishes.
48% of paramedics have initiated resuscitations against family wishes. Of medics who have initiated resuscitation against family wishes 83% were bothered by the experience.
When faced with a family’s verbal request to withhold resuscitation in absence of DNR papers, only 16% would begin full resuscitation. 56% would limit initial resuscitation to basic CPR. 27% would delay CPR while contacting medical control. Actions are unrelated to years on the job or past experience.
***
State Guidelines
If the field technician arrives at the scene of a clinically dead patient before a medical order not to start resuscitative measures had been given, resuscitation will be initiated while communication is established, assessment information is gathered, and a medical decision is being made, except in cases of decapitation, decomposition, transection of the torso, or incineration.
Medical control must be established early to reduce delay as resuscitative measures cannot be withheld until ordered by the physician. The on-line Medical Control physician will be given information about early assessment, findings, and procedures initiated. The physician may then order withholding resuscitation before complete resuscitative efforts have been initiated.-REFERENCE #908,EFFECTIVE MARCH 27, 1996, GUIDELINES FOR WITHHOLDING RESUSCITATION
***
Potential Study Drawbacks:
While 99% of paramedics said they were aware of state regulations, it is not clear that those who said they withhold CPR while contacting medical control were aware that that action violated state guidelines.
***
Paramedic DNR Study (96 completed surveys) Rough Initial Results
Favor Change in Protocol to honor verbal request 80% (8.28 years exp)
Oppose Change in protocol to honor verbal request 20% (6.05 years exp)
When faced with family verbal wishes not to implement resuscitation of a terminal patient, paramedics answered they would:
A. Immediately Begin CPR/ACLS 16% (8.4 years)
B. Begin CPR, delay ACLS, contact med control 52% (7.62 years)
C. Begin CPR, delay ALS, wait for DNR papers 4% (9.75 years)
D. Hold off CPR, contact medical control 27% (7.96 years)
E. Presume Patient Dead 0%
Have Worked Codes against Family wishes 48%
Have Not Worked Codes against Family Wishes 52%
Of those who have worked Codes against family wishes
Not Bothered 17%
Somewhat Bothered 26%
Bothered 46%
Greatly 13%
Of Those Who Have Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 78%
Oppose Change to Honor Verbal Wishes 22%
Of Those Who Have Not Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 82%
Oppose Changer Change to Honor Verbal Wishes 18%
Have Worked Codes and Favor Change 38%
Have Not Worked Codes and Favor Change 43%
Have Worked Codes and Oppose Change 10%
Have Not Worked Codes and Oppose Change 9%
***
I choose D - to hold off CPR and contact medical control. I admit I did not realize it was spelled out so clearly in the state guidlines that not initialing basic CPR was a violation of the guideline. I think many medics as well as doctors may be under the impression that simply contacting medical control is okay.
I found the fact that 80% of medics would like to change the guidelines to permit verbal wishes to be honored quite telling about medics's feelings about patient dignity and toward futile resucitations.
***
Here's more info on the Washington King County Protocol
Ann Intern Med. 2006 May 2;144(9):634-40.
Withholding resuscitation: a new approach to prehospital end-of-life decisions.
Feder S, Matheny RL, Loveless RS Jr, Rea TD.
King County Medic One and Kent Fire Department, Kent, Washington, USA. sylvia_feder@kcfiremed.org
BACKGROUND: Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order. OBJECTIVE: To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines. DESIGN: Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation. SETTING: King County, Washington. PATIENTS: 2770 patients with EMS-attended cardiac arrest. INTERVENTION: New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired. MEASUREMENTS: Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not. RESULTS: Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients). LIMITATIONS: The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines. CONCLUSIONS: Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.
Withholding Prehospital Resucitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)
Withholding Prehospital Resucitation (Editorial)
A potential problem for us is the possible opinion of the IRB that the project if it involves prehospital people should be sponsored not by the hospital IRB, but by the ambulance service's IRB. Our service doesn't have one -- at least not yet. I recently corresponded with the national medical director of our company, and was quite encouraged by his plans and commitment to prehospital research utilizing the company's resources, which probably will ultimately include a company IRB.
Yesterday we had our regional paramedic skill sessions, which presented an opportunity to question over a 100 paramedics about their attitudes. We decided to go ahead with a questionnaire, even though we have not yet gained IRB approval for this particular questionnaire, as a test run for future projects, and with luck we may be able to get this project approved as well.
I have been reading a book called An Introduction to EMS Research, which is informative on the subject.
Questionnaires are one of the easist forms of research, although as the book warns, they are not as simple as they might seem. The questions need to be carefully worded. It was interesting watching the medics answer the questions, and hearing their concerns about some of the questions. I realized how I could improve the questionannaire in the future.
The goal behind this particular questionnaire was to gauge paramedic attitudes toward the DNR issue, particuarly the issue of enabling a paramedic to accept a family's verbal request not to begin resucitation on a terminally ill family member in absence of DNR papers.
King County in Washington state recently changed their protocols to allow this option and they found a large reduction in rescusitations in those services that chose to adopt the new protocol.
Futile Rescusitations
I modeled the particular scenario after one I had encountered and described in Understand.
***
Paramedic DNR Study
Hypothesis: Paramedics will not deviate from state guidelines to consider a family’s verbal requests not to initiate resuscitation on a terminal patient.
Results:
Hypothesis partially disproved. 27% of paramedics when confronted with family verbal request not to implement resuscitation on a terminal patient deviate from state guidelines by not implementing at least Basic CPR prior to receiving approval from Medical Control to withhold resuscitation.
80% of paramedics favor changing protocols to honor verbal family wishes in cases of terminal patients. This may be related to years experience as a paramedic but doesn’t appear to be related to experiences initiating resuscitation against family wishes.
48% of paramedics have initiated resuscitations against family wishes. Of medics who have initiated resuscitation against family wishes 83% were bothered by the experience.
When faced with a family’s verbal request to withhold resuscitation in absence of DNR papers, only 16% would begin full resuscitation. 56% would limit initial resuscitation to basic CPR. 27% would delay CPR while contacting medical control. Actions are unrelated to years on the job or past experience.
***
State Guidelines
If the field technician arrives at the scene of a clinically dead patient before a medical order not to start resuscitative measures had been given, resuscitation will be initiated while communication is established, assessment information is gathered, and a medical decision is being made, except in cases of decapitation, decomposition, transection of the torso, or incineration.
Medical control must be established early to reduce delay as resuscitative measures cannot be withheld until ordered by the physician. The on-line Medical Control physician will be given information about early assessment, findings, and procedures initiated. The physician may then order withholding resuscitation before complete resuscitative efforts have been initiated.-REFERENCE #908,EFFECTIVE MARCH 27, 1996, GUIDELINES FOR WITHHOLDING RESUSCITATION
***
Potential Study Drawbacks:
While 99% of paramedics said they were aware of state regulations, it is not clear that those who said they withhold CPR while contacting medical control were aware that that action violated state guidelines.
