I have been a big advocate of pain relief for patients. All the studies show that patients are consistently undermedicated both prehospitally and in the ER. Pain relief is something we can do that makes a huge difference for the patient. We can take care of their pain. I try to be as aggressive as I can be within hemodynamic bounds.
Recently I made a new protocol proposal to the medical advisory committee involving morphine. In the old days we were taught never to give morphine to patients with abdominal pain because it masked their diagnosis. Then we could give it with medical control permission if we made a good case that their probably had kidney stones.
Proposed Protocol Change # 1:
Morphine for Undifferentiated Abdominal Pain
The Change:
In the Pain algorithm under Other Pain, change the heading to “Abdominal Pain (possible kidney stone, sickle cell anemia or undifferentiated pain)” and include the following:
If patient is hemodynamically stable: Administer .05 mg/kg Morphine Sulfate (MS) SIVP to a max of 5mg.
Establish Medical Control
Possible Physican Orders:
Additional MS
Also, add the following footnote:
“This change is due to recent research that shows morphine does not hinder abdominal pain assessment, and may in fact improve diagnoisis. Thus paramedics may give “a judicious dose” of morphine (.05 mg/kg) on standing order to patients with non-traumatic abdominal pain. Additional needed morphine may be requested upon contact with medical control.”
Background:
Withholding morphine for abdominal pain in the belief that it might mask pain, delay diagnosis and contribute to mortality has been a long-standing practice in medicine despite the lack of any research supporting such a practice. As medicine has turned to evidence-based practice and with a concern toward alieviateing patient pain, as well as the presence of increased laboratory and imaging tools, there has been a paradigm shift on this issue.
“The judicious use of analgesics in the setting of acute abdominal pain is appropriate.”
-Cope’s Early Diagnosis of the Acute Abdomen
2000 Edition
“Administration of narcotics to patients with abdominal pain to facilitate the diagnostic evaluation is safe, humane, and in some cases, improves diagnostic accuracy. Incremental doses of an intraneneous narcotic agent can eliminate pain but not palpation tenderness. Analgesics decrease patient anxiety and cause relaxation of their abdominal muscles, thus potentially improving the information obtained from the physical examination. There is evidence that pain treatment does not obscure abdominal findings, or cause increased morbidity or mortality.”
-Clinical Policy: Critical Issues for the Initial Evaluation and Management of Patients Presenting With the Chief Complaint of NonTraumatic Acute Abdominal Pain
American College of Emergency Physicians, 2000
“It should be recognized that no study establishing negative outcomes (of giving MS to patients prior to surgical exam) of any sort has been published. Humane treatment of suffering should therefore be the only argument required to treat abdominal pain.”
-Pain Management and Sedation: Emergency Department Management
McGraw Hill, 2006
Studies- (Full Abstracts and Additional Related Studies attached in Science Document)
1. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg. 2003 Jan;196(1):18-31, Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.
CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons
2. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996 Dec;3(12):1086-92. Pace S, Burke TF.
CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.
3. Intravenous Morphine in Emergency Department Patients with Acute Abdominal Pain Does Not Alter Disposition Decision, Acad Emerg Med Volume 12, Number 5_suppl_1 18-19, David Esses, Polly Bijur, Conroy Lee, Michael Lahn and E. John Gallagher
Conclusions: The decisions to admit or discharge patients with acute abdominal pain were comparable, regardless of the administration of morphine.
We discussed the proposal for awhile at the last meeting but couldn’t vote on it because we didn’t have a quorum. I got a good deal of support for it, and only enountered one doctor, who hadn’t read my briefing papers, who tried the old argument of his need to see the patient unmarred by morphine. We will continue our debate in September when we meet again.
Recently I have had a couple patients who told me they were allergic to morphine. One had it typed in big front, the other just said she always got really sick when she took it. I asked my medical control doctor, who is also on the medical advisory committee for the region about the possibility of us getting another drug so we can provide relief to the people with the morphine allergy. He said he would look into it, but also said that most people just got nauseous and that's why we carried phenergan. He suggested just premedicating them with phenergan, and then giving them the morphine.
