Street Watch: Notes of a Paramedic: June 2020

Tuesday, June 30, 2020

Penetrating Trauma

With the onset of summer, one of our more long standing epidemics is raising its head and demanding it not be forgotten

In the north end of Hartford that means penetrating trauma -- the knife and gun club. In my earlier years in the city, I often worked nights when the trauma numbers were highest, The last several years my shift was Sunday through Tuesday 5:30-AM-5:30 PM, not really prime hours for trauma. Lately, I have been working Fridays from 9 AM to 7 PM in a city fly car where I respond to all 911s, often arriving before the ambulance and in many cases, before the fire department first responders. Along about four on a Friday afternoon, people start to get riled up.

I am slowly getting back in form.

Transport times are very short in Hartford with two level one trauma centers not two miles apart. I find traumas challenging, but often unsatisfying. The challenge is to accomplish as much as you can in as short a time as possible. The lack of satisfaction is that the call is often over in minutes.

I am 100% in the “bag and drag” school of trauma for those cases where a surgeon is (or likely might be) needed. Stop an immediate life-threat -- bleeding, tension pneumothorax, sucking chest wound, and then haul, doing everything on the move. In cases of gunshot or knife wounds, the damage is internal and there is not much I can do but get them to the hospital. I used to tell medics I was precepting the priorities in trauma were find the injury, get them on the stretcher, tell your partner to go (safe, but fast), call the hospital with a trauma alert, remove or cut off the patient’s clothes and get the patient’s name, date of birth and social security number, all while trying not to get any blood on yourself. With any extra time, get an IV, give pain meds if not contraindicated and unload. On arrival, hand the registrar the name, dob and social security as you pass her, and into the trauma room, where you give a quick report to the trauma team, and then go write your report.

Your measure of success is not how pretty your patient looks when you come in the trauma room, but the time from when you arrived at the scene to the time you arrive in the trauma room.

Think of an imaginary stop watch over the trauma bay. If you break the tape at 6:43:02, that’s better than bringing in a neat looking patient at 12:56:14

Sometimes I don’t even try for an IV, others I don’t have a blood pressure beyond saying I felt a radial pulse.

It’s okay. I can’t count the number of times I’ve had IVs pulled and ECG wires cut by overanxious members of the trauma teams. If I do have time, I will wrap cling around the IV to better secure it, and I often yank the monitor wires myself on arrival at the hospital (unless there is good cause to keep the patient on the monitor for the sixty seconds it takes to get in the trauma room).

You can be sitting in the EMS room, get a call for a shooting down the street, and be back in the EMS room writing your report before ten minutes have passed. Sometimes it can be so quick, another EMT can get up to use the bathroom and then come back and find you are still there.

"You know you got some blood on your shirt," he says.

You notice it for the first time. "Damn, I'm losing my edge."

"Friday night. Craziness will be starting soon," he says.

You answer. "No doubt."

***

Note: the illustration above is the cover of a great book of photography, The Knife and Gun Club by Eugene Richards. It is out of print now, but you can get a used copy here:

Knife and Gun Club

Monday, June 29, 2020

capnography

10 Things Every Paramedic Should Know About Capnography

Capnography is the vital sign of ventilation.

By tracking the carbon dioxide in a patient’s exhaled breath, capnography enables paramedics to objectively evaluate a patient’s ventilatory status (and indirectly circulatory and metabolic status), as the medics utilize their clinical judgement to assess and treat their patients.

Part One: The Science

Definitions:

Capnography – the measurement of carbon dioxide (CO2) in exhaled breath.

Capnometer – the numeric measurement of CO2.

Capnogram – the wave form.

End Tidal CO2 (ETCO2 or PetCO2) - the level of (partial pressure of) carbon dioxide released at end of expiration.

Oxygenation Versus Ventilation

Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled into the lungs where gas exchange occurs at the capillary-alveolar membrane. Oxygen is transported to the tissues through the blood stream. Pulse oximetry measures oxygenation.

At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste product of this process (The Krebs cycle), diffuses into the blood.

Ventilation (the movement of air) is how we get rid of carbon dioxide. Carbon dioxide is carried back through the blood and exhaled by the lungs through the alveoli. Capnography measures ventilation.

Capnography versus Pulse Oximetry

Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed. Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a high saturation for several minutes.

Circulation and Metabolism

While capnography is a direct measurement of ventilation in the lungs, it also indirectly measures metabolism and circulation. For example, an increased metabolism will increase the production of carbon dioxide increasing the ETCO2. A decrease in cardiac output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2.

“CO2 is the smoke from the flames of metabolism.”– Ray Fowler, M.D. Dallas, Street Doc’s Society

PaCO2 vs. PeTCO2

PaCO2= Partial Pressure of Carbon Dioxide in arterial blood gases. The PaCO2 is measured by drawing the ABGs, which also measure the arterial PH.

