The old man was upstairs in the room in this farmhouse in which he was born. His granddaughter explained that he had Alzheimer’s and would not go easily. She said he had stopped eating and drinking. In the past, they had always been able to get him to eat and drink when he had been stubborn, but not this time. She feared he was dehydrated.
We found him sitting on the bed in the sparsely furnished room. I could hear the winter wind rattle the window sill. I told him we had come to take him to the hospital to see the doctor, but he looked away. I sat beside him on the bed while he looked about the room and talked in a language all his own. “It’s okay,” I said. “We’re just going to take an easy ride to the hospital. No worries, just an easy ride.”
He finally stood and nodded toward the door. “Thank you,” I said. He gestured for me, and my partner and his granddaughter to move toward the door. He followed behind us. We left the room, one at a time. I was the last to go. He was right behind me. As soon as I was through the door, he closed it behind me. I quickly shoved my foot to block the door from closing, but his granddaughter said, “There’s no lock on it. Just wait, and you’ll be able to go back in.”
He stood behind the door holding it. After a few minutes when I tried the door again, it was open, and he was back to sitting on the bed, looking down at his old shoes, thinking about I know not what.
More cajoling and persuading to no end. We ended the standoff by bringing up the stair chair and lifting him from the bed onto it. He gave minimal resistance. We strapped him in and carried him down the creaky wooden steps, and then out of this house where he had lived for eight-five years.
The wind blew across the snow covered farmland. We had his head covered with a towel and blankets wrapped around him. We lifted him up into the back of the ambulance. One of my partners is a woman amazingly enough in her eighties herself, who now sits in the back of the ambulance on our calls, never venturing into the scene, but she is there to great the patients when we lift them in, and she knows many of them, and comforts them while I treat them. She addressed this man by name, but he didn’t recognize her. He said some words to the back door that we could not understand.
“He was a school teacher,” she said aloud. “He always wanted to go to Tahiti. He always talked about it. My husband told him to pack his suitcase and leave the day he retired.”
“Look at you now,” she said. “You never did get to Tahiti, did you?”
**
Today (a week later)we read his obituary in the paper. He died in a local nursing home.
Monday, December 29, 2008
Monday, December 22, 2008
New 12-Lead Blog and EMS Crime Novels
Check out this new blog about 12-Lead ECG's. Very informative. Tom B who runs it has posted some thoughtful comments here, including ones that helped me understand MIs and bundle branches.
EMS 12-Lead
***
Katherine Howell, the Australian paramedic turned thriller writer, recently had her books reviewed on EMSResponder.com
She also recently won the award for best crime novel by an Australian woman.
Her books aren't yet available in the US, but can be purchased from Amazon Canada.
Or, if you want a free copy:
Be one of the first 25 people to email Katherine a photo of you and your colleagues in front of your ambulance, fire truck, police car, whatever you have, outside your station, and she'll post it on her web site here and send you a copy of Frantic as a thank you. AND THEN if you post a review of the book on Amazon or wherever and send her the link, she'll send you a copy of The Darkest Hour.
Here's her email:
katherine@katherinehowell.com
Katherine Howell Web site
Here are my old reviews of her two novels.
The Darkest Hour
Frantic
EMS 12-Lead
***
Katherine Howell, the Australian paramedic turned thriller writer, recently had her books reviewed on EMSResponder.com
She also recently won the award for best crime novel by an Australian woman.
Her books aren't yet available in the US, but can be purchased from Amazon Canada.
Or, if you want a free copy:
Be one of the first 25 people to email Katherine a photo of you and your colleagues in front of your ambulance, fire truck, police car, whatever you have, outside your station, and she'll post it on her web site here and send you a copy of Frantic as a thank you. AND THEN if you post a review of the book on Amazon or wherever and send her the link, she'll send you a copy of The Darkest Hour.
Here's her email:
katherine@katherinehowell.com
Katherine Howell Web site
Here are my old reviews of her two novels.
The Darkest Hour
Frantic
Monday, December 15, 2008
"Funky Troubling Looking" -- Right Bundle Branch Block and MI
As I mentioned in a recent post, we have a process for instituting a STEMI alert to, in consultation with an ED doctor, activate the cath lab prehospitally based on clinical assessment and a 12-Lead ECG. The coordinator at the hospital that I transport most of my patients to told me so far EMS is batting 1000 when it comes to accurately calling STEMIs, but he did add the reason for that is EMS has been very conservative in calling for the cath lab. In other words, only the obvious STEMIs are getting called in. I can understand that as I am guilty of it myself. If I have an no-brainer, I don't hesitate to call in, but I don't want to call in a false alarm. The coordinator said he would like to see people being more aggressive, calling in to consult with the MD even in marginal cases. If the MD isn't convinced, he can always delay calling until arrival at the hospital. The coordinator did say when EMS activated the cath lab, it is cutting door to balloon time in half.
I had this call the other day:
Chest pain at a local factory that employs a lot of temporary help, and where we are often called for get-out-of-workitsis. We find a muscular 40-year-old male with some serious Biggie Smalls gold bling around his neck. He is lying on the ground rolling around holding his chest. We wheel the stretcher over to him, and I, unimpressed, say, "Get on the stretcher," which he does, although he continues to grimace quite excessively. There is a bit of coworker crowd there, so I say to my partner, let's just get him out into the ambulance. I prefer working people in the ambulance. There is privacy. I have everything I need there, and if anything turns bad, we are already on our way to the hospital. Also, actors tend to cease their dramatics once they are in the ambulance, out of sight of their audience.
In the ambulance, I have him take off his shirt, which reveals a thick scar across his abdomen. He tells me got stabbed many years ago. His only current history is HTN, although he admits to a family cardiac history. He is quite muscular but denies any recent muscle strain. He was opening boxes at work when the pain started, but noting so strenuous to cause a muscle tear. The pain is substernal, squeezing and not affected by movement. While I take his vitals, which are quite good, my partner puts him on the monitor. The initial three lead looks a little funky. And then he comes the full 12-lead:
Okay so he has a right bundle branch block. I have to admit I have rarely seen a right bundle branch in a 45-year-old, and there is what I would call an atypical pattern in V2 and V3. It looks like an ST elevation coming off the bundle. Odd. I know a Left bundle branch block can obscure an MI, but I am not so sure about a right bundle. Still, it is enough for me to take a little more seriously than if he was in a perfect sinus.
I give him 02 by cannula, pop in a line, give the ASA and nitros (one every 5 minutes) which provide no relief. When I patch to the hospital -- I do not call a STEMI alert, but I say something along the lines of "the patient has a right bundle branch block, but it is sort of funky troubling looking. No idea what his norm is."
I do a bunch of serial ECGs and they are all the same. I should take some relief in that, but the last one I do, has something else troubling. The computer has decided to call the strip an "ACUTE MI SUSPECTED" even though it looks exactly like the other 12-leads.
At the hospital, I tell the nurse I am troubled and we both approach a doctor and show him the strip. I preface, by saying I know it is a right bundle, but it doesn't look like a normal one. He is not certain what to make of it, so he walks over to the patient and starts questioning him, and agrees he needs the full cardiac workup. They draw labs, and hook him up to some heparin and nitro.
***
A week later I get the followup. About an hour after I left the ED, after consulting with cardiology, they take him up to the cath lab, where it is discovered he has a 90% lesion in the left anterior descending artery. For some reason they can't cath him properly, so he ends up getting cardiac bypass.
Interesting call.
Here's a final closer look at V1-V3
***
Some tidbits I learned about RBBB.
It is in fact very rare in men under 50 ( less than .7 percent of the population.)
RBBB
Gennerally speaking an RBBB does not obscure a STEMI like a LBBB can.
RBBB
***
In researching other systems STEMI alerts, I discovered in Massachusetts there are some hospitals that have a dual STEMI alert. The medic can call in and say "I have a definite STEMI" or they can say "I have a possible STEMI." The definite STEMI gets the cath lab alert, the possible STEMI just gives the cath lab a heads up.
If I had such a choice I would have called in a possible STEMI on this one.
I also have to give props to the LP12. After apparently waffling on making a call, it finally came down on the side of the STEMI.
I know there is some talk of having basics in our states get 12-lead monitors that they will not be able to interpret, but if the patient is having clinical signs of an MI and their strip reads Acute MI Suspected, they may be able at some point to activate the cath lab if no paramedic is available on the call.
I had this call the other day:
Chest pain at a local factory that employs a lot of temporary help, and where we are often called for get-out-of-workitsis. We find a muscular 40-year-old male with some serious Biggie Smalls gold bling around his neck. He is lying on the ground rolling around holding his chest. We wheel the stretcher over to him, and I, unimpressed, say, "Get on the stretcher," which he does, although he continues to grimace quite excessively. There is a bit of coworker crowd there, so I say to my partner, let's just get him out into the ambulance. I prefer working people in the ambulance. There is privacy. I have everything I need there, and if anything turns bad, we are already on our way to the hospital. Also, actors tend to cease their dramatics once they are in the ambulance, out of sight of their audience.
In the ambulance, I have him take off his shirt, which reveals a thick scar across his abdomen. He tells me got stabbed many years ago. His only current history is HTN, although he admits to a family cardiac history. He is quite muscular but denies any recent muscle strain. He was opening boxes at work when the pain started, but noting so strenuous to cause a muscle tear. The pain is substernal, squeezing and not affected by movement. While I take his vitals, which are quite good, my partner puts him on the monitor. The initial three lead looks a little funky. And then he comes the full 12-lead:
Okay so he has a right bundle branch block. I have to admit I have rarely seen a right bundle branch in a 45-year-old, and there is what I would call an atypical pattern in V2 and V3. It looks like an ST elevation coming off the bundle. Odd. I know a Left bundle branch block can obscure an MI, but I am not so sure about a right bundle. Still, it is enough for me to take a little more seriously than if he was in a perfect sinus.
I give him 02 by cannula, pop in a line, give the ASA and nitros (one every 5 minutes) which provide no relief. When I patch to the hospital -- I do not call a STEMI alert, but I say something along the lines of "the patient has a right bundle branch block, but it is sort of funky troubling looking. No idea what his norm is."
I do a bunch of serial ECGs and they are all the same. I should take some relief in that, but the last one I do, has something else troubling. The computer has decided to call the strip an "ACUTE MI SUSPECTED" even though it looks exactly like the other 12-leads.
At the hospital, I tell the nurse I am troubled and we both approach a doctor and show him the strip. I preface, by saying I know it is a right bundle, but it doesn't look like a normal one. He is not certain what to make of it, so he walks over to the patient and starts questioning him, and agrees he needs the full cardiac workup. They draw labs, and hook him up to some heparin and nitro.
***
A week later I get the followup. About an hour after I left the ED, after consulting with cardiology, they take him up to the cath lab, where it is discovered he has a 90% lesion in the left anterior descending artery. For some reason they can't cath him properly, so he ends up getting cardiac bypass.
Interesting call.
Here's a final closer look at V1-V3
***
Some tidbits I learned about RBBB.
It is in fact very rare in men under 50 ( less than .7 percent of the population.)
RBBB
Gennerally speaking an RBBB does not obscure a STEMI like a LBBB can.
RBBB
***
In researching other systems STEMI alerts, I discovered in Massachusetts there are some hospitals that have a dual STEMI alert. The medic can call in and say "I have a definite STEMI" or they can say "I have a possible STEMI." The definite STEMI gets the cath lab alert, the possible STEMI just gives the cath lab a heads up.
If I had such a choice I would have called in a possible STEMI on this one.
I also have to give props to the LP12. After apparently waffling on making a call, it finally came down on the side of the STEMI.
I know there is some talk of having basics in our states get 12-lead monitors that they will not be able to interpret, but if the patient is having clinical signs of an MI and their strip reads Acute MI Suspected, they may be able at some point to activate the cath lab if no paramedic is available on the call.
Tuesday, December 09, 2008
Nursing Home Codes
I did another nursing home code this weekend. We have five nursing homes in our town. Two are very nice and are the final stop in larger retirement communities where residents start off in the own cottages or apartments, move to their own rooms and then go to skilled care before they pass on. The only codes I have ever done at these places are patients who drop in their apartments or on the grounds. I can't remember doing a single one in the skilled nursing section. I think the patients must all be DNRs. Both of these facilities have very affluent clientele. Most of the calls they generate are falls with hip fractures or head lacs and on the medical side lots of pneumonia and COPD exacerbations.
The other three nursing homes are the more generic types. I do lots of diabetics, sepsis, respiratory failure, aspiration pneumonia, and of course, lots of codes. Most of the codes are poorer patients with train wreck medical histories. The one this weekend was typical. Obsese, IDDM, dementia, HTN, COPD, CHF, CAD, depression, hypo this and hyperthat.
We used to transport all these patients in arrest, but then when we got permission to cease asystole rescusitations after twenty minutes of ACLS, including intubation, IV and three rounds of cardiac drugs), we stopped transporting most, but now with the new CPR, we are back transporting because they keep coming back from the dead, or at least their hearts do. Get some rounds of epi in them and circulate them with some solid hard fast deep CPR and that flat line starts getting some blips and bleeps. I walk in, take a glance at the person whose chests the nursing aides are pounding on, hear a snippet of their medical history and think no way are we going to end up transporting. But then sure enough. Way.
You stare at the monitor. I don't believe that I am seeing that. Maybe someone is shaking the wire. You would think that getting a rhythm back would make you excited, and it does only to a point. Then you remember your patient's eyes are fixed and dilated. And their bodies are wracked by disease and years of living, followed by more disease and years of laying in their nursing home beds. And all the rhythm is is the drug you put in to their veins as part of your ACLS protocol. Anyone would says epi doesn't work is wrong. But of course they are just saying epi doesn't help with the outcome and I would have a harder time disputing that. Epi certainly can produce electrical activity on a monitor and sometimes even a pulse and blood pressure.
On this day it just produces PEA. We continue to work the patient, even going to the point of getting all 300 pounds of the patient on our long board and strapped down and ready to go, but then the patient goes asystole again. We make the decision to stay and fight the battle on the bed, rather than trying to do the over to the stretcher, out the room, down the hallways, and out to the ambulance, and bump all the way to the hospital routine. We'll do that if we get the rhythm and a pulse back. After a total of 40 minutes with just occasional PEAs, I call the hospital and ask for permission to stop, which is quickly granted.
One partner picks up all the wrappers and waste from the floor and put it in a big red biohazard bag, and then zips up our IV, med and intubation kits and place them in the house bag. My other partner and I unstrap the man from the long board and gently ease him back onto the mattress. We set a pillow under his head, cover him with a sheet up to his neck and then with my finger tips, close his eyes for the last time.
On the way out I glance at the roommate in the next bed. Sound asleep.
The other three nursing homes are the more generic types. I do lots of diabetics, sepsis, respiratory failure, aspiration pneumonia, and of course, lots of codes. Most of the codes are poorer patients with train wreck medical histories. The one this weekend was typical. Obsese, IDDM, dementia, HTN, COPD, CHF, CAD, depression, hypo this and hyperthat.
We used to transport all these patients in arrest, but then when we got permission to cease asystole rescusitations after twenty minutes of ACLS, including intubation, IV and three rounds of cardiac drugs), we stopped transporting most, but now with the new CPR, we are back transporting because they keep coming back from the dead, or at least their hearts do. Get some rounds of epi in them and circulate them with some solid hard fast deep CPR and that flat line starts getting some blips and bleeps. I walk in, take a glance at the person whose chests the nursing aides are pounding on, hear a snippet of their medical history and think no way are we going to end up transporting. But then sure enough. Way.
You stare at the monitor. I don't believe that I am seeing that. Maybe someone is shaking the wire. You would think that getting a rhythm back would make you excited, and it does only to a point. Then you remember your patient's eyes are fixed and dilated. And their bodies are wracked by disease and years of living, followed by more disease and years of laying in their nursing home beds. And all the rhythm is is the drug you put in to their veins as part of your ACLS protocol. Anyone would says epi doesn't work is wrong. But of course they are just saying epi doesn't help with the outcome and I would have a harder time disputing that. Epi certainly can produce electrical activity on a monitor and sometimes even a pulse and blood pressure.
On this day it just produces PEA. We continue to work the patient, even going to the point of getting all 300 pounds of the patient on our long board and strapped down and ready to go, but then the patient goes asystole again. We make the decision to stay and fight the battle on the bed, rather than trying to do the over to the stretcher, out the room, down the hallways, and out to the ambulance, and bump all the way to the hospital routine. We'll do that if we get the rhythm and a pulse back. After a total of 40 minutes with just occasional PEAs, I call the hospital and ask for permission to stop, which is quickly granted.
One partner picks up all the wrappers and waste from the floor and put it in a big red biohazard bag, and then zips up our IV, med and intubation kits and place them in the house bag. My other partner and I unstrap the man from the long board and gently ease him back onto the mattress. We set a pillow under his head, cover him with a sheet up to his neck and then with my finger tips, close his eyes for the last time.
On the way out I glance at the roommate in the next bed. Sound asleep.
Monday, December 08, 2008
"That Narcan Shit"
What follows first is fiction:
“482. Lawrence Street. 2nd Floor, unknown on a one. PD on the way. Advise when you get there.”
We were around the corner having just cleared Hartford Hospital. “Shouldn’t we wait for the cops?” I said, as Troy grabbed his house bag and monitor from the side door.
“No, it’s shift change. We’ll be out of here before they even get here. Besides it’s just going to be an OD. This place is the junkie’s version of Studio 54. They buy their heroin down the street, and then head for their club. They ought to install an emergency syringe of narcan behind glass on the wall up in the shooting gallery. Then when one of them stops breathing, his homeys can break the glass, pull out the syringe and zap them with the narcan without having to bother us.”