A couple days later, I had a call for a lady who fell down three stairs, severely breaking her forearm and twisting her ankle. She was crying in pain. I asked her about allergies, and whether she could take morphine. She said it always made her sick. I convinced her to let me give her some phenergan first, then then I gave some morphine very slowly. I ended up giving her 12.5 of morphine, and it helped a great deal. No nausea.
I told the doctor about it and he was happy, and he said he was still looking into another drug we could carry - maybe tramadol - to take care of the people with a true morphine allergy.
Two days ago, I did a call at an exclusive retirement community for a 100 year old lady, who tripped in the dark during the night and broke her arm. She was in great shape for a 100 year old (except for her broken humerous). She said her pain wasn't bad as long as she wasn't moving her arm. I asked her if she wanted any morphine and she said, quite appalled, heavens no. She was a very proper old woman who had spent her life at an upper class country club and who had quite high social standing. I felt like she was thinking who did I think she was some common street skank.
There is a whole group of patients out there, who are not allergic to morphine, but who think they are not hurt enough to have to get MORPHINE or that MORPHINE will turn them into crazed junkies. The 100-year old lady was in this group. Proper ladies do not partake of morphine unless they truly, truly can't bear the pain(after hours of torture).
I think we should rename MORPHINE to Herbal Balm or Chicken Soup. I think if I said, I've just going to give you a little tincture of chicken soup, they would have no objections and feel quite better.
Yesterday I responded for a guy with a hernia that had popped out and he wasn't able to reduce it as he sometimes could. He said it would have to be resewn -- he knew the jargon. He was in a fair amount of pain. I thought this would be a great test case for me to call to ask for morphine for abdominal pain, but he said he would wait until the hospital. He wasn't that bad. I felt like saying, then don't tell me you're in pain, and stop grimacing if you don't want me to help you. I should have just said, I'm going to give you a little IV herbal balm that will make it feel better.
I don't want anyone to suffer.
I imagine myself as a Jewish Mother. Her young boy has scrapped his knee. Stop your crying, let me shoot you up with some morphine and you'll be all better.
Monday, June 26, 2006
Tuesday, June 20, 2006
Problems Associated with the Determination of Carbon Dioxide by Infrared Absorbtion
I apologize again for the lack of a post for the last two weeks. I have been very busy and have had too much to write, and so haven't written anything.
The title above refers to a study I was trying to find this morning as I researched a question raised to me by a reader of my Capnography for Paramedics blog.
I spent most of the morning learning about the perfusion/ventilation mismatch in patients with severe respiratory disease and other factors that can alter the end tidal capnography value.
While I love being a paramedic, my primary love as been for the patients as humans, for the people aspect of the job. I have considered myself servicable at best on the science. I have been quite surprised by the passion and attention that the new technology capnography has inspired in me. Any time there are more chemical signs on a page that words I understand, then I feel I am treading on unfamiliar territory.
Life is full of surprises. The older I get the more interested in life's strange offerings I seem to become, and the more I wish to live fully.
Lately I have been consumed by a number of topics -- Capnography, Pain Management, Poker, Fitness, American Idol (Soul Patrol!), World Cup Soccer, Improving My Spanish, the Red Sox, as well as trying to be a good man for my girlfriend and a good influence on her two young children.
With all of this going on, I have somewhat neglected my writing, which often has seemed to be (misguided as it is) my only purpose in life.
A couple weeks ago I got some bad news about one of my oldest friends who has just been diagnosed with a deadly form of cancer that has spread at least to some lymph nodes and involves an ominous tumor that will require major radiation and chemotherapy. The radiation she has already started. The chemo begins this week. The prognosis is not known.
I traveled this weekend out to visit her and her family in the Southwest. I have never had such a close friend with cancer. My view of cancer is largely shaped by my experiences as a paramedic, taking patients by ambulance for radiation therapy or taking them into hospice care.
