Thoughts on Ebola

 Working at the hospital and on the ambulance, it has been heavy duty Ebola lately. Memos, flyers, posters, policies, and lots of questions. I have written power points, given talks and had many conversations on Ebola. Every day I read the CDC site for updates, which are numerous. I have even, along with two of my daughters, played an Ebola patient in a hospital drill.

Ebola hasn’t been with us long, but already I am hearing a lot of people have Ebola fatigue. While the actual number of cases in the US is likely to remain small – at least in the near term -- I don't think we have heard anywhere near the last of Ebola.

Ebola is like a serial killer assassin who we believe is coming here to do some killing. We are not certain his target, but we believe, based on his rap sheet, he will most likely come after health care workers. We have set up roadblocks at airports, the most likely place Ebola is going to enter the country. We are quarantining people who are coming in from West Africa. In some states like Connecticut, we are quarantining people even if they are symptom-free, just to make certain Ebola is not hiding out in them. And, thankfully, we are hopefully training all of our responders in the proper use of PPE, and letting them practice in case Ebola shows up in our town and we show up on his scene.

Ebola is a tricky microbe. While he has us all busy up here in the US of A battening down the hatches to keep us all safe, he is doing his really nasty work down in West Africa. We can take all the safeguards we want up here, but unless we can stop Ebola in West Africa, we are going to be dealing with Ebola for a long time. Sure we can limit his damage and contain him in each isolated case that comes to America, but there will be more and more cases here unless we kick his ass in Africa and drive him back into the bats in the jungle from which he likely came.

Think about this. With, at the time only 2,000 cases of Ebola in West Africa, Ebola sent two exports out -— one to Spain and one to Texas. (Imagine if the guy in Texas went to a bar instead of a hospital, and there he got drunk, vomited, stumbled, hit his head, died and then someone lifted his wallet before calling EMS). The cases are increasing exponentially in Africa. People are dying in the streets and in crowded apartments. There are not nearly enough isolation centers to contain all the patients. The CDC has predicted there could be 1.4 million cases by January. 1.4 million. Wow. That's some heavy duty suffering. And for those who care only about this country, how many of those cases will be exported here? Imagine even if they don't get to the US right away, what if they get to India or China, countries that may not be able to contain Ebola like we can? More cases, more exports here. More chance we are in his reach. Millions dead and Worldwide Ebola's red laser on our foreheads the next time we walk into an unknown.

Those of you who have seen the movie World War Z may recall a scene where Brad Pitt and his family are eating breakfast in their home while on the small TV Zombies are eating everyone in sight. Think Ebola. I say load up the transport planes with building materials, IV fluids and PPE gear. Recruit doctors and nurses and paramedics and EMTs and send them in with combat pay. Here's a real chance to be a hero, to make a difference. You can go from being Meat in the Seat up here to Ebola Killer. You think you're an inner-city bad ass with a bullet-proof vest and an ET tube? Imagine yourself with a blue hood and cape on the continent where we all came from. Fighting for the future of civilization. Beat Ebola down in his own hood.

Isolate those with symptoms, give them the best care and most compassion we can, and trace their contacts. Isolate, treat, and trace on and on until there are no new cases – at least until the next time Ebola spills over from the jungle to people. Just as Ebola did last December to a 2 year old village boy. One two year old boy in December. 10,000 Ebola cases today. 10,000 is no easy task, but if we don’t act now, there will be 100,000, then a million. The math won't be working in our favor.

Tired of asking patients if they have traveled to West Africa? What question will be asking a year from now? It depends on how and where we respond today.

STEMI Call

 Years ago my favorite calls were the traumas-- the shootings, stabbings, high-speed MVAs. You were on the clock and there was a task list. You had to c-spine immobilize the patient, get their vitals, put in two large bore IVs, open up the fluids wide, and do it all on the go, as well as getting name, date of birth and social security number on your race to the trauma room.

After the initial rush, they were unsatisfying because the calls were over almost before they even started, and there wasn’t a real sense that what you did for them made any real difference. Their injuries were their injuries. It is hard to fix a bullet to the head, a broken spine or a torn aorta. And eventually we learned that the fluids wide open and even the c-spine were bad for the patient.

Today, my favorite call is the STEMI. It is also a clock and task call, but there are so many more tasks. Plus your recognition abilities are tested and the outcomes are much better. Do your job well and can make a huge difference. Screw up, either missing the recognition or not calling soon enough and the patient will suffer harm.

Here’s my vision of the perfect STEMI:

I get called for an unusual complaint, toe pain or vomiting or something not quite so obvious as “Man clutching chest, says he’s having the big one!”

My sixth sense tells me to do a quick ECG. Within two minutes of arrival, I have the patient’s chest exposed, and am running my 12-lead. It is not a huge honking STEMI with tombstone T-waves. No, it is subtle. Let’s say an isolated posterior, where I spot the inverted T waves in V1-V3. No hesitating a moment, I am on my cellphone simultaneous with tossing four baby aspirin in the patient’s mouth (after of course asking is he has any allergies.) On the phone, I call CMED, and request a phone patch with medical control for the STEMI Alert to my favorite cath lab hospital. As they connect me, I orchestrate getting the patient on the stretcher, after first having him stripped naked and have applied the defib patches, and then of course recovered him with the sheet. We are already moving down the hall when the doctor picks up. “This is Ace paramedic with a STEMI Alert requesting cath lab activation, " I tell him. "I have a 55 year old male with toe pain and a diagnostic 12-lead that shows a posterior STEMI with isolated T wave inversion in V1-V3. He says his father and seven uncles all died of MIs at the same age after experiencing the same symptoms. We’re twenty minutes from your door. I’ll transmit when I get down to the ambulance, but trust me on this one…”

En route, I bang in two large bore IVs, give the patient Zofran and Fentanyl (He’s vomiting now and in 10 of 10 pain that has now moved from his toe to his chest). His ECG has now popped an inferior with elevation in II, III, and aVF. I withhold the nitro to not risk knocking his pressure down. I get all his demographics while explaining to him what will happen at the hospital, how we will go right up to the cath lab and they will put him on the table and run a wire into his heart to clear the blockage. I stop the explanation only long enough to defibrillate him as he goes into sudden v-fib, but because I have the pads on already, I just shock him back to our conversation, missing only the slightest beat.

At the hospital, I hand the demos to the registrar and she chases after us with the bracelet. The ED staff bows as they signal for us to go right up to the cath lab. We are upstairs in a flash, and on to the table, where after the patient signs the consent with the pen I have already strategically put in his hand, cap off, ready to sign. Before we even have our stretcher out of the room, the interventionist (using the radial artery approach) has the wire across the lesion and the patient sighs and says, “Wow, I feel so much better,” and the cath lab doc says, you owe your life to these wonderful public servants. Door to Balloon 9 minutes, beating your old record of 10 minutes. Hats off gentleman!”

That’s how its supposed to go.

Here’s how my last one went.

Dispatched to MD’s office for “Confirmed STEMI.”

Now, keep in mind, I have been to many doctor’s offices for ECG changes that the doctor thought was a STEMI, but clearly were not. “Interesting, doc," I say looking at the ECG he has handed me. "How long has the patient had a pacemaker?” But in this case, the doctor’s office is actually a cardiologists’s office so "Confirmed STEMI" sounds much more likely.

Mentally, I psych myself up for the call. Got to make this qood and quick.