***
Paramedic DNR Study (96 completed surveys) Rough Initial Results
Favor Change in Protocol to honor verbal request 80% (8.28 years exp)
Oppose Change in protocol to honor verbal request 20% (6.05 years exp)
When faced with family verbal wishes not to implement resuscitation of a terminal patient, paramedics answered they would:
A. Immediately Begin CPR/ACLS 16% (8.4 years)
B. Begin CPR, delay ACLS, contact med control 52% (7.62 years)
C. Begin CPR, delay ALS, wait for DNR papers 4% (9.75 years)
D. Hold off CPR, contact medical control 27% (7.96 years)
E. Presume Patient Dead 0%
Have Worked Codes against Family wishes 48%
Have Not Worked Codes against Family Wishes 52%
Of those who have worked Codes against family wishes
Not Bothered 17%
Somewhat Bothered 26%
Bothered 46%
Greatly 13%
Of Those Who Have Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 78%
Oppose Change to Honor Verbal Wishes 22%
Of Those Who Have Not Worked Codes Against Family Wishes
Favor Change to Honor Verbal Wishes 82%
Oppose Changer Change to Honor Verbal Wishes 18%
Have Worked Codes and Favor Change 38%
Have Not Worked Codes and Favor Change 43%
Have Worked Codes and Oppose Change 10%
Have Not Worked Codes and Oppose Change 9%
***
I choose D - to hold off CPR and contact medical control. I admit I did not realize it was spelled out so clearly in the state guidlines that not initialing basic CPR was a violation of the guideline. I think many medics as well as doctors may be under the impression that simply contacting medical control is okay.
I found the fact that 80% of medics would like to change the guidelines to permit verbal wishes to be honored quite telling about medics's feelings about patient dignity and toward futile resucitations.
***
Here's more info on the Washington King County Protocol
Ann Intern Med. 2006 May 2;144(9):634-40.
Withholding resuscitation: a new approach to prehospital end-of-life decisions.
Feder S, Matheny RL, Loveless RS Jr, Rea TD.
King County Medic One and Kent Fire Department, Kent, Washington, USA. sylvia_feder@kcfiremed.org
BACKGROUND: Emergency medical services (EMS) personnel often are not permitted to honor requests to withhold resuscitation at the end of life, particularly if there is no written do-not-resuscitate (DNR) order. OBJECTIVE: To determine whether EMS personnel from agencies implementing new guidelines would be more likely to withhold resuscitation from persons having out-of-hospital cardiac arrests than would personnel from agencies that did not implement the guidelines. DESIGN: Observational study in which 16 of 35 local EMS agencies volunteered to implement new guidelines for withholding resuscitation. SETTING: King County, Washington. PATIENTS: 2770 patients with EMS-attended cardiac arrest. INTERVENTION: New guidelines adopted by participating agencies permitted EMS personnel to withhold resuscitation if the patient had a terminal condition and if the patient, family, or caregivers indicated, in writing or verbally, that no resuscitation was desired. MEASUREMENTS: Proportion of resuscitations withheld in agencies that implemented new guidelines compared with those that did not. RESULTS: Emergency medical services personnel from agencies implementing new guidelines withheld resuscitation in 11.8% of patients (99 of 841 patients) having cardiac arrests, compared with an average of 5.3% (range, 4.2% to 5.9%) of patients (103 of 1929 patients) in 3 historical and contemporary control groups. Honoring verbal requests alone accounted for 53% of withheld resuscitations in the intervention group (52 of 99 patients) compared with an average of 8% (range, 7% to 9%) in the control groups (8 of 103 patients). LIMITATIONS: The study was not a randomized, controlled trial; individual agencies chose whether to implement the guidelines. CONCLUSIONS: Implementation of new guidelines was associated with an increase in the number of resuscitations withheld by EMS personnel. This increase was primarily due to honoring verbal requests.
Withholding Prehospital Resucitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)
Withholding Prehospital Resucitation (Editorial)
Tuesday, December 05, 2006
Questionnaire
Today as part of a research project, I distributed the following questionnaire to paramedics at our annual paramedic skills session.
***
Paramedic DNR Study
Please Fill in or Circle Your Answers
How many years have you been a paramedic? ____
How old are you now? ____
To the best of your recollection how many times have you attempted resuscitation in the field? _______
Are you aware of your current protocols for withholding resuscitation? Yes No
Do you feel they are adequate? Yes No
Have you ever resuscitated a cardiac arrest against a family’s wishes due to lack of documentation? Yes No
If so, were you bothered by that action?
No Somewhat Yes Greatly
You are called to respond to a 90-year-old male who has stopped breathing. On arrival at the single family home, the patient’s son says his father had terminal cancer and did not wish to be revived. He says he called 911 only to alert police to his father’s passing, not to request medical assistance and attempts at resuscitation. On questioning, he says his father is a DNR, but the papers are locked in a safe. His wife, who has the combination, is on her way and should arrive in ten to twenty minutes. The patient is pulseless and apneic. What do you do?
a. Immediately begin CPR and initiate ACLS.
b. Begin CPR, but hold off on initiation of ACLS while you contact medical control for permission to cease resuscitation.
c. Begin CPR, but hold off on initiation of ACLS pending arrival of wife and her ability to produce DNR papers from the safe.
d. Hold off on CPR while you contact medical control for permission not to implement resuscitation.
e. Do not implement CPR. Instead presume the patient dead.
Do you favor changing the regulations to enable paramedics to honor a family’s verbal request not to initiate CPR if the patient has a terminal condition (cancer, end-stage renal failure, etc.)? Yes No
This is a study about paramedic attitudes toward DNR issues. By completing the questionnaire you consent to having your responses published. Your answers will be kept anonymous. No punitive action will ever arise from your answers.
***
I recieved 96 completed questionnaires. I'll publish preliminary results tomorrow with comment.
***
Paramedic DNR Study
Please Fill in or Circle Your Answers
How many years have you been a paramedic? ____
How old are you now? ____
To the best of your recollection how many times have you attempted resuscitation in the field? _______
Are you aware of your current protocols for withholding resuscitation? Yes No
Do you feel they are adequate? Yes No
Have you ever resuscitated a cardiac arrest against a family’s wishes due to lack of documentation? Yes No
If so, were you bothered by that action?
No Somewhat Yes Greatly
You are called to respond to a 90-year-old male who has stopped breathing. On arrival at the single family home, the patient’s son says his father had terminal cancer and did not wish to be revived. He says he called 911 only to alert police to his father’s passing, not to request medical assistance and attempts at resuscitation. On questioning, he says his father is a DNR, but the papers are locked in a safe. His wife, who has the combination, is on her way and should arrive in ten to twenty minutes. The patient is pulseless and apneic. What do you do?
a. Immediately begin CPR and initiate ACLS.
b. Begin CPR, but hold off on initiation of ACLS while you contact medical control for permission to cease resuscitation.
c. Begin CPR, but hold off on initiation of ACLS pending arrival of wife and her ability to produce DNR papers from the safe.
d. Hold off on CPR while you contact medical control for permission not to implement resuscitation.
e. Do not implement CPR. Instead presume the patient dead.
Do you favor changing the regulations to enable paramedics to honor a family’s verbal request not to initiate CPR if the patient has a terminal condition (cancer, end-stage renal failure, etc.)? Yes No
This is a study about paramedic attitudes toward DNR issues. By completing the questionnaire you consent to having your responses published. Your answers will be kept anonymous. No punitive action will ever arise from your answers.