Narcan was to heroin what kryptonite was to Superman. It worked by reversing the effects of the opiate on the brain. Once injected in the body, it raced up to the brain, kicked down the party door, slapped the brain hard and said “Wake the fuck up! The shindig’s over!” Within moments of getting injected with narcan a previously stuporous junky was on his knees puking, his high gone, his mind a stoned out Daffy Duck “Who? What? When? Where? Why?” routine until he finally recognized a paramedic standing over him, and realized he’d gotten “that narcan shit.”
A skinny woman who looked like she hadn’t bathed for days met us out in front of the abandoned partially burned out building and led us up the staircase to the second floor, then down a hallway to a room without a door. I carried a flashlight with the plastic IV bag wrapper over the light creating a makeshift torch. We saw a man laying against a wall, a belt around his left bicep. The syringe lay on the floor just beyond his fingers. Troy leaned down and felt the man’s neck. From where I stood I could he was still breathing, but only a few times a minute.
“How well do you like this guy?” Troy asked the woman who’d led us to him.
“I like him better now he paid me the money he owe me.”
The unconscious man’s wallet protruded from his pants. A roll of bills stuck out of the woman's shirt pocket.
“Pretend he’s dead. Okay?"
“He’s dead?”
“No, no, he’s not. We’re going to save him. I just want you to pretend that he’s dead when he comes around. Can you do that?”
“I think I got you,” the woman said. “You giving him that narcan shit?”
Troy took the prefilled syringe out of his pocket.
“This going be good,” the woman said.
Troy wiped a spot on the man’s shoulder with an alcohol prep, then stuck in the syringe and pushed the drug.
“What’s his name?” Troy asked, as he discarded the syringe in the sharps container in the bag.
“Samuel.”
“Lee, grab the tarp over there.”
I could see the man was beginning to breathe better, rousing.
I handed the tarp to Troy. Troy leaned down and whispered in the man’s ear. “Next stop. Pearly Gates. Pearly Gates. Next.”
Troy spread the tarp out next to the man whose eyes were now open though he looked groggy and diaphoretic. He sat up suddenly, fighting back a retch. I thought he might throw up.
“It’s a shame we didn’t get here in time,” Troy said. “I hate to see a life end like this. You have anything you want to say about your friend?”
“That motherfucker owed me money, but I still tried to save his life.”
“You almost did, but we were late I’m afraid. Here lies...What did you say his name was again?”
“Samuel. Samuel Pugh.”
“Here lies Samuel Pugh. Ashes to ashes, dust to dust. Another one’s gone, another one’s gone...” He looked to me.
“Another one bites the dust,” I said.
“That’s what he gets for not listening to his Mama. Let’s go eat. I could go for tacos.”
“Hey,” the man on the ground said.
“You hear anything?” Troy asked.
“No,” I said. “But I don’t hear so well.”
“I don’t hear nothing,” the friend said.
“I thought I heard something.”
“Hey!” The man grabbed Troy’s leg. “I know you. You the one always giving me that narcan shit, motherfucker.”
Troy started shaking in mock fear. “Do you guys see anything?”
“No, I don’t see anything,” I said.
“Me neither.”
“Something’s touching my leg. I can’t move it.”
“Quit fucking around. Let’s get out of here.”
“I swear something’s got my leg.”
“I got your leg motherfucker. I ain’t dead.”
“Your imagination again,” I said. I lifted the tarp up, and pointed at the floor. “See. Dead is dead. Cut it with your seeing ghosts again.”
The man let go of Troy’s leg. “I ain’t dead.” He touched his chest and face. He looked alarmed. “What’s that shit?”
“Oh, dear!” Troy stared in mock horror at the apparition. “I’m not well.” He grabbed the medic bag and walked toward the stairway, shaking his head.
“He’s been seeing ghosts all weekend,” I said to the woman, as we started to walk away.
“He must work too hard.”
“Wait! I ain’t dead!” The man called after us as he tried, stumblingly, to get to his feet. “I ain’t dead!”
- excerpt from Mortal Men
***
Above is an excerpt from the EMS novel I have been reworking on for the last many years. It seems every EMS novel or movie has an obligatory wake the junkie up with narcan chapter and I, as evidenced above, am as guilty as the rest.
What follows now is true:
When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie's IV, and slamming the narcan as they'd go through the ED door so the junkie would sit up and puke all over the medic's nemesis -- the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.
I did, however, slam narcan into lots of junkies and wake them up. When I say slam, I'm not taking about pushing the narcan in like I push adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.
I'd slam it. They'd puke, curse, rip their IV out and stalk off. One guy I found in an abanoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push narcan. I'd had no idea.
Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.
Slamming a full dose of narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.
It used to be if I was called for an OD and the patient had used heroin, they got narcan even if they were breathing okay. As long as they were slightly altered, I'd hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.
"Did you do drugs?"
"No."
"Then why do you keep dropping asleep?"
"I didn't do drugs."
I'd push the narcan. They are wide awake and puking. Stupid. Them and me.
"Did you do drugs?"
"No."
"Then why are you wide awake now and puking?"
I don't give narcan now as much as I used too because I don't work in the city nearly as much, plus now, like I said, I only give narcan if I suspect an opiate overdose and the patient's respirations are extremely depressed. Sometimes I bring heroin users in to the hospital and the first thing the hospital staff does is give the patient narcan. Wake them up and make them puke. I shake my head. That's just no way to treat people. Put them in a hallway and let them sleep it off -- as long as they are breathing okay.
We also used to give narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.
Here's two cases where I gave narcan to coma of unknown origin with bad consequences.
1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did -- living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills -- opiates -- I zapped him with narcan. So now I went from a patient in a smi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I'd just zapped all the pain medicine he needed to tolerate living into the ether. My bad.
2. Called for a possible stroke, I found an 80-yea-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn't find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Odd. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.
Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of narcan.
Narcan Solves the Riddle, Part I
More Rogue Medic Narcan Posts
Ambulance Driver Article "Naloxone: The Most Abused Drug in EMS"
I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:
"Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic
Rogue Medic sites an excellent study done years ago in LA.
The empiric use of naloxone in patients with altered mental status: a reappraisal.
The study asked the following questions:
# 1 - Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?
# 2 - Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?
-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52
730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period
Only 25 patients (3.4%) demonstrated a complete response to narcan
32 (4.4%) manifested a partial or equivocal response.
673 (92%) had no response.
19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed
2 of 26 partial responders (8%) (with known final diagnosis)
4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.
Of the 25 complete responders to Narcan
19 had opiate overdose
6 had seizure or closed head injury.
Their conclusion was:
“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”
“In addition, response to naloxone created a substantial amount of diagnostic confusion...”
-Ann Emerg Med. 1991 Mar;20(3):246-52
That study came out when I was still as EMT.
Good lessons, as I had learned the hard way.
The bottom line:
Just because they woke up after you gave them narcan doesn't mean they woke up because you gave them narcan.
“482. Lawrence Street. 2nd Floor, unknown on a one. PD on the way. Advise when you get there.”
We were around the corner having just cleared Hartford Hospital. “Shouldn’t we wait for the cops?” I said, as Troy grabbed his house bag and monitor from the side door.
“No, it’s shift change. We’ll be out of here before they even get here. Besides it’s just going to be an OD. This place is the junkie’s version of Studio 54. They buy their heroin down the street, and then head for their club. They ought to install an emergency syringe of narcan behind glass on the wall up in the shooting gallery. Then when one of them stops breathing, his homeys can break the glass, pull out the syringe and zap them with the narcan without having to bother us.”
Narcan was to heroin what kryptonite was to Superman. It worked by reversing the effects of the opiate on the brain. Once injected in the body, it raced up to the brain, kicked down the party door, slapped the brain hard and said “Wake the fuck up! The shindig’s over!” Within moments of getting injected with narcan a previously stuporous junky was on his knees puking, his high gone, his mind a stoned out Daffy Duck “Who? What? When? Where? Why?” routine until he finally recognized a paramedic standing over him, and realized he’d gotten “that narcan shit.”
A skinny woman who looked like she hadn’t bathed for days met us out in front of the abandoned partially burned out building and led us up the staircase to the second floor, then down a hallway to a room without a door. I carried a flashlight with the plastic IV bag wrapper over the light creating a makeshift torch. We saw a man laying against a wall, a belt around his left bicep. The syringe lay on the floor just beyond his fingers. Troy leaned down and felt the man’s neck. From where I stood I could he was still breathing, but only a few times a minute.
“How well do you like this guy?” Troy asked the woman who’d led us to him.
“I like him better now he paid me the money he owe me.”
The unconscious man’s wallet protruded from his pants. A roll of bills stuck out of the woman's shirt pocket.
“Pretend he’s dead. Okay?"
“He’s dead?”
“No, no, he’s not. We’re going to save him. I just want you to pretend that he’s dead when he comes around. Can you do that?”
“I think I got you,” the woman said. “You giving him that narcan shit?”
Troy took the prefilled syringe out of his pocket.
“This going be good,” the woman said.
Troy wiped a spot on the man’s shoulder with an alcohol prep, then stuck in the syringe and pushed the drug.
“What’s his name?” Troy asked, as he discarded the syringe in the sharps container in the bag.
“Samuel.”
“Lee, grab the tarp over there.”
I could see the man was beginning to breathe better, rousing.
I handed the tarp to Troy. Troy leaned down and whispered in the man’s ear. “Next stop. Pearly Gates. Pearly Gates. Next.”
Troy spread the tarp out next to the man whose eyes were now open though he looked groggy and diaphoretic. He sat up suddenly, fighting back a retch. I thought he might throw up.
“It’s a shame we didn’t get here in time,” Troy said. “I hate to see a life end like this. You have anything you want to say about your friend?”
“That motherfucker owed me money, but I still tried to save his life.”
“You almost did, but we were late I’m afraid. Here lies...What did you say his name was again?”
“Samuel. Samuel Pugh.”
“Here lies Samuel Pugh. Ashes to ashes, dust to dust. Another one’s gone, another one’s gone...” He looked to me.
“Another one bites the dust,” I said.
“That’s what he gets for not listening to his Mama. Let’s go eat. I could go for tacos.”
“Hey,” the man on the ground said.
“You hear anything?” Troy asked.
“No,” I said. “But I don’t hear so well.”
“I don’t hear nothing,” the friend said.
“I thought I heard something.”
“Hey!” The man grabbed Troy’s leg. “I know you. You the one always giving me that narcan shit, motherfucker.”
Troy started shaking in mock fear. “Do you guys see anything?”
“No, I don’t see anything,” I said.
“Me neither.”
“Something’s touching my leg. I can’t move it.”
“Quit fucking around. Let’s get out of here.”
“I swear something’s got my leg.”
“I got your leg motherfucker. I ain’t dead.”
“Your imagination again,” I said. I lifted the tarp up, and pointed at the floor. “See. Dead is dead. Cut it with your seeing ghosts again.”
The man let go of Troy’s leg. “I ain’t dead.” He touched his chest and face. He looked alarmed. “What’s that shit?”
“Oh, dear!” Troy stared in mock horror at the apparition. “I’m not well.” He grabbed the medic bag and walked toward the stairway, shaking his head.
“He’s been seeing ghosts all weekend,” I said to the woman, as we started to walk away.
“He must work too hard.”
“Wait! I ain’t dead!” The man called after us as he tried, stumblingly, to get to his feet. “I ain’t dead!”
- excerpt from Mortal Men
***
Above is an excerpt from the EMS novel I have been reworking on for the last many years. It seems every EMS novel or movie has an obligatory wake the junkie up with narcan chapter and I, as evidenced above, am as guilty as the rest.
What follows now is true:
When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie's IV, and slamming the narcan as they'd go through the ED door so the junkie would sit up and puke all over the medic's nemesis -- the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.
I did, however, slam narcan into lots of junkies and wake them up. When I say slam, I'm not taking about pushing the narcan in like I push adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.
I'd slam it. They'd puke, curse, rip their IV out and stalk off. One guy I found in an abanoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push narcan. I'd had no idea.
Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.
Slamming a full dose of narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.
It used to be if I was called for an OD and the patient had used heroin, they got narcan even if they were breathing okay. As long as they were slightly altered, I'd hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.
"Did you do drugs?"
"No."
"Then why do you keep dropping asleep?"
"I didn't do drugs."
I'd push the narcan. They are wide awake and puking. Stupid. Them and me.
"Did you do drugs?"
"No."
"Then why are you wide awake now and puking?"
I don't give narcan now as much as I used too because I don't work in the city nearly as much, plus now, like I said, I only give narcan if I suspect an opiate overdose and the patient's respirations are extremely depressed. Sometimes I bring heroin users in to the hospital and the first thing the hospital staff does is give the patient narcan. Wake them up and make them puke. I shake my head. That's just no way to treat people. Put them in a hallway and let them sleep it off -- as long as they are breathing okay.
We also used to give narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.
Here's two cases where I gave narcan to coma of unknown origin with bad consequences.
1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did -- living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills -- opiates -- I zapped him with narcan. So now I went from a patient in a smi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I'd just zapped all the pain medicine he needed to tolerate living into the ether. My bad.
2. Called for a possible stroke, I found an 80-yea-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn't find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Odd. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.
Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of narcan.
Narcan Solves the Riddle, Part I
More Rogue Medic Narcan Posts
Ambulance Driver Article "Naloxone: The Most Abused Drug in EMS"
I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:
"Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic
Rogue Medic sites an excellent study done years ago in LA.
The empiric use of naloxone in patients with altered mental status: a reappraisal.
The study asked the following questions:
# 1 - Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?
# 2 - Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?
-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52
730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period
Only 25 patients (3.4%) demonstrated a complete response to narcan
32 (4.4%) manifested a partial or equivocal response.
673 (92%) had no response.
19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed
2 of 26 partial responders (8%) (with known final diagnosis)
4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.
Of the 25 complete responders to Narcan
19 had opiate overdose
6 had seizure or closed head injury.
Their conclusion was:
“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”
“In addition, response to naloxone created a substantial amount of diagnostic confusion...”
-Ann Emerg Med. 1991 Mar;20(3):246-52
That study came out when I was still as EMT.
Good lessons, as I had learned the hard way.
The bottom line:
Just because they woke up after you gave them narcan doesn't mean they woke up because you gave them narcan.
Saturday, December 06, 2008
Two Jobs: Good and Bad
I’m back at work today on the ambulance after four days working the desk job, reading run forms, working on education presentations, and entering trauma data. There are good and bad things about each job. Here’s a brief run down.
Desk job:
The Good – I can sleep until 7 in the morning. I don’t have to worry about getting shit on my boots, vomit and blood on my pants or MRSA filled phlegm on my gloved hands. I get paid to read research studies. The biggest thing I have to lift is my laptop or a package of copy paper. I have met many intelligent, interesting people. They have an awesome lunchtime cafeteria where I work. I get to see a more global picture of EMS and my mind fills constantly with new insights and ways to make things better. If I work twenty years, I will get a nice pension. (19 years and six months to go).
The Bad – I have to critique other paramedics based on calls I have not been on. While I understand this is a necessary part of my job, I am still uncomfortable with it. As in any desk job/office environment I have to be mindful of proper etiquette and chains of authority. Not that I violate these, just that it takes much effort to remind myself of them and keep my actions guided by them. I cannot always belch when I wish to belch. Some projects seem to take forever and are dependent on other people. The data entry can be tedious. I have no patient contact.
Street medic Job:
The Bad:
I have to get up at 5 in the morning. I have to scrub my hands all day long. After some calls I still smell the patient. I hate the sound of lights and sirens and I hate putting my life in the hands of another driver. I have to wait in the triage line. My 401K retirement plan is in the toilet. Carrydowns.
The Good:
Every call is a new experience. Every day a new day. I am in charge of the scene. I still love the adrenaline rush of a challenging call. Each call is a complete episode. I have a choice of any restaurant or market in town to eat at. I meet lots of interesting people and have great stories to tell. It’s the best job I’ve ever had. I feel like a good guy. I get to take care of people.
Desk job:
The Good – I can sleep until 7 in the morning. I don’t have to worry about getting shit on my boots, vomit and blood on my pants or MRSA filled phlegm on my gloved hands. I get paid to read research studies. The biggest thing I have to lift is my laptop or a package of copy paper. I have met many intelligent, interesting people. They have an awesome lunchtime cafeteria where I work. I get to see a more global picture of EMS and my mind fills constantly with new insights and ways to make things better. If I work twenty years, I will get a nice pension. (19 years and six months to go).
The Bad – I have to critique other paramedics based on calls I have not been on. While I understand this is a necessary part of my job, I am still uncomfortable with it. As in any desk job/office environment I have to be mindful of proper etiquette and chains of authority. Not that I violate these, just that it takes much effort to remind myself of them and keep my actions guided by them. I cannot always belch when I wish to belch. Some projects seem to take forever and are dependent on other people. The data entry can be tedious. I have no patient contact.
Street medic Job:
The Bad:
I have to get up at 5 in the morning. I have to scrub my hands all day long. After some calls I still smell the patient. I hate the sound of lights and sirens and I hate putting my life in the hands of another driver. I have to wait in the triage line. My 401K retirement plan is in the toilet. Carrydowns.
The Good:
Every call is a new experience. Every day a new day. I am in charge of the scene. I still love the adrenaline rush of a challenging call. Each call is a complete episode. I have a choice of any restaurant or market in town to eat at. I meet lots of interesting people and have great stories to tell. It’s the best job I’ve ever had. I feel like a good guy. I get to take care of people.
Tuesday, November 25, 2008
My Hall of Fame
Every now and then I marvel at how far EMS has come, I did three calls on Sunday that had they happened fifteen years ago would have gone quite differently.
The first was a CHFer. Obese woman, filled up with rales, felt like she was suffocating with the nonrebreather on her. I strapped on the CPAP and in no time, she had pinked up and was breathing easier. No need for intubation, no struggle hoping the nitro and lasix would work before she crashed, just sit back and enjoy a nice ride into the hospital with a now stable patient.