The Fire Department first responders are already there. There are in fact so many of them, I can barely make it the room. Someone hands me a 12-lead ECG and sure enough it looks like an inferior STEMI. ST elevation in II, III, and aVF, slightly less than 1 mm, but with a distinct cove shape as well as slight reciprocal depression in I and aVL.

I look for the patient now, and after clearing the room somewhat I find a fairly athletic looking man in his 50’s sitting comfortably in his chair. I introduce myself and ask how he is doing. “Fine,” he says. "I feel great."

He does not look like a man having a STEMI. I ask him if he is having any pain, nausea, shortness of breath? Nothing. How did you come to be here today? He says he saw his own doctor earlier in the day, and the doctor was concerned with his ECG so he set up the appointment this afternoon with the cardiologist. I ask why he saw his own doctor this morning. He says he wasn’t feeling well yesterday. He says he felt like he had the flu.

I have him strip down and get him in a gown, then attach him to my monitor and start taking him down to the ambulance. I did not get a chance to speak to the doctor directly, but the staff tells us to take him to the cath lab at their affiliated hospital. They will be expecting him.

In the ambulance, I do my own 12-lead so I can transmit it to the hospital. Not certain that I have to, since the patient is apparently already scheduled to go there, but it is protocol, and you never know. I do my 12-lead and it looks like this:

I look in the lower left at my inferior leads and I only see elevation in one lead, and the corresponding lateral depression is gone. I re-check my placement. It is pristine. I ask the man again about how he feels and he says he is fine. No symptoms. I ask about family history. None. I start to wonder if maybe the 12-lead placement in the doctor’s office was screwed up. I transmit the 12-lead calling in a STEMI alert, telling them we are en route to the cath lab. I mention that the patient is asymptomatic and my 12-lead is no longer showing the clear STEMI the doctor’s office ECG was. They tell me they are familiar with the patient and I should continue to the cath lab.

Meanwhile, I am trying to get an IV, and having difficulty. The first blows. On the second, the catheter bends on the patient's tough skin. On my third shot I have dropped from an 18 to a 20 to a 22 which is all I can fit in the one vein I can find in the wrist. At least this one is good.

I ask the patient again how he feels and he assures me he has never felt better. I open my mouth then and say, well, maybe his arteries will come out clean and this all just a better safe than sorry deal. I feel great, he said again, putting conviction into it.

When we arrive at the ED, their first question is did we patch? Most certainly. I have the name and social security and DOB all set for the registrar, but they are training a new registrar and tell us to wait. When I tell them we are supposed to be going right up the cath lab, I am able to leave my piece of paper with them so they can enter it.

Up in the cath lab, the team is waiting for us. They ask if we have registered the patient and we say yes, we left the information with the registrar. They demand to know why the patient doesn’t have a bracelet on. We repeat that we registered them. More argument until someone announces the patient's name is in fact in their system now so they can begin their procedure. The doctor comes over and I hand him the ECG and tell him the patient is asymptomatic. He stares at the ECG as well, then begins the questioning. At first the patient denies the symptoms, then under grilling he confesses that it feels like someone is sitting on his chest, and that he was sweaty earlier and also felt nauseous. My partner and I just shake our heads and remain silent. It never ends. The man has a hairy chest and the leads are coming off. One of the nurses plucks at them so my partner goes ahead and takes the man off the monitor as we prepare to move him to the table. Another nurse looks at me and demands to know why I took him off the monitor before they hooked him up to theirs. Again, I just shake my head, thinking why are you yelling at us?

We get him over then sure enough, as they look for what kind of access I obtained, they see the 22 and the harassment starts anew. "A 22! That's all? A 22!" We don’t bother to stay to watch the procedure. We just pack up our stretcher. On the way down in the elevator, I say to my partner, "10 times I asked him if he felt anything but fine." "What are you going to do?" my partner says.

The call is completely unsatisfying. Last time we went up that lab we were heroes, treated like honored guests. Today we are just bumbling delivery workers. I sit in the ambulance and stare at the ECG. I still can’t figure it out. There is elevation where there should be depression and no elevation where there once was. It takes me 10 minutes of starring at it to figure it out.

The first six leads are completely scrambled.

Lead I is where Lead II should be, lead II is where aVR should be, lead aVR is where III should be, lead aVR is where III should be, aVL is where I should be, and aVF is where aVL should be.

F-me, I say. Can you believe this?

I think what would have happened is I had this guy on the street, presenting like he was, denying any problem and this was his ECG. I would never have called it a STEMI. Good thing he was already booked for the cath lab.

Back at the base, I report my monitor malfunction and have the monitor reprogrammed. I go into archives and I am able to retrieve the 12-lead now in the proper order.

In 20 years, I have never seen anything like this. I find an ECG from earlier in the day and see it too was scrambled. I find one from two weeks before with the same monitor and it was proper.

I can only think of 2 explanations. 1. There was a computer glitch or 2. Someone went in and reprogrammed it.

You get so used to seeing things a certain way, you don't notice the lead labels anymore.

Ebola

 Virginia suddenly started dying from what turned out to be the only strain of Ebola that doesn’t affect humans. A great read and thriller that I highly recommend.

Over the years I have followed the periodic outbreaks of the Ebola virus that all were fairly quickly extinguished. I also read another great book called The Coming Plague: Newly Emerging Diseases in a World Out of Balance by Laurie Garrett about emerging infectious diseases, which I also highly recommend.

There are few who are not aware of this current outbreak of Ebola, which continues to escalate and for the first time reached this county with a patient found in Texas, although most believe this additional cases that may reach us, will be fairly easily contained because of the health care structure here, higher sanitary standards and the cooler climate. Let us hope so.

Let me try now, based on what I have read to describe how the Ebola outbreak happened and why it has been so bad, as well as make some predictions for the future.

Ebola may have lived in the jungle for millions of years. Although its natural reservoir has not been found, most believe it likely lives in bats. A bat with Ebola eats some fruit, which it drops while flying. A chimpanzee picks up the fruit and eats it, getting some of the bat's saliva in its mouth, and then the chimp gets sick and dies. Perhaps in more recent days, a hunter comes along and eats meat from the freshly deceased chimp. The hunter gets sick and dies alone in the jungle, or returns to his isolated village where half the tribe will die because they believe they have angered the spirits. Life goes on.

Fast forward to the modern world. The jungle has been deforested, roads have been built. The dead monkey is now brought into the village, where it is eaten by several people, who infect other members of their families. Hand washing is not a norm in their culture. One of them, who does not yet know he is sick, takes the road to the next village, where he becomes ill and spreads the disease to others. Soon Ebola is in the city, and the fear is it is next on an airplane and landing in New York City or an airport near you.

Typically, in past cases as soon as there has been an outbreak, health workers have quarantined the sick and traced all of their contacts. This time the system broke down. There weren’t enough workers and in some cases the workers who all arrived in yellow suits spooked the villagers who thought that perhaps the workers were the ones spreading the disease. People hid in the jungle or hid their symptoms. Some visited a bush doctor who declared she could heal the sick. There was lots of hands on attempts at healing. She died along with most she had contact with. In one area armed men attacked a quaranteen center believing the doctors were evil. Other health workers were macheted to death by those who blamed them for the outbreak. Infected patients fled.