***
I recieved 96 completed questionnaires. I'll publish preliminary results tomorrow with comment.
Sunday, December 03, 2006
Johnny Tops
I always put a fresh hospital Johnny (gown) on my stretcher along with a clean sheet, bath blanket and towel. If I am going to do a 12-lead ECG, run a bag of fluid or even just do a good torso exam, I like to get the patient out of their tee-shirt, button down shirt and sweater and right into the Johnny top (I don’t do the pajama bottoms).
I hate having to reach down under a patient’s clothes to put the electrodes on and try to guess where the proper placement is. I hate taking blood pressures over tight fitting sleeves or being at the ER and watching them trying to undress the patient with the IV line in their arms.
Sometimes when I bring a patient into the ER with a Johnny on, the nurse, if she doesn’t know me, will ask for the nursing home W-10. They’re from home, I’ll say. Where’d they get the Johnny? I put it on them. Interesting.
When it’s busy at the ER, or even when it’s slow, the nurses love it when I bring them in a patient with an IV, a 12 lead, bloods drawn, and gowned in a Johnny, the patient’s personal clothes already in a plastic belongings bag. I love it when they smile at me and say thanks. Good for the nurses, good for the patients, good for me.
Sometimes the patients don’t like getting into a Johnny. They dislike it in the same way they dislike an IV or having to give a history. They’ll do that at the hospital, they say. Just take me there.
I feel like saying, and once in awhile, if I let my mood get the best of me, I actually do say: You called 911 not a taxi. If you want medical evaluation and care and not tips on the horse races, then you need to let me do my job.
But I don’t force the Johnny on them. Often with women I will leave their bra on, even though they take it off in the hospital when they put the Johnny on. If the bra is not in my way, I let them keep their modesty. It helps if you have a female partner or there is a family member or nurse on scene who can put them in the Johnny for you.
Now we are getting to the time of year where it is getting a little tougher to put them in Johnnys. It may be chilly in their house and they are all bundled up in bathrobes, and it is cold outside. Sometimes you don't even try.
Yesterday I had a woman with severe abdominal pain. She was sitting on her bed in a cluttered room that our stretcher couldn’t reach. She was wearing one of those full length bathrobes from her neck all the way down to her ankles. Underneath that she had on a sweater, and beneath that a shirt and then a tee-shirt and then a bra. She said she was cold and felt nauseus. She had a history of ulcerative colitis. I helped her walk out to the living room where we got her on the stretcher and bundled her up in our blankets, and placed the towel around her head like a nun's habit.
I tried to assess her further in the ambulance. I couldn’t roll up her sleeves to be able to hear the BP. I had to palpate the abdomen through the bathrobe, so I finally had to at least get her arm out, which was difficult because she was large and slow moving. And then she told me she had a burning feeling in her chest. I ended up doing a twelve lead, reaching my hand in through the top of her turtleneck to get the top leads, and then going up under her tee-shirt at the bottom to get the others. The twelve lead was okay. I didn’t look for an IV because she told me she had a port.
When I got to the ED, I felt a little disorganized. A part of me wished I had gotten a family member to help get her undressed in the bedroom so I could have done a full assessment there, but with the way she was feeling, I think she just wanted to go to the hospital. If I had her in a Johnny I might have been able to see a vein, and get a peripheral IV, and then call the hospital to get orders for a judicious amount of morphine to take the edge of her pain.
Field assessment isn’t as easy as walking into a clean well light exam room to find your patient wearing just a Johnny laying there on the exam table. You want to be a professional, and be thorough, and not miss anything. But you also don’t like to trouble people.
I guess sometimes it’s a matter of choreography, of style, of making the moves and speaking the word music to make the patient comfortable, assuring them they will be warm and will not catch cold, and that above all they are in the hands of a medical professional, a caregiver, and not just an ambulance attendant.
I hate having to reach down under a patient’s clothes to put the electrodes on and try to guess where the proper placement is. I hate taking blood pressures over tight fitting sleeves or being at the ER and watching them trying to undress the patient with the IV line in their arms.
Sometimes when I bring a patient into the ER with a Johnny on, the nurse, if she doesn’t know me, will ask for the nursing home W-10. They’re from home, I’ll say. Where’d they get the Johnny? I put it on them. Interesting.
When it’s busy at the ER, or even when it’s slow, the nurses love it when I bring them in a patient with an IV, a 12 lead, bloods drawn, and gowned in a Johnny, the patient’s personal clothes already in a plastic belongings bag. I love it when they smile at me and say thanks. Good for the nurses, good for the patients, good for me.
Sometimes the patients don’t like getting into a Johnny. They dislike it in the same way they dislike an IV or having to give a history. They’ll do that at the hospital, they say. Just take me there.
I feel like saying, and once in awhile, if I let my mood get the best of me, I actually do say: You called 911 not a taxi. If you want medical evaluation and care and not tips on the horse races, then you need to let me do my job.
But I don’t force the Johnny on them. Often with women I will leave their bra on, even though they take it off in the hospital when they put the Johnny on. If the bra is not in my way, I let them keep their modesty. It helps if you have a female partner or there is a family member or nurse on scene who can put them in the Johnny for you.
Now we are getting to the time of year where it is getting a little tougher to put them in Johnnys. It may be chilly in their house and they are all bundled up in bathrobes, and it is cold outside. Sometimes you don't even try.
Yesterday I had a woman with severe abdominal pain. She was sitting on her bed in a cluttered room that our stretcher couldn’t reach. She was wearing one of those full length bathrobes from her neck all the way down to her ankles. Underneath that she had on a sweater, and beneath that a shirt and then a tee-shirt and then a bra. She said she was cold and felt nauseus. She had a history of ulcerative colitis. I helped her walk out to the living room where we got her on the stretcher and bundled her up in our blankets, and placed the towel around her head like a nun's habit.
I tried to assess her further in the ambulance. I couldn’t roll up her sleeves to be able to hear the BP. I had to palpate the abdomen through the bathrobe, so I finally had to at least get her arm out, which was difficult because she was large and slow moving. And then she told me she had a burning feeling in her chest. I ended up doing a twelve lead, reaching my hand in through the top of her turtleneck to get the top leads, and then going up under her tee-shirt at the bottom to get the others. The twelve lead was okay. I didn’t look for an IV because she told me she had a port.
When I got to the ED, I felt a little disorganized. A part of me wished I had gotten a family member to help get her undressed in the bedroom so I could have done a full assessment there, but with the way she was feeling, I think she just wanted to go to the hospital. If I had her in a Johnny I might have been able to see a vein, and get a peripheral IV, and then call the hospital to get orders for a judicious amount of morphine to take the edge of her pain.
Field assessment isn’t as easy as walking into a clean well light exam room to find your patient wearing just a Johnny laying there on the exam table. You want to be a professional, and be thorough, and not miss anything. But you also don’t like to trouble people.
I guess sometimes it’s a matter of choreography, of style, of making the moves and speaking the word music to make the patient comfortable, assuring them they will be warm and will not catch cold, and that above all they are in the hands of a medical professional, a caregiver, and not just an ambulance attendant.