The second was a cardiac arrest in a nursing home, Man found in a chair not breathing. I arrived to find CPR in progress and a mouth full of fluid. It was like staring into a submerged cave with just a tiny air pocket at the top. I was able to lift up enough to see the chords. I slid the tube in and the capnography confirmed a good intubation. The high initial reading - 95 - suggested a respiratory cause of the arrest. After ventilating off the excess C02, she went down to the 20's with CPR, but then after some epi and some of the new CPR, she jumped again to the 60's -- a sign of ROSC. When the epi wore off, the ETC02 went back to the 20's and we started CPR again. We got her back a couple times, but would lose her as the epi wore off. We ended up transporting and they worked her briefly at the hospital before calling her. Had I used the EZ-IO which I have used on my last three codes, I could boast of that change, but she had too big of an AC for me to ignore the standard peripheral IV. To date I have used the EZ-IO on eight codes, including on three one legged diabetic dialysis patients with no visible IV access.
Had this call occurred 15 years ago, I would have sweated the tube with all the rough jostling (I did have to pull it back one time when a nurse's aide was a little rough with the bagging. At the time there was only me, my partner and two nurse's aides, who for the most part, once coached, did quite well). I think also had this call happened 15 years ago, we would have never gotten ROSC even briefly because the old CPR wasn't quite up to snuff.
One bad thing about the last fifteen years is the prevalence of MRSA. This man had it in his sputum and since there was so much secretions from this call, we(my partner doing the bulk of it) had to spend quite a bit of time cleaning up everything (while I spent the bulk of my time typing in the electronic run form, which while I am getting better at still takes a fairly long time, particularly entering all the cardiac drugs in the their proper times. I mentioned there was only my partner and I. Normally we have at least a police officer to back us up, but when one hadn't arrived, we called dispatch, only to be told he was on scene. It turns out because the room -- a rare single (used probably due to the respiratory MRSA) was very tight -- she chose to wait in the hall. Or maybe it was because despite the mask, gloves and yellow gown she had donned, she didn't want any part of the patient requiring "universal precautions."
The last call was a woman with degenerative arthritis and severe back problems who was in ten of ten pain had been throwing up her dilaudid. We were able to medicate her and give her a peaceful pain-free ride into the hospital for which we got warm thanks and appreciations from the patient and family.
I have tried to rank the new innovations, but I can't. They are like my children -- I love them all the same. So instead of ranking, I give you my Hall of Fame (in alphabetical order).
CPAP
Electronic Run Forms (a pain to do, but my run forms are now legible and the combined collected data will no doubt be fascinating and add to research gains)
EZ-IO
Liberalized Pain Management Guidelines
New CRP
Wave Form Capnography
Hall of Shame
MRSA
The first was a CHFer. Obese woman, filled up with rales, felt like she was suffocating with the nonrebreather on her. I strapped on the CPAP and in no time, she had pinked up and was breathing easier. No need for intubation, no struggle hoping the nitro and lasix would work before she crashed, just sit back and enjoy a nice ride into the hospital with a now stable patient.
The second was a cardiac arrest in a nursing home, Man found in a chair not breathing. I arrived to find CPR in progress and a mouth full of fluid. It was like staring into a submerged cave with just a tiny air pocket at the top. I was able to lift up enough to see the chords. I slid the tube in and the capnography confirmed a good intubation. The high initial reading - 95 - suggested a respiratory cause of the arrest. After ventilating off the excess C02, she went down to the 20's with CPR, but then after some epi and some of the new CPR, she jumped again to the 60's -- a sign of ROSC. When the epi wore off, the ETC02 went back to the 20's and we started CPR again. We got her back a couple times, but would lose her as the epi wore off. We ended up transporting and they worked her briefly at the hospital before calling her. Had I used the EZ-IO which I have used on my last three codes, I could boast of that change, but she had too big of an AC for me to ignore the standard peripheral IV. To date I have used the EZ-IO on eight codes, including on three one legged diabetic dialysis patients with no visible IV access.
Had this call occurred 15 years ago, I would have sweated the tube with all the rough jostling (I did have to pull it back one time when a nurse's aide was a little rough with the bagging. At the time there was only me, my partner and two nurse's aides, who for the most part, once coached, did quite well). I think also had this call happened 15 years ago, we would have never gotten ROSC even briefly because the old CPR wasn't quite up to snuff.
One bad thing about the last fifteen years is the prevalence of MRSA. This man had it in his sputum and since there was so much secretions from this call, we(my partner doing the bulk of it) had to spend quite a bit of time cleaning up everything (while I spent the bulk of my time typing in the electronic run form, which while I am getting better at still takes a fairly long time, particularly entering all the cardiac drugs in the their proper times. I mentioned there was only my partner and I. Normally we have at least a police officer to back us up, but when one hadn't arrived, we called dispatch, only to be told he was on scene. It turns out because the room -- a rare single (used probably due to the respiratory MRSA) was very tight -- she chose to wait in the hall. Or maybe it was because despite the mask, gloves and yellow gown she had donned, she didn't want any part of the patient requiring "universal precautions."
The last call was a woman with degenerative arthritis and severe back problems who was in ten of ten pain had been throwing up her dilaudid. We were able to medicate her and give her a peaceful pain-free ride into the hospital for which we got warm thanks and appreciations from the patient and family.
I have tried to rank the new innovations, but I can't. They are like my children -- I love them all the same. So instead of ranking, I give you my Hall of Fame (in alphabetical order).
CPAP
Electronic Run Forms (a pain to do, but my run forms are now legible and the combined collected data will no doubt be fascinating and add to research gains)
EZ-IO
Liberalized Pain Management Guidelines
New CRP
Wave Form Capnography
Hall of Shame
MRSA
Monday, November 24, 2008
Hip Fractures (2) and Dr. Welby
So I have been talking to many people about this hip fracture issue and it is quite a dilemma.
I want to change the dispatch protocols to send ALS to fall with hip pain. They don't have to go lights and sirens. They can go "cold," but they should at least be on the way.
But here are the problems:
In one of the areas, we are short medics so medics aren't wild about going to a hip fracture when the chest pain comes in. Basics are reluctant to call for medics for pain control because they don't want to tie up medics and probably don't want to be accused of not being able to handle a hip fracture themselves.
In my job as trauma data collector at the hospital, I review the prehospital, ED and in hospital care for all admitted trauma patients. I have been keeping a spread sheet on the hip fracture calls and it is quite revealing. Without giving away the numbers (which I will need permission to do) the general truths are as follows:
1. Prehospital personnel are not using pain scales and they are not medicating the patients, even when the ambulance is a paramedic ambulance.
2. Hospitals are almost universally medicating these patients, but the time between triage and med administration is quite lengthy as has been borne out in many studies.
3. When patients are medicated prehopsitally, time to administration is extremely short. Prehospital medication results in what I am recording as negative time meaning time before hospital triage. In one case the patient is medicated 52 minutes before hospital triage login. A medic's choice to medicate a patient in pain can easily mean two hours of pain relief before they would otherwise receive medicine. So for any medic who thinks, I'll hold off on giving morphine because I'm close to the hospital and the hospital will medicate the patient, I say, go ahead and do it yourself. Your patient will appreciate it.
My hope is that when my little study is done, I can use it as a preeducation program benchmark to compare progress against. I know there is growing movement pushing EDs to emphasise early pain management administration.
In the meantime at one of our regional meetings I hope to raise the issue about how the regional doctors think about the question of using paramedics to manage prehospital pain versus keeping medics available for the next big call.
***
Now for a story. I was corresponding about this issue via email with a doctor when we were toned out -- dispatched appropriately to an elderly fall with "excruciating hip pain." I ended the email saying I was off on a hip call and would report back.
I was expecting us to be sent cold. In this town, as the only ambulance, we are sent to all calls (obviously). We were instead dispatched "hot" but that was clarified because the EMD dispatcher informed us the patient had a head lac (injury to a dangerous area).
On arrival at the retirement community, I put my narcs in my pocket and entered the facility with a backboard, straps and extra blankets for padding. I found the woman in the kitchen area, laying on her back. The head lac was too minor to apply a band aid, but she did appear to have considerable hip pain. "On a scale of zero to ten with ten being the worst pain you ever felt in your life and zero being no pain, how would you rate your pain?"
"I will not tell you! I am not talking to you."
"Huh?"
"Are you a doctor?"
"No, I'm a paramedic."
"I'll have you know I am a nurse and I will speak only to a doctor!"
"Look, I think you broke your hip, and since you are a nurse you no doubt know that pain is not good for you. Before I can give you any pain medicine I need you to give me your pain score."
"You will under no circumstances give me any medication until I am seen by a doctor!"
"I have standing orders from a doctor to give people pain medicine. As a nurse, how would you feel being questioned by a patient when you wanted to give them pain medicine."
"I would never give anyone medication under they were first seen by the doctor."
This went on for a little bit with me getting testier and testier until I realized that she was completely demented and what was I doing trying to argue with someone with dementia.
So I padded her as well as I could and got her on the stretcher and out to the ambulance and on over the bumpy roads all the way to the hospital with her complaining the whole way. "Slow down! Owww! Oww! Would you tell your driver to slow down! Oww! Oww!"
It was funny, but it was also sort of sad. At one point, I said, "I told you it was going to be a rough ride that's why I wanted to give you some pain medicine."
"You will under no circumstances give me pain medicine until I am seen by a doctor!"
At triage, I explained why I had not only not medicated her but failed to have a pain score. "She's a former nurse and will only talk to a doctor," I said.
The triage nurse smiled and then sauntered over to the patient. "On a scale of 1-10," she began before the patient cut her off.
"You're wasting your words. I will only speak with a doctor!"
Later my partner told me the aide who rode in the front with him said she went through this same routine every day when they tried to give her her daily meds. They resorted to using one of the silver-haired male dementia patients as a surrogate. Dr. Welby over there says its okay.
Unfortunately at the hospital, the former nurse was put in the hallway, but Dr. Welby was still back at the home.
I want to change the dispatch protocols to send ALS to fall with hip pain. They don't have to go lights and sirens. They can go "cold," but they should at least be on the way.
But here are the problems:
In one of the areas, we are short medics so medics aren't wild about going to a hip fracture when the chest pain comes in. Basics are reluctant to call for medics for pain control because they don't want to tie up medics and probably don't want to be accused of not being able to handle a hip fracture themselves.
In my job as trauma data collector at the hospital, I review the prehospital, ED and in hospital care for all admitted trauma patients. I have been keeping a spread sheet on the hip fracture calls and it is quite revealing. Without giving away the numbers (which I will need permission to do) the general truths are as follows:
1. Prehospital personnel are not using pain scales and they are not medicating the patients, even when the ambulance is a paramedic ambulance.
2. Hospitals are almost universally medicating these patients, but the time between triage and med administration is quite lengthy as has been borne out in many studies.
3. When patients are medicated prehopsitally, time to administration is extremely short. Prehospital medication results in what I am recording as negative time meaning time before hospital triage. In one case the patient is medicated 52 minutes before hospital triage login. A medic's choice to medicate a patient in pain can easily mean two hours of pain relief before they would otherwise receive medicine. So for any medic who thinks, I'll hold off on giving morphine because I'm close to the hospital and the hospital will medicate the patient, I say, go ahead and do it yourself. Your patient will appreciate it.
My hope is that when my little study is done, I can use it as a preeducation program benchmark to compare progress against. I know there is growing movement pushing EDs to emphasise early pain management administration.
In the meantime at one of our regional meetings I hope to raise the issue about how the regional doctors think about the question of using paramedics to manage prehospital pain versus keeping medics available for the next big call.
***
Now for a story. I was corresponding about this issue via email with a doctor when we were toned out -- dispatched appropriately to an elderly fall with "excruciating hip pain." I ended the email saying I was off on a hip call and would report back.
I was expecting us to be sent cold. In this town, as the only ambulance, we are sent to all calls (obviously). We were instead dispatched "hot" but that was clarified because the EMD dispatcher informed us the patient had a head lac (injury to a dangerous area).
On arrival at the retirement community, I put my narcs in my pocket and entered the facility with a backboard, straps and extra blankets for padding. I found the woman in the kitchen area, laying on her back. The head lac was too minor to apply a band aid, but she did appear to have considerable hip pain. "On a scale of zero to ten with ten being the worst pain you ever felt in your life and zero being no pain, how would you rate your pain?"
"I will not tell you! I am not talking to you."
"Huh?"
"Are you a doctor?"
"No, I'm a paramedic."
"I'll have you know I am a nurse and I will speak only to a doctor!"
"Look, I think you broke your hip, and since you are a nurse you no doubt know that pain is not good for you. Before I can give you any pain medicine I need you to give me your pain score."
"You will under no circumstances give me any medication until I am seen by a doctor!"
"I have standing orders from a doctor to give people pain medicine. As a nurse, how would you feel being questioned by a patient when you wanted to give them pain medicine."
"I would never give anyone medication under they were first seen by the doctor."
This went on for a little bit with me getting testier and testier until I realized that she was completely demented and what was I doing trying to argue with someone with dementia.
So I padded her as well as I could and got her on the stretcher and out to the ambulance and on over the bumpy roads all the way to the hospital with her complaining the whole way. "Slow down! Owww! Oww! Would you tell your driver to slow down! Oww! Oww!"
It was funny, but it was also sort of sad. At one point, I said, "I told you it was going to be a rough ride that's why I wanted to give you some pain medicine."
"You will under no circumstances give me pain medicine until I am seen by a doctor!"
At triage, I explained why I had not only not medicated her but failed to have a pain score. "She's a former nurse and will only talk to a doctor," I said.
The triage nurse smiled and then sauntered over to the patient. "On a scale of 1-10," she began before the patient cut her off.
"You're wasting your words. I will only speak with a doctor!"
Later my partner told me the aide who rode in the front with him said she went through this same routine every day when they tried to give her her daily meds. They resorted to using one of the silver-haired male dementia patients as a surrogate. Dr. Welby over there says its okay.
Unfortunately at the hospital, the former nurse was put in the hallway, but Dr. Welby was still back at the home.
Saturday, November 15, 2008
Hip Fractures
A hip fracture is not a prehospital emergency.
Let me repeat that.
A hip fracture is not a prehospital emergency.
I couldn't believe it. But there is was written in bold. Not just a stray sentence by listed as "an axiom."
A hip fracture is not a prehospital emergency.
For those who know this or have had least read this claim, it may not be news, but I found it shocking. It did explain much, however.
As some of you know I recently took a second job as a prehospital coordinator at a local hospital. The job, while taking me off the streets during what would have been my overtime shift hours, has been very enlightening. I am learning some inside system management I had missed. Let me tell you how I found out about this.
Out of curiosity I began tabulating all the drugs one of our medic services has given over the last year. I learned how to do an Excel spreadsheet and it was pretty easy inputting and I was fascinated by the results. Without going into all the numbers, these were the drugs given most(in order):
ASA, NTG, breathing treatments (albuterol and combi-vents), dextrose, epinephrine, atropine, zofran... The list went on and ended in the low single digits with drugs like metoprolol and dopamine.
As a big advocate for pain management, I was surprised to find morphine much lower on the list than I would have expected. So I started to trying to figure out why it was so low.
I considered several reasons:
1. The time and hassle element of exchanging used narcotic kits
2. The old school handed down over the ages philospphy of you have to prove to me you're in pain before I will medicate you.
3. Lack of knowledge about pain's destructivness.
But before I could make too many assumptions I did realize that for all the run forms that did cross my desk, there were very few that were glaring examples of people needing but not getting pain management, which led me to suspect that either people were made out of rubber in this area or maybe the medics were simply not getting dispatched to pain management calls.
This service is an ALS intercept service only. When I looked into the issue from the dispatch angle, I found my answer. ALS is not dispatched on low falls, where most fractures occur(due more to frequency of low falls over mechanism).
This isn't to say a basic ambulance couldn't call for a medic for pain management, but in an area of scarce medic resources, they may not be prone too. Besides splinting is a basic skill.
That same day I found an old book in my desk at work, called Emergency Medical Dispatch, and was flipping through the pages and then that's where I saw it.
A hip fracture is not a prehospital emergency.
I made a copy of the page and approached several doctors with it. Can you believe this? They couldn't.
This explained why when working as a paramedic on an ambulance, I often get sent lights and sirens for a fall with a head lac (fall with injury to a dangerous area) but am never sent lights and sirens to a fall with hip pain. As the only ambulance in town we are sent to all calls(And I have no problem going non-lights and sirens -- safety first, but at least I am sent). That's why I give more morphine in two months than a medic intercept service might give in a year. I work in a town full of old people and they are always suffering low falls and nearly every low fall that comes in with hip pain turns out to be a hip fracture with a person in pain. And all those broken ankles and shoulders and arms and wrists. I give them Morphine.
Sir William Osler, the founder of modern medicine, called morphine "God's medicine."
I can see why.
For years I used to pick these people up, throw them on the stretcher and bounce them through the city to the hospital, while they cried out in pain. This was in the pre-pain management era when you had to have bones sticking through your skin to get a doctor to give you the order to give morphine. But times have changed.
All those studies came out that showed how people were being under medicated and left in pain, and how pain is itself destructive to the body, how it often leads to chronic pain. One of our hospitals started requesting a pain scale on every patient we brought through the doors. Our pain control orders became standing and then increased in the amount we could give on standing orders. Up to 15 mg for a 100 kg patient, 7.5 for a 50 kg patient.