Ebola is spread by body fluids -- saliva, blood, vomit, feces, urine, perspiration and by prolonged touching of the dead body. In Africa, when someone dies there is a lot of touching and cleaning of the body. Also, in Africa, the hot humid climate contributes to perspiration and makes cleanliness difficult. There is a lack of medical supplies and beds for sick patients. They die because Ebola cripples their immune systems, the vomiting and diarrhea lead to dehydration. They are ravished by infections, their organs fail. Bodies are not disposed of properly. The virus spreads again.

The Americans who have gotten the disease and survived likely survived not because of the “miracle drug” they received, but because they got first rate medical care, hydration, electrolyte replacement, and antibiotics in a timely fashion. Fluid replacement is critical to survival.

Many fear the the worst case scenario is if this strain of Ebola mutates (Ebola as an RNA virus is subject to constant mutation) into an airborne contagion. There reportedly was a study that showed the virus was passed by pigs to monkeys through a respiratory droplets, but I have also read that they don’t know that the disease might not have been spread in another manner, passed by unclean conditions in feces from one stall to the next.

I am currently reading a third recommended book called Spillover: Animal Infections and the Next Human Pandemic by David Quammen. Ebola is a zoonotic disease, meaning a disease that has jumped from animals to humans -- like SARS, avian flu, rabies, Lyme Disease and Hanta Fever. According to Quamman, these zoonotic diseases are becoming more and more prevalent as we humans disrupt the natural world and allow these diseases the opportunity to catch a ride on humans. He cites a great example of the opportunity for a disease to jump to humans. Cities and villages disrupt the forest, bats now live in closer contact with humans. A farmer builds a giant pig stockade under a mango tree that is home to many bats. A sick bat eats a mango that drops to the pig pen. The pigs eat the saliva infected fruit. The pigs live in close quarters with each other and then are shipped all over Asia, again stored in tight dirty quarters. Feces is spread from one pen to the next. A rule of epidemics is population density increases the threat of the spread. Walla!

With regard to Ebola, he makes an interesting observation. He says Ebola is not very contagious but extremely infectious. By this he means, you can sit in a crowded room with someone with Ebola and perhaps no one else in the room will become infected, but should you give the Ebola patient an Iv, and accidentally prick your finger, you could be dead in seven days without proper care.

Generally Ebola is not contagious until it turns symptomatic. The fear again is someone who is not symptomatic gets on a plane, and becomes symptomatic shortly after landing. (One of the American doctors had been scheduled to return home a few days before he became sick, but was delayed so he was still in Africa when he became symptomatic). When someone fits this scenario, what if they believe their symptoms are not due to Ebola, but perhaps a common cold or the flu? What if in fear, they deny their symptoms instead of seeking immediate help. We need to be ready.

What are the symptoms of Ebola? The key early symptoms are fever, sore throat, and body aches, followed shortly after by abdominal pain, vomiting and diarrhea. GI and mucosal bleeding comes later. Some people develop a rash. Patients will go into shock before death, and become listless. Oddly, hiccups can be a telltale sign.

For EMS providers, according to the latest CDC advisory, we should be on the alert for patients who are both symptomatic and who have risk factors such as recent travel in an area ravaged by Ebola.

As I mentioned because it is an RNA virus, it mutates easily. Perhaps it may mutate into a less lethal disease, which while good on one hand, would mean it would then have a greater chance of spreading and staying alive in humans, while causing great although not as lethal suffering.

One of the books I read said we need to not view Ebola as invading our world, but as humans living in Ebola and other microbe's world. We are both prey and a vehicle for Ebola’s survival. If it kills us too efficiently without finding a way to spread to others, it will not survive in humans.

Two things I predict in the near future, we will see more Ebola cases in the US. With luck, these people will be quarantined(the government has this power), and their contacts checked, and excellent care given them, and the spread will be minimal. Nigeria has reportedly done a great job at halting the spread of the disease in their country through such measures. Liberia and West Africa lack the infrastructure to do this, thus the disease continues to rise there, and will until sufficient resources gain traction. I also predit shortly after out first case of Ebola in Texas, we will experience an even greater number of Ebola scares or false alarms that will test us.

What will you do when the dispatch comes for the man vomiting blood recently arrived from West Africa? What will your partner and the first responders do? How will the hospital staff react? How will your friends and family react to you when you tell them about the call? Will they even let you in the door? Or maybe out of fear for your family, you won’t want to possibly risk infecting them. Where will you go? (It is good to keep in mind if you are exposed, you have time to go home have a nice family dinner, and then back your suitcase before you are at risk of infecting your family.)

Chilling times.

I don’t think Ebola will be the end of the world for us here. The fact that for the most part the disease doesn’t spread until it is symptomatic (although it stays in the semen of men who have recovered from Ebola and can be passed sexually for up to six weeks) heightened awareness, cooler temperatures, different habits, hand washing, and a strong public health structure should protect us.

I said at the beginning I would make a prediction for the future. Here it is. At some point in the future, a super deadly disease will come out of the jungle and wreak havoc worldwide. Imagine an Ebola like illness that spreads through the respiratory route but stays hidden in the body while still being contagious. HIV came out of the jungle, caught a ride on a dirt road to the city or came downriver on a canoe, and then jumped a plane to the modern world, and 30 million have died with another 30 million infected. The coming plague that Laurie Garrett writes about in her book and the others have talked about may be among us one day. I don’t think Ebola is it. From what I have read, what experts fear the most is a pandemic flu that spread across the world in a matter of days.

All we can do is plan and prepare.

Here is the latest CDC guidance:

EMS patient assessment criteria for isolation/hospital notification are likely to be:

1. Fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding.

AND

2. Travel to West Africa (Guinea, Liberia, Sierra Leone, Senegal, Nigeria or other countries where Ebola transmission has been reported by W HO) within 21 days (3 weeks) of symptom onset.

If both criteria are met, then the patient should be isolated and STANDARD, CONTACT, and DROPLET precautions followed during further assessment, treatment, and transport.

IMMEDIATELY Report Suspected Ebola Case(s) to Receiving Facility.

Source-CDC

Check out these links for more CDC Ebola Advisory Information:

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States

CDC EMS Checklist
Stay safe.

Streamline

 This is the first I have written since May. I did not mean to stop writing. I had many thoughts, but just never got around to putting them down. Why no posts? A variety of reasons, primarily time. As I get older I find myself less sure of myself and my ideas. I can spout anything, but it takes time to write well and with reason. I want what I write to be considered and thoughtful. That takes the time to sit down and write and rewrite.

I do not have the full energy that I used to have. Now after work or even at work between calls, I no longer take advantage of the time, what little there is. At home I sit on the couch and talk to my family or watch TV. I am big into cooking shows. in the ambulance, I simply try to stretch my legs and relax a little.

I have two jobs as I have written about previously. Sunday, Monday and Tuesday, I work the ambulance in the city from 5:30 to 17:30, although I often don’t get out till 18:30. When I first started working there twenty years ago, three days in the city wore me out so much I usually spent the next day home in bed all day resting. Now, I go to my hospital job. And where years ago, in between calls, we hung out with other crews in parks or at stations, now it seems we are always on the move, if we are not doing a call, we are driving to a post, usually getting a call before we get to the post or are redirected to another post. You can not do a call for two hours, yet still spend those two hours driving in traffic from one post to the next. I am six foot eight. I used to be six nine, but life has beat me down a bit. The front of the ambulances are getting smaller and smaller faster than I am getting shorter. I had a bout of plantar fasciitis a year ago that made my first steps out of the truck excruciating, but the feet are better now. Still, I don’t get out as nimbly as I used to. It is not unusual for us to respond to 10-15 calls in a shift, and from those do 8-10 transports. We get a fair number of cancels or diversions from one call to the next. We carry these pagers called Zip-its now that emit an annoying beep every time we get a priority call (you can't put the beeper on vibrate for priorities), which can be frustrating as we try to respond on the radio to three different dispatchers (company dispatch, city dispatch, CMED dispatch) all while trying to figure out where we are going, and hit the little buttons on the Zip It to get it to shut up. Some times the Zip-Its go off while we are in the triage line at the hospital or while we are giving a report in the trauma room to a doctor. We have to call dispatch and say we can’t respond to the next call because we are still on this one.

