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.
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