Drove down with a fellow medic, and on the way discussed ways to get other medics more interested in education. I believe medics are not opposed to getting more education, its just that the economics of the job make it difficult to take the time off, not just to get to a nightly session, but more particularly to take a few days off and spend the money to get down to a place like Baltimore, pay for a hotel, meals, conference fees, and other costs.
Still, going to a conference is great way to improve yourself and your patient care. Last night I attended Bob Page’s “Slap the Cap” capnography class.
Last year in Las Vegas I saw the half hour condensed version. I envy anyone who has been able to attend his half day course. He is a phenomenal educator/entertainer.
People filtered into the classroom before show time to see Queen and then Billy Joel performing on the big screens set up in the front of the room. When Bob Page appeared to start the class, he humbly thanked his opening acts...Queen and Billy Joel.
Page calls capnography an “upgrade,” and to illustrate this he describes his first airline upgrade to first class and how he found out the drinks were unlimited, you could be served before the plane took off, you got peanuts, cashews and pistachios in a bowl rather than a tiny bag of salted peanuts and you also got warm moist lemon scented towels. Like first class on an airplane, capnography gives you stuff that you can’t get in coach.
Before getting into what that stuff is, he does a great demonstration of a blood cell carrying carbon dioxide in which he plays the blood cell running through the body. He simulates what happens to him during cardiac arrest, during a PE, and during a hemorrhage how he is thrown out of the body, and describes the effect of that all on the end tidal C02.
I’m not going to go through his entire class, but I will point out the key points from his presentation that I found personnaly found valuable or helped clarify my own thinking on the issue.
1. While most people use the definition of hyperventilation and hypoventilation to describe low and high ETCO2 numbers, he uses the terms hypocapnia and hypercapnia, which may be a more accurate was of describing it.
2. He does a killer job of trashing colorimetric capnography devices and the turkey baster/bulb syringe by reading their instructions and then applying them to real situations. For instance, the colorimetric says you must give six breaths to determine the reading to make certain all of the carbon dioxide is out of the stomach. Well six bags into the stomach is going to visually tell you there is a problem before the device does.
3. He takes about the wave form you will get from an intubated patient who is coming out of sedation before they start bucking the tube, so you can get out more sedation before they actually buck the tube. It is another example of how capnography makes you proactive as opposed to reactive.
4. He talks about asthma and makes the point you can’t fake a broncospasm/shark fin wave form. Anyone who says they are having an asthma attack and is trying to make a wheezing sound deliberately will have a straight up wave form unless they are actually having an asthma attack.
5. He calls wave form capnography a “one stop tube confirmation stop.” Technically, it is a two stop shop, because you still have to listen to lung sounds to make certain you don’t have a right mainstem intubation, which won’t show up on capnography. Still a desciptive phrase, meaning you don't have to go through all the step you might otherwise have to use if you didn't hve capnography.
6. He suggests hitting record on your intubated patients right before you move them to the ED’s stretcher and then immediately after you have moved them over to time stamp your intubation in case the ED says your tube is no good.
7. On the issue of ventilation rate, while the new AHA guidelines specify the rate as 8-10 for a patient in arrest and 10-12 for an intubated patient, you should instead use the capnography as your guide. If their ETCO2 is 70, you might want to increase your ventilation rate to blow some of that CO2 off.
8. Finally, before I could ask, he addressed the COPD/CHF question and his take is if the wave form is upright, there is no obstruction, so the wheezing is caused by the CHF, not the COPD, so you might want to withhold the neb treatment.
There is obviously much more to the class than this. As I have said before, if you ever get a chance to attend one of his courses, do it, he is great.
Afterwards I had a couple beers with some friends, and then got to bed early. I’m in a nicer hotel this year than last. This morning, though I was disappointed by the fitness center that had only four cardio machines and no weights. I rode a bike for fifteen minutes until a treadmill opened up and I could run.
I made it to the opening ceremonies on time, but it turned out they didn’t start for another half hour, so I could have eaten my Dunk'n Doughts bagel a little slower rather than scarfing it down on the way.
Paul Pepe was the opening speaker, and he spoke about the future of disaster management although much of his speech was a recap of Hurricane Katrina. The Hurricane has been the big topic at all the conferences and the bottom line is always the same – it was a mess, but we worked through it, and something like will happen again and we need to be prepared, etc. He said many people are worried about the avian flu pandemic.
Here are the three educational classes I attended today.
Primary Care -- An interesting history of attempts to expand paramedics into primary care, nearly all of which failed. I walked out convinced it was not going to happen soon. There are too many competing interests and roadblocks, not to mention lack of a financial mechanism. Probably the best chance and the biggest need would be to train us for primary care during disasters – we could tetanus shots like we did during Katrina or hydrate people in their homes.
Seizures – Couldn’t decide which class to take so I went with the best instructor and I’m glad I took the class. Page went through all the differenct types of seizures as well as showing video of them. Boy do I feel bad now, I can’t tell you how many people I have pooh-poohed their seizures, only now to discover now they may have actually had seizures.
I took about eight pages of notes. He covered partial seizures, partial complex seizures, generalized seizures, and broke them all down. I learned about myclonic seizures, more bout febrile seizures than I knew, absense seizures, atonic drop seizures and psuedo-seizures. In a few days I will transcribe my notes to share all the excellent information I received. It was very instructive and I will be much more understanding of people who have had nontraditional seizures.
Pain Management - A good class. The instructor made a big pitch for fentanyl as the perfect pain med. I think I am going to spend the year gathering information and studies on fentanyl with the goal of trying to get it in next year’s new protocols.
They are having a 25th anniversary party for JEMS at the Baltimore Aquarium tonight, but they sold out before I could get a ticket so instead I went to California Pizza Kitchen, ate one pizza, had two beers and bought another pizza, some for later and the rest for breakfast, then returned to my hotel to watch American Idol before getting to bed early.