And I have to tell you, once you start practicing pain management as a tenet of your paramedic practice, it quickly becomes one of the most rewarding aspects of the job. I medicate people with hip fractures where they have fallen. While the medicine is starting to work, I make them comfortable with pillows and blankets. If after ten minutes, they need more medicine, I give it to them. By the time I am moving them, I am their new best friend or their favorite son or grandson. And not only are they grateful, their family is grateful because their relative who was suffering before them, is now calm and pain-free and the event is less hard on all of them. What power we have as medics to make people feel better, to relieve suffering and agony. And if it means listening to a patient sing an off-key "The Farmer in the Dell" so be it.
So, it just happened, in my coordinator job, I was at a meeting to go over the lastest verion of changes in medical dispatch protocols for one of the areas that we provide medical control. As we went through the dispatch cards we came upon falls and there it was again in the dispatcher notes:
A hip fracture is not a prehospital emergency.
We were trying decide what calls you send medics to and what calls to send responders "hot" or "cold." So I spoke up on the hip fracture issue. I said you need to at least start medics to low falls with hip pain, but I was unconvincing to the others.
How do we know its a fracture? Maybe its a bruise. Besides, its just a simple fracture. They can always call for pain management. And we're short enough on medics as it is. We can't tie them up on a low fall. This is an education, not a dispatch issue.
Some days my mind is sharp and my words are clear and pristine. Other days I am in a fog. I babbled on, but wasn't clear maybe even to myself. I eventually gave up. I could see I had no allies.
Hip fractures are lengthy calls. I can be on scene a half and hour or more (where I am someone who generally likes to just pick a patient up and do everything on the way to the hospital). And the ride is always slow -- turtle speed to avoid bumps in the road, and then there is the issue at the hospital of having to exchange narcotics afterwards.
And maybe you do need to have medics available for "the big" calls.
But here's what I do know -- I give more medicine on low falls than I do on multisystem trauma. And with the big recent study showing ALS makes no difference in major trauma, I can argue, as a paramedic, I make a bigger difference on low fall calls than I do on major trauma. But I don't think the majority of people in EMS, particuarly are ready to grasp that yet because after all, its there in black and white.
A hip fracture is not a prehospital emergency.
***
Here's a good article on hip fractures:
Prehospital Hip Fracture Assessment and Treatment
Here's the link to the OPALS Trauma study that that showed that(in their study): "systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced lifesupport phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma."
The OPALS Major Trauma Study: impact of advanced
life-support on survival and morbidity
Let me repeat that.
A hip fracture is not a prehospital emergency.
I couldn't believe it. But there is was written in bold. Not just a stray sentence by listed as "an axiom."
A hip fracture is not a prehospital emergency.
For those who know this or have had least read this claim, it may not be news, but I found it shocking. It did explain much, however.
As some of you know I recently took a second job as a prehospital coordinator at a local hospital. The job, while taking me off the streets during what would have been my overtime shift hours, has been very enlightening. I am learning some inside system management I had missed. Let me tell you how I found out about this.
Out of curiosity I began tabulating all the drugs one of our medic services has given over the last year. I learned how to do an Excel spreadsheet and it was pretty easy inputting and I was fascinated by the results. Without going into all the numbers, these were the drugs given most(in order):
ASA, NTG, breathing treatments (albuterol and combi-vents), dextrose, epinephrine, atropine, zofran... The list went on and ended in the low single digits with drugs like metoprolol and dopamine.
As a big advocate for pain management, I was surprised to find morphine much lower on the list than I would have expected. So I started to trying to figure out why it was so low.
I considered several reasons:
1. The time and hassle element of exchanging used narcotic kits
2. The old school handed down over the ages philospphy of you have to prove to me you're in pain before I will medicate you.
3. Lack of knowledge about pain's destructivness.
But before I could make too many assumptions I did realize that for all the run forms that did cross my desk, there were very few that were glaring examples of people needing but not getting pain management, which led me to suspect that either people were made out of rubber in this area or maybe the medics were simply not getting dispatched to pain management calls.
This service is an ALS intercept service only. When I looked into the issue from the dispatch angle, I found my answer. ALS is not dispatched on low falls, where most fractures occur(due more to frequency of low falls over mechanism).
This isn't to say a basic ambulance couldn't call for a medic for pain management, but in an area of scarce medic resources, they may not be prone too. Besides splinting is a basic skill.
That same day I found an old book in my desk at work, called Emergency Medical Dispatch, and was flipping through the pages and then that's where I saw it.
A hip fracture is not a prehospital emergency.
I made a copy of the page and approached several doctors with it. Can you believe this? They couldn't.
This explained why when working as a paramedic on an ambulance, I often get sent lights and sirens for a fall with a head lac (fall with injury to a dangerous area) but am never sent lights and sirens to a fall with hip pain. As the only ambulance in town we are sent to all calls(And I have no problem going non-lights and sirens -- safety first, but at least I am sent). That's why I give more morphine in two months than a medic intercept service might give in a year. I work in a town full of old people and they are always suffering low falls and nearly every low fall that comes in with hip pain turns out to be a hip fracture with a person in pain. And all those broken ankles and shoulders and arms and wrists. I give them Morphine.
Sir William Osler, the founder of modern medicine, called morphine "God's medicine."
I can see why.
For years I used to pick these people up, throw them on the stretcher and bounce them through the city to the hospital, while they cried out in pain. This was in the pre-pain management era when you had to have bones sticking through your skin to get a doctor to give you the order to give morphine. But times have changed.
All those studies came out that showed how people were being under medicated and left in pain, and how pain is itself destructive to the body, how it often leads to chronic pain. One of our hospitals started requesting a pain scale on every patient we brought through the doors. Our pain control orders became standing and then increased in the amount we could give on standing orders. Up to 15 mg for a 100 kg patient, 7.5 for a 50 kg patient.
And I have to tell you, once you start practicing pain management as a tenet of your paramedic practice, it quickly becomes one of the most rewarding aspects of the job. I medicate people with hip fractures where they have fallen. While the medicine is starting to work, I make them comfortable with pillows and blankets. If after ten minutes, they need more medicine, I give it to them. By the time I am moving them, I am their new best friend or their favorite son or grandson. And not only are they grateful, their family is grateful because their relative who was suffering before them, is now calm and pain-free and the event is less hard on all of them. What power we have as medics to make people feel better, to relieve suffering and agony. And if it means listening to a patient sing an off-key "The Farmer in the Dell" so be it.
So, it just happened, in my coordinator job, I was at a meeting to go over the lastest verion of changes in medical dispatch protocols for one of the areas that we provide medical control. As we went through the dispatch cards we came upon falls and there it was again in the dispatcher notes:
A hip fracture is not a prehospital emergency.
We were trying decide what calls you send medics to and what calls to send responders "hot" or "cold." So I spoke up on the hip fracture issue. I said you need to at least start medics to low falls with hip pain, but I was unconvincing to the others.
How do we know its a fracture? Maybe its a bruise. Besides, its just a simple fracture. They can always call for pain management. And we're short enough on medics as it is. We can't tie them up on a low fall. This is an education, not a dispatch issue.
Some days my mind is sharp and my words are clear and pristine. Other days I am in a fog. I babbled on, but wasn't clear maybe even to myself. I eventually gave up. I could see I had no allies.
Hip fractures are lengthy calls. I can be on scene a half and hour or more (where I am someone who generally likes to just pick a patient up and do everything on the way to the hospital). And the ride is always slow -- turtle speed to avoid bumps in the road, and then there is the issue at the hospital of having to exchange narcotics afterwards.
And maybe you do need to have medics available for "the big" calls.
But here's what I do know -- I give more medicine on low falls than I do on multisystem trauma. And with the big recent study showing ALS makes no difference in major trauma, I can argue, as a paramedic, I make a bigger difference on low fall calls than I do on major trauma. But I don't think the majority of people in EMS, particuarly are ready to grasp that yet because after all, its there in black and white.
A hip fracture is not a prehospital emergency.
***
Here's a good article on hip fractures:
Prehospital Hip Fracture Assessment and Treatment
Here's the link to the OPALS Trauma study that that showed that(in their study): "systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced lifesupport phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma."
The OPALS Major Trauma Study: impact of advanced
life-support on survival and morbidity
Wednesday, November 12, 2008
The Company of Others
We've been here before to pick the woman up. 99 years old, lives in a second floor apartment, uses a walker to get around. Once she hits the deck, she lacks the strength to get up. Tiny little white lady with severe kifosis ( a hunched back).
The last time we were here the fire department had to climb in through the balcony as the neighbor who sometimes looks after her was at the hospital with her own husband who is dying of cancer.
Today as we stand by the locked door to the 2nd floor and are about to radio our dispatch for assistance, the woman who sometimes looks in on her, a large black woman in her early fifties, comes in the lobby carrying groceries.
She asks if we are there for her neighbour again, and we nod. She just shakes her head as she heads up the stairs, and then, after handing us her bags, gets her key out and unlocks the landing door. We all walk together down the hall to the old woman's apartment, where we find the door is surprisingly unlocked. The woman as always is on the ground in front of the TV and her big electric chair. She is not hurt and we help her up.
She is upset that she has been falling so much and says she is afraid. Her neighbour says she will check on her at nine to give her her nine o'clock pill and then come back at ten to give her her ten o'clock pill, but right now the older woman needs to sit down in front of the TV and take it easy so the other woman can go down the hall and take care of the baby as well as her husband. The baby we learn is just a year old. It is her granddaughter and she is raising her. We don't ask beyond that.
The old woman doesn't want to be left alone. I'm sacred she says. What if I fall again.
Sit in your chair, watch TV, and I'll come back at nine, the woman says.
How about I go to your house and sit with you? the old woman says. At least that way I'll have someone to talk to.
The woman with the sick husband and the baby looks at her and lets her breath out a little, but then says, "Sure, why not? I'm making soup tonight."
And so all leave the apartment, my partner and I to the right back toward the stairs and the outside and our ambulance, and the two woman, one large and tired, and one old and frail using her walker, head to the left to the one woman's apartment where it will be warm inside, and where there will be the company of others.
The last time we were here the fire department had to climb in through the balcony as the neighbor who sometimes looks after her was at the hospital with her own husband who is dying of cancer.
Today as we stand by the locked door to the 2nd floor and are about to radio our dispatch for assistance, the woman who sometimes looks in on her, a large black woman in her early fifties, comes in the lobby carrying groceries.
She asks if we are there for her neighbour again, and we nod. She just shakes her head as she heads up the stairs, and then, after handing us her bags, gets her key out and unlocks the landing door. We all walk together down the hall to the old woman's apartment, where we find the door is surprisingly unlocked. The woman as always is on the ground in front of the TV and her big electric chair. She is not hurt and we help her up.
She is upset that she has been falling so much and says she is afraid. Her neighbour says she will check on her at nine to give her her nine o'clock pill and then come back at ten to give her her ten o'clock pill, but right now the older woman needs to sit down in front of the TV and take it easy so the other woman can go down the hall and take care of the baby as well as her husband. The baby we learn is just a year old. It is her granddaughter and she is raising her. We don't ask beyond that.
The old woman doesn't want to be left alone. I'm sacred she says. What if I fall again.
Sit in your chair, watch TV, and I'll come back at nine, the woman says.
How about I go to your house and sit with you? the old woman says. At least that way I'll have someone to talk to.
The woman with the sick husband and the baby looks at her and lets her breath out a little, but then says, "Sure, why not? I'm making soup tonight."
And so all leave the apartment, my partner and I to the right back toward the stairs and the outside and our ambulance, and the two woman, one large and tired, and one old and frail using her walker, head to the left to the one woman's apartment where it will be warm inside, and where there will be the company of others.
Tuesday, November 04, 2008
STEMI (ST-Elevation Myocardial Infarction)
Dispatch: 8:07 Chest Pain
Enroute: 8:08
On Scene: 8:14
At Patient: 8:15
66-year-old female with 3 out of 10 chest pain X 2 hours. Periodic chest pain for last week. Skin warm and dry. No prior heart hx.
Initial 3-lead strip: 8:16
Vitals, 02 by cannula. 324 ASA PO. Patient shirt removed, put in hospital gown
Initial 12-Lead: 8:19 (Watch V4 in particular, as well as V1-V3 over course of ECGs)
IV # 18 in left AC. 0.4 NTG SL
Depart Scene: 8:21
Hospital called for official STEMI Notification: 8:22
2nd 12-lead ECG: 8:22 (Note LP12 spitting out 12-leads every three minutes.
8:23 2nd NTG SL. 2nd IV # 18 in right AC
(In meantime hospital alerting cath lab team)
8:25 3rd 12-Lead ECG
8:26 Cath Lab team arrives in ED
8:28: 4th 12-Lead ECG Pain now up to a 5.
Begin preparing patient for quick exit from ambulance
8:31 5th 12-Lead ECG
8:34 Out at Hospital
8:35 Transfer Care to ED Doc/medical staff/ cath lab team
8:36 Hospital ECG
Next ten minutes Patient is prepped(additional drugs, procedure discussed, consent given) and then hustled upstairs.
8:50 Patient hits cath lab table.
9:08 Balloon inflated (Hospital Door to Balloon Time - 34 minutes).
Patient has 100% occlusion of Left Anterior Descending artery (The Widowmaker). Suffers arrhythmia. V-Tac. cardio-verted X 1. Then full reperfusion.
Normalized ECG.
***
First there were hospitals, then ambulances, then emergency departments, then EMTs, then paramedics, then prehospital ECGs, and then STEMI alerts with cath lab notifications.
Progress
***
Paramedics Activate Cath Lab for STEMI Patients in Some Areas
Enroute: 8:08
On Scene: 8:14
At Patient: 8:15
66-year-old female with 3 out of 10 chest pain X 2 hours. Periodic chest pain for last week. Skin warm and dry. No prior heart hx.
Initial 3-lead strip: 8:16
Vitals, 02 by cannula. 324 ASA PO. Patient shirt removed, put in hospital gown
Initial 12-Lead: 8:19 (Watch V4 in particular, as well as V1-V3 over course of ECGs)
IV # 18 in left AC. 0.4 NTG SL
Depart Scene: 8:21
Hospital called for official STEMI Notification: 8:22
2nd 12-lead ECG: 8:22 (Note LP12 spitting out 12-leads every three minutes.
8:23 2nd NTG SL. 2nd IV # 18 in right AC
(In meantime hospital alerting cath lab team)
8:25 3rd 12-Lead ECG
8:26 Cath Lab team arrives in ED
8:28: 4th 12-Lead ECG Pain now up to a 5.
Begin preparing patient for quick exit from ambulance
8:31 5th 12-Lead ECG
8:34 Out at Hospital
8:35 Transfer Care to ED Doc/medical staff/ cath lab team
8:36 Hospital ECG
Next ten minutes Patient is prepped(additional drugs, procedure discussed, consent given) and then hustled upstairs.
8:50 Patient hits cath lab table.
9:08 Balloon inflated (Hospital Door to Balloon Time - 34 minutes).
Patient has 100% occlusion of Left Anterior Descending artery (The Widowmaker). Suffers arrhythmia. V-Tac. cardio-verted X 1. Then full reperfusion.
Normalized ECG.
***
First there were hospitals, then ambulances, then emergency departments, then EMTs, then paramedics, then prehospital ECGs, and then STEMI alerts with cath lab notifications.
Progress
***
Paramedics Activate Cath Lab for STEMI Patients in Some Areas
Saturday, November 01, 2008
Cardiac Arrest Thoughts
I've been doing this a long time -- 15 years as a medic -- and it amazes me how often I find new ways to do things or think about things.
I did another cardiac arrest yesterday. Fairly routine. Yet another nursing home hospital bed one legged diabetic dialysis patient pulseless, apneic, CPR in progress, first responders defib - No shock advised. Patient a full code. Done it many times before, so what was different?
1. My eyesight is getting worse. I've remarked on it before how I have to squint sometimes when I am trying to thread a 24 gauge catheter into a tiny vein. Yesterday I had trouble reading the lip line markers on the ET tube. The lighting wasn't great and there was some thick mucus on the tube, but I couldn't tell if the number at lip line was 21 or 23? I couldn't make it out. I squinted harder, but still couldn't see it clearly.
Also when the nurse handed me the W10, I was trying to read the medical history and again, I couldn't read it. It is one thing to sit on an ambulance bench seat on a nice easy ride to the hospital and read a W10, but in the middle of a code when you are the only ALS provider, it is quite another. I have decided in the future what I will do is have the nurse stand by me while I am doing my code things and read the W10 aloud. Start with medical history and proceed through the medications. I have of necessity over the years learned to make use of nursing home staff on codes -- yesterday they did a fine job with CPR and handing me what I asked for from my gear, that this is just a logical extension.
2. ETCO2 and cardiac arrest. I have also written about this extensively (See Post), but I continue to gain new insights. The clear utility of continuous capnography is a quick verification that your tube is good (you still have to listen to lung sounds because ETCO2 won't detect a right mainstem). The other benefit is it can provide a glimpse into your patient's survivability chances as well as measure how well CPR is being done. This woman had an ETC02 of 35 on intubation (with CPR), which suggested she was not as dead as she looked. She was initially in a PEA but after some epi went into v-fib. I shocked her a total of three times, then she went back to a PEA, which dwindled to asystole and then back and forth between PEA and asystole for the duration of the call. I don't like to transport dead people, so I usually follow the 20 minute and out rule for patients in asystole, and under our new guidelines I can call medical control to cease resuscitation even on patients who have been in v-fib or PEA for a period of time if after 20 minutes, they remain pulseless. The problem here was we were getting such good ETCO2 readings. The patient stayed in the 20-30 range. What was most interesting was every time I gave her epi, the ETCO2 rose up to the 30's. We never did get pulses back. My guess was a dopler would have showed a BP in the 50's or 60's during the epi effect. Anyway, I felt we had to bring her in.