Thursday, November 30, 2006
Postscript
It's funny in EMS how you can get talking about something, and then something similar happens. You talk about a bad motorcycle accident or messy GI bleed code and then that's what you get sent for. Why we were just talking about...
It's really just random chance. How many times do people use the Q-word and then right away you get a call and it gets very busy? But then again how many times do people use the Q-word and you give them a hard time for saying it, but then nothing happens?
Monday night I wrote the post below (Intubation and Capnography) talking about how I had model tested putting the capnography filter on before intubating and trying to use the wave form while the tube was still being placed to aid in the intubation.
The next morning -- the very first call. Not only do I get to try it when orally intubating, I get to try it nasally -- and I haven't done a nasal tube for years.
***
The call was for unresponsive patient with severe dsypnea. We found an 80 year old female with a GSC of 4-5 breathing at a rate of 60 with cool extremities. Unable to hear BP. Heart rate on the monitor 130-140. Blood sugar - 213. I attached the capnography filter to the end of the ET tube. Some of our ET tubes come with stylets already in them. I removed the stylet, but could not put it back in because it was too thick, so I used a thinner stylet we we stock independently. (Inside the capnography filter is a little bar through its diameter.) I went in, and had a hard time getting the woman's jaw open enough to see the chords. We don't have RSI so I was faced with what our intubation survey form calls "inadequate relaxation." I could just barely get an occasional glimpse of the chords under the epiglottis, but couldn't get the tube to pass through. Instead of checking by assessing breath sounds, I just looked at the monitor. The ETCO2 would just go straight and I'd know I had gone below the chords. I tried twice and then gave up. I imagined the woman in her comma dreaming about a demon with horns sticking a piece of cold steel in her mouth, and trying to lift her tongue up.
I ended up nasally intubating her, which I probably should have done first, but I like to get a bigger tube in. The nasal tube went in great. I used some neosynephrine, rolled the tube up in a circle to give it some natural curve, lubed it up with jelly and slid it into her right nostril. I used a 6.0 and watched the wave forms appear as I fed it into the hypopharanx. I kept feeding it slow. Then suddenly the form started getting smaller and then down to nothing. I pulled back and repositioned her head and then advanced the tube again, and felt it go through and had the big wave forms to confirm it.
Her SAT went up to 98% from the 80% and her ETCO2 came up from the mid twenties to low to mid thirties. About ten minutes later she puked, so I was glad I had her airway protected. She opened her eyes by the time we were in the ED.
(The next time I do a nasal tube I am just going to hit print button on the monitor from the start so I have a long strip to cut up and show the wave form changes.)
I'm still waiting to hear what was wrong with her. They were thinking sepsis and cerebral hypoperfusion.
A couple curious things about the call:
1. I was in the back alone when I was intubating her -- we were on the way to the hospital. After I got the tube in, I thought I need some tape to tie this. I had laid out the mouth tube holder, but the tape was out of my reach. I couldn't hold the tube and reach the tape. I could barely reach the ambu bag. I'm kneeling in the back of the bus, I'm calling to my partner to pull over for a minute to give me a quick hand -- he can't hear me -- I'm getting tossed by the bumps in the road. I ended up just letting go of the tube and hoping it stayed in place, I remembered I had the capnography to tell me if I was still in or not. Its part of the reason I dislike the box ambulance. In the vans everything is in my reach.
2. When I brought the patient into the ER and showed the medical staff the wave form on the monitor, the RT took the capnography filter off the tube when she attached the patient to the vent, and then the doctor called for capnography and they handed him a colorimetric device.
***
Anyway, I'll try not to write about hypothetical train wrecks or plane crashes for awhile.
It's really just random chance. How many times do people use the Q-word and then right away you get a call and it gets very busy? But then again how many times do people use the Q-word and you give them a hard time for saying it, but then nothing happens?
Monday night I wrote the post below (Intubation and Capnography) talking about how I had model tested putting the capnography filter on before intubating and trying to use the wave form while the tube was still being placed to aid in the intubation.
The next morning -- the very first call. Not only do I get to try it when orally intubating, I get to try it nasally -- and I haven't done a nasal tube for years.
***
The call was for unresponsive patient with severe dsypnea. We found an 80 year old female with a GSC of 4-5 breathing at a rate of 60 with cool extremities. Unable to hear BP. Heart rate on the monitor 130-140. Blood sugar - 213. I attached the capnography filter to the end of the ET tube. Some of our ET tubes come with stylets already in them. I removed the stylet, but could not put it back in because it was too thick, so I used a thinner stylet we we stock independently. (Inside the capnography filter is a little bar through its diameter.) I went in, and had a hard time getting the woman's jaw open enough to see the chords. We don't have RSI so I was faced with what our intubation survey form calls "inadequate relaxation." I could just barely get an occasional glimpse of the chords under the epiglottis, but couldn't get the tube to pass through. Instead of checking by assessing breath sounds, I just looked at the monitor. The ETCO2 would just go straight and I'd know I had gone below the chords. I tried twice and then gave up. I imagined the woman in her comma dreaming about a demon with horns sticking a piece of cold steel in her mouth, and trying to lift her tongue up.
I ended up nasally intubating her, which I probably should have done first, but I like to get a bigger tube in. The nasal tube went in great. I used some neosynephrine, rolled the tube up in a circle to give it some natural curve, lubed it up with jelly and slid it into her right nostril. I used a 6.0 and watched the wave forms appear as I fed it into the hypopharanx. I kept feeding it slow. Then suddenly the form started getting smaller and then down to nothing. I pulled back and repositioned her head and then advanced the tube again, and felt it go through and had the big wave forms to confirm it.
Her SAT went up to 98% from the 80% and her ETCO2 came up from the mid twenties to low to mid thirties. About ten minutes later she puked, so I was glad I had her airway protected. She opened her eyes by the time we were in the ED.
(The next time I do a nasal tube I am just going to hit print button on the monitor from the start so I have a long strip to cut up and show the wave form changes.)
I'm still waiting to hear what was wrong with her. They were thinking sepsis and cerebral hypoperfusion.
A couple curious things about the call:
1. I was in the back alone when I was intubating her -- we were on the way to the hospital. After I got the tube in, I thought I need some tape to tie this. I had laid out the mouth tube holder, but the tape was out of my reach. I couldn't hold the tube and reach the tape. I could barely reach the ambu bag. I'm kneeling in the back of the bus, I'm calling to my partner to pull over for a minute to give me a quick hand -- he can't hear me -- I'm getting tossed by the bumps in the road. I ended up just letting go of the tube and hoping it stayed in place, I remembered I had the capnography to tell me if I was still in or not. Its part of the reason I dislike the box ambulance. In the vans everything is in my reach.
2. When I brought the patient into the ER and showed the medical staff the wave form on the monitor, the RT took the capnography filter off the tube when she attached the patient to the vent, and then the doctor called for capnography and they handed him a colorimetric device.
***
Anyway, I'll try not to write about hypothetical train wrecks or plane crashes for awhile.