I was glad, but somewhat shocked to find her looking healthy and strong and working as normal. It was good to see her and to see that she has a good support network among family and friends in her community as well as health benefits (which while not perfect are better than the years she went without insurance).
I sat with her and her family in their back yard that looked out over the desert and, with her son (now in his 30's, I've known him since he was 10) drank Techate with lime and salt, as we all talked about life and music and the beauty of the afternoon and then early evening.
The vista of the open sky with mountains far in the distance and desert birds and a jack rabbit and cactus and trucks along the distant highway was really quite spectacular. It was over 100 degrees, but it was a dry heat and we had a small fan keeping a breeze on us in the times when the desert was calm, and we wore sunscreen and hats and had a good supply of cold beer and limes.
Flying home, while glad that I had gone, I felt a little like I was leaving the Gulf Coast with Hurricane Katrina brewing in the gulf, not yet visible to the naked eye, but out there on the radar, headed toward shore.
What will happen? Will the cancer swirl in for a direct devestating hit? Will it deal a hard, but recoverable blow? Or will it miraculously go away with nothing more than a rainstorm leaving everything and everyone standing as they were? Prayers answered.
Coming back on the plane, I took my novel manuscript out and tried to work on it. I made some progress, but my view of the story and the words on the page aren't quite in line yet. I have to keep at it.
What do I want most from life? To be a great a writer? To leave my stories? To be a great paramedic? To make a difference in people's lives? To be a good man and a true friend? To always do what's right?
This weekend we listened to Gram Parsons, the late great early country rock pioneer, and author of some of the greatest songs I've ever heard. He died at a young age, and members of his band stole his body and coffin and drove him out to the Joshua Tree Desert where they set his coffin ablaze.
We watched the sun setting. The desert sky turned orange.
Gram Parsons sang:
"In my hour of darkness
in my time of need
Oh, Lord, grant me vision
Oh Lord, grant me speed."
If I met God on the edge of the desert, I would tell him I just want my friend to get well.
The title above refers to a study I was trying to find this morning as I researched a question raised to me by a reader of my Capnography for Paramedics blog.
I spent most of the morning learning about the perfusion/ventilation mismatch in patients with severe respiratory disease and other factors that can alter the end tidal capnography value.
While I love being a paramedic, my primary love as been for the patients as humans, for the people aspect of the job. I have considered myself servicable at best on the science. I have been quite surprised by the passion and attention that the new technology capnography has inspired in me. Any time there are more chemical signs on a page that words I understand, then I feel I am treading on unfamiliar territory.
Life is full of surprises. The older I get the more interested in life's strange offerings I seem to become, and the more I wish to live fully.
Lately I have been consumed by a number of topics -- Capnography, Pain Management, Poker, Fitness, American Idol (Soul Patrol!), World Cup Soccer, Improving My Spanish, the Red Sox, as well as trying to be a good man for my girlfriend and a good influence on her two young children.
With all of this going on, I have somewhat neglected my writing, which often has seemed to be (misguided as it is) my only purpose in life.
A couple weeks ago I got some bad news about one of my oldest friends who has just been diagnosed with a deadly form of cancer that has spread at least to some lymph nodes and involves an ominous tumor that will require major radiation and chemotherapy. The radiation she has already started. The chemo begins this week. The prognosis is not known.
I traveled this weekend out to visit her and her family in the Southwest. I have never had such a close friend with cancer. My view of cancer is largely shaped by my experiences as a paramedic, taking patients by ambulance for radiation therapy or taking them into hospice care.
I was glad, but somewhat shocked to find her looking healthy and strong and working as normal. It was good to see her and to see that she has a good support network among family and friends in her community as well as health benefits (which while not perfect are better than the years she went without insurance).
I sat with her and her family in their back yard that looked out over the desert and, with her son (now in his 30's, I've known him since he was 10) drank Techate with lime and salt, as we all talked about life and music and the beauty of the afternoon and then early evening.