Now in the past without ETCO2 to monitor the effectiveness of CPR many of us became rather casual in our efforts. The patient was dead and wasn't coming back but was still alive enough that we had to work them. Now with ETCO2 measuring the effectiveness -- basically, the better your CPR, the better the cardiac output, the higher the ETCO2 number -- you are obligated to maintain maximum CPR efforts. As soon as you start to get lax, the monitor is going to tell you. 28, 27, 26, 25, better start pumping harder. 26, 27, 28. You stop CPR briefly to switch positions or administer a drug and your ETC02 is down to 18, 17, 16, 14. And it takes some pumping to get it back up into the mid 20's.
I had just one partner yesterday so he drove, while a cop rode in the back with me, which leads to another thing I learned.
3. IOs -- I love the EZ-IO. One legged diabetic, dialysis patient with me the only ALS responder, it's a no brainer -- I don't even look for a peripheral vein, I just get out the drill. Brrrrrr. I have access in the tibia. But here's the problem. In the past, I would have put in a line in the AC or an EJ, which would enable me to sit at the head and bag the patient while also administering drugs. I could do a code with just two people in the back. But now with the line just below the knee, no way. So, I'm trying to administer drugs and do CPR at the same time. That's challenging. You stop CPR for a moment and the ETCO2 plummets because your circulation/pressure has just dropped to Zero. Epi and atropine push pretty easy and quick, but due to the patient's history and down time, I decided to try some bicarb. Let me tell you bicarb is a bear to push through an IO. Its like pushing D50 through a 24. It is slow, so I'm doing one-handed CPR, and one handed bicarb pushing against the bristojet, all trying to maintain my balance as we go over the bumps in the road. Bottom line, I really need to get a third person in the back.
4. The patient's husband was in the nursing home lobby. When I saw him, I do as I often have done in the past -- have him come over and say something brief to his spouse. I do this to give them a chance to say goodbye. I tell them we are breathing for their spouse, but they may still be able to hear. And then the one says to the other, I love you, etc. I want them to have that moment, and it usually works out well. Yesterday, I did it, and the man told her heartfully he loved her and then we pushed on through the door and then behind us came an awful howling. A howling that did not abate. I could only picture the man on his knees crying out to the heavens.
It is hard to know what is right sometimes. Did I give him a chance to say goodbye? For him to know that his loved wife heard his words? Or did I give him an awful memory that he'll never forget -- a picture of his unresponsive wife on a board with a plastic tube sticking out of her mouth and people pounding on her chest?
They worked the patient in the ED for another twenty minutes. She had a recent admission for hyperkalemia so they gave more bicarb and then calcium, but to no avail.
I did another cardiac arrest yesterday. Fairly routine. Yet another nursing home hospital bed one legged diabetic dialysis patient pulseless, apneic, CPR in progress, first responders defib - No shock advised. Patient a full code. Done it many times before, so what was different?
1. My eyesight is getting worse. I've remarked on it before how I have to squint sometimes when I am trying to thread a 24 gauge catheter into a tiny vein. Yesterday I had trouble reading the lip line markers on the ET tube. The lighting wasn't great and there was some thick mucus on the tube, but I couldn't tell if the number at lip line was 21 or 23? I couldn't make it out. I squinted harder, but still couldn't see it clearly.
Also when the nurse handed me the W10, I was trying to read the medical history and again, I couldn't read it. It is one thing to sit on an ambulance bench seat on a nice easy ride to the hospital and read a W10, but in the middle of a code when you are the only ALS provider, it is quite another. I have decided in the future what I will do is have the nurse stand by me while I am doing my code things and read the W10 aloud. Start with medical history and proceed through the medications. I have of necessity over the years learned to make use of nursing home staff on codes -- yesterday they did a fine job with CPR and handing me what I asked for from my gear, that this is just a logical extension.
2. ETCO2 and cardiac arrest. I have also written about this extensively (See Post), but I continue to gain new insights. The clear utility of continuous capnography is a quick verification that your tube is good (you still have to listen to lung sounds because ETCO2 won't detect a right mainstem). The other benefit is it can provide a glimpse into your patient's survivability chances as well as measure how well CPR is being done. This woman had an ETC02 of 35 on intubation (with CPR), which suggested she was not as dead as she looked. She was initially in a PEA but after some epi went into v-fib. I shocked her a total of three times, then she went back to a PEA, which dwindled to asystole and then back and forth between PEA and asystole for the duration of the call. I don't like to transport dead people, so I usually follow the 20 minute and out rule for patients in asystole, and under our new guidelines I can call medical control to cease resuscitation even on patients who have been in v-fib or PEA for a period of time if after 20 minutes, they remain pulseless. The problem here was we were getting such good ETCO2 readings. The patient stayed in the 20-30 range. What was most interesting was every time I gave her epi, the ETCO2 rose up to the 30's. We never did get pulses back. My guess was a dopler would have showed a BP in the 50's or 60's during the epi effect. Anyway, I felt we had to bring her in.
Now in the past without ETCO2 to monitor the effectiveness of CPR many of us became rather casual in our efforts. The patient was dead and wasn't coming back but was still alive enough that we had to work them. Now with ETCO2 measuring the effectiveness -- basically, the better your CPR, the better the cardiac output, the higher the ETCO2 number -- you are obligated to maintain maximum CPR efforts. As soon as you start to get lax, the monitor is going to tell you. 28, 27, 26, 25, better start pumping harder. 26, 27, 28. You stop CPR briefly to switch positions or administer a drug and your ETC02 is down to 18, 17, 16, 14. And it takes some pumping to get it back up into the mid 20's.
I had just one partner yesterday so he drove, while a cop rode in the back with me, which leads to another thing I learned.
3. IOs -- I love the EZ-IO. One legged diabetic, dialysis patient with me the only ALS responder, it's a no brainer -- I don't even look for a peripheral vein, I just get out the drill. Brrrrrr. I have access in the tibia. But here's the problem. In the past, I would have put in a line in the AC or an EJ, which would enable me to sit at the head and bag the patient while also administering drugs. I could do a code with just two people in the back. But now with the line just below the knee, no way. So, I'm trying to administer drugs and do CPR at the same time. That's challenging. You stop CPR for a moment and the ETCO2 plummets because your circulation/pressure has just dropped to Zero. Epi and atropine push pretty easy and quick, but due to the patient's history and down time, I decided to try some bicarb. Let me tell you bicarb is a bear to push through an IO. Its like pushing D50 through a 24. It is slow, so I'm doing one-handed CPR, and one handed bicarb pushing against the bristojet, all trying to maintain my balance as we go over the bumps in the road. Bottom line, I really need to get a third person in the back.
4. The patient's husband was in the nursing home lobby. When I saw him, I do as I often have done in the past -- have him come over and say something brief to his spouse. I do this to give them a chance to say goodbye. I tell them we are breathing for their spouse, but they may still be able to hear. And then the one says to the other, I love you, etc. I want them to have that moment, and it usually works out well. Yesterday, I did it, and the man told her heartfully he loved her and then we pushed on through the door and then behind us came an awful howling. A howling that did not abate. I could only picture the man on his knees crying out to the heavens.
It is hard to know what is right sometimes. Did I give him a chance to say goodbye? For him to know that his loved wife heard his words? Or did I give him an awful memory that he'll never forget -- a picture of his unresponsive wife on a board with a plastic tube sticking out of her mouth and people pounding on her chest?
They worked the patient in the ED for another twenty minutes. She had a recent admission for hyperkalemia so they gave more bicarb and then calcium, but to no avail.
Tuesday, October 28, 2008
Collar-Applying and Other Paramedic Skills
I was talking with a hospital management person the other day about how much I love being a street paramedic, and how I didn’t think I could do my new job – a part-time position as a clinical coordinator at the hospital if I wasn’t still working in the street. The manager’s response was I could do more good in my new position and that the manager never understood all the big deal about putting on a collar. Anyone could put on a cervical collar.
I’ve been thinking about the comment, and while the manager did have a point – good management people can affect a far greater array of patients than a single clinical practitioner – being an EMS responder is of course, about much more than putting on a collar, about much more than simple do again and again skills.
I had a call the other day that helped bring the question into focus. We were called to a local restaurant for a woman passed out in the bathroom. Not an unfamiliar call. Usually, a person with a bad case of diarrhea or vomiting. Sometimes a young woman having her period, who hasn’t been eating or drinking enough.
Then we were updated that it might be a cardiac arrest, and then another update – a likely diabetic.
So I go in, for better or worse, in diabetic mode. I have all my equipment (house bag, monitor, 02, stretcher), but I am thinking, check the sugar, it’ll be low, pop in an IV, push an amp of D50, try to persuade the patient to go to the hospital, but likely end up with a refusal. We’d watch the patient now alert, eat some food and then leave under the care of a friend. Done variations of it 100 times.
A morbidly obese woman is lying on her back in the middle of the bathroom – not in a stall. For all intents and purposes she is out cold. Her skin is warm and dry and her breathing has just a hint of the dreaded “guppy breathing.” I try to ignore that ominous sign. Already I am thinking this is probably not a diabetic, but maybe she is breathing this way because she is so fat and laying on her back is not helping her breathe any. I slap the nasal end-tidal on her and am relieved to see a reading of 30. While a partner tries to get a blood pressure -- I can't feel a pulse, but her wrists are fat -- my plan is do a quick sugar check. If it reads low, then we are all set, if it is normal or high, it’s on the stretcher and out to the ambulance lickety -split. 220. Let's get her out of here, I tell my crew. I'm now thinking maybe CVA. We roll her on board, lift her quickly and are on our way, ambu-bag in hand to assist ventilations if necessary and I am thinking it may soon be necessary.
In the ambulance, I intubate her quickly. No gag at all. Good tube. I can't make out the chords, but can see the epiglottis and lift it as high as I can. I have preattached my capnography filter and am confident I can slide the tube in. I pass it carefully. My fingertips feel a little resistance. I think I am at the chords and I push through. On the monitor, I see the beautiful ETCO2 wave form. I check lung sounds. Pefect. I secure the tube and then look back at the monitor - the ECG leads now attached. She is bradycardic in the 40’s and looks almost like she has a funky block. Is it from hypoxia or is this a cardiac event. I don’t see a hint of a vein, so without investigating further I get out the EZ-IO and drill, baby, drill. The only problem is her leg is so fat, I am already up to the hub of the catheter and it is spinning around and around in the gelatin of her skin, finding no purchase in bone. I take the needle out, find a new spot and bear down hard. This time I make it though to the bone, solid. I secure the IO, attach a bag of fluid, wrap a pressure dressing around it, and then push in a milligram of atropine. No change. A couple minutes later, I push a second milligram, and this time it does the trick. Her rate comes up to the 80’s. With a hundred ccs of fluid in and her heart cranking to boot, we finally get a blood pressure -- 100/60. Her end tidal is a perfect 40.
As we approach the hospital, I am feeling pretty good about my care, and I’ve got that old medic stud rush going on, but then when we get to the ED, the doctor asks for the story, and it occurs to me then I never really got a story beyond the dispatch. I was so caught up in the moment, I never did find out what happened. I knew nothing about the patient other than the fact she was a diabetic. I had no witnesses, no one who could tell me anything about her or what had happened, before, during and after. While I immobilized her on a spine-board, that was more to be able to lift her and manage her in the event she arrested than to protect her spine. I never considered the fact she might have been a trauma. As I sit to write my run form, and come to the boxes about pupils, I slap my forehead. Pupils? Do’oh. I never looked. Suddenly I wonder if maybe she was a heroin OD and could have been woken up with a touch of narcan before dismissing the idea as sudden paranoid fantasy. When I go to put down my drug doses, I realize I lapsed back to the old dosing scheme for atropine, not the latest ACLS guidelines, which call for a half milligram instead of the whole. My bad.
Later, after the family comes to the hospital, we get more of the story. The woman had started acting confused, and then went to the bathroom with an awkward gait, and then synocopized entering a stall, was helped to the ground, and then dragged out of the stall by her ankles. I’ve followed up a couple times, and she remains in the ICU. Her labs weren’t significantly off. Her CAT scan clean. They don’t seem to know what happened. A mystery.
But anyway, the point of this story is that what I like about EMS is the challenge – the array of skills you need to bring to a call -- assessment, scene management, intubation, pharmacology, and that no call, no matter how well you may think you are performing goes flawlessly. I did great in some areas and was weak in others. But it just goes to show how much is involved in a call. It is not just about putting a collar on. In this case particularly because I never got around to putting one on(if i could have found one to go around her ox-like neck), which certainly would have been indicated if I thought she was a trauma or merely indicated because it is good practice because I don't know it is not a trauma.
I no longer expect to be perfect. But I still relish the challenge. A situation is thrown at you and you have to perform. Sometimes you do great, sometimes you stumble, most of the time, you are somewhere in between. It is exciting. I am much better at it than when I first began, but always have room for improvement. You learn from each call, and although you never get the same call twice -- there are no direct do-overs -- you always get a chance to redeem and hopefully, shine. I took pride in my tube, but next time I will work to improve my history taking skills or delegation. I should have just said to one of my partners. Find out what happened for me. Be quick about it and report back. I love delegation. I need to use it more.
So anyway, after several days working the new desk job, I’m back on the street. Instead of reading other medics run forms and living vicariously through their exploits, I’m out there doing it, touching patients and writing my own run forms again. And it’s been busy today, only the calls are not really what I had been hoping for. No big tests yet.
Old lady with a heart history in a neck high bathrobe stone cold deaf having chest tightness with a congested cough. I like to get my patients in a Johnny, but disrobing her was just going to be too hard, plus it was pouring rain outside and we needed to stair chair her out and I didn't want her to freeze. In the ambulance, trying to do a 12 lead, and explain to a deaf lady why I needed to reach down her robe was challenging. Not as challenging as the lady in the restaurant, but a challenge nonetheless. Then it was two nursing home calls one for a woman with dementia and paranoia with a fever and coughing up green phlegm which she had all over her fingers, the other for a man with MRSA affected weeping wounds. That patient refused to get on our stretcher until he had put his good clothes on and gone to the bathroom. He was also close to four hundred pounds. And it was still pouring rain. The challenge on those calls was how many times and with what variety of soaps, sanitizers and disinfectants could I wash my hands.
The potential paramedic skill set is limitless.
I’ve been thinking about the comment, and while the manager did have a point – good management people can affect a far greater array of patients than a single clinical practitioner – being an EMS responder is of course, about much more than putting on a collar, about much more than simple do again and again skills.
I had a call the other day that helped bring the question into focus. We were called to a local restaurant for a woman passed out in the bathroom. Not an unfamiliar call. Usually, a person with a bad case of diarrhea or vomiting. Sometimes a young woman having her period, who hasn’t been eating or drinking enough.
Then we were updated that it might be a cardiac arrest, and then another update – a likely diabetic.
So I go in, for better or worse, in diabetic mode. I have all my equipment (house bag, monitor, 02, stretcher), but I am thinking, check the sugar, it’ll be low, pop in an IV, push an amp of D50, try to persuade the patient to go to the hospital, but likely end up with a refusal. We’d watch the patient now alert, eat some food and then leave under the care of a friend. Done variations of it 100 times.
A morbidly obese woman is lying on her back in the middle of the bathroom – not in a stall. For all intents and purposes she is out cold. Her skin is warm and dry and her breathing has just a hint of the dreaded “guppy breathing.” I try to ignore that ominous sign. Already I am thinking this is probably not a diabetic, but maybe she is breathing this way because she is so fat and laying on her back is not helping her breathe any. I slap the nasal end-tidal on her and am relieved to see a reading of 30. While a partner tries to get a blood pressure -- I can't feel a pulse, but her wrists are fat -- my plan is do a quick sugar check. If it reads low, then we are all set, if it is normal or high, it’s on the stretcher and out to the ambulance lickety -split. 220. Let's get her out of here, I tell my crew. I'm now thinking maybe CVA. We roll her on board, lift her quickly and are on our way, ambu-bag in hand to assist ventilations if necessary and I am thinking it may soon be necessary.
In the ambulance, I intubate her quickly. No gag at all. Good tube. I can't make out the chords, but can see the epiglottis and lift it as high as I can. I have preattached my capnography filter and am confident I can slide the tube in. I pass it carefully. My fingertips feel a little resistance. I think I am at the chords and I push through. On the monitor, I see the beautiful ETCO2 wave form. I check lung sounds. Pefect. I secure the tube and then look back at the monitor - the ECG leads now attached. She is bradycardic in the 40’s and looks almost like she has a funky block. Is it from hypoxia or is this a cardiac event. I don’t see a hint of a vein, so without investigating further I get out the EZ-IO and drill, baby, drill. The only problem is her leg is so fat, I am already up to the hub of the catheter and it is spinning around and around in the gelatin of her skin, finding no purchase in bone. I take the needle out, find a new spot and bear down hard. This time I make it though to the bone, solid. I secure the IO, attach a bag of fluid, wrap a pressure dressing around it, and then push in a milligram of atropine. No change. A couple minutes later, I push a second milligram, and this time it does the trick. Her rate comes up to the 80’s. With a hundred ccs of fluid in and her heart cranking to boot, we finally get a blood pressure -- 100/60. Her end tidal is a perfect 40.
As we approach the hospital, I am feeling pretty good about my care, and I’ve got that old medic stud rush going on, but then when we get to the ED, the doctor asks for the story, and it occurs to me then I never really got a story beyond the dispatch. I was so caught up in the moment, I never did find out what happened. I knew nothing about the patient other than the fact she was a diabetic. I had no witnesses, no one who could tell me anything about her or what had happened, before, during and after. While I immobilized her on a spine-board, that was more to be able to lift her and manage her in the event she arrested than to protect her spine. I never considered the fact she might have been a trauma. As I sit to write my run form, and come to the boxes about pupils, I slap my forehead. Pupils? Do’oh. I never looked. Suddenly I wonder if maybe she was a heroin OD and could have been woken up with a touch of narcan before dismissing the idea as sudden paranoid fantasy. When I go to put down my drug doses, I realize I lapsed back to the old dosing scheme for atropine, not the latest ACLS guidelines, which call for a half milligram instead of the whole. My bad.
Later, after the family comes to the hospital, we get more of the story. The woman had started acting confused, and then went to the bathroom with an awkward gait, and then synocopized entering a stall, was helped to the ground, and then dragged out of the stall by her ankles. I’ve followed up a couple times, and she remains in the ICU. Her labs weren’t significantly off. Her CAT scan clean. They don’t seem to know what happened. A mystery.
But anyway, the point of this story is that what I like about EMS is the challenge – the array of skills you need to bring to a call -- assessment, scene management, intubation, pharmacology, and that no call, no matter how well you may think you are performing goes flawlessly. I did great in some areas and was weak in others. But it just goes to show how much is involved in a call. It is not just about putting a collar on. In this case particularly because I never got around to putting one on(if i could have found one to go around her ox-like neck), which certainly would have been indicated if I thought she was a trauma or merely indicated because it is good practice because I don't know it is not a trauma.
I no longer expect to be perfect. But I still relish the challenge. A situation is thrown at you and you have to perform. Sometimes you do great, sometimes you stumble, most of the time, you are somewhere in between. It is exciting. I am much better at it than when I first began, but always have room for improvement. You learn from each call, and although you never get the same call twice -- there are no direct do-overs -- you always get a chance to redeem and hopefully, shine. I took pride in my tube, but next time I will work to improve my history taking skills or delegation. I should have just said to one of my partners. Find out what happened for me. Be quick about it and report back. I love delegation. I need to use it more.
So anyway, after several days working the new desk job, I’m back on the street. Instead of reading other medics run forms and living vicariously through their exploits, I’m out there doing it, touching patients and writing my own run forms again. And it’s been busy today, only the calls are not really what I had been hoping for. No big tests yet.
Old lady with a heart history in a neck high bathrobe stone cold deaf having chest tightness with a congested cough. I like to get my patients in a Johnny, but disrobing her was just going to be too hard, plus it was pouring rain outside and we needed to stair chair her out and I didn't want her to freeze. In the ambulance, trying to do a 12 lead, and explain to a deaf lady why I needed to reach down her robe was challenging. Not as challenging as the lady in the restaurant, but a challenge nonetheless. Then it was two nursing home calls one for a woman with dementia and paranoia with a fever and coughing up green phlegm which she had all over her fingers, the other for a man with MRSA affected weeping wounds. That patient refused to get on our stretcher until he had put his good clothes on and gone to the bathroom. He was also close to four hundred pounds. And it was still pouring rain. The challenge on those calls was how many times and with what variety of soaps, sanitizers and disinfectants could I wash my hands.
The potential paramedic skill set is limitless.
Saturday, October 18, 2008
Betrayed
My old partner Arthur once said I was too nice -- that I believed everything my patients told me. I didn't really agree with him. I was actually sort of torqued he said it because he told it to a newspaper reporter who was riding along with us that day to do a story. I didn't like the implication that I might be naive or gullible.
True, he made that comment ten years ago, but I think I am as good as anyone at sorting out the bullshit. I've done enough calls over the years to be have been able to build up a pretty good "Yeah, right" meter. I can spot a fake seizure the moment I walk in the door. I need a little more proximity to a patient to tell when they are feigning unresponsiveness, but I am rarely fooled. These of course involve a degree of physical assessment and observation. Any medic who has spent his time in the street can pick this up. After awhile, you run out of ways to get burned. You've learned every trick in the book, and you don't fall for the shit anymore.
I remember quite a number of years ago I was called to help another medic on a seizure call. This was when we only carried Valium and could only give it IV. A patient was seizing, you had to get a line and this medic was having trouble getting one. I opened up the back door and saw right away that the patient was arching their back and moving their limbs asynchronously. I climbed into the back leaned over the man and said "Knock it off!" he immediately stopped. I nodded to the other medic, who was dumbfounded. Then I exited, clearing the assist without another word.
I have found that phrase and the authoritative tone behind it to be quite effective on other similar occasions.
I don't mean to imply that I am never fooled. I am. But if I am fooled, it is because I have come to start taking the patient at their word, and I pass their word on with the phrase, "patient states..."
When I was a younger medic it was a badge of honor to never be fooled. For some reason it came to deal with your manhood. A stud medic was never fooled. It wasn't just a patient deliberately fooling you with their story, but fooling you with their presentation. That, for some (never for me), meant not treating a patient with pleuritic chest pain, not working up a drunk, not c-spining an elderly person with a low fall because you were sure they didn't have a fracture. And giving pain-meds to anyone, forget about it. You couldn't let a drug-seeker fool you.
Drug seekers do fool me. Not all of them, but I have been burned by a few just because I would rather give drugs to a drug-seeker than deny someone in legitimate pain.
I guess my basic attitude these days is, who am I to judge? I have to go with what people tell me. You look fine, but you tell me you are sick, okay, what hospital do you want to go to? I'll just relay what the patient (or bystanders) tell me, and then I relay what I have seen. Just the facts.
Still I am hurt when I find out someone has lied to me. Here's what happened the other day:
We get called for chest pain. Attractive 45-year-old woman at work having ten out of ten chest pain. Pain goes into her neck and down her arms. She's been having the pain for an hour, but she still drove to work. She is under a lot of stress. She's going through a divorce. There have been layoffs at work. Nice woman. She's been seeing a psychiatrist for anxiety. This she says feels like an anxiety attack, but much worse. Those have never lasted longer than five minutes. She's a little hypertensive (BP 170/100), a little tachycardic (104-112) skin warm and dry, has some congestion in her lungs, she says she's getting over bronchitis. She's all concerned she needs to call her mother and she doesn't want to worry her mother.
I put her on oxygen by cannula. The nurse at her job has already given her aspirin and one nitro with only temporary relief. I pop her on the monitor and the initial leads look good. NO ST elevations. I tell the nurse, we'll do the full workup out in the ambulance. The nurse notes a PVC. Maybe, I think or maybe it is just a wire being jostled.
I ask the patient for some more history. Anything different today or recently? Anything out of the ordinary? Any reason you could be feeling like this?
No. Just the stress. Lots of stress.
The patient is having an anxiety attack in my opinion, but I fully plan to treat it as cardiac. I explain this to her. I don't think it is your heart, I say, but I'm going to treat you like it is.
The full 12-lead is normal, except for a PVC or two. I ask her if she has ever had any heart trouble or the feeling of an irregular rate. She says no. I am seeing an occasional PVC -- unifocal, but fairly regular. So I guess it is more than an occasional PVC. That is a concern. I give her a full three nitros that don't seem to help, but do bring her pressure down a little. She is bouncing off the walls now with her anxiety, and I am seriously thinking about giving her some ativan. And, while I rarely give morphine to patients with chest pain (due to some recent literature that raises the possibility that it may do more harm than good), I go ahead and give her 2 mgs and then another 2 mgs just to calm her down.
It gets her pain down to a 6. Throughout all of this, she is complimenting me, telling me what a nice guy I am, how compassionate I must be to do this work. She keeps her arm on my knee. She calls me by my first name. Asks me if I am married? When I show her the pictures of my daughter, she tells me what a beautiful girl she is. I feel we are bonding. Not just paramedic to patient, but person to person.
We, of course, are well on our way in to the hospital. Not going lights or siren, but proceeding directly. I call in my patch that goes something like this:
"We're five minutes out with a 45 year old female with substernal chest pressure X 1 hour that goes into arms and neck. No prior cardiac history. Patient does have a history of anxiety and recent bronchitis. The 12 lead is normal, but the patient is having occasional PCS. She says she has had similar episodes in the past none lasting more than 5 minutes that her doctor's attribute to anxiety. She's gotten ASA, NTG X 3 and 4 of morphine with the pain initially a 10 of 10 now down to a 6..."
Pretty impartial patch. I'm basically saying she's having chest pain, but there is a good possibility it is anxiety. She'll need a room in the main with a cardiac workup, but there is no need to activate the cath lab yet or haul an ED doctor out of a procedure to prepare for our arrival. Just a room with a nurse and an ECG machine to start.
We get her registered, get her to the room. She is much calmer now. I get her to sign my run form. She thanks me again for being so nice. I go and find a nurse, who is very busy with another patient so I sit near the nurse's desk, typing up my run form until I can give her the report. She's finally ready and I bring her into the room and give her the run down while a paramedic student looks for an ECG machine. The nurse has some general questions for the patient and I excuse myself to head out for the ambulance. The patient calls after me, thanking me again. I say you are in good hands.
I come back later with another patient and when I see the nurse I ask how the woman made out. Was it anxiety or truly a cardiac issue?
Sky high cardiac enzymes, the nurse says. She's upstairs waiting for the cath lab.
Really?
Then the nurse says the patient finally admitted that she did some cocaine with her boyfriend late last night.
Cocaine.
I have to admit, I felt hurt. Betrayed. She shouldn't have hidden that from me. I thought we were friends.
True, he made that comment ten years ago, but I think I am as good as anyone at sorting out the bullshit. I've done enough calls over the years to be have been able to build up a pretty good "Yeah, right" meter. I can spot a fake seizure the moment I walk in the door. I need a little more proximity to a patient to tell when they are feigning unresponsiveness, but I am rarely fooled. These of course involve a degree of physical assessment and observation. Any medic who has spent his time in the street can pick this up. After awhile, you run out of ways to get burned. You've learned every trick in the book, and you don't fall for the shit anymore.
I remember quite a number of years ago I was called to help another medic on a seizure call. This was when we only carried Valium and could only give it IV. A patient was seizing, you had to get a line and this medic was having trouble getting one. I opened up the back door and saw right away that the patient was arching their back and moving their limbs asynchronously. I climbed into the back leaned over the man and said "Knock it off!" he immediately stopped. I nodded to the other medic, who was dumbfounded. Then I exited, clearing the assist without another word.
I have found that phrase and the authoritative tone behind it to be quite effective on other similar occasions.
I don't mean to imply that I am never fooled. I am. But if I am fooled, it is because I have come to start taking the patient at their word, and I pass their word on with the phrase, "patient states..."
When I was a younger medic it was a badge of honor to never be fooled. For some reason it came to deal with your manhood. A stud medic was never fooled. It wasn't just a patient deliberately fooling you with their story, but fooling you with their presentation. That, for some (never for me), meant not treating a patient with pleuritic chest pain, not working up a drunk, not c-spining an elderly person with a low fall because you were sure they didn't have a fracture. And giving pain-meds to anyone, forget about it. You couldn't let a drug-seeker fool you.
Drug seekers do fool me. Not all of them, but I have been burned by a few just because I would rather give drugs to a drug-seeker than deny someone in legitimate pain.
I guess my basic attitude these days is, who am I to judge? I have to go with what people tell me. You look fine, but you tell me you are sick, okay, what hospital do you want to go to? I'll just relay what the patient (or bystanders) tell me, and then I relay what I have seen. Just the facts.
Still I am hurt when I find out someone has lied to me. Here's what happened the other day:
We get called for chest pain. Attractive 45-year-old woman at work having ten out of ten chest pain. Pain goes into her neck and down her arms. She's been having the pain for an hour, but she still drove to work. She is under a lot of stress. She's going through a divorce. There have been layoffs at work. Nice woman. She's been seeing a psychiatrist for anxiety. This she says feels like an anxiety attack, but much worse. Those have never lasted longer than five minutes. She's a little hypertensive (BP 170/100), a little tachycardic (104-112) skin warm and dry, has some congestion in her lungs, she says she's getting over bronchitis. She's all concerned she needs to call her mother and she doesn't want to worry her mother.
I put her on oxygen by cannula. The nurse at her job has already given her aspirin and one nitro with only temporary relief. I pop her on the monitor and the initial leads look good. NO ST elevations. I tell the nurse, we'll do the full workup out in the ambulance. The nurse notes a PVC. Maybe, I think or maybe it is just a wire being jostled.
I ask the patient for some more history. Anything different today or recently? Anything out of the ordinary? Any reason you could be feeling like this?
No. Just the stress. Lots of stress.
The patient is having an anxiety attack in my opinion, but I fully plan to treat it as cardiac. I explain this to her. I don't think it is your heart, I say, but I'm going to treat you like it is.
The full 12-lead is normal, except for a PVC or two. I ask her if she has ever had any heart trouble or the feeling of an irregular rate. She says no. I am seeing an occasional PVC -- unifocal, but fairly regular. So I guess it is more than an occasional PVC. That is a concern. I give her a full three nitros that don't seem to help, but do bring her pressure down a little. She is bouncing off the walls now with her anxiety, and I am seriously thinking about giving her some ativan. And, while I rarely give morphine to patients with chest pain (due to some recent literature that raises the possibility that it may do more harm than good), I go ahead and give her 2 mgs and then another 2 mgs just to calm her down.
It gets her pain down to a 6. Throughout all of this, she is complimenting me, telling me what a nice guy I am, how compassionate I must be to do this work. She keeps her arm on my knee. She calls me by my first name. Asks me if I am married? When I show her the pictures of my daughter, she tells me what a beautiful girl she is. I feel we are bonding. Not just paramedic to patient, but person to person.
We, of course, are well on our way in to the hospital. Not going lights or siren, but proceeding directly. I call in my patch that goes something like this:
"We're five minutes out with a 45 year old female with substernal chest pressure X 1 hour that goes into arms and neck. No prior cardiac history. Patient does have a history of anxiety and recent bronchitis. The 12 lead is normal, but the patient is having occasional PCS. She says she has had similar episodes in the past none lasting more than 5 minutes that her doctor's attribute to anxiety. She's gotten ASA, NTG X 3 and 4 of morphine with the pain initially a 10 of 10 now down to a 6..."
Pretty impartial patch. I'm basically saying she's having chest pain, but there is a good possibility it is anxiety. She'll need a room in the main with a cardiac workup, but there is no need to activate the cath lab yet or haul an ED doctor out of a procedure to prepare for our arrival. Just a room with a nurse and an ECG machine to start.
We get her registered, get her to the room. She is much calmer now. I get her to sign my run form. She thanks me again for being so nice. I go and find a nurse, who is very busy with another patient so I sit near the nurse's desk, typing up my run form until I can give her the report. She's finally ready and I bring her into the room and give her the run down while a paramedic student looks for an ECG machine. The nurse has some general questions for the patient and I excuse myself to head out for the ambulance. The patient calls after me, thanking me again. I say you are in good hands.
I come back later with another patient and when I see the nurse I ask how the woman made out. Was it anxiety or truly a cardiac issue?
Sky high cardiac enzymes, the nurse says. She's upstairs waiting for the cath lab.
Really?
Then the nurse says the patient finally admitted that she did some cocaine with her boyfriend late last night.
Cocaine.
I have to admit, I felt hurt. Betrayed. She shouldn't have hidden that from me. I thought we were friends.
Friday, October 10, 2008
A Dark and Stormy Night
Well, for the last month now we have been using electronic run forms. For the most part, I like them. I like most being able to type out an extended narrative, instead of trying to scribble it all into a confined space. (I know you could always attach a supplemental page, but I rarely did.) I like that people can read my writing now.
I've never considered myself a great run form writer. I would scrawl out a basic template that, if you could make out the chicken scratch, usually went something like this:
"76-year-old female not feeling well since last night. Denies chest pain or dsypnea. Vomited X-1. No diarrhea. Found supine in bed. GCS-15, skin warm dry, lungs clear, ab soft non-tender, good neuros. Vitals as below. Sinus, no ST aberrations. IV # 20 in Left forearm. S. Lock. BS-144. Taken to hospital, turned over to ED staff with full report."
But now with a keyboard and an unlimited space, I can be more free-flowing.
I did a call recently involving an old man found curled up in his apartment with altered mental status (See Sha La Lala Lala, Live For Today).
The next day I received an email from the hospital's Clinical Coordinator asking for a copy of the form for my stroke patient. I guessed he was talking about the old man found curled up in his apartment who was possibly a stroke patient. But I knew I had given a copy of my run form to the nurse as well as put a second copy in the QA box, which I told the Coordinator in a return email.
Still, I spent a sleepless night, wondering if I had done something wrong.
He emailed me back that the reason he was looking for the form was because the stroke doctor (the patient did have a head bleed) said it was one of the best run forms he had ever read.
I emailed him back asking if he was sure it was my patient and not one brought in by my relief later in the day. I said I did not think I wrote very good run forms and it was likely my relief who wrote excellent ones.
He emailed me back that it was indeed my patient, and that the doctor had been very impressed with the narrative that was full of information (scene description, co-worker's account, etc.) that had been very helpful to him.
The narrative. Yes! I had written quite a detailed narrative.
Suddenly I began to understand the meaning of it all.
I've written novels, essays, memoirs, speeches, poems, blog posts, and now I can write RUN FORMS!
Writers so love audiences. Might I say, we desperately crave them.
Now I have an entirely new audience.
Nurses, ED physicians, stroke doctors, cardiologists, trauma surgeons, internists, maybe even medical records personnel.
Now each time I sit down to do an electronic run form, after checking the obligatory boxes, my heart rises as I begin to type. I think I mustn't disappoint my readership. I must educate and entertain them. I must make them feel as if they were there on the call with me. Ahh, the poetry of it!
After a motor vehicle accident, I ponder a moment, and then inspiration strikes.
I type:
"It was a dark and stormy night..."
I've never considered myself a great run form writer. I would scrawl out a basic template that, if you could make out the chicken scratch, usually went something like this:
"76-year-old female not feeling well since last night. Denies chest pain or dsypnea. Vomited X-1. No diarrhea. Found supine in bed. GCS-15, skin warm dry, lungs clear, ab soft non-tender, good neuros. Vitals as below. Sinus, no ST aberrations. IV # 20 in Left forearm. S. Lock. BS-144. Taken to hospital, turned over to ED staff with full report."
But now with a keyboard and an unlimited space, I can be more free-flowing.
I did a call recently involving an old man found curled up in his apartment with altered mental status (See Sha La Lala Lala, Live For Today).
The next day I received an email from the hospital's Clinical Coordinator asking for a copy of the form for my stroke patient. I guessed he was talking about the old man found curled up in his apartment who was possibly a stroke patient. But I knew I had given a copy of my run form to the nurse as well as put a second copy in the QA box, which I told the Coordinator in a return email.
Still, I spent a sleepless night, wondering if I had done something wrong.
He emailed me back that the reason he was looking for the form was because the stroke doctor (the patient did have a head bleed) said it was one of the best run forms he had ever read.
I emailed him back asking if he was sure it was my patient and not one brought in by my relief later in the day. I said I did not think I wrote very good run forms and it was likely my relief who wrote excellent ones.
He emailed me back that it was indeed my patient, and that the doctor had been very impressed with the narrative that was full of information (scene description, co-worker's account, etc.) that had been very helpful to him.
The narrative. Yes! I had written quite a detailed narrative.
Suddenly I began to understand the meaning of it all.
I've written novels, essays, memoirs, speeches, poems, blog posts, and now I can write RUN FORMS!
Writers so love audiences. Might I say, we desperately crave them.
Now I have an entirely new audience.
Nurses, ED physicians, stroke doctors, cardiologists, trauma surgeons, internists, maybe even medical records personnel.
Now each time I sit down to do an electronic run form, after checking the obligatory boxes, my heart rises as I begin to type. I think I mustn't disappoint my readership. I must educate and entertain them. I must make them feel as if they were there on the call with me. Ahh, the poetry of it!
After a motor vehicle accident, I ponder a moment, and then inspiration strikes.
I type:
"It was a dark and stormy night..."
Friday, September 26, 2008
Out of Time
Difficulty breathing at the nursing home. The officer who arrives on scene tells us to keep coming lights and sirens.
The room in the nursing home is sparse. The patient, a large man in a hospital johnny, is pale and diaphoretic with a low grade fever and edema in his abdomen and extremities. His eyes follow me slowly as I assess him. His lungs are full of rhonci and probably some rales mixed in. It all sounds crappy. I ask him if he is in any pain and he says his back hurts. He says the bed is uncomfortable, and he is too weak to position himself better. With a nonrebreather on he is only SATing at 90%. His heart rate is in the 130's. The nurse comes in with the W10 and I ask what kind of respiratory history he has. None, she says. He has metastasized cancer into his bones. He just came back from radiation. He's only been here a few days. He just started breathing poorly an hour ago, although he has been edematous since he got here. Also, he hasn't peed for a while. And he's a DNR.
Whenever I hear the DNR status, I admit, I feel a small, if sad relief. I won't have to work as hard on this one as I thought, I think. I check quickly through the paperwork, verify the DNR order, and then slip the papers in my pocket. "We'll get you over to my stretcher now," I say, "and try to get you comfortable." The police officer helps us move the man who is quite heavy. I try to get his head under the pillow comfortably, but as it is, his feet are hanging off one end of the stretcher and his head the other. I sit him up to aid his breathing.
When we put him in the back off the ambulance, I look up at him and think for a moment that he has coded. His head is still and cocked slightly back with his mouth open. I see no chest rise. "Stimulate him," I call to our third partner, who rubs his shoulder and he lifts his head slightly and looks at her.
I tell my other partner to just head to the hospital. He is a DNR, but I don't want him to die on us, so I tell him to go lights and sirens, but easy.
And dying is what this man is doing. His breathing is becoming agonal. The light is leaving his eyes. His lungs are slowly filling with more fluid. I can't hear a blood pressure and he only rouses if we stimulate him. I think for a moment about calling the hospital and requesting permission to use some aggression in my treatment, but I can't figure out quite how to ask, plus I know once I mention he is a DNR, they will likely say no because what he needs is to be intubated. He is too lethargic for CPAP, doesn't have the pressure for nitro. My only option is probably dopamine. I use the electronic cuff and it comes back with a BP of 120/90, which I do not believe. I do it again and it reads 80/40. I try a manual again and hear nothing. After I pop in an IV, I look up at the man and his eyes are completely glazed. His mouth is moving in the classic fish out of water manner. I shake his shoulder and ask how he is. He looks at me and just nods.
When I call the hospital, they ask to verify if the man in indeed a DNR. Yes, I say. Very good, they respond and I can tell they are feeling the same as I did initially. Okay, he's really sick, but we don't have to devote full resources to him.
It's awful watching somebody die like this. Wheeling him down the hall, I see nurses and other EMS people looking at the patient. I can see they are thinking. He's not doing too well. One EMT looks at me and gives an expression as if to say, how come I'm not assisting his breathing. "D-N-R," I mouth and he nods.
They assign us a room and I relay the story to the nurse and show her the paperwork. She goes to get a doctor. My partners and I try to get the man comfortable sitting up on the bed. I rub his shoulder and again he opens his now blank eyes. "You all right?"
He nods, gives a small tired grunt and closes his eyes.
The doctor comes in and I haven't gotten thirty seconds into my report when the man's daughter is led into the room by a registrar. The doctor turns to her and she is crying already. He asks what her wishes are and she says she doesn't know. She wants to know how he is, and the doctor says, he is not doing well. The doctor sees that the DNR is only a week old and tells her it represents her father's wishes and that this is probably what they should honor. I'm standing in the corner watching. It is a heartbreaking scene and an urgent discussion, but at the same time I am aware of something else going on. The man is passing. I don't know if he will be dead in the next minute, but I think his ability to respond is slipping away rapidly. I don't want to interrupt the doctor and the man's daughter, while they decide, but I feel I should speak up. The doctor is staring at the woman as she sobs and shakes her head. "I don't know. I don't know," she says.
I wait. I wait.
Finally, I break in. "Excuse me, I hate to interrupt," I say. "Come, take your Dad's hand," I say. "Tell him you're here. Talk to him. He can probably hear you."
She takes his hand. His eyes are closed. His breathing is shallow, irratic. She kisses his head. "Dad. It's me. I'm here. Can you squeeze my hand?"
I look down at where she holds his hand. There is no movement.
The room in the nursing home is sparse. The patient, a large man in a hospital johnny, is pale and diaphoretic with a low grade fever and edema in his abdomen and extremities. His eyes follow me slowly as I assess him. His lungs are full of rhonci and probably some rales mixed in. It all sounds crappy. I ask him if he is in any pain and he says his back hurts. He says the bed is uncomfortable, and he is too weak to position himself better. With a nonrebreather on he is only SATing at 90%. His heart rate is in the 130's. The nurse comes in with the W10 and I ask what kind of respiratory history he has. None, she says. He has metastasized cancer into his bones. He just came back from radiation. He's only been here a few days. He just started breathing poorly an hour ago, although he has been edematous since he got here. Also, he hasn't peed for a while. And he's a DNR.
Whenever I hear the DNR status, I admit, I feel a small, if sad relief. I won't have to work as hard on this one as I thought, I think. I check quickly through the paperwork, verify the DNR order, and then slip the papers in my pocket. "We'll get you over to my stretcher now," I say, "and try to get you comfortable." The police officer helps us move the man who is quite heavy. I try to get his head under the pillow comfortably, but as it is, his feet are hanging off one end of the stretcher and his head the other. I sit him up to aid his breathing.
When we put him in the back off the ambulance, I look up at him and think for a moment that he has coded. His head is still and cocked slightly back with his mouth open. I see no chest rise. "Stimulate him," I call to our third partner, who rubs his shoulder and he lifts his head slightly and looks at her.
I tell my other partner to just head to the hospital. He is a DNR, but I don't want him to die on us, so I tell him to go lights and sirens, but easy.
And dying is what this man is doing. His breathing is becoming agonal. The light is leaving his eyes. His lungs are slowly filling with more fluid. I can't hear a blood pressure and he only rouses if we stimulate him. I think for a moment about calling the hospital and requesting permission to use some aggression in my treatment, but I can't figure out quite how to ask, plus I know once I mention he is a DNR, they will likely say no because what he needs is to be intubated. He is too lethargic for CPAP, doesn't have the pressure for nitro. My only option is probably dopamine. I use the electronic cuff and it comes back with a BP of 120/90, which I do not believe. I do it again and it reads 80/40. I try a manual again and hear nothing. After I pop in an IV, I look up at the man and his eyes are completely glazed. His mouth is moving in the classic fish out of water manner. I shake his shoulder and ask how he is. He looks at me and just nods.
When I call the hospital, they ask to verify if the man in indeed a DNR. Yes, I say. Very good, they respond and I can tell they are feeling the same as I did initially. Okay, he's really sick, but we don't have to devote full resources to him.
It's awful watching somebody die like this. Wheeling him down the hall, I see nurses and other EMS people looking at the patient. I can see they are thinking. He's not doing too well. One EMT looks at me and gives an expression as if to say, how come I'm not assisting his breathing. "D-N-R," I mouth and he nods.
They assign us a room and I relay the story to the nurse and show her the paperwork. She goes to get a doctor. My partners and I try to get the man comfortable sitting up on the bed. I rub his shoulder and again he opens his now blank eyes. "You all right?"
He nods, gives a small tired grunt and closes his eyes.
The doctor comes in and I haven't gotten thirty seconds into my report when the man's daughter is led into the room by a registrar. The doctor turns to her and she is crying already. He asks what her wishes are and she says she doesn't know. She wants to know how he is, and the doctor says, he is not doing well. The doctor sees that the DNR is only a week old and tells her it represents her father's wishes and that this is probably what they should honor. I'm standing in the corner watching. It is a heartbreaking scene and an urgent discussion, but at the same time I am aware of something else going on. The man is passing. I don't know if he will be dead in the next minute, but I think his ability to respond is slipping away rapidly. I don't want to interrupt the doctor and the man's daughter, while they decide, but I feel I should speak up. The doctor is staring at the woman as she sobs and shakes her head. "I don't know. I don't know," she says.
I wait. I wait.
Finally, I break in. "Excuse me, I hate to interrupt," I say. "Come, take your Dad's hand," I say. "Tell him you're here. Talk to him. He can probably hear you."
She takes his hand. His eyes are closed. His breathing is shallow, irratic. She kisses his head. "Dad. It's me. I'm here. Can you squeeze my hand?"
I look down at where she holds his hand. There is no movement.
Saturday, September 20, 2008
Sha La Lala Lala, Live For Today
Elderly man. Alzheimers. DNR. No history of seizures. Had a witnessed seizure at the nursing home. Started with his eyes twitching, progressed to a full gran mal. Now the patient who is normally verbal, isn't saying anything, and has snoring respirations. His pressure is 200/110. I stick an oral airway in after a slight gag, the patient takes it fine and the snoring stops. We start to the hospital no-lights, no siren. I put in an IV. As I'm patching to the hospital, I notice the patient's eyelids are starting to twitch. I get out the Ativan. Like a speeding freight train that you hear coming that you feel the ground shake before it roars into view, so comes this seizure till it is full and upon him, and violent. The stretcher itself is rattling with the force of energy seizing in the man. I draw the Ativan up, but wait a little to see if it will subside on its own, but it is just too violent and I have to try to kill it before it blows this man apart, before the alien force inside him comes out and gets me. I give him one milligram and wait a minute and then give him a second milligram. But he is still seizing to beat the band, so after a few more minutes I draw up another dose, but then the shaking slowly slows inside him until he is still. The monitor shows his heart beating. I can see his chest rise. His body looks really, really tired. In his eyes, it doesn't look like he is even there anymore.
At the hospital, I notice his left arm turning in. Posturing. I overhear the doctor telling his daughter the prognosis is grim. She says she just wants him to be comfortable. I walk by the lighted X-ray viewer on the wall and see a scan of a brain with a large white patch in the middle of it.
***
We're called for an unconscious student at the high school. When we arrive at the classroom, I see a nurse with an ambu-bag in hand, kneeling by a young man who is prone on the floor, jerking asynchronously, arching his back, and slamming his arms against the floor. "He's been seizing for seven minutes," the nurse says. I nod and reach over and touch the student and say "Okay, time to stop." I help him to a sitting position and he ceases his activity. I help him to his feet and over to the stretcher, where my crew buckles him in. He is of course, alert and oriented. His pressure is 120/70. One of his fellow students brings him his jacket from his locker along with a New York Jets cap. On the way to the hospital "DeShawn" tells us his mother is out of the country and he doesn't like his step-father. The young EMT working with me tells the boy at least he probably won't have to go to school tomorrow. I see the student smile.
***
Unconscious elderly man found in a fetal position in his home by a coworker who went to check on him because he didn't show up at work. The officer tells us not to bother with the stretcher. When I enter the house I see why. There is clutter and junk piled to the celling. This is the home of a pack rat. The officer says he is in the living room, but to get to him, I have to snake my way through the clutter in the kitchen. The hallway is completely blocked. I find him amid a fallen pile of magazines. The coworker is as shocked as we are by the surrounding says she has never seen him like this. He is a vibrant man who every year wins sales awards at their office. He looks like a malnourished homeless man. I see a few liquor bottles around -- wine, vodka -- but there is no evidence of recent drinking. And no signs of physical trauma. His eyes don't focus. His grips are equal and there is no facial droop. No arm drift. Could he be a hidden drunk? He certainly manages to hide his clutter habit from his coworker. He struggles to tell me his date of birth. He says he drank last night. But I don't smell liquor on his breath. I wonder if he is also having a head bleed. His blood pressure is 180/110. I pick him up in my arms and carry him carefully through the narrow passages. He seems frightened like a small deer.
***
I take the next day off and take the kids to the Big E -- The Eastern State's Exposition -- New England's big fair. It's a beautiful day so nice I don't even mind the twenty dollar bills flying out of my wallet every time I turn around. Bumper cars. The Fun House. Smoked Turkey Legs. A midget roller coaster. Mini Doughnuts with cinnamon powder. The water gun races to see who pops the balloon first. Fresh squeezed lemonade. The barkers selling kitchen cleanup supplies. Miracle mops and knifes that never dull. I win a Yosemite Sam doll when the man fails to guess my age within two years. Throw the rings at the bottles to try to win an I-pod. More bumper cars. Watch chicks hatch from their eggs. See the sheep, cows and horses. The Haunted House. Knock over the milk cartons. Ride the Ferris Wheel as the sun sets. The Petting Zoo where you can feed the billy goats and a Camel.
And then I think I see him. A young man in a New York Jets hat. I think that little shit. I push through the crowd. I call his name "Hey DeShawn!" The young man turns, but it's not my patient from the previous day -- the boy who faked the seizure to get out of school. It's someone else.
But then I think, hell even if it was him. Can I blame him?
Everybody ought to enjoy a fair in their lives. As often as they can.
Eat the mini doughnuts.
At the hospital, I notice his left arm turning in. Posturing. I overhear the doctor telling his daughter the prognosis is grim. She says she just wants him to be comfortable. I walk by the lighted X-ray viewer on the wall and see a scan of a brain with a large white patch in the middle of it.
***
We're called for an unconscious student at the high school. When we arrive at the classroom, I see a nurse with an ambu-bag in hand, kneeling by a young man who is prone on the floor, jerking asynchronously, arching his back, and slamming his arms against the floor. "He's been seizing for seven minutes," the nurse says. I nod and reach over and touch the student and say "Okay, time to stop." I help him to a sitting position and he ceases his activity. I help him to his feet and over to the stretcher, where my crew buckles him in. He is of course, alert and oriented. His pressure is 120/70. One of his fellow students brings him his jacket from his locker along with a New York Jets cap. On the way to the hospital "DeShawn" tells us his mother is out of the country and he doesn't like his step-father. The young EMT working with me tells the boy at least he probably won't have to go to school tomorrow. I see the student smile.
***
Unconscious elderly man found in a fetal position in his home by a coworker who went to check on him because he didn't show up at work. The officer tells us not to bother with the stretcher. When I enter the house I see why. There is clutter and junk piled to the celling. This is the home of a pack rat. The officer says he is in the living room, but to get to him, I have to snake my way through the clutter in the kitchen. The hallway is completely blocked. I find him amid a fallen pile of magazines. The coworker is as shocked as we are by the surrounding says she has never seen him like this. He is a vibrant man who every year wins sales awards at their office. He looks like a malnourished homeless man. I see a few liquor bottles around -- wine, vodka -- but there is no evidence of recent drinking. And no signs of physical trauma. His eyes don't focus. His grips are equal and there is no facial droop. No arm drift. Could he be a hidden drunk? He certainly manages to hide his clutter habit from his coworker. He struggles to tell me his date of birth. He says he drank last night. But I don't smell liquor on his breath. I wonder if he is also having a head bleed. His blood pressure is 180/110. I pick him up in my arms and carry him carefully through the narrow passages. He seems frightened like a small deer.
***
I take the next day off and take the kids to the Big E -- The Eastern State's Exposition -- New England's big fair. It's a beautiful day so nice I don't even mind the twenty dollar bills flying out of my wallet every time I turn around. Bumper cars. The Fun House. Smoked Turkey Legs. A midget roller coaster. Mini Doughnuts with cinnamon powder. The water gun races to see who pops the balloon first. Fresh squeezed lemonade. The barkers selling kitchen cleanup supplies. Miracle mops and knifes that never dull. I win a Yosemite Sam doll when the man fails to guess my age within two years. Throw the rings at the bottles to try to win an I-pod. More bumper cars. Watch chicks hatch from their eggs. See the sheep, cows and horses. The Haunted House. Knock over the milk cartons. Ride the Ferris Wheel as the sun sets. The Petting Zoo where you can feed the billy goats and a Camel.