Times are hard in health care. Less money, more work. ED staffs are strapped, and so are ambulance companies. No rest for the weary. And the calls, sure there are some challenging ones, but the non-urgent ones continue to dominate. We have gone to a closest car responds rather than a more nuanced approach of maybe sending the BLS car to the intoxicated person, and leaving the medic free for another, possibly more serious call. The calls lately have been typical: 0ld person too tired to get up, young person with a chest cold too uninformed to get medical care anyway but through the 911 system. Some dogs start to look like their owners. I look like my patients sometimes. 56 year old man close to being too tired to take another step who also has a chest cold.

In my twenty years I have gone through phases of burnout, and recovered each time, so I am not worried that the true love for EMS inside me will fade away. I am lucky now that recently I have been paired at least two days a week with an old partner of mine – a man of my age who has a good spirit and sense of humor. It helps when we are sent on a wait and return while BLS units are calling for medics to have someone you enjoy working with, to pass the day with. We have a good time, cracking jokes and getting laughs out of our patients, believing ourselves comedians.

Wednesdays through Fridays and certain Tuesdays (which I take off from the ambulance job to work the hospital job), I work as a clinical coordinator. The hospital is near my house and I have a great boss. I get to work on many interesting projects. Still, the longer I am there, the more projects I get put on. My to do list includes STEMI Door to Balloon Stats and agenda, stroke reports and stroke workbook, trauma data and pain management project, EBOLA talk, patient handover research projects, 12-lead Exams, coming up with a plan to curb linen loss, EMS breakfast preparation, as well as handling day to day QA, followup and fires to be put out.

I go in very early so I can get some quiet time to work before the crews start coming in. My office is in the EMS room, and I enjoy hearing the crews talk about their calls and their thoughts about the system. I try to get home while the sun is still out so I can take my six year old daughter to the park or to the pool. Of all the time I have to spare this is the most precious to me. At night, we read to each other. We just finished reading the Odyssey (kid's version), which I was thrilled she enjoyed. She was fascinated with the idea of the gods living up on Mount Olympus, and messing with the mortals's lives below. She also thinks Oddysseus is very clever. She liked the Trojan Horse and how he outfoxed the Cyclops. She thinks Oddysseus's nemesis Posiden is very mean.

The last thing I have been doing with my time has been swimming. Every night on the way home from the ambulance, I stop at the pool (we have a great indoor aquatics center in our town very near my house). I was on a swim team when I was ten. Other than that I have over the years swum laps at a slow steady pace. I stumbled into a masters swim program last November in place of running (due to the plantar fasciitis) and fell in love with the workouts and the swim coaches pushing me to swim harder. One coach in particular told me I had the natural build of a swimmer and if I worked hard I could become really fast. With encouragement, I worked hard over the winter and into the spring, and managed to qualify for the World Masters Championships in my age group 55-59. I qualified in the 50 meter freestyle by 1 one hundredth of a second and in the 100 meter freestyle by 3 one hundredths of a second. Since the World Masters Championships were held in Montreal this year and Montreal is only a five hour drive from Connecticut, we decided to do a family vacation there.

It was great, although there was pressure on me as the rules of the event were if you did not surpass the qualifying time in your race, you did not get an official time. Fortunately, I managed to make it.  In the 100 meter freestyle I finished in 1:17:45. In needed 1:18:00 to get an official result. I came in 105 of 123 who raced.  Only 108 made the time.  That's me below in American flag cap..  They had swimmers from 97 countries there.

 

In the 50 meter freestyle, I had to get 34:00 to get an official time. I  made the time with 33:59 and also won my heat.  Overall I came in 95 of 125 who raced.  Only 99 made the time.

While in Montreal, I also got to sample some of the local delicacies, poutine (french fries with gravy and cheese curds) smoked meat sandwiches, horse meat, and Montreal bagels, which have sesame seeds on them and are lighter than American bagels. We also ate at several of the gourmet food trucks Montreal is famous for.

This is perhaps a bit of a tangent away from EMS, but the point is, everyone needs to step away. Swimming (and my family) are that for me. All day at work, I think about getting in the pool. I put on my cap and googles, then climb on top of the starting blocks. I take the start position, then spring (or spring at least as well as a stiff old man can) diving into the water, gliding through the clear aqua blue in streamline under the surface. I feel like all the grime of the city is being washed off me, and my soul and heart are being cleansed. An hour later I am home relaxing, laughing with my children, cooking dinner, then sitting down on the couch and resting. I like to be in bed by 9:30, so I am not too tired to do all over again the next day.

It is Saturday morning now, and the kids are eating cereal and watching cartoons. I think if there is a time for me to write weekly, this is it. If I take advantage of the time, I may be able to start posting again regularly.

In a few minutes, I am going to shout, “Come on kids, get your shoes on, we’re going out." We have a lot on the agenda today. Mini-golf, apple-picking, stop in the pet store to think about what we are going to get when Spike, our beta fish, dies (he has lived most of the summer, but is looking tired these days, resting on the gravel more and more rather than flashing all about) soccer in the park, ice cream, swimming at the pool, and then cookout at home. Maybe even a beer for me. I have become found of the Shock Top Belgian White (I limit myself to one. Two interferes with my sleep, three leaves me tired. I only go for 4 or beyond if I am on vacation and can sleep in or better yet, lay on the beach). Hopefully I am in bed by 9:30, my work clothes and boots laid out for my early morning rise.

Breaker of Men

 We find our patient by the elevator doors in a public building. He is on all fours, dry heaving, and shaking. He says he is in terrible pain. Security tells us he is a visitor to this public building. They don't know anything about him other than that he has been screaming that he is in pain. I do my best to assess the patient. He is alert, with warm, dry skin. His pulse is in the 90's. His abdomen is soft. I tell him we are going to get him on the stretcher and examine him further, and depending on a number of things, we hope to be able to help him. He continues to squirm. He is in his forties, wearing, shorts and sneakers and a tee-shirt. He seems oddly out-of-place. I ask him if he has ever felt this pain before. He says yes. I ask him what caused it on those occasions. He says he has gastroenteritis. In the elevator, he tells me he has no allergies. In the ambulance, I take his pressure and find it within normal limits. I am going to give medicine. I take my patients (for the most part) at their word. Yet, my twenty years experience suggest to me that this man falls into the category of drug-seeker.

I have no doubt but that he is in pain, and as I said, I am going to medicate him. I just wonder at the quality of his performance. The manner that he contorts himself and screams that the pain is killing him and that he is burning are both true to real pain and true to performance pain.

He seems almost like a dog who knows he has to perform in a certain way to get his bone. Or a court jester who has to put on a good show to avoid being kicked by larger men. I get the feeling that while there is passion in his performance, there is no joy. He is doing what he does in order to survive.