Monday, November 27, 2006
Capnography and Intubation
Note: I am double posting this on this blog and my capnography blog.
When I was at a conference this past year one of the speakers said the data on prehospital intubation is so bad that if EMS had to go before the FDA to get approval to allow medics to intubate, it would be denied. Based on those studies, which include the LA pediatric intubation study, as well as many RSI studies, I can understand why.
However, those studies (to my knowledge) did not incorporporate continuous wave form capnography.
I believe continuous wave form capnography will eliminate all unrecognized misplaced tubes.
Capnography will prevent hyperventilation in head injured patients and critically injured patients(which may be the reason the RSI studies have poor results -- by letting medics intubate patients, RSI puts them at increased risk for hyperventiulation which is much easier to do with an patent airway and an ambu bag just begging to be squeezed.
And capnography can aid in the placement of difficult intubations. It can help prevent multiple attempts and even momentarily delayed recognition of misplaced tubes -- all of which cost the patient critical time without effective oxygenation and ventilation.
I believe continuous wave-form capnography will be the savior of prehospital intubation.
***
When many of us were taught to intubate the golden rule was:
NEVER PASS THE TUBE UNLESS YOU VISUALIZE IT PASSING THROUGH THE CHORDS.
The only ways we had to verify our tubes back then were this mantra, listening to lungs sounds and absence of belly sounds, looking for chest rise and mist in the tube -- all methods that cannot be considered fully reliable. My safety net was a partner who always held crick pressure for me and could tell me if I was in when he felt the tube pass under his fingers. That was my most reliable confirmation, but we didn't work together every shift so it was only part-time reliability. We didn’t have the bulb syringe then or colorimetric capnography much less continuous wave-form capnography.
While we all tried to live the mantra of never passing the tube unless we saw it pass through the chords, not all our tubes were in. Hopefully we recognized them right away – either by not hearing lung sounds or having warm gastric contents come flying up the tube to tell us we weren’t where we were supposed to be. How many times did we legitimately think we had passed the tube through the chords and how many times had we hoped we were through? Does the phrase “I think I’m in” sound familiar? particuarly coming from precepting or student medics?
As was proven in a recent study (see below), capnography has the ability to reduce misplaced ET tubes to zero if used. Instead of answering “You think! Pull it out!" or "You’re better hope you’re in – My license and mortgage and food in my babies mouths are riding on it!" Now capnography will tell you. He thinks right or he thinks wrong.
What I am going to suggest now is controversial. It stems from an interesting discussion I had with an articulate commenter on the November log. I suggest that with capnography’s ability to so quickly confirm or disprove a tube that it might no longer be a sin to pass the tube if you are not sure – particularly in the context of the difficult airway. If it wasn’t difficult we would easily see the chords, right? Now I’ll admit to shoving a tube or two in in my time. When you’re looking down the bloody throat of a gunshot or highway crash victim and you can’t tell what you are looking at or when puke and vomit are rising like a biblical Mississippi flood, sometimes you just put it where you think you see air bubbles or where anatomy wise the chords should be. When your own body is crooked trying to get an airway into the man wedged behind the toilet, sometime the view isn't the best. Ever tried an ice pick style tube?
In people whose chords are hard to see and who are difficult to bag, maybe the best thing to do is just shove the tube in to the best of your ability. And now with capnography, you’ll know you’re in or out almost instantly. Blind tubes are not after all that unusual in EMS. I have done digital intubations, intubations with a bougie and nasal intubations. All blind. I did them that way because that was the only way to get the tube. (Sometimes with IVs on people in extremis, you take a blind shot based on anatomy.) I say if you only have a partial view of the chords or the chords get obscured when you try to pass the tube, go for it if you think you can get it – as long as you have capnography to immediately check the tube.
***
Now here’s a tip. I haven’t done it yet in the field (it only occured to me the other day), but I think I will try it the next time I have to intubate a breathing patient. I have tested the concept and believe it will work.
Before you intubate, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind, hook up the capnography to the machine, turn it on, and then go in for the tube. If your partner knows how to read wave forms he should be able to tell you if you are in or not when you ask. Either that or listen to the apnea alarm or the lack of an alarm. Make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.
For apneic patients you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter -- it is already in place. Keep in mind as always for pulseless patients you may need a little CPR to get your wave form reading. And of course, you'll need to pull the stylet before you bag the patient.
Make certain you have an extra capnography filter available as backup because if by chance you miss your tube abd gastric contents come up, they will contaminate your filter in addition to your tube.
This method of attaching the capnography filter to the ET tube before intubating also works for nasal tubes. Watch the wave forms as you advance the tube while listening for respirations Once you think you are deep enough and then cough gag and you push through, verify with the wave forms. Just make certain you are not still in the hypopharanx.
Don't misunderstand me. I still believe you should strive for the gold standard of watching the tube pass through the chords. Don’t make capnography your crutch, but in a difficult airway, it may be your new best friend.
***
Misplaced Tubes
The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. Annals of Emergency Medicine, May 2005, pgs 497-503l
If there ever was an argument for requiring continuous ETCO2 monitoring on all intubations, this is it. Over a ten month period, in 11 counties in Florida there were 153 intubations. 93 (61%) used continuous ETCO2 Monitoring. 60 (39%) did not. Upon arrival at the Emergency department there were 14 (9%) unrecognized misplaced intubations. There were 0 (0%) misplaced tubes in the group that used continuous ETCO2 monitoring. There were 14 (23%) in unmonitored group.
The authors wrote: “The unobserved unrecognized misplaced intubation risk difference is compelling. This study demonstrates that it is possible to attain a zero unrecognized misplaced intubation rate.”
Four years earlier, another study was done in Florida that showed during an 8 month period out of 108 “intubated” patients brought to a large Florida ED, there were 27 misplaced tubes (27%) on arrival at ED. 18 were in the esophagus, 9 in hypopharanx. 17 of 18 esophageal intubations had an absence of expired CO2, the one with CO2 was nasally intubated and breathing their own. 4 of 9 hyphopharengal intubations had an absence of expired CO2. - Katz SH, Falk JL, Misplaced endotracheal tubes by paramedics in an urban emergency medical services system, Annals of Emergency Medicine, January 2001
The authors wrote: “The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occuring in other communities...Functionally, whether the tubes were misplaced initially or dislodged en route to the hospital makes little difference to the patient....Despite written protocols requiring the out-of-hospital use of ETCO2 devices in our community, we...found their use to be sporadic... We believe that routine use of this technique, both at the time of intubation and as an ongoing monitor during transport, could potentially eliminate the problem of unrecognized misplaced ETT placement....”
Bottom Line: Intubated patients should all have continuous ETCO2 monitoring.
When I was at a conference this past year one of the speakers said the data on prehospital intubation is so bad that if EMS had to go before the FDA to get approval to allow medics to intubate, it would be denied. Based on those studies, which include the LA pediatric intubation study, as well as many RSI studies, I can understand why.
However, those studies (to my knowledge) did not incorporporate continuous wave form capnography.
I believe continuous wave form capnography will eliminate all unrecognized misplaced tubes.
Capnography will prevent hyperventilation in head injured patients and critically injured patients(which may be the reason the RSI studies have poor results -- by letting medics intubate patients, RSI puts them at increased risk for hyperventiulation which is much easier to do with an patent airway and an ambu bag just begging to be squeezed.
And capnography can aid in the placement of difficult intubations. It can help prevent multiple attempts and even momentarily delayed recognition of misplaced tubes -- all of which cost the patient critical time without effective oxygenation and ventilation.
I believe continuous wave-form capnography will be the savior of prehospital intubation.
***
When many of us were taught to intubate the golden rule was:
NEVER PASS THE TUBE UNLESS YOU VISUALIZE IT PASSING THROUGH THE CHORDS.
The only ways we had to verify our tubes back then were this mantra, listening to lungs sounds and absence of belly sounds, looking for chest rise and mist in the tube -- all methods that cannot be considered fully reliable. My safety net was a partner who always held crick pressure for me and could tell me if I was in when he felt the tube pass under his fingers. That was my most reliable confirmation, but we didn't work together every shift so it was only part-time reliability. We didn’t have the bulb syringe then or colorimetric capnography much less continuous wave-form capnography.
While we all tried to live the mantra of never passing the tube unless we saw it pass through the chords, not all our tubes were in. Hopefully we recognized them right away – either by not hearing lung sounds or having warm gastric contents come flying up the tube to tell us we weren’t where we were supposed to be. How many times did we legitimately think we had passed the tube through the chords and how many times had we hoped we were through? Does the phrase “I think I’m in” sound familiar? particuarly coming from precepting or student medics?
As was proven in a recent study (see below), capnography has the ability to reduce misplaced ET tubes to zero if used. Instead of answering “You think! Pull it out!" or "You’re better hope you’re in – My license and mortgage and food in my babies mouths are riding on it!" Now capnography will tell you. He thinks right or he thinks wrong.
What I am going to suggest now is controversial. It stems from an interesting discussion I had with an articulate commenter on the November log. I suggest that with capnography’s ability to so quickly confirm or disprove a tube that it might no longer be a sin to pass the tube if you are not sure – particularly in the context of the difficult airway. If it wasn’t difficult we would easily see the chords, right? Now I’ll admit to shoving a tube or two in in my time. When you’re looking down the bloody throat of a gunshot or highway crash victim and you can’t tell what you are looking at or when puke and vomit are rising like a biblical Mississippi flood, sometimes you just put it where you think you see air bubbles or where anatomy wise the chords should be. When your own body is crooked trying to get an airway into the man wedged behind the toilet, sometime the view isn't the best. Ever tried an ice pick style tube?
In people whose chords are hard to see and who are difficult to bag, maybe the best thing to do is just shove the tube in to the best of your ability. And now with capnography, you’ll know you’re in or out almost instantly. Blind tubes are not after all that unusual in EMS. I have done digital intubations, intubations with a bougie and nasal intubations. All blind. I did them that way because that was the only way to get the tube. (Sometimes with IVs on people in extremis, you take a blind shot based on anatomy.) I say if you only have a partial view of the chords or the chords get obscured when you try to pass the tube, go for it if you think you can get it – as long as you have capnography to immediately check the tube.
***
Now here’s a tip. I haven’t done it yet in the field (it only occured to me the other day), but I think I will try it the next time I have to intubate a breathing patient. I have tested the concept and believe it will work.
Before you intubate, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind, hook up the capnography to the machine, turn it on, and then go in for the tube. If your partner knows how to read wave forms he should be able to tell you if you are in or not when you ask. Either that or listen to the apnea alarm or the lack of an alarm. Make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.
For apneic patients you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter -- it is already in place. Keep in mind as always for pulseless patients you may need a little CPR to get your wave form reading. And of course, you'll need to pull the stylet before you bag the patient.
Make certain you have an extra capnography filter available as backup because if by chance you miss your tube abd gastric contents come up, they will contaminate your filter in addition to your tube.
This method of attaching the capnography filter to the ET tube before intubating also works for nasal tubes. Watch the wave forms as you advance the tube while listening for respirations Once you think you are deep enough and then cough gag and you push through, verify with the wave forms. Just make certain you are not still in the hypopharanx.
Don't misunderstand me. I still believe you should strive for the gold standard of watching the tube pass through the chords. Don’t make capnography your crutch, but in a difficult airway, it may be your new best friend.
***
Misplaced Tubes
The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.
Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. Annals of Emergency Medicine, May 2005, pgs 497-503l
If there ever was an argument for requiring continuous ETCO2 monitoring on all intubations, this is it. Over a ten month period, in 11 counties in Florida there were 153 intubations. 93 (61%) used continuous ETCO2 Monitoring. 60 (39%) did not. Upon arrival at the Emergency department there were 14 (9%) unrecognized misplaced intubations. There were 0 (0%) misplaced tubes in the group that used continuous ETCO2 monitoring. There were 14 (23%) in unmonitored group.
The authors wrote: “The unobserved unrecognized misplaced intubation risk difference is compelling. This study demonstrates that it is possible to attain a zero unrecognized misplaced intubation rate.”
Four years earlier, another study was done in Florida that showed during an 8 month period out of 108 “intubated” patients brought to a large Florida ED, there were 27 misplaced tubes (27%) on arrival at ED. 18 were in the esophagus, 9 in hypopharanx. 17 of 18 esophageal intubations had an absence of expired CO2, the one with CO2 was nasally intubated and breathing their own. 4 of 9 hyphopharengal intubations had an absence of expired CO2. - Katz SH, Falk JL, Misplaced endotracheal tubes by paramedics in an urban emergency medical services system, Annals of Emergency Medicine, January 2001
The authors wrote: “The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occuring in other communities...Functionally, whether the tubes were misplaced initially or dislodged en route to the hospital makes little difference to the patient....Despite written protocols requiring the out-of-hospital use of ETCO2 devices in our community, we...found their use to be sporadic... We believe that routine use of this technique, both at the time of intubation and as an ongoing monitor during transport, could potentially eliminate the problem of unrecognized misplaced ETT placement....”
Bottom Line: Intubated patients should all have continuous ETCO2 monitoring.
Friday, November 24, 2006
Syncope
Old woman has a syncopal episode at the dinning room table. No prior history. The family says she was out 1-2 minutes. Her eyes rolled back into her head and she vomited. Can't determine whether she vomited and then passed out or passed out and vomited.
She looks terrible, although she is alert. She says she feels weak, but she doesn't want to go to the hospital. Despite her age she had no significant medical history and lives independently. Her pressure is 120/70. Here is her strip:
I tell them in any unexplained syncope, it is important to go to the hospital. I can understand how given the dinner occasion, she might not want to go. I am thinking this is a vasol vagal episode. I want to do orthostatics, just to see what happens, but she says she is too weak to stand. And then she is unresponsive and vomits again. Unfortunately the leads have come off due to her sweaty skin, but I manage to get new leads on all the while supporting her airway, and hoping she doesn't code. Here is what I capture:
She wakes up and her rythm goes back to this:
We still insist she go to the hospital. With the help of her granddaughters, I get her out of her vomit drenched blouse and into a hospital gown, which I carry on the stretcher with the sheets.
