Capnography - Shark Fin

A couple weeks ago I took a really good class on capnography, which is the measurement of carbon dioxide (C02) during the respiratory cycle and display of the the measurements as a wave form on a monitor.

For the last year I have been using capnography on all my intubated patients. A good capnography wave insures that the tube is in the trachea where its supposed to be and not in the esophagas which would produce a flat line, immediately on the capnography wave form and eventually on the heart monitor as well if the tube is not moved to the right place.

Part of the class covered capnography for the non-intubated patient. Instead of an attachment on an ET tube, a nasal cannula-like monitoring device was put on the patient. We were taught about the shape of the wave form changed depending on the problem. Asthmatics and COPDers had a characteristic shark fin shape, which indicated resistance to expiration.

Yesterday we had an eighty-year COPDer with Sats in the 80's, alert, but not moving too much air. We gave her two back to back combi-nebs and monitored her with capnography. It was the first time I used capnography on a COPDer.

Here are the wave forms. Keep in mind a slanted "shark fin" wave form shows the person is struggling to exhale through resistance. A more box like wave form shows no resistance. Here's a normal wave form and a bronchospastic wave form:

And here's our patient's wave forms, initially, during the first treatment(combi-vent, which bronchodilates) and after two treatments:

Way cool, I thought. It really shows how effective our treatment was. The woman felt much better and was breathing easier. The nurse at the ED asked what the funny looking cannula was for. She was impressed when we said capnography. We tried to show her the wave forms, but she just nodded, and it seemed to me the wave forms meant nothing to her. A couple weeks ago, they would have meant nothing to me, too.

***

For more information on capnography:

Capnography

Practice

My preceptee needs a code. He probably needs a couple. He hasn’t done one as a medic yet. He’s intubated “ Fred the Head,” but mannequins just aren't the real McCoy. While managing a cardiac arrest is about more than just intubating, a medic needs at least one intubation to get cut loose to practice on his own.

A week ago we were called for "a fall, not breathing," then updated that it was a dead body with no one doing CPR. When we got there, we found a four hundred plus pound woman face down on the carpet in front of her motorized lark. She was just a big blob of flesh. You couldn’t even see her face. It took a moment to make out where it was. We rolled her over, and quickly assessed her. She was in the gray area between being dead and workable by protocol and being dead and not workable by protocol. In either case, she was dead and not coming back. Asystole in three leads, unknown down time. Warm, but with a touch of rigor perhaps in the jaw, a touch of lividity.

Many things go through your head in the split seconds that you have to decide to start CPR or withhold it. If you are going to start, you havetostartrightthisveryinstant, but if you aren’t, you obviously have all the time in the world to do nothing but call the time.

Here's what went through my head (as my preceptee looked to me for direction):

She’s dead. I have a preceptee, my preceptee needs a code, but she’s dead, plus she’s huge. No neck, difficult tube. It might take us awhile to get the tube, much less find her sternum to start CPR. Damn, she’s big. We do need a code. But she’s not coming back. Getting a tube in her would be a feat. My preceptee might have a hard time. I would have a hard time, but getting a tube in her, that’d be a feat. I’d be the man – but who would I show it too other than my preceptee and my partner. Look at me, I got a tube in her. She surely isn’t going anywhere. We’ll work her for twenty minutes and call her. We’ll probably break her sternum, and who knows what make come out of her stomach, and maybe we’ll chew up her throat and break some teeth trying to get a tube into that jaw and mouth. All for what? Valiant effort. She’s dead. Let her be. There’s enough stiffness in the jaw to call it. Give her her peace. Her dignity. No, we should code her. No, no, she’s dead.

“No, no,” I said to my preceptee. “She’d dead.”

***

That call and a comment I received on this blog set me to thinking about the subject of “practice.” Practice on bodies.

Another medic told me about a medic he knew who told him when she was precepting after she brought in a code, which was declared dead at the hospital, the doctor pulled the curtain and let her practice intubating the deceased patient. Perhaps the doctor said, “He’s all yours, Go nuts!” He said she got an hour practice before they came and took the body away.

This is not the first time I have heard of this happening. It may not be common, but it is not unheard of. The theory is practice on a dead person may save a live one someday. Along with that goes the belief that the dead are dead.

I was on a call where a paramedic worked a code for twenty minutes, and then presumed the still asystolic patient. Then with no bystanders in the room, he extubated the patient, and then let the partner, who was a paramedic student, intubate the dead man.

(On a slightly different issue, I know another paramedic who let his partner, a paramedic student intubate a working code so he could get some practice. He did it successfully on the first try, but because he wasn’t functioning as a paramedic student at the time, a member of the crew backing them up complained, and they were both suspended. Another time a medic let his partner, a paramedic student, do an IV on a code when he couldn’t get one. The partner got the IV, and together, they saved the patient. A member of another crew reported him to the state and he nearly lost his license. You can only do paramedicine when you are working as a paramedic student, not when you are working your regular EMT shift.)

Matters are grey for some, black and white for others. While I might not cross the line in the cases above, I wouldn’t feel comfortable reporting it to authorities, either.

I have been considering taking an airway class down in Baltimore where you get your own fresh cadaver to practice on for the day. There is a disclaimer, something about you may have to share a cadaver in the event of a shortfall in supply. They don’t know in April, how many cadavers will be available on a certain date in November.

I suppose they get them at the city morgue – people who have checked organ donor on their license plates.

Maybe its okay then, if after checking the patient’s wallets for organ donor status, for medics to practice on them – to do extra intubations after the code has been called or to work them even though they are pretty much dead. People could have a DNR that says, they can be coded, but you have to stop after twenty minutes no matter what the outcome and let them go back to the shadows, the dying light.

***

It all leaves me...uneasy.

What I Would Want

One of the comments to a recent post was from Henrick, who wrote: “Maybe I´ve misunderstood your post ( english isn´t my first language)and so this could be a reallt stupid question... But I have to ask! Do you really schock people who are awake and talking?”

The answer of course is yes, we do, if we can’t avoid it. If we think we have time and we think that it will work we can give a round of medicine. If we don’t, we shock away.

This all set me to thinking.

What would I want if I were the patient?

I would want medicine first if there was time. And I would want a seasoned medic taking care of me. I would want a medic who had gone to a good medic program and who was subject to a rigorous QI program, a medic who got a lot of continuing education every year. And I would want a little luck and good fortune. I would want the medicine to work.

And then I thought, what else would I want if I were a patient in the 911 system?

I would want:

Morphine if I broke my leg or arm or hip, or cut my fingers off with a snow blower or spilled boiling water on myself or had kidney stones, or even abdominal pain of unknown origin, provided I was hemodynamically stable.

A pillow and enough blankets if I was cold. Working air-conditioning in the summer.

A smooth easy ride, a rig with good shocks, a smooth experienced driver, and no lights and sirens unless I was dying of a correctable cause.

A paramedic or EMT who was nice and asked my name and told me what they were doing before they did it.

Amiodarone instead of lidocaine.

A family member sitting in the back with me unless I was out-of-control or I required much active care by a medic on each side of me and one at the head.

Phenergan if I was nauseous.

Here’s what I wouldn’t want:

Ten people from three different services: EMS, fire, police, coming charging into my house (unless I was in cardiac arrest).

Drugs down my tube.

RSI if I could be bagged, or if I was conscious.

C-spined unless I couldn’t move my neck due to the pain.

An IV unless it was necessary to give me fluid or medicine (same goes for the hospital) or unless I was really sick. (Same goes for in-hospital).

To be flown in a helicopter if I could just as easily go by ground.

An EMT who answered his cell phone while treating me.

And finally CPR if I was dead.

I’m sure there is more, but that’s what immediately comes to my mind. Some of what I would want, conflicts with what I would want to provide my own patients, but not much of it.

The Juice

My cold is still lingering, although I might say I am feeling a little better. Still after three back to back calls yesterday, I was getting tired of lugging my gear and lifting people. Everything seems heavier than it should be when you aren't feeling 100%. I hate standing at the top of the stairs feeling my heart pound, my breathing quicker.

On our last call, when we got there the cops were still trying to get into the house. I saw that a window screen was just barely open, so I climbed out on a ledge and jimmied it open, then I passed the flower pots that were on the window sill to a police officer and had called for my partner to boost me just a touch so I could get my arms into the window enough to pull myself up and in up. I love being a second story cat burgler man, but even as I was preparing to do it, I was thinking I was crazy. Maybe when I was feeling better, I could try it. Here I was with two fit police officers in the late twenties, and me a forty-seven year old man, getting ready to go head first through a high window. I think I was trying to prove something to myself. Fortunately, someone finally came to the door, just as I was getting boosted up. The patient had soiled herself during a syncopal episode, so her daughter was cleaning her up in the shower and hadn’t heard the knocks on the door.

I have been reading this book about Barry Bonds and steroids called Game of Shadows. It is a pretty amazing book about more than just Bonds. It meticulously details the drugs Bonds and other athletes – not just baseball players, but world class track and field athletes --were taking. They'd be over the hill, their careers on a downward slide, and then they'd get on this drug regime and start setting world records. They were taking up to 50 pills a day, but the main ones were undetectable steroids and human growth hormone. They'd also take insulin, clomid, a female fertility drug, and some stuff to make lean muscle in cattle.