"What are you giving me?" he says as I slowly push the plunger on the syringe. "I like Morphine."

"Well, too late. It's Fentanyl," I say. I give him a 100 mcgs, and I watch his whole body relax and he slumps back on the stretcher, and closes his eyes. This is truly one of the better responses to Fentanyl I have seen.

I was expecting to give him at least 200, but the 100 does the trick. In the ED, he sleeps curled in fetal position in dreamland.

I have to say, I have rarely regretted giving pain meds to any of my patients. And I have no doubt medicated many a "drug-seeker."

Do I care if I have been played?

I don't. My job is not to be the Judge Wapner of Drug Seeker Court. My job is to treat my patients as compassionately as I can and bring them to the ED where if they are a drug abuser, they can hopefully get more detailed care aimed at breaking their cycle of dependence. And if they are not a drug abuser, then I have not withheld treatment.

I write about this case in particular because of a pain policy I read recently that comes out of LA. Here are two passages I find striking.

1). Pain changes human behavior. People performing torture have long known that the intentional inflection of pain can cause a person to behave in ways that they normally would not behave just to avoid the pain. Pain is very powerful. Chronic pain changes personalities. People who have been happy and kind their entire life before being subjected to chronic pain (such as arthritis or an old injury) have been known to become irritable, angry and unsociable.

2). Addiction is a very real problem and treatment is very complex. One thing is certain, the treatment of drug addiction is not in the paramedic scope of practice and the withholding of narcotics by a paramedic is not going to end an addiction. It is better to give narcotics to 100 addicts than to deny pain management to a single patient who is in real pain.

Watching my patient contort and squirm and cry out for his medicine made me wonder what he was like before pain got a hold of him, before pain broke him, and turned him into what he was there before us. How often has he had to perform? How long as he had to find creative ways to get the medicine to fill that broken space in him where once he was whole?

Read this document:

Los Angeles Prehospital Pain Management Policy

Bravo to its authors! And while maybe they might want to consider letting their medics give narcs on standing orders, their policy has much in it to emulate.

***

I hope to write more about pain in the coming weeks, including about the raging war between the anti-drug overdose group and those who advocate for humane treatment of those in chronic pain.

Whup Kits and Chihuahas

Many of us in EMS love gadgets I remember when I started another EMT sold me a "whup kit," which was a holster that attached to my belt to hold my tools. I didn't get a big one, just a modest sized one. It held a pen light, trauma shears, bandage scissors, tweezers, and a window punch. I stopped wearing the whup kit after a month or so. I only ever used the pen light and the trauma shears on any kind of regular basis.

I also remember back then how much I liked c-spining people. There was a craft to it. We didn't have head blocks then, so we rolled our own towel rolls. You folded a bath blanket into thirds length-wise, then rolled it tightly and taped it with adhesive tape to hold it firm. It was a skill to secure someone to a board. I never did it half-assed, at least not in those early years when we truly thought we were preventing people from paralysis.

There was a pleasure in using equipment, be it a spinal board and towel rolls or a window punch (which I did use once) that made me feel like a craftsman. How I used to enjoy opening my intubation kit, taking out the laryngoscope and clicking in blade after blade to make certain everything was working properly. I even remember briefly for a period entertaining buying my own intubation kit, much like a plumber or carpenter has his own set of tools.

I remember how much I used to like going to EMS Conferences and checking out all the new gizmos, and hoping that some would make their way to my ambulance. And some of the gizmos we have gotten over the years have been great AEDS, pulse oximeters, glucometers, capnography, EZ-IOs, CPAP, 12-leads, power stretchers, stair chairs with tracks, intranasal atomizers. Still many of the conference gizmos disappeared, or just haven't proven their worth.

I remember I came back from one conference l was all fired up about the ResQPOD. I attended an educational session where the presenter made an outstanding case for it. He was an impressive speaker, and did not appear to have any agenda beyond improving patient care. Only later did I learn that all the studies he cited, including some he had co-authored, were also co-authored by the device's inventor. In time, I learned that all the studies that the inventor had authored were positive, while most of the independent studies showed there were issues with the device. I felt a little burned by this because I had beaten the band for the device in presentations of my own, and once I realized and learned to examine the literature for myself, I felt like I had been played for a fool.

One day I learned that a large first responder service in our area was going to be using the ResQPOD. This it turned out was news to the service's sponsor hospital, who put a quash to it. Nevertheless, bizarrely, a member of Parliament over in Great Britain made a speech to that distinguished body about how a city in Connecticut was using this exceptional device, in condemning a British medical director for removing the device from a local service in his district.

ResQPOD Goes to Parliment

The local fire department here, like many, had fallen prey to a vendor's claims without having the ability to thoroughly understand the research. This is a problem many sponsor hospitals in our state have vendors sell the services on their products, and the services buy them, and then the local hospital says, I don't think so.

At one of regional meetings, we used to have vendors come in and demonstrate the latest products. A salesman came in to talk about the ResQPOD. While I have been impressed by many of the vendors, this salesman was not good at his work. He lacked the medical knowledge to answer our committee's questions, falling back on the superlatives in his sales literature. Although it is funny, I remember him at the time saying the ResQPOD was far better for the patient than epinephrine! Perhaps he was a seer. Maybe today, it can be argued, it harms fewer patients in cardiac arrest than epinephrine does.

I remember not long after the disastrous meeting, the salesman forwarded all members of the committee an article from USA Today, about a man who suffered cardiac arrest. The family Chihuahua started barking and alerted family members who quickly started CPR and called 911. The patient received defibrillation and CPR, including the ResQPOD.

Take Heart America

The article said the patient had a full recovery. The salesman's note said:

see attached article that was published in the USA Today the other day. Just another source for validation. SAVE LIVES NOW!!!

Please let me know if we could set up a time to discuss this further

One of the doctors wrote back:

That was a very provocative article. The evidence was compelling. I think we should launch a campaign to have ever household buy a Chihuahua which clearly is a life saving device. I am not sure if it would be entered in to our database as witnessed arrests or not.

More on the ResQPOD in a minute.

The big device that has been sweeping the EMS World in recent years are the CPR machines. The theory behind these contraptions makes a lot of sense. Good CPR saves lives. Why not make a machine that can do perfect CPR? Yet the studies, and there have been quite a few now of fairly high repute that are not showing this theoretical advantage is bearing fruit. It seems the best that can be said is the machines are as good as human CPR so why have people do it when you can rely on a machine?

For excellent commentary on the recent study involving the LUCUS device, see the following posts by Rogue Medic and Brooks Walsh in Mill Hill Avenue Command, who are far better at analyzing these studies than I am.

Failure of LUCAS to Improve Outcomes in LINC Trial

We Had a LUCUS Save!” No, You Didn’t.

In our region, we addressed the machine issue a few years ago by saying services could only use them with their service’s sponsor hospital’s approval, and then only after comprehensive training to ensure there were no delays in applying them. Several hospitals found themselves in the position of being told by their services that they had already paid the $10,000 each or so for the machine, and so at least one hospital that was not going to approve them, gave reluctant approval.

The services all seem to love the machines. Their members boast of amazing pulses during CPR and an increase in ROSC, but we have seen no evidence of improved neurological outcomes. All the saves in the service I most directly oversee have come from witnessed arrests of people aged 40-69, in public, who get bystander CPR, and early defib, and not much if any epi before they come around. We have no saves we can attribute to the machine. And as far as prolonged CPR, we have a case of a man who got nearly 20 minutes of human CPR on scene before the ambulance could arrive and defibrillate him. He survived neurologically intact.