We go on a non-priority. I put her on some 02 and put in an IV as we drive. Her color is much better. I get her demographic information, and then go to call the hospital. Right when I get ready to patch, I glance at her and she is vomitting again. I give a quick patch, "Sorry, my patient just started vomiting and is bradying down. Bottom line syncope at the dinner table. Be there in 5 minutes."
I hit print on the monitor while I try to keep the vomit in the small garbadge pail I grabbed and off her face. The episode isn't as long as the others and I can't say she is unresponsive during it. We are already at the hospital now. I have her cleaned off, and we take her in.
I give the report, and then write my run form. When I see the doctor, he shows me her 12 lead. The computer printout says possible posterior MI, although it doesn't jump out at me, and I'm not certain I agree. I show him my strips, and tell him this is what she was doing when vomitting, although she appeared normal at other times.
And then I look closely at the strip I recorded during the last vomiting episode. Here the ST is clearly elevated, but only for a few beats.
Its odd, but maybe what happens to her is similar to what happens when someone gets ST elevation during a stress test. She has a near blockage perhaps, which occludes during the stress of vomiting or is spasming. I'm not really sure.
I was surprised afterward that I didn't do a 12 lead myself and wish I had. I normally always do. I was just sort of busy, and I guess I was just thinking it was all a vagal episode and/or an upset stomach, but maybe it was an MI, and so was lower on my priority list. I think I might have done one in the house if there hadn't been so many firefighters and police offiders standing around the patient. I could have asked them to leave. Not that as health care providers, they shouldn't be involved, just having so many people -- firefighters, cops or medics makes it more awkward for the patient.
I'll post more later on this case when I next see the doctor and I can get more information.
I have also noticed that it is easier to study a strip after a call, than during one. It is hard to pick out subtleties unless you really study the strip. I think I should also have said to myself -- the irregular beats while she was vomiting are not typical of vagal episodes, at least in my experience.
I had another interesting call the same day, which I write about in my November log on my Capnography for Paramedics web site. It is another call where things aren't always what they may appear at first glance.
Hypoventilation not Hyperventilation
She looks terrible, although she is alert. She says she feels weak, but she doesn't want to go to the hospital. Despite her age she had no significant medical history and lives independently. Her pressure is 120/70. Here is her strip:
I tell them in any unexplained syncope, it is important to go to the hospital. I can understand how given the dinner occasion, she might not want to go. I am thinking this is a vasol vagal episode. I want to do orthostatics, just to see what happens, but she says she is too weak to stand. And then she is unresponsive and vomits again. Unfortunately the leads have come off due to her sweaty skin, but I manage to get new leads on all the while supporting her airway, and hoping she doesn't code. Here is what I capture:
She wakes up and her rythm goes back to this:
We still insist she go to the hospital. With the help of her granddaughters, I get her out of her vomit drenched blouse and into a hospital gown, which I carry on the stretcher with the sheets.
We go on a non-priority. I put her on some 02 and put in an IV as we drive. Her color is much better. I get her demographic information, and then go to call the hospital. Right when I get ready to patch, I glance at her and she is vomitting again. I give a quick patch, "Sorry, my patient just started vomiting and is bradying down. Bottom line syncope at the dinner table. Be there in 5 minutes."
I hit print on the monitor while I try to keep the vomit in the small garbadge pail I grabbed and off her face. The episode isn't as long as the others and I can't say she is unresponsive during it. We are already at the hospital now. I have her cleaned off, and we take her in.
I give the report, and then write my run form. When I see the doctor, he shows me her 12 lead. The computer printout says possible posterior MI, although it doesn't jump out at me, and I'm not certain I agree. I show him my strips, and tell him this is what she was doing when vomitting, although she appeared normal at other times.
And then I look closely at the strip I recorded during the last vomiting episode. Here the ST is clearly elevated, but only for a few beats.
Its odd, but maybe what happens to her is similar to what happens when someone gets ST elevation during a stress test. She has a near blockage perhaps, which occludes during the stress of vomiting or is spasming. I'm not really sure.
I was surprised afterward that I didn't do a 12 lead myself and wish I had. I normally always do. I was just sort of busy, and I guess I was just thinking it was all a vagal episode and/or an upset stomach, but maybe it was an MI, and so was lower on my priority list. I think I might have done one in the house if there hadn't been so many firefighters and police offiders standing around the patient. I could have asked them to leave. Not that as health care providers, they shouldn't be involved, just having so many people -- firefighters, cops or medics makes it more awkward for the patient.
I'll post more later on this case when I next see the doctor and I can get more information.
I have also noticed that it is easier to study a strip after a call, than during one. It is hard to pick out subtleties unless you really study the strip. I think I should also have said to myself -- the irregular beats while she was vomiting are not typical of vagal episodes, at least in my experience.
I had another interesting call the same day, which I write about in my November log on my Capnography for Paramedics web site. It is another call where things aren't always what they may appear at first glance.
Hypoventilation not Hyperventilation
Wednesday, November 22, 2006
Happy Thanksgiving
Happy Thanksgiving everyone. This is the first Thursday since I have been in EMS that I have not had a regular shift scheduled on this day.
When I started in 1989 at a small ambulance company, I worked every Thursday. When I went to work for the state, I rode with a volunteer ambulance every Thursday night. When I became a full-time paramedic in 1995, I worked Tuesdays through Thursdays. When I went to nights, I worked Thursday nights. When my shift changed to being the contract medic in the suburban town, I worked Thursdays through Saturdays. This past year I switched to Sundays through Tuesdays as my regular shift.
So what did I do for my first free Thanksgiving?
I signed up to work 18 hours in the city. 18 hours at double time and a half, and because it is an overtime shift, it really works out to be triple time. For that kind of money, I can roast my turkey on Wednesday.
Earlier this week, one of the ambulance volunteers stopped by and said the Food Share turkey drive was 3,000 turkeys short. He left us $20 to go buy some turkeys, so my partner and I went down to the supermarket and pitched in some money of our own and bought 8 turkeys, which we brought up to the Food Share lot. They were so happy to see us their manager took our picture. Nothing beats giving for putting you in a good spirit.
What am I thankful for on this holiday?
That everyone I have known who has gone to Iraq has come back alive.
That I still have my health and am still working as a paramedic -- that I have a job where I can help people -- help which for the most part, they appreciate. And while it is not everyday I medically save anyone's life, simply by being nice to them, talking to them, making sure they are comfortable, I can make a difference in their day when they are in need of a little compassion.
And I'm thankful for my friends and family, who I should spend more time with than I do, particuarly around Holidays.
Life never takes you where you thought it might, but I still appreciate the chance to walk through the leaves on November days.
***
"walking through the leaves, falling from the trees..."-Bob Dylan
"Mississippi"
When I started in 1989 at a small ambulance company, I worked every Thursday. When I went to work for the state, I rode with a volunteer ambulance every Thursday night. When I became a full-time paramedic in 1995, I worked Tuesdays through Thursdays. When I went to nights, I worked Thursday nights. When my shift changed to being the contract medic in the suburban town, I worked Thursdays through Saturdays. This past year I switched to Sundays through Tuesdays as my regular shift.
So what did I do for my first free Thanksgiving?