The vista of the open sky with mountains far in the distance and desert birds and a jack rabbit and cactus and trucks along the distant highway was really quite spectacular. It was over 100 degrees, but it was a dry heat and we had a small fan keeping a breeze on us in the times when the desert was calm, and we wore sunscreen and hats and had a good supply of cold beer and limes.
Flying home, while glad that I had gone, I felt a little like I was leaving the Gulf Coast with Hurricane Katrina brewing in the gulf, not yet visible to the naked eye, but out there on the radar, headed toward shore.
What will happen? Will the cancer swirl in for a direct devestating hit? Will it deal a hard, but recoverable blow? Or will it miraculously go away with nothing more than a rainstorm leaving everything and everyone standing as they were? Prayers answered.
Coming back on the plane, I took my novel manuscript out and tried to work on it. I made some progress, but my view of the story and the words on the page aren't quite in line yet. I have to keep at it.
What do I want most from life? To be a great a writer? To leave my stories? To be a great paramedic? To make a difference in people's lives? To be a good man and a true friend? To always do what's right?
This weekend we listened to Gram Parsons, the late great early country rock pioneer, and author of some of the greatest songs I've ever heard. He died at a young age, and members of his band stole his body and coffin and drove him out to the Joshua Tree Desert where they set his coffin ablaze.
We watched the sun setting. The desert sky turned orange.
Gram Parsons sang:
"In my hour of darkness
in my time of need
Oh, Lord, grant me vision
Oh Lord, grant me speed."
If I met God on the edge of the desert, I would tell him I just want my friend to get well.
Saturday, June 17, 2006
Posts
Sorry about the lack of new posts. I have been working on two, but am not ready to post them yet. I am away for a couple days, but will try to have some new posts ready to post when I get back if not before.
I do have some daily posts at
Paramedic Journal: A Year on the Streets
I do have some daily posts at
Paramedic Journal: A Year on the Streets
Tuesday, June 06, 2006
Safe
It’s raining. The Saab comes around the corner and sees a car pull out ahead of it. The driver turns to the right. Immediately the car begins to hydroplane. Ahead is a telephone pole.
We are dispatched to a MVA at a familiar location – a known bad corner. It is ten minutes before crew change. I leave with a new EMT and a young MRT, awaiting his EMT written results. The EMT’s father, who is coming in for the next shift, says he will wait for the night medic. We should be all set.
When we come around the corner, I think, Oh shit. This person is going to be f----ed up. This could be a fatal. The Saab is wrapped around the telephone pole, driver’s side impact.
The pole is up an incline, The car’s rear wheels point straight up the incline, the front points to the left and almost back around. Approaching the car, I can see an airbag has deployed. A bystander stands in the open driver window, holding her hand against the driver’s head. I hear the driver screaming. “He’s bleeding real bad. His head is open," the bystander says. I tell my crew to bring a collar, the 02 tank and a nonrebreather. The patient is pale and clammy. He says his head hurts. He asks to get out of the car.
I tell him my name. “We’re going to do our best.
This is a serious pin job. The driver is not getting out of this car without the fire department. The door is wedged into his thigh. The steering column has been crumpled by the door. The car is tight against the pole. The passenger door is also warped.
I ask if he can move his legs.
He says he’s stuck.
I apply a trauma pad to the back of his head and wrap a cervical collar around his neck, telling him to hold still. I put on a nonrebreather. I reassure him that we will do the best we can, but I feel helpless to get him out. Suddenly the car is shaking. I look and see two police officers pounding against the door, with a crop bar and a hammer, trying to pry it open.
“Even if we get the door off," I say, "He’s not coming out without the fire department. He's completely wedged in." I still can’t believe he’s even talking to me. The door is two thirds of the way into the driver’s seat.
“We have to do something.”
The car shakes. I look up at the wires on the pole. They look pretty secure. I listen for a fire engine. The siren I hear is our other ambulance. The night medic has arrived. I go over the situation with him. He asks if we can get him out through the roof. "He’s wedged in the seat," I say.