Some say, well, the machines are great for transportation. Responders are less likely to get hurt, You can do CPR while carrying someone down the stairs. All of which may be true and be a worthy use of the device. But, in our region, we now work nearly all cardiac arrests on scene. We have no cases at our hospital of patients whose arrest precipitated a 911 call, being revived in a moving ambulance, and later walking out with full neurological recovery.

We just approved our state going to Cardiocerebral Resuscitation, which emphasis continuous quality chest compressions. Included in that document is a reference to the CPR machines.

Delay application of mechanical device until 5th cycle of CPR unless it can be reliably applied in less than 10 seconds, without delay in compressions.

During the debate, Brooks Walsh spoke up, and started to question the utility of the machines at all. While I agreed with him (as I do on most issues), I spoke against deleting it because the document was a consensus document, and many of the players had already spent a great deal of money on the machines, which they use extensively in their systems, and were unlikely to approve their elimination. I just wanted to get the document done.

My personal belief is that while the machines may save some people, they likely kill as many through the delay in application. When we arrive, these patients in cardiac arrest are on the precipice of no return. They may not have 30 seconds or even 10 more seconds without perfusion to spare. I believe what we do in those first few minutes makes the difference, not the quality of the CPR as we bump down the road 30 minutes later bringing another dead body in to have the time called on it officially.

I would on another day bring the issue of the eliminating the machines back up for discussion, along with getting rid epinephrine in cardiac arrest, unless the literature changes to show clear benefit. I like to pick battles I think I can win, or if not win totally, get to a compromise position I wouldn't have otherwise gotten to without first extending my argument.

The problem with the machines is that they are so expensive and so many services have already shelled out for them, it is hard to just say no. Despite the lack of evidence of benefit, their supporters persist. I was amused to hear that some have even linked the CPR machine with the ResQPOD and saying it is possibly the combination of devices that make the difference. Maybe it is. But I would like for once, to have it proved. I am all for quality research trials for these devices. But the selling and the buying should halt until their worth can be proved.

Perhaps we should add a Chihuahua?

And speaking of research, instead of seeing all the research center on these expensive devices, I'd like to see the research funding go to questions that likely matter more such as does epi hurt or help? But there is not as much money in epi as there is in CPR machines and ResQPODs. 

BLS Narcan

 There was a recent editorial in the Hartford Courant, First Responders Could Help Cut Heroin Deaths, citing the rash of recent heroin deaths and calling for all first responders to be equipped with Narcan in order to stop the rise. Narcan is provided to first responders in some of our neighboring states, and the editorial writer thought this should happen here as well. It is my understanding that there is a strong political push, some of it coming from the substance abuse community, for such a proposal.

Heroin Related Deaths Up Sharply in Connecticut
Many months ago, we debated BLS Narcan at our state EMS medical advisory committee and despite, what I thought was a well put together proposal, the effort was knocked down very soundly. The reason seemed to be responders have ambu-bags, Narcan is often misused, and if the patient is hypo-ventilating a paramedic should be on the way anyway. Additionally, there was some fear of BLS creep, diluting the paramedic arsenal, and thus the need to have paramedics, which could lead to an overall deterioration of care for all patients. All points largely true.

 

As far as Narcan misuse, I can say that my data in reviewing prehospital care as an EMS Clinical Coordinator and anecdotally talking with other paramedics about calls they have done involving narcan, shows that yes, it can be misused by paramedics. (But with education, we have seen the number of misuses drop considerably.) Generally, the misuse stems from two situations.

 

1) Patient who is unresponsive with pinpoint pupils, but breathing fine. (We used to give Narcan in this situation for "coma of unknown etiology" and our guidelines at the time (1990s into mid 2000's) stated there were no contraindications for emergency use) and

 

2) Person who took heroin, who is altered, but breathing fine. The reasoning seems to be, they are altered, they took heroin, which is bad. I am going to give them Narcan and knock the bad heroin out of their system and wake them so they can admit they used heroin so I will know for certain what is going on. (Not good reasoning from health care providers, whose role is to do no harm.)

 

When operating under the old guidelines, I can say, there were times I did harm to patients. I gave multiple doses of Narcan to an unresponsive patient who, while now breathing on his own, still did not wake up, and was soon in pulmonary edema. I gave Narcan to a paraplegic (due to an old gunshot injury) and wiped out his pain meds while doing nothing to resolve his UTI, which was the true cause of his unresponsiveness. I misdiagnosed a stroke (I called off the stroke alert I had given initially) simply because the old woman with pin point pupils woke up after I gave her Narcan. I assumed her sudden lucidness was due to the Narcan and not the lucid interval of her head bleed. And I put more than a few people into withdrawal by giving more Narcan than needed.

 

I know better now, and fortunately our guidelines reflect our learned knowledge, although there are still many out there who continue to  follow the old way. The fault there has to be shared between the medic and the system for not providing better oversight and remediation.

 

Back to today. Here are three recent situations (four calls - two with similar situations) I encountered, and I will test each as to whether or not I believe equipping first responders and or family/friends would prevent a heroin OD death in these cases.

 

Situation 1. Patient in bathroom of McDonald’s not breathing. We arrive to find the Fire Department first responders already there. They have recognized the patient is hypoxic, and are doing a very nice two person seal, ambu=bag rescue breathing. We examine the patient, get their story, give a light dose of Narcan and the patient is now breathing on their own. A similar situation occurred when a BLS unit was sent for the unresponsive overdose. They called for medic backup and when we arrived, they were effectively ventilating the patient with a bag valve mask. Again, we gave Narcan and the patient began breathing on their own.

 

Situation 2: Patient found in car not breathing. We arrive to find a car in middle of road, patient in front seat, blue, with zero respirations, no response to sternal rubs, but still has a faint pulse. Police officer who found patient is directing traffic around the car. Fire Department not yet arrived. We use ambu-bag and IM Narcan injection, get patient into back of ambulance, where he eventually starts breathing on own well enough that we no longer have to bag.

 

Situation 3: Patient unresponsive in apartment. Roommate heard her breathing heavily during night, found her not breathing this morning. BLS unit doing CPR when we arrive. Fortunately we are able to restore pulses with epinephrine, the patient has spontaneous respirations by our arrival at the hospital, and she walks out of the hospital (actually is sent to a treatment center) a week later neurologically intact, but with likely less brain cells than before.

 

In Situation 1,  Narcan by first responders would not have made any difference, other than sparing several minutes of ambu-bag work. The first patient was found alone by the restaurant manager. The second patient was found by family. Had the family had Narcan on hand, there would not have been a 911 call, and the patient presumably would have lived to shoot heroin again another day.

 

In Situation 2, If the police officer had Narcan and used it, it could have been the difference in a similar case. You could argue that if the police officer had an ambu-bag, he could have used that, all while hoping not to get hit by traffic. My experience has been in those towns where police are not the designated first medical responder, they do not carry ambu-bags or assist with respirations by any means.

 

In Situation 3, if the roommate had Narcan, and recognized patient’s unresponsiveness as the result of her heroin use (which is no certainty), she could have possibly prevented the cardiac arrest in the first place if she had administered the Narcan before the patient actually arrested, although she likely would have had to deal with a pissed off roommate, who might have left with back rent unpaid.

 

I am all in favor of Narcan for family and friends of known opiate abusers, and I would also favor law enforcement carrying it, as they may not all be carrying ambu-bags or have the help of knowledge to use them most properly.

 

I have in the past stepped off the fence to the side of Narcan for first responders and BLS despite the potential ill effects of using it incorrectly on stroke patients, non-opiate ODs, and for opiate overdoses who do not need it, and who could thus be put into withdrawal.

 

Having said I am for their using it, I don't buy their arguments that it will save lives that couldn't otherwise be saved.   It will, however, make care easier, and I am for that.

 

If we are going to give Narcan to BLS and first responders, we just have to make certain there is adequate training and oversight to see that it is only used in tight-well defined situations, and not just to use it because a person is unresponsive or used heroin.

 

Just because EMS has misused and may currently misuse a drug doesn't mean they can't be or shouldn't be taught to use it properly.  That is what EMS systems and medical directors are for.  Medical Direction needs to step up to the plate here and take responsibility. Review every use of Narcan. If people are practicing bad medicine, it needs to be pointed out and remediated. Education.

 

I also particularly think that the IN form of narcan lends itself well to non-paramedic use. I have found it to be very mild and with less chance of side-effects than IM or certainly, IV. I found it very interesting in a comment to a recent post of mine a paramedic in Lousiana said they are required to first give the drug IN for just that reason.

 

Bottom Line:  IN Narcan provides the drug in a mild form that is easy to administer, and if used properly by BLS and first responders,  is unlikely to cause harm greater than the benefit it may provide.

 

***
Here is an older post I wrote on the same topic:

IN Narcan for BLS

***

I will keep you all updated as to the outcome of this debate here in Connecticut.

New World Heroin

 There was a recent editorial in the Hartford Courant, First Responders Could Help Cut Heroin Deaths, citing the rash of recent heroin deaths and calling for all first responders to be equipped with Narcan in order to stop the rise. Narcan is provided to first responders in some of our neighboring states, and the editorial writer thought this should happen here as well. It is my understanding that there is a strong political push, some of it coming from the substance abuse community, for such a proposal.

Heroin Related Deaths Up Sharply in Connecticut
Many months ago, we debated BLS Narcan at our state EMS medical advisory committee and despite, what I thought was a well put together proposal, the effort was knocked down very soundly. The reason seemed to be responders have ambu-bags, Narcan is often misused, and if the patient is hypo-ventilating a paramedic should be on the way anyway. Additionally, there was some fear of BLS creep, diluting the paramedic arsenal, and thus the need to have paramedics, which could lead to an overall deterioration of care for all patients. All points largely true.

 

As far as Narcan misuse, I can say that my data in reviewing prehospital care as an EMS Clinical Coordinator and anecdotally talking with other paramedics about calls they have done involving narcan, shows that yes, it can be misused by paramedics. (But with education, we have seen the number of misuses drop considerably.) Generally, the misuse stems from two situations.

 

1) Patient who is unresponsive with pinpoint pupils, but breathing fine. (We used to give Narcan in this situation for "coma of unknown etiology" and our guidelines at the time (1990s into mid 2000's) stated there were no contraindications for emergency use) and

 

2) Person who took heroin, who is altered, but breathing fine. The reasoning seems to be, they are altered, they took heroin, which is bad. I am going to give them Narcan and knock the bad heroin out of their system and wake them so they can admit they used heroin so I will know for certain what is going on. (Not good reasoning from health care providers, whose role is to do no harm.)

 

When operating under the old guidelines, I can say, there were times I did harm to patients. I gave multiple doses of Narcan to an unresponsive patient who, while now breathing on his own, still did not wake up, and was soon in pulmonary edema. I gave Narcan to a paraplegic (due to an old gunshot injury) and wiped out his pain meds while doing nothing to resolve his UTI, which was the true cause of his unresponsiveness. I misdiagnosed a stroke (I called off the stroke alert I had given initially) simply because the old woman with pin point pupils woke up after I gave her Narcan. I assumed her sudden lucidness was due to the Narcan and not the lucid interval of her head bleed. And I put more than a few people into withdrawal by giving more Narcan than needed.

 

I know better now, and fortunately our guidelines reflect our learned knowledge, although there are still many out there who continue to  follow the old way. The fault there has to be shared between the medic and the system for not providing better oversight and remediation.

 

Back to today. Here are three recent situations (four calls - two with similar situations) I encountered, and I will test each as to whether or not I believe equipping first responders and or family/friends would prevent a heroin OD death in these cases.

 

Situation 1. Patient in bathroom of McDonald’s not breathing. We arrive to find the Fire Department first responders already there. They have recognized the patient is hypoxic, and are doing a very nice two person seal, ambu=bag rescue breathing. We examine the patient, get their story, give a light dose of Narcan and the patient is now breathing on their own. A similar situation occurred when a BLS unit was sent for the unresponsive overdose. They called for medic backup and when we arrived, they were effectively ventilating the patient with a bag valve mask. Again, we gave Narcan and the patient began breathing on their own.

 

Situation 2: Patient found in car not breathing. We arrive to find a car in middle of road, patient in front seat, blue, with zero respirations, no response to sternal rubs, but still has a faint pulse. Police officer who found patient is directing traffic around the car. Fire Department not yet arrived. We use ambu-bag and IM Narcan injection, get patient into back of ambulance, where he eventually starts breathing on own well enough that we no longer have to bag.

 

Situation 3: Patient unresponsive in apartment. Roommate heard her breathing heavily during night, found her not breathing this morning. BLS unit doing CPR when we arrive. Fortunately we are able to restore pulses with epinephrine, the patient has spontaneous respirations by our arrival at the hospital, and she walks out of the hospital (actually is sent to a treatment center) a week later neurologically intact, but with likely less brain cells than before.

 

In Situation 1,  Narcan by first responders would not have made any difference, other than sparing several minutes of ambu-bag work. The first patient was found alone by the restaurant manager. The second patient was found by family. Had the family had Narcan on hand, there would not have been a 911 call, and the patient presumably would have lived to shoot heroin again another day.

 

In Situation 2, If the police officer had Narcan and used it, it could have been the difference in a similar case. You could argue that if the police officer had an ambu-bag, he could have used that, all while hoping not to get hit by traffic. My experience has been in those towns where police are not the designated first medical responder, they do not carry ambu-bags or assist with respirations by any means.

 

In Situation 3, if the roommate had Narcan, and recognized patient’s unresponsiveness as the result of her heroin use (which is no certainty), she could have possibly prevented the cardiac arrest in the first place if she had administered the Narcan before the patient actually arrested, although she likely would have had to deal with a pissed off roommate, who might have left with back rent unpaid.

 

I am all in favor of Narcan for family and friends of known opiate abusers, and I would also favor law enforcement carrying it, as they may not all be carrying ambu-bags or have the help of knowledge to use them most properly.

 

I have in the past stepped off the fence to the side of Narcan for first responders and BLS despite the potential ill effects of using it incorrectly on stroke patients, non-opiate ODs, and for opiate overdoses who do not need it, and who could thus be put into withdrawal.

 

Having said I am for their using it, I don't buy their arguments that it will save lives that couldn't otherwise be saved.   It will, however, make care easier, and I am for that.

 

If we are going to give Narcan to BLS and first responders, we just have to make certain there is adequate training and oversight to see that it is only used in tight-well defined situations, and not just to use it because a person is unresponsive or used heroin.