I signed up to work 18 hours in the city. 18 hours at double time and a half, and because it is an overtime shift, it really works out to be triple time. For that kind of money, I can roast my turkey on Wednesday.
Earlier this week, one of the ambulance volunteers stopped by and said the Food Share turkey drive was 3,000 turkeys short. He left us $20 to go buy some turkeys, so my partner and I went down to the supermarket and pitched in some money of our own and bought 8 turkeys, which we brought up to the Food Share lot. They were so happy to see us their manager took our picture. Nothing beats giving for putting you in a good spirit.
What am I thankful for on this holiday?
That everyone I have known who has gone to Iraq has come back alive.
That I still have my health and am still working as a paramedic -- that I have a job where I can help people -- help which for the most part, they appreciate. And while it is not everyday I medically save anyone's life, simply by being nice to them, talking to them, making sure they are comfortable, I can make a difference in their day when they are in need of a little compassion.
And I'm thankful for my friends and family, who I should spend more time with than I do, particuarly around Holidays.
Life never takes you where you thought it might, but I still appreciate the chance to walk through the leaves on November days.
***
"walking through the leaves, falling from the trees..."-Bob Dylan
"Mississippi"
Tuesday, November 21, 2006
Sunday, November 19, 2006
Hit Me With Your Best Shot
My left deltoid is killing me. I can hardly lift my arm up. I got a flu shot last night. Needles don’t bother me. I took the PPD like a pro. The little tuberculin syringe into the right forearm. I hardly felt it. Then the nurse pulled out the flu shot needle. I wasn’t even thinking about it at the time, but I guess it was a 3 cc syringe with maybe a 21 needle(actually it was a smaller 25 needle). I’ve had the shot lots of times and it never bothered me, but this time it was uncomfortable. It didn’t take long for my arm to start aching. Last night I couldn’t sleep on my left side.
Sometimes I think we should have to personally undergo every procedure we do on a patient on ourselves. Some services make their employees ride on the stretcher, looking up at the ceiling to see just how unpleasant the ride can be not to mention how dirty the ceiling might be. But I’m talking about much more than that. Within reason of course.
In our medic class we did IVs on each other. But never gave each other IM or SC injections. We spinally immobilized each other and put on traction splints in EMT school, but we never shoved nasal airways up each other’s nostrils.
I’ve heard of pranksters putting nitro paste on door handles to make their coworkers dizzy, but I’ve never pulled that prank or fallen victim to it. I’ve taken baby aspirin. I’ve had benadryl in pill form, and of course, lots of glucose in a variety of oral forms. I’ve produced natural epinephrine, but never had a shot of it. I had versed IV when I had a cyst removed from my scalp. I had fentanyl for pain then, which we don’t carry, not morphine which we do. I have had an albuterol breathing treatment. But not atrovent. I’ve had phenergan and reglan, but I’ve never popped a nitro, never had cardizem or amiodarone or procainimide. And, no I've never had pitocin, which we no longer carry. I’ll admit I have had curiosity about what it would feel like to hook myself up to a monitor and inject myself with adenosine -- to watch as my heart stops, and then hopefully restarts in not too long a time. But I am not without common sense.
I’ve never had valium or ativan or haldol. No atropine, dopamine, or vasopressin. No solumedrol. No Sodium Bicarb(although I have had a lot of diet soda). Never put tetracaine in my eyes. I have had lidociane as a local anesthetic, but never for V-tack.
I’ve know what it feels like to have electrodes ripped off hairy skin. Painful. But I’ve never been paced, cardioverted or defibrillated. I might have been intubated when I had a bone spur taken off my knee when I was ten, but I’m not certain. Nothing since then. I’ve gotten a few IVs. Once in college I had food poisoning and had been vomiting every hour for six hours. They gave me a bag of IV fluid and it was very cold and unpleasant to feel that slow drip drip of ice cold fluid into my arm. Subsequently I have had IVs of saline when I had the flu and felt much better afterwards. Its a miracle what a 1000 cc bag will do for you. I’ve never had an EJ in my neck or an IO drilled in my bone.
Like everyone I’ve had blood drawn and had to sit there while the tech roots around to hit the vein, even though I have ropes. I’ve wanted to say, give me that needle -- just let me do it.
Tonight when I go to have my PPD read (no swelling yet) by the nurse who stuck the flu shot needle in my shoulder, I probably won’t say anything to her about how much it hurt.
I do think there is some merit in knowing what you will be dishing out feels like on the other end.
To anyone I have hurt with my shots, sorry.
Sometimes I think we should have to personally undergo every procedure we do on a patient on ourselves. Some services make their employees ride on the stretcher, looking up at the ceiling to see just how unpleasant the ride can be not to mention how dirty the ceiling might be. But I’m talking about much more than that. Within reason of course.
In our medic class we did IVs on each other. But never gave each other IM or SC injections. We spinally immobilized each other and put on traction splints in EMT school, but we never shoved nasal airways up each other’s nostrils.
I’ve heard of pranksters putting nitro paste on door handles to make their coworkers dizzy, but I’ve never pulled that prank or fallen victim to it. I’ve taken baby aspirin. I’ve had benadryl in pill form, and of course, lots of glucose in a variety of oral forms. I’ve produced natural epinephrine, but never had a shot of it. I had versed IV when I had a cyst removed from my scalp. I had fentanyl for pain then, which we don’t carry, not morphine which we do. I have had an albuterol breathing treatment. But not atrovent. I’ve had phenergan and reglan, but I’ve never popped a nitro, never had cardizem or amiodarone or procainimide. And, no I've never had pitocin, which we no longer carry. I’ll admit I have had curiosity about what it would feel like to hook myself up to a monitor and inject myself with adenosine -- to watch as my heart stops, and then hopefully restarts in not too long a time. But I am not without common sense.
I’ve never had valium or ativan or haldol. No atropine, dopamine, or vasopressin. No solumedrol. No Sodium Bicarb(although I have had a lot of diet soda). Never put tetracaine in my eyes. I have had lidociane as a local anesthetic, but never for V-tack.
I’ve know what it feels like to have electrodes ripped off hairy skin. Painful. But I’ve never been paced, cardioverted or defibrillated. I might have been intubated when I had a bone spur taken off my knee when I was ten, but I’m not certain. Nothing since then. I’ve gotten a few IVs. Once in college I had food poisoning and had been vomiting every hour for six hours. They gave me a bag of IV fluid and it was very cold and unpleasant to feel that slow drip drip of ice cold fluid into my arm. Subsequently I have had IVs of saline when I had the flu and felt much better afterwards. Its a miracle what a 1000 cc bag will do for you. I’ve never had an EJ in my neck or an IO drilled in my bone.
Like everyone I’ve had blood drawn and had to sit there while the tech roots around to hit the vein, even though I have ropes. I’ve wanted to say, give me that needle -- just let me do it.
Tonight when I go to have my PPD read (no swelling yet) by the nurse who stuck the flu shot needle in my shoulder, I probably won’t say anything to her about how much it hurt.
I do think there is some merit in knowing what you will be dishing out feels like on the other end.
To anyone I have hurt with my shots, sorry.
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