I'm reading this book and thinking, you know I've been feeling run down and over the hill, maybe I could use this stuff. Let's look at the public good here. Barry Bonds takes steroids to hit home runs, Marion Jones takes steroids to run fast, I would be taking steroids to help people. And I could go for a world record, too. Instead of hitting 73 home runs, I could carry 73 millions pounds of patients and equipment in a year. And steroids would prolong my career. Of course, I wouldn't want to swallow all the pills, rub all the crème on, and stick myself with all the syringes Bonds used. Forget about the female fertility and the cow stuff, just give me the Clear and the Cream and HGB, along with the legal supplement ZMA -- zinc and magnesium.

Worry about getting caught? No, the state doesn't test medics for steroids. Not yet anyway. But, you know, I might be a standup guy anyway. What bugs me the most about these athletes is not that they took steroids, but that they lie about it. They deny what anyone with eyes can see. I wouldn't be like that. If someone asks me how I lifted that 400-pounder all by myself, I'll say, "It's the juice! man. It’s the juice!"

Anyway, tomorrow I start taking my daily vitamins again.

***



***


My Vitamins. Not! Okay, I took them for awhile, then I was worried I was going to get mad cow disease due to the crushed cow pituitary glands.

"What's Going on Back There?"

"Woman not acting right according to her husband. History of lupus," the dispatcher tells us.

It is a nice house in a residential neighborhood in the north section of town. We back in the drive, and then wheel the stretcher in through the open garage door.

"You don't need that. She can walk out," an officer says, as he comes out of the door leading into the house.

So we leave the stretcher in the garage and walk into the sparely furnished spacious house. Inside we find a woman in her thirties sitting in a chair with a faraway look in her eyes. "She's not acting right," her husband, a large muscular man in a orange shirt that is the color of a prison jumpsuit, says. "It is not her at all. This been going on all day."

I approach her and have her squeeze my hands. She has equal grips. I raise my arms and she keeps holding my hands. "Let's go and keep your hands up." She lets go and keeps her arms up. While they appear a little unsteady, there is no drift. Her pupils are equal but not reactive at all to my penlight. "Are you in any pain?"

She shakes her head.

I ask the husband what hospital he wants us to take her too. He tells us. I ask if he knows her meds.

"I have them right here," he says. He is holding her pocket book.

"Any drugs or alcohol?" I ask.

"No," he says, sounding close to being offended.

It is genneraly my style to do as much as I can while transporting. If the patient doesn't appear critical or to need an immediate intervention, I tend to always do my workup in the back of the ambulance on the way to the hospital. We are about twenty minutes from the hospital. I expect to have a complete assement, history, and basic ALS done along with my runform written by the time we hit the hospital. I help her up and we walk out to the garage where my partner has set up the stretcher. The woman appears slightly unsteady, so I hold her left arm as we walk.

The husband steps up into the back of the ambulance with us. "No, you have to sit in the front," I say. For a moment I think why not let him sit there. I can the history I need from him without having to schooch up to the front to talk to him, but I have another partner in the back with me and I am going to do an ALS workup, so I guess I'd rather not have him back there.

My partners are fairly new to EMS. Driving for the first time is the young man I wrote about in the story Compressions. In the back with me is another new EMT, who is very eager, but still needs more seasoning. My partner takes her blood pressure while I strap a tourniquet on her arm. He gets 160/100. That's certainly noteworthy.

She is watching me as I look for a vein. She seems almost like someone who is high. I'm wondering if she is seeing tracks when I move my hand in front of her eyes. It is very strange.

I get a flash on the IV, and withdraw the needle, and start drawing blood. I have about half a tube, but it is drawing so slowly, I decide to just attach the saline lock. I detach the vacutainer, and while I am clamping down on the vein with my left hand, suddenly the patient starts to shake. She isn't just shaking, she is seizing violently.

"What's going on back there? What's going on?" the husband demands.

"She's having a seizure," I say. "It's okay; I have medicine to stop it."

"What's going on? What's going on! Is she all right?"

I am holding on to her arm, clamping the vein off for dear life. She is having a gran mal seizure. I can't reach my narcs, which are locked up in a cabinet behind the captain's chair. I'm not panicked because I'm thinking maybe she had a seizure earlier and was acting so weird because she was postictal. Besides, most seizures stop after a couple minutes anyway. I have to believe hers will stop, or hope so at least. I'm going to give her a minute or two to find out. While she is still flailing I manage to get the saline lock attacked to the catheter and taped down.