Somehow they pop the door, and force it open. The night medic goes in the back seat, I go in the front. I tell the crew to bring the stretcher around and a board. We’ll give it a try.
In my head I am flashing back to a call I did many many years ago, a young woman wedged in a car, and we couldn’t get her out, her leg crushed under the front door. We did futile CPR with her half in the car, half out. I wonder if this patient will die still in the car.
Amazingly, although he is screaming in pain, we are able to pull him out. I get my right hand in under his legs and my left on the back of his pants. Fortunately, he is not a big man. it seems as if I am holding him in the palms of my hands. We ease the board under him and then we are out, and out of there. Onto the stretcher, into the back of the ambulance, and off lights and sirens. I have the other medic in the back with me while the EMT's father – one of the best and smoothest drivers I have ever worked with, driving lights and sirens. How great it is to work with another medic. I get the patient’s clothes off and do a full assessment while the other medic gets a BP and a line in the right arm. Lung sounds are clear and equal, good chest rise, ab soft. The patient’s heart rate is in the 150’s. Bp 130/60. The left hip/pelvis is badly deformed, but the patient is still alert, although he doesn’t remember everything about the accident, just skidding. I call the hospital right away and request the trauma room. I tell them we are ten minutes out. I hear back just a lot of static mixed in with voices. “Did you hear me, I need the trauma room!”
“You’re scratchy. Is the patient stable?”
“No, the patient is not stable.”
“Okay, we’ll see you in the trauma room.”
His hip is killing him. We can’t get him to straighten his leg. It is almost as if his left leg has been displaced into his body. I have to hold it in just the right way to keep the pain under control. We switch holding the leg as each of us do what needs to be done. I get a line in the left arm and then get his name, date of birth and medical history. The other medic does the pressure again and repeats the assessment.
I wish I could give him morphine, but he is not stable and this is multi-system trauma. Who knows what else has been injured?
They are ready for us in the trauma room. I give the report and then clear out. As I am leaving the room, the patient calls me by name, as he is being turned over to check his backside, and thanks me. I tell him, he is in good hands.
After writing my report, I go look at the X-rays.
The doctor has seen nothing like it. The left pelvis is almost where the right pelvis is. It looks almost like one person sitting on top of another.
He is headed up to surgery as we leave. The next day I will learn, the patient is in intensive care – much of the pelvis is dust.
I think that is probably the only way we could have gotten that patient out. The pinned left side wasn’t there. It was over on the right
One of the crew comes in the next morning with pictures of the car taken at the garage where it was towed to. Unbelievable that anyone could have survived that.
I wonder how the patient would have done if we couldn’t get him out. If we had to wait for the car to be moved and the metal bent to free him. When I see the cops who were hammering at the door, I tell them what a job they did, how they may have saved his life.
“There was nothing else to do,” one says, “The guy was screaming. We had to do something.”
***
Driving home in my own old Saab the night of the accident, I feel the car skimming over the road. I look ahead at the turns, the telephone poles. I ease back on the speed. I look around at the car that holds me. Solidly built, room to move around in. Hold the blacktop. Take me on up the road. Get me home safe.
We are dispatched to a MVA at a familiar location – a known bad corner. It is ten minutes before crew change. I leave with a new EMT and a young MRT, awaiting his EMT written results. The EMT’s father, who is coming in for the next shift, says he will wait for the night medic. We should be all set.
When we come around the corner, I think, Oh shit. This person is going to be f----ed up. This could be a fatal. The Saab is wrapped around the telephone pole, driver’s side impact.
The pole is up an incline, The car’s rear wheels point straight up the incline, the front points to the left and almost back around. Approaching the car, I can see an airbag has deployed. A bystander stands in the open driver window, holding her hand against the driver’s head. I hear the driver screaming. “He’s bleeding real bad. His head is open," the bystander says. I tell my crew to bring a collar, the 02 tank and a nonrebreather. The patient is pale and clammy. He says his head hurts. He asks to get out of the car.