If ventilation and perfusion are stable PaCO2 should correlate to PetCO2.

In a study comparing PaCO2 and PetCO2 in 39 patients with severe asthma, the mean difference between PaCO2 and PetCO2 was 1.0 mm Hg, the median difference was 0 mm Hg. Only 2 patients were outside the 5 mg HG agreement (1-6, 1-12). -Jill Corbo, MD, et al, Concordance Between Capnography and Arterial Blood Gas Measurements of Carbon Dioxide in Acute Asthma, Annals of Emergency Medicine, October 2005

V/Q Mismatch

“Research has (also) shown good concordance...in patients with normal lung function, upper and lower airway disease, seizures, and diabetic ketoacidosis.” –ibid.

If ventilation or perfusion are unstable, a Ventilation/Perfusion (V/Q) mismatch can occur. This will alter the correlation between PaC02 and PetCO2.

This V/Q mismatch can be caused by blood shunting such as occurs during atelectasis (perfusing unventilated lung area) or by dead space in the lungs (Ventilating unperfused lung area) such as occurs with a pulmonary embolisim or hypovolemia.

Normal Capnography Values

ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say 30 mm HG - 43 mm Hg can be considered normal.

Cautions: Imperfect positioning of nasal cannula capnofilters may cause distorted readings. Unique nasal anatomy, obstructed nares and mouth breathers may skew results and/or require repositioning of cannula. Also, oxygen by mask may lower the reading by 10% or more.

Capnography Wave Form

The normal wave form appears as straight boxes on the monitor screen:

cap2

But the wave form appears more drawn out on the print out because the monitor screen is compressed time while the print out is in real time.

cap3

The capnogram wave form begins before exhalation and ends with inspiration. Breathing out comes before breathing in.

A to B is post inspiration/dead space exhalation, B is the start of alveolar exhalation, B-C is the exhalation upstroke where dead space gas mixes with lung gas, C-D is the continuation of exhalation, or the plateau(all the gas is alveolar now, rich in C02). D is the end-tidal value – the peak concentration, D-E is the inspiration washout.

Abnormal Values and Wave Forms

ETCO2 Less Than 35 mmHg = "Hyperventilation/Hypocapnia"

ETC02 Greater Than 45 mmHg = "Hypoventilation/Hypercapnia"

Caution:

“End Tidal CO2 reading without a waveform is like a heart rate without an ECG recording.” – Bob Page “Riding the Waves”

However, unlike ECGs, there are only a few capnography wave forms. The main abnormal ones -- hyperventilation, hypoventilation, esophageal intubation and obstructive airway/shark fin -- are described below.

Part Two: Clinical Uses of Capnography

1. Monitoring Ventilation

Capnography monitors patient ventilation, providing a breath by breath trend of respirations and an early warning system of impending respiratory crisis.

Hyperventilation

When a person hyperventilates, their CO2 goes down.

Hyperventilation can be caused by many factors from anxiety to bronchospasm to pulmonary embolus. Other reasons C02 may be low: cardiac arrest, decreased cardiac output, hypotension, cold, severe pulmonary edema.

Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a large tidal volume can still hyperventilate with a normal respiratory rate just as a person with a small tidal volume can hypoventilate with a normal respiratory rate.

Hypoventilation

When a person hypoventilates, their CO2 goes up.

Hypoventilation can be caused by altered mental status such as overdose, sedation, intoxication, postictal states, head trauma, or stroke, or by a tiring CHF patient. Other reasons CO2 may be high: Increased cardiac output with increased breathing, fever, sepsis, pain, severe difficulty breathing, depressed respirations, chronic hypercapnia.

Some diseases may cause the CO2 to go down, then up, then down. (See asthma below).

Pay more attention to the ETCO2 trend than the actual number.

A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic anticipate when a patient may soon require assisted ventilations or intubation.

Heroin Overdoses - Some EMS systems permit medics to administer narcan only to unresponsive patients with suspected opiate overdoses with respiratory rates less than 10. Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate. ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a respiratory rate of 8, but an ETCO2 of 35.

2. Confirming, Maintaining , and Assisting Intubation

Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. A good wave form indicating the presence of CO2 ensures the ET tube is in the trachea.

A 2005 study comparing field intubations that used continuous capnography to confirm intubations versus non-use showed zero unrecognized misplaced intubations in the monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir, Annals of Emergency Medicine, May 2005

“When exhaled CO2 is detected (positive reading for CO2) in cardiac arrest, it is usually a reliable indicator of tube position in the trachea.” - The American Heart Association 2005 CPR and ECG Guidelines

Reasons ETCO2 is zero: The tube is in the esophagus.*

* True as a general rule, but may not hold for cