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
Tuesday, November 25, 2008
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.
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