Then she stops seizing. She sits there now, looking off to the left. She is awfully still. I don't think she is breathing. I look at her closely, but I can't see any movement. I do a sternal rub. No response. I don't feel a pulse, but we are bumping down the road so I can't be certain.

The man in front is flipping out. "Shouldn't we be going faster? Shouldn't you have the lights on? Is she all right?"

"get out my airway kit," I say to my partner, while I quickly put her on the monitor. I need to see what is going on. I'm hoping for a nice sinus tack.

Here's what I see:

I cut off her shirt and slap the pads on.

"Step it up to a three," I say to the driver.

I am tempted to shock her, but I flash back to calls I have had in the past where a patient suddenly went into v-tack and I shocked them -- few with a good outcome. I shock them, they die. First shock doesn't do anything, second shock kills them. Not everytime for sure, but several memmorable times. I had patients who were talking to me. I'd shock them, and they would say -- they both in fact said the same words. "You're killing me." I'd apologize, hit them again, and they would die. In ACLS they teach you to jump to electricity if the patient is unstable. I remember one teacher saying "Go ahead and jolt em!" But I don't think she has seen what I have. I don't like electricity on a live person. But on the other hand -- not only is she not talking, she might not even be breathing. I can't readily tell. She is having a period of post-seizure apnea or she is breathing mightly lightly. I do have an IV. My med kit is on the bench next to me. There is that line in the ACLS books about giving a brief trail of meds if there is time. She is going to need me to breathe for her in a minute, but she should still have some good oxygenated blood in her. I unzip the med kit and pull out a vial of amiodarone. I draw up 150 mg and push it in into the lock. I look at the monitor.

EMS is all about the action, but sometimes it’s about waiting.

What happened? I'm thinking. Did she seize because she was in v-tach or did she go into v-tack because of the seizure? It was a true gran mal seizure, not a hypoxic seizure. People stop breathing after a seizure sometimes, but then start up again. But she's in v-tack. What the ? What do I do?

"What's going on?" the husband is shouting. The driver has one hand on the wheel and the other trying to hold the man into his seat.

Should I shock her? If I do, the next minute I know I'm going to be doing CPR. But soon I am going to have to do something more. I can't wait too long.

Should I have the driver pull over and grab a board out of the outside compartment so we can lay her down on it and verifying that she is pulseless start CPR? How is the husband going to act?

I look back at the monitor.

Whew! She is out of v-tack. Thank the Lord. The amio worked. I'm not certain if it’s a sinus tack or a rapid afib. The rate runs from 140 to 170.

I have the ambu-bag in my hand, but now I tell my partner to get a nonrebreather out of the cabinet.

I have a pulse. There's some small chest rise. I get a blood pressure 170/120. She still doesn't respond to a sternal rub. We check her blood sugar. HI, which means it’s over 600.

I try to patch to the hospital, but all I can hear on the radio is a high-pitched whine.

"What's going on? What's going on back there?" the husband demands.

The whining stops on the radio and when I ask if the hospital is on, the operator tells me they are off now, but he will try to get them back on. They come back on, I give my patch, but get no acknowledgement.

I put in another IV and start running fluid in. She is still unresponsive. Her rhythm is looking better.

I think about tubing her, but she is satting at 98%, so I just watch her airway.

We park at the hospital, and the husband, comes around to the back and when we open the doors, he sees her laying there, her breasts hanging out in the open. I quickly grab a sheet and cover her up.

The husband wants to know what's going on. I tell him I'm not really certain. She had a lethal heart rhythm, but she's out of it now. Her sugar is high. He confirms she is not a diabetic and has never had seizures before.

We wheel her in. They never got our patch so they are not expecting us. They quickly get us a room. She is responding to the sternal rub now, and mutters a few words. I give my report while they get the rest of her clothes off.

When her lab results come back, her sugar is 1200, and most of her electrolytes are way out of whack.

The nurse tells me her husband kept saying how slow we drove to the hospital.

Here’s what her final rhythm looked like when we turned her over.

I'm been doing nothing but nursing home, doctor's offices, visiting nurse, and minor MVA calls. I knew I was due.

Maybe if I shocked her, she would have converted and been okay. Maybe not. I'm glad it worked out the way it did. I wish I had her on the monitor before she seized, curious what her original rythmn was. If she had seized a few minutes later I would have had her on there. I'm glad I already had the IV in.

"Woman not acting right according to her husband. History of lupus," the dispatcher tells us.

You never know in this job.