I tell him my name. “We’re going to do our best.
This is a serious pin job. The driver is not getting out of this car without the fire department. The door is wedged into his thigh. The steering column has been crumpled by the door. The car is tight against the pole. The passenger door is also warped.
I ask if he can move his legs.
He says he’s stuck.
I apply a trauma pad to the back of his head and wrap a cervical collar around his neck, telling him to hold still. I put on a nonrebreather. I reassure him that we will do the best we can, but I feel helpless to get him out. Suddenly the car is shaking. I look and see two police officers pounding against the door, with a crop bar and a hammer, trying to pry it open.
“Even if we get the door off," I say, "He’s not coming out without the fire department. He's completely wedged in." I still can’t believe he’s even talking to me. The door is two thirds of the way into the driver’s seat.
“We have to do something.”
The car shakes. I look up at the wires on the pole. They look pretty secure. I listen for a fire engine. The siren I hear is our other ambulance. The night medic has arrived. I go over the situation with him. He asks if we can get him out through the roof. "He’s wedged in the seat," I say.
Somehow they pop the door, and force it open. The night medic goes in the back seat, I go in the front. I tell the crew to bring the stretcher around and a board. We’ll give it a try.
In my head I am flashing back to a call I did many many years ago, a young woman wedged in a car, and we couldn’t get her out, her leg crushed under the front door. We did futile CPR with her half in the car, half out. I wonder if this patient will die still in the car.
Amazingly, although he is screaming in pain, we are able to pull him out. I get my right hand in under his legs and my left on the back of his pants. Fortunately, he is not a big man. it seems as if I am holding him in the palms of my hands. We ease the board under him and then we are out, and out of there. Onto the stretcher, into the back of the ambulance, and off lights and sirens. I have the other medic in the back with me while the EMT's father – one of the best and smoothest drivers I have ever worked with, driving lights and sirens. How great it is to work with another medic. I get the patient’s clothes off and do a full assessment while the other medic gets a BP and a line in the right arm. Lung sounds are clear and equal, good chest rise, ab soft. The patient’s heart rate is in the 150’s. Bp 130/60. The left hip/pelvis is badly deformed, but the patient is still alert, although he doesn’t remember everything about the accident, just skidding. I call the hospital right away and request the trauma room. I tell them we are ten minutes out. I hear back just a lot of static mixed in with voices. “Did you hear me, I need the trauma room!”
“You’re scratchy. Is the patient stable?”
“No, the patient is not stable.”
“Okay, we’ll see you in the trauma room.”
His hip is killing him. We can’t get him to straighten his leg. It is almost as if his left leg has been displaced into his body. I have to hold it in just the right way to keep the pain under control. We switch holding the leg as each of us do what needs to be done. I get a line in the left arm and then get his name, date of birth and medical history. The other medic does the pressure again and repeats the assessment.
I wish I could give him morphine, but he is not stable and this is multi-system trauma. Who knows what else has been injured?
They are ready for us in the trauma room. I give the report and then clear out. As I am leaving the room, the patient calls me by name, as he is being turned over to check his backside, and thanks me. I tell him, he is in good hands.
After writing my report, I go look at the X-rays.
The doctor has seen nothing like it. The left pelvis is almost where the right pelvis is. It looks almost like one person sitting on top of another.
He is headed up to surgery as we leave. The next day I will learn, the patient is in intensive care – much of the pelvis is dust.
I think that is probably the only way we could have gotten that patient out. The pinned left side wasn’t there. It was over on the right
One of the crew comes in the next morning with pictures of the car taken at the garage where it was towed to. Unbelievable that anyone could have survived that.
I wonder how the patient would have done if we couldn’t get him out. If we had to wait for the car to be moved and the metal bent to free him. When I see the cops who were hammering at the door, I tell them what a job they did, how they may have saved his life.
“There was nothing else to do,” one says, “The guy was screaming. We had to do something.”