 

Just because EMS has misused and may currently misuse a drug doesn't mean they can't be or shouldn't be taught to use it properly.  That is what EMS systems and medical directors are for.  Medical Direction needs to step up to the plate here and take responsibility. Review every use of Narcan. If people are practicing bad medicine, it needs to be pointed out and remediated. Education.

 

I also particularly think that the IN form of narcan lends itself well to non-paramedic use. I have found it to be very mild and with less chance of side-effects than IM or certainly, IV. I found it very interesting in a comment to a recent post of mine a paramedic in Lousiana said they are required to first give the drug IN for just that reason.

 

Bottom Line:  IN Narcan provides the drug in a mild form that is easy to administer, and if used properly by BLS and first responders,  is unlikely to cause harm greater than the benefit it may provide.

 

***
Here is an older post I wrote on the same topic:

IN Narcan for BLS

***

I will keep you all updated as to the outcome of this debate here in Connecticut.

Final Exam

 You should never have been precepting. You did not have enough street experience, not to mention you were not even old enough to buy a drink when you started. But these days like too many of your peers, you go from EMT school to paramedic school without putting in the time on the road. Sure you worked for another service for awhile, but the volume was low and you mainly did transfers. Had I been in charge I would have insisted on your putting in a year in the city, banging out 911s, cleaning up the mess your paramedic partners would make in the back of the ambulance. But it was what it was. You showed up in your new yellow reflective coat and the freshly sew paramedic patch on your sleeve, and a copy of Tim Phalen's 12-Lead in Acute Coronary Syndromes under your arm, and they put us on the road together.

My first impression was you were you are nice young man, extremely polite, very nice to patients, respectful of other responders and health care professionals. Your work ethic was good. You were always there before me, always checking your gear out when you came in, even before you were permitted to punch in. After a call, you always listened to what I had to say, and thanked me, even if you made me feel like an old headmaster and not your partner, with yoru “thank you, sirs!” And when I didn’t have anything to say, you had your pencil out and were filling in all the answers to the questions Tim Phalen asks in his book.

Your IV skills were surprisingly good, which didn’t mean I didn’t have to step in a time or two, but that is what preceptors are for. I tried to teach you to be thorough, and met no resistance from you. It didn’t take you long for you to get into the routine. I would start to think you were doing okay, and then we would get a really sick patient, and you wouldn't perform as well as I wanted to see. You were slow to recognize, slow to react, and at the hospital, your reports were so jumbled, I often thought we had been on different calls.

That was were your lack of experience showed. It was hard for me to imagine you out on your own. You felt it too. You asked me twice if maybe we should end the experiment and have you put in your year of BLS in the city. I have never had a preceptee say that to me before. Normally, when they aren’t doing well, they are demanding to know how much longer until they are cut loose. They feel they paid their money for their course, they passed it, got their license and now they just want to know how much longer until their misery ends and they can start being their own bosses.

How many ALS calls have we done together these last three or four months? A lot. We bang out 9-10 transports a shift. Maybe from those we did two, three hundred ALS calls. We did three codes, you got two tubes, and on the one you couldn’t, you got a combitube in. While you weren’t as forceful as I would have liked to have seen, you weren’t completely lost. We got pulses back twice and kept them to the hospital (thanks epi and dopamine for contributing to yet more ICU deaths). We did a few STEMIs, some room one traumas, stroke alerts, used CPAP a few times, did a lot of 12-leads, and were exchanging controlled substance kits nearly every day.

I was still undecided about you. Every day I discovered something you didn’t know, but I suppose that also meant every day you learned something new. I tried to remember back when I was new, and how unprepared I had been, but that was a long time ago, and I am getting old and my memory is hazy.

Last week we got a call for a young adult with dyspnea. Young, early twenty something year old kid in the North End, complaining of difficulty breathing. They initially sent a BLS unit, but because we were floating, we said we’d take it on the theory the more calls we do the better. The kid was laying on the couch on the second floor, holding his chest and moaning. He said he had a history of asthma.

You set your gear down and knelt down in front of him and introduced yourself by name  like you always do, while I leaned against the wall, staying out of the way watching you. As you asked questions, you felt his forehead, which appeared dry, listened to his lungs, which were clear. You checked his vitals which were normal. His pulse SAT was 100% on room air. This was not asthma. Everything appeared normal in this otherwise fit young man who had this sudden onset of chest pain that he said felt like a squeezing in his chest.

You looked over at me then. I waited to see what you would say. “I guess I should do a 12-lead,” you said.

“Good,” I said. “Go ahead.”

You explained to the patient, you were going to put these stickers on his chest to check his heart. Then you entered his young age and pressed the button. You cautioned him to sit still. Finally, the 12-lead came out like so many we had done before. I watched as you tried to peel the 12-lead off the machine. All this time and you still have difficulty ripping it off smoothly. I saw you look at it. You seemed to stare at it. You kept staring and then saying nothing you walked over to me and held it up in front of me. You looked at me, then back at the 12-lead, as if to say. “Is this really what I think it is?”

It wasn’t like the pictures in your Tim Phalen book for pericarditis and it wasn’t like the ones for early repol. Twenty-two years old, be damned, it looked like the ones for an anteriorlateral STEMI with hyperacute T waves.

I nodded my assent.

A quick question about family history. Yes, with death at a young age. History, presentation, diagnostic 12-lead.

To our partner, get the stair chair, immediate STEMI alert from second floor, aspirin, down in the ambulance, transmit ECG, transport, strip patient, two big IVs, NTG, defib pads applied, …

100% occlusion in the cath lab.

I think of all the paramedics who might have blown that kid off. He’s only in his early twenties, his vitals are fine, he looks like he could outrun Wily E. Coyote. Walk him down the stairs, sit him on the bench seat, put him in the waiting room with all the other pleuritic chest pains.

So that patient was your final exam. I have made up my mind to pass you. That doesn’t mean you know everything there is to know. You are not close to that. But as I see it. You will never not medicate a hip fracture who is in pain. You will never not do a 12-lead on an elderly woman with weakness. You will never not treat a patient with respect. You may know less than other new paramedics, but at least you know that. And I would rather have you out there being cautious than someone who knows more, but thinks they know everything.

Your parents raised you well. And you will represent your profession and your service well. Sure there will be times, you will screw up. I have been doing this longer than you have been alive and I still screw up, but you will learn from your failures and your triumphs. And someday, you will sit in my seat and train a younger, less experienced paramedic. And when you do, remember what you went through.

You are not done with me yet.  I'm going to hold you for another week or two for final polishing, and then once you are on your own, I will still be around if you have questions or want to go over calls you did, and I will want to hear about them.  I will rejoice in your triumphs, and will talk your through the ones that don't go as well.

Now get out there, and do some good!

Wipe Out

 Darkness. Cold. Reflection of fire in the water. Hoses on the ground. Onlookers. The stretcher, pulled by my partner and a firefighter, races through the scene to the the unknown victim carried out of the building. Behind them my feet are up in the air. I am three feet above the ground, suspended parallel, my arms wide out. A snapshot in time. I land hard on the black ice. I lay there. I am fifty-five years old. I do a body assessment. Still have feeling in my hands and toes. No acute pain. I didn’t hear any cracks. I get to my feet and take a few tenuous steps, and then move quicker, Moments later I am at the patient’s side, giving commands, Still a working paramedic.