Posting

There is a message for us on the board at the office telling us to no longer park in the lot of a chain drug store when we are posted in a particular area of territory. It seems the manager complained about the presence of our ambulance in what is a fairly large parking lot. When I parked there I often went into the drug store to get something to drink or a magazine to read, or a power bar or needed toiletries. I’m sure other employees did as well.

I find it hard to believe every time something like this comes up. We are the good guys. You would think a business would welcome our presence. Besides the extra business, it certainly guarantees a quick response should any misfortune befall one of their customers or employees.

We use system status management so our ambulances are always on the move, so we are spread out to decrease response time. System status management is fairly controversial, and has some downsides – the discomfort of being cramped up in an ambulance all day. It is particularly hard for me at my height – six-seven and a half. I used to six nine, but I have started to shrink. Sometimes when I get out of an ambulance, it takes me several strides to straighten my spine. Still, I can’t argue with the logic of being in the ambulance, ready to respond. Instead of sliding down a pole and jumping into a truck, we are already on our way. That is if we get dispatched efficiently. Sometimes the PD gives the call to the fire department well before us, and the fire engine is already whoo-whooing by us, with all the fire guys waving to us before our number has even been called.

Years ago when I worked at night, we used to all park at a gas station that had a national doughnut chain in it. It was a great location, right off the highway. You could get anywhere from that location. We bought a lot of doughnuts and coffee and the management let us use their private bathroom. They loved us there because, while they were always getting robbed, they never got robbed when we were there. All they asked was that we move the ambulances when the doughnut delivery truck pulled in at four in the morning. No problem. I stopped working nights so I don’t know when it happened or why, but all of a sudden we couldn’t park there anymore. Maybe they got new management.

One day I parked in the lot of a church. It was during the week and there was a single car in the lot. It was empty. I was there about ten minutes when the priest came out and looking very agitated came out and said I couldn’t park there. “This is private property!” he said. I didn’t say anything because frankly, I didn’t know what to say. I was a text book case of being speechless. I thought later of all the wise-ass things I could have said to him to make him think about what a man of the cloth was doing harassing good Samaritans, but I am not a wise ass.

I think sometimes the problem is I do see us as good Samaritans. I mean you call 911 and we respond. No questions asked. Just like police and fire. We are all there together for the public good, standing shoulder to shoulder as they say. But because we are a commercial ambulance, some few may see us as something less innocent.

We used to park downtown across from another doughnut shop. Sometimes we’d have to park up on a curb, so we could run in and grab coffee and a doughnut (or in my case, a diet coke and a bagel) and still be able to make a quick exit if a 911 call came in. One day a cop wrote a ticket and stuck it on one of the ambulances. Not a typical gesture of public safety solidarity.

(I used to go to the Symphony. Well, actually, I only went once, but I was going to go again. Then I heard they offered free tickets to a performance for all public safety personnel, but since we worked for a commercial service, even though we did 911, we weren’t included. Another medic who likes to go to the symphony told me this. Only police and fire got the free tickets. No ambulance. The symphony people call me every year asking for money, and every year I tell them not to call me again. They ask why, I tell them. They keep calling. I guess the message hasn’t gotten through.)

Yeah, my feelings get hurt when they tell us they don’t want us. No admission to the symphony, no red carpet to the parking lot, move along buddy, move along.

Still there are lots of places to park in the city. Everyone has their favorite spots. An old partner of mine liked to park across the street from the secretarial school just before three in the afternoon when all the young secretarial aspirees got out of class. Another partner liked to park down behind the railroad tracks by the cement plant where there was a natural whiffle ball field. There is a great parking spot near the YWCA with easy access to the highway. There used to be a great clover patch there where my partner and I found many four leaf clovers, but she was anything but a conservationist, and I don’t know if any survived her onslaught.

At night cozy partners have been known to park down by the creek behind the college in the large unlit lot. One not so savvy crew parked in another lot that was monitored by video cameras. While the video tape did not to my knowledge make it on the internet (which was in its infancy Pre-Paris Hilton days), it was passed to the director of operations who counseled the guilty partners to seek employment elsewhere.

There are several nice parks where you can spend some time while waiting for the call to come in, particularly in the spring and summer. You can sit outside your ambulance, radio on, enjoying the air, the smell of flowers and the laughter of children playing in the fields or by the ponds. You have to be sure and turn your diesel engine off though. I always do.

Yesterday I bought some jerk chicken with stew chicken gravy and rice and peas from a Jamaican restaurant, then drove up the avenue and parked in an abandoned car dealership under a giant billboard. It was a nice day, and I rolled the window down and ate my chicken and read the paper, while my partner studied for her psychology test. Nobody bothered us.