And then I think I see him. A young man in a New York Jets hat. I think that little shit. I push through the crowd. I call his name "Hey DeShawn!" The young man turns, but it's not my patient from the previous day -- the boy who faked the seizure to get out of school. It's someone else.
But then I think, hell even if it was him. Can I blame him?
Everybody ought to enjoy a fair in their lives. As often as they can.
Eat the mini doughnuts.
Sunday, September 14, 2008
Run Forms
A fundamental tenet of the street medic is that you do not criticize another medic if you were not there on the call yourself.
Countless times I have had people come to me and tell me what so and so medic did on a call and can I believe how stupid they were.
But most of the time when you actually talk to the medic and hear first hand what actually happened, there is quite a different spin on the story.
The other problem with criticizing another medic is it always seems that shortly thereafter fate whips itself around and you find yourself in a difficult situation, doing something foolish yourself, and as it is happening, you know deep down it is payback for your dissing another.
I write all this as an introduction to a situation I find myself in that is a key part of my new part-time job as an EMS clinical coordinator. It is now my job to read run forms.
The run form police? Me? Oh my.
How do I handle this? How can I do one job and yet be faithful to my street medic creed?
This is how I am trying to handle it.
I say aloud, "I was not there. I do not know what happened. I cannot judge on what actually happened. But I can judge on the story you have written. You may have provided great care and I respect you for that, but what you have written here does not tell the story of your heroism, and we need to work on that."
I actually am enjoying reading the run forms. I do so at lunch. I go up to the cafeteria, get myself a turkey and bacon sandwich on rye with a slice of jack cheese and a leaf of lettuce, a bag of mesquite barbecue chips and a Diet Coke over ice and then back at my desk, I pull out the stack and I read.
I don't read the run forms red pen in hand. I read them as a true fan of EMS. Others may pop in DVDs of old episodes of Emergency, me I prefer (my eternal love for Dixie McCall aside) these yellow or pink carbon copies that tell tales of true life.
A well-written run form puts me right there on the scene. I see the sixty-three year old man, sitting upright, struggling to breathe. I can hear the rales in his lungs. Feel the edema in his feet and see the JVD in his neck. I am worried by the low pulse sat reading, the high blood pressure. When the medic squirts the nitro under his tongue it is as if I am doing it myself. I cheer as an IV line goes in on the first try and rise applauding as the medic straps on the CPAP, and the patient almost instantly begins to relax. Well done! Well done! Bravisimo!
The stories I have read! The medic does a 12-Lead. Huge ST-elevation and then a mad dash for the hospital ensues. The patient codes at the hospital door, but the medics are quick with the defibrillator. Boom! Boom! and a perfusing rhythm returns.
While others may talk about the latest episode of ER or what happened at the Olympics or the political convention speeches, I wish they could read what I have read so I could say "How about that call on the highway? Or the 3rd Degree heart block? Or can you believe the story of the unsigned DNR?
What is even better is if the patient was delivered to my hospital, I can -- right from my desk access the ED records -- to read the next episode -- what happened to the patient in the ED.
I hope the medics are learning not to run in fear from me as I pursue them, calling after them, "We must talk about that call on Main Street."
I don't want to get on them about how they left out the time of their 2nd set of vitals or how they misspelled "consciousness," I want to tell them what happened to the characters. He had a 95% occlusion of the LAD or she had a sub arachnoid bleed. Or she got a pacemaker and is doing fine. Or after ten days your cardiac arrest patient walked out of the hospital on his own.
What delight I get when I read a great case I can later share with all the medics at case reviews!
But sometimes I do have questions. I was reading your story and you gave your patient atropine. I couldn't quite follow why. Part of the narrative must be missing. Or it says you got a refusal, but you left out my favorite part where you try to convince them to go and you detail all the things that can happened to them if they don't. You might think it is boring, but I love that part!
I have never been the greatest run form writer myself, but I find that reading other's run forms is helping me improve the writing of my own. I am reading both masterworks and stories that should never leave the slush pile. Now on days when I am back on the street I am thinking of someone else reading my form and I am trying to do my best to tell them the complete story to make them feel as if they were right there beside me at the patient's side.
Countless times I have had people come to me and tell me what so and so medic did on a call and can I believe how stupid they were.
But most of the time when you actually talk to the medic and hear first hand what actually happened, there is quite a different spin on the story.
The other problem with criticizing another medic is it always seems that shortly thereafter fate whips itself around and you find yourself in a difficult situation, doing something foolish yourself, and as it is happening, you know deep down it is payback for your dissing another.
I write all this as an introduction to a situation I find myself in that is a key part of my new part-time job as an EMS clinical coordinator. It is now my job to read run forms.
The run form police? Me? Oh my.
How do I handle this? How can I do one job and yet be faithful to my street medic creed?
This is how I am trying to handle it.
I say aloud, "I was not there. I do not know what happened. I cannot judge on what actually happened. But I can judge on the story you have written. You may have provided great care and I respect you for that, but what you have written here does not tell the story of your heroism, and we need to work on that."
I actually am enjoying reading the run forms. I do so at lunch. I go up to the cafeteria, get myself a turkey and bacon sandwich on rye with a slice of jack cheese and a leaf of lettuce, a bag of mesquite barbecue chips and a Diet Coke over ice and then back at my desk, I pull out the stack and I read.
I don't read the run forms red pen in hand. I read them as a true fan of EMS. Others may pop in DVDs of old episodes of Emergency, me I prefer (my eternal love for Dixie McCall aside) these yellow or pink carbon copies that tell tales of true life.
A well-written run form puts me right there on the scene. I see the sixty-three year old man, sitting upright, struggling to breathe. I can hear the rales in his lungs. Feel the edema in his feet and see the JVD in his neck. I am worried by the low pulse sat reading, the high blood pressure. When the medic squirts the nitro under his tongue it is as if I am doing it myself. I cheer as an IV line goes in on the first try and rise applauding as the medic straps on the CPAP, and the patient almost instantly begins to relax. Well done! Well done! Bravisimo!
The stories I have read! The medic does a 12-Lead. Huge ST-elevation and then a mad dash for the hospital ensues. The patient codes at the hospital door, but the medics are quick with the defibrillator. Boom! Boom! and a perfusing rhythm returns.
While others may talk about the latest episode of ER or what happened at the Olympics or the political convention speeches, I wish they could read what I have read so I could say "How about that call on the highway? Or the 3rd Degree heart block? Or can you believe the story of the unsigned DNR?
What is even better is if the patient was delivered to my hospital, I can -- right from my desk access the ED records -- to read the next episode -- what happened to the patient in the ED.
I hope the medics are learning not to run in fear from me as I pursue them, calling after them, "We must talk about that call on Main Street."
I don't want to get on them about how they left out the time of their 2nd set of vitals or how they misspelled "consciousness," I want to tell them what happened to the characters. He had a 95% occlusion of the LAD or she had a sub arachnoid bleed. Or she got a pacemaker and is doing fine. Or after ten days your cardiac arrest patient walked out of the hospital on his own.
What delight I get when I read a great case I can later share with all the medics at case reviews!
But sometimes I do have questions. I was reading your story and you gave your patient atropine. I couldn't quite follow why. Part of the narrative must be missing. Or it says you got a refusal, but you left out my favorite part where you try to convince them to go and you detail all the things that can happened to them if they don't. You might think it is boring, but I love that part!
I have never been the greatest run form writer myself, but I find that reading other's run forms is helping me improve the writing of my own. I am reading both masterworks and stories that should never leave the slush pile. Now on days when I am back on the street I am thinking of someone else reading my form and I am trying to do my best to tell them the complete story to make them feel as if they were right there beside me at the patient's side.
Sunday, September 07, 2008
Straps
I may have mentioned recently that I started a new part-time job. I'm an EMS coordinator at a local hospital. I'm still keeping my full-time medic job, only I won't be working so much overtime. I haven't written yet about the new job -- I need to think more about the proper way to write about it. I obviously will have to keep the same confidentiality and fair play standards I have tried to keep when writing about EMS calls. In the meantime, the job affects this blog in that it I have less calls to chose from by only working the street 40 hours instead of 60-70, and I have less time to write. I hope to still post at least twice a week with at least one post being street material.
***
Today, I'm going to resort to an old trick that served me well as far as material in the past. Instead of posting a comment on another blogger's site, I'm going to use his post to riff on my own.
Again I turn to one of my favorite bloggers, Baby Medic, who recently posted Points of View, a thoughtful account of doing a great job medically, getting a STEMI patient to the cath lab, only to return to his ambulance to receive a "ticket" from a supervisor for not using all five straps (leg, waist, chest with connection to right and left shoulder) to secure the patient on his stretcher.
In general, I sympathize with Baby Medic on this. He did an awesome job, helping save a patient's life only to be met with demerits for not using all the straps. On the other hand, (maybe it is my new position talking), if you have policies, and you are going to enforce those policies, you have to be even-handed about it. You can't ticket only medics you dislike or only medics who provide inferior care if you are going to let medics you like and medics who provide great care get away with violating the policy. And far as policies go, if 5-straps are the safety standard, then you have to encourage the application of that standard.
Again on one hand, I understand the need for patient safety. Heaven forbid, you have a rollover and your patient is not properly secured. On the other hand, had that supervisor witnessed nearly every patient I have brought in for however long back, he wouldn't have enough ticket books to write me up with. I am, you see, a chronic violator of the 5-strap rule.
In fact, in the middle of writing this post, in which I will finally come down on the side of needing to properly secure patients, I did a call (an OD), in which I only used two of the 5 straps. I try not to be a do as I say, not as I do guy, but sometimes, it is what it is.
When I started in EMS in 1989, we only had two straps. Sometime in the early 90's we got three. We went to five sometime back -- I don't know maybe five or six years ago. I had a hard time with that new third strap. I have a really hard time with the 5-straps. By hard, I mean hard time complying, not hard time understanding the need. (I do love the five straps on boarded patients -- keeps them from coming off the board on decelerations).
Here's why it is hard. I work in high volume systems where care is largely provided during transport. Not just rare lights and sirens transports, but routine no L&S emergency transports. I get the patient, I get them in the ambulance, we get on the way to the hospital and I do what I have to do. It is hard for me to properly assess a patient with the five straps on, sitting them up to listen to lung sounds, getting an accurate 12-lead, or keeping them in a comfortable position when they are having a hard time breathing or are nauseous. This isn't to say, it can't be done, it is just often difficult. The same goes with the seat belt around my waist, which I confess I don't wear much either.
Maybe I need to change my ways. Maybe I need to do as much care as possible in the driveway or at curbside, and then when all is done, strap everyone up and say to my partner. We're all set. I do this only on occasion when I have certain unnamed drivers who I deem to be lead-foot, herky-jerky, take-my-life-in-their-hands drivers.
If I do use all five straps, I'll get one of those few movie, or coffee and doughnut coupons I have heard they at times pass out to people who bring in their patients in with the proper straps as a reward incentive. While at the same time, I'll be arriving at the hospital five or ten minutes later than I might have otherwise. In most patients, that won't make a difference, but in a STEMI like Baby Medic's, it may in fact make a big difference.
Years ago I use to work in a hardware factory on an assembly line. They run assembly lines at a speed a little faster than comfortable, which is the most efficient speed. Just enough to keep you working at your peak. Too slow and it is unproductive, too fast and it falls completely apart. We had three bosses -- each of which had different agenda. The time keepers wanted things done the fastest, the quality control person wanted them done the best. And the line supervisor wanted the best done product in the shortest amount of time.
One of our many projects was assembling door knobs and screws on a large paper sheet (30 or so door knobs to a sheet) that was then heat-wrapped and chopped into 30 individual door knob units all ready for sale.
The conflict came when the time keeper was on me or my co-workers to be more efficient in our movements, which to satisfy him, invariably led to poorer quality (the knobs would be laid down slightly off-centered), which caused the line supervisor to get angry because we'd have to rerun the sheet.
Me, I'd just shrug when they yelled at me and say, "I'm doing the best I can." If pressed, I would freely admit I preferred to err on the side of quality. (F- the time keeper.)
We do -- in this job of taking care of people -- the best we can. We need to do our best to do what is best for their safety. In almost all cases that will involve using those troublesome straps. But if I have a STEMI right now and I need a good 12-lead or set of lung sounds or whatever, I can tell you I will likely unsnap those top straps and may not get around to resnapping them. But I will try. I make that resolution today.
***
A question has been raised in the comments about how do we know the five point straps are actually safe. I admit I was taking that on faith alone. I have just looked up the web site of the noted ambulance safety expert Nadine Levick and found the following from one of her handouts:
"Firmly secure patients with over the shoulder harnesses. If medically feasible, have them sit as upright as possible for safety."
Here are two links:
Best Practices Interview
Objective Safety Home Page
Check Nadine Levick out, and if you ever get a chance to hear one of her lectures and watch some of her videos on ambulances classes, they will chill you to the bone.
Here's some comments of mine after attending her lecture in Baltimore last year:
Funk
***
Today, I'm going to resort to an old trick that served me well as far as material in the past. Instead of posting a comment on another blogger's site, I'm going to use his post to riff on my own.
Again I turn to one of my favorite bloggers, Baby Medic, who recently posted Points of View, a thoughtful account of doing a great job medically, getting a STEMI patient to the cath lab, only to return to his ambulance to receive a "ticket" from a supervisor for not using all five straps (leg, waist, chest with connection to right and left shoulder) to secure the patient on his stretcher.
In general, I sympathize with Baby Medic on this. He did an awesome job, helping save a patient's life only to be met with demerits for not using all the straps. On the other hand, (maybe it is my new position talking), if you have policies, and you are going to enforce those policies, you have to be even-handed about it. You can't ticket only medics you dislike or only medics who provide inferior care if you are going to let medics you like and medics who provide great care get away with violating the policy. And far as policies go, if 5-straps are the safety standard, then you have to encourage the application of that standard.
Again on one hand, I understand the need for patient safety. Heaven forbid, you have a rollover and your patient is not properly secured. On the other hand, had that supervisor witnessed nearly every patient I have brought in for however long back, he wouldn't have enough ticket books to write me up with. I am, you see, a chronic violator of the 5-strap rule.
In fact, in the middle of writing this post, in which I will finally come down on the side of needing to properly secure patients, I did a call (an OD), in which I only used two of the 5 straps. I try not to be a do as I say, not as I do guy, but sometimes, it is what it is.
When I started in EMS in 1989, we only had two straps. Sometime in the early 90's we got three. We went to five sometime back -- I don't know maybe five or six years ago. I had a hard time with that new third strap. I have a really hard time with the 5-straps. By hard, I mean hard time complying, not hard time understanding the need. (I do love the five straps on boarded patients -- keeps them from coming off the board on decelerations).
Here's why it is hard. I work in high volume systems where care is largely provided during transport. Not just rare lights and sirens transports, but routine no L&S emergency transports. I get the patient, I get them in the ambulance, we get on the way to the hospital and I do what I have to do. It is hard for me to properly assess a patient with the five straps on, sitting them up to listen to lung sounds, getting an accurate 12-lead, or keeping them in a comfortable position when they are having a hard time breathing or are nauseous. This isn't to say, it can't be done, it is just often difficult. The same goes with the seat belt around my waist, which I confess I don't wear much either.
Maybe I need to change my ways. Maybe I need to do as much care as possible in the driveway or at curbside, and then when all is done, strap everyone up and say to my partner. We're all set. I do this only on occasion when I have certain unnamed drivers who I deem to be lead-foot, herky-jerky, take-my-life-in-their-hands drivers.
If I do use all five straps, I'll get one of those few movie, or coffee and doughnut coupons I have heard they at times pass out to people who bring in their patients in with the proper straps as a reward incentive. While at the same time, I'll be arriving at the hospital five or ten minutes later than I might have otherwise. In most patients, that won't make a difference, but in a STEMI like Baby Medic's, it may in fact make a big difference.
Years ago I use to work in a hardware factory on an assembly line. They run assembly lines at a speed a little faster than comfortable, which is the most efficient speed. Just enough to keep you working at your peak. Too slow and it is unproductive, too fast and it falls completely apart. We had three bosses -- each of which had different agenda. The time keepers wanted things done the fastest, the quality control person wanted them done the best. And the line supervisor wanted the best done product in the shortest amount of time.
One of our many projects was assembling door knobs and screws on a large paper sheet (30 or so door knobs to a sheet) that was then heat-wrapped and chopped into 30 individual door knob units all ready for sale.
The conflict came when the time keeper was on me or my co-workers to be more efficient in our movements, which to satisfy him, invariably led to poorer quality (the knobs would be laid down slightly off-centered), which caused the line supervisor to get angry because we'd have to rerun the sheet.
Me, I'd just shrug when they yelled at me and say, "I'm doing the best I can." If pressed, I would freely admit I preferred to err on the side of quality. (F- the time keeper.)
We do -- in this job of taking care of people -- the best we can. We need to do our best to do what is best for their safety. In almost all cases that will involve using those troublesome straps. But if I have a STEMI right now and I need a good 12-lead or set of lung sounds or whatever, I can tell you I will likely unsnap those top straps and may not get around to resnapping them. But I will try. I make that resolution today.
***
A question has been raised in the comments about how do we know the five point straps are actually safe. I admit I was taking that on faith alone. I have just looked up the web site of the noted ambulance safety expert Nadine Levick and found the following from one of her handouts:
"Firmly secure patients with over the shoulder harnesses. If medically feasible, have them sit as upright as possible for safety."
Here are two links:
Best Practices Interview
Objective Safety Home Page
Check Nadine Levick out, and if you ever get a chance to hear one of her lectures and watch some of her videos on ambulances classes, they will chill you to the bone.
Here's some comments of mine after attending her lecture in Baltimore last year:
Funk
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