***
Driving home in my own old Saab the night of the accident, I feel the car skimming over the road. I look ahead at the turns, the telephone poles. I ease back on the speed. I look around at the car that holds me. Solidly built, room to move around in. Hold the blacktop. Take me on up the road. Get me home safe.
Friday, June 02, 2006
Electricity
The call is for a man's defibrillator going off.
When we arrive, it has gone off four times already. I put him on the monitor.
"No wonder," I say. "It looks like v-tach" to me.
Then all of a sudden, he cries out as his whole body convulses in pain.
(The artifact was caused by the wires moving as he reacted to the jolt.)
His internal defib shocks him once more before I can get the line in and start giving him some 150 mg of Amiodarone over 10 minutes.
Here's the initial 12-Lead:
Shocking is incredibly painful. This guy, who even though he was diaphoretic, was joking with us, and then when the defibrillator went off, his whole body winced in pain, and he started cussing at me to hurry up and give him the medicine. I also gave him some Versed, and then hung an Amio drip at 30 mg/hr. He didn't get shocked again and felt much better.
His final rhythm was hard to determine. I still called the underlying rythmn v-tack. The axis was still about 215 degrees (Extreme right axis deviation). The rythmn was very funky, but his rate slowed from the 150s to 100 and he was perfusing better. It was irregular. His wife said he only had 1/3 of a functioning heart.
In the hospital his rate was down in the 80's and showed his pacemaker kicking in. They ended up admitting him.
***
I have done quite a number of these calls over the years -- it seems with increasing frequency (probably due to more people being equipped with them). Now at least we can give them Versed to sedate them a little and hopefully later forget whatever pain they feel when the thing goes off. Also I believe the amiodarone is a great improvement over the lidoicaine.
Once I did a patient who was testifying at the state capitol when he was shocked. He tried to continue, but got shocked again. (I can think of some people testifying I would love to have a button to give them a a little jolt when they tell lies).
I read once about a man who had an internal defibrillator. He was in his thirties and had several children. His defib was going off over 200 times a day. Nothing the doctors could do could get his rythmn under control. After months and months of agony, he finally asked to die. They turned his defib off and he died with his family around him.
When we arrive, it has gone off four times already. I put him on the monitor.
"No wonder," I say. "It looks like v-tach" to me.
Then all of a sudden, he cries out as his whole body convulses in pain.
(The artifact was caused by the wires moving as he reacted to the jolt.)
His internal defib shocks him once more before I can get the line in and start giving him some 150 mg of Amiodarone over 10 minutes.
Here's the initial 12-Lead:
Shocking is incredibly painful. This guy, who even though he was diaphoretic, was joking with us, and then when the defibrillator went off, his whole body winced in pain, and he started cussing at me to hurry up and give him the medicine. I also gave him some Versed, and then hung an Amio drip at 30 mg/hr. He didn't get shocked again and felt much better.
His final rhythm was hard to determine. I still called the underlying rythmn v-tack. The axis was still about 215 degrees (Extreme right axis deviation). The rythmn was very funky, but his rate slowed from the 150s to 100 and he was perfusing better. It was irregular. His wife said he only had 1/3 of a functioning heart.
In the hospital his rate was down in the 80's and showed his pacemaker kicking in. They ended up admitting him.
***
I have done quite a number of these calls over the years -- it seems with increasing frequency (probably due to more people being equipped with them). Now at least we can give them Versed to sedate them a little and hopefully later forget whatever pain they feel when the thing goes off. Also I believe the amiodarone is a great improvement over the lidoicaine.
Once I did a patient who was testifying at the state capitol when he was shocked. He tried to continue, but got shocked again. (I can think of some people testifying I would love to have a button to give them a a little jolt when they tell lies).
I read once about a man who had an internal defibrillator. He was in his thirties and had several children. His defib was going off over 200 times a day. Nothing the doctors could do could get his rythmn under control. After months and months of agony, he finally asked to die. They turned his defib off and he died with his family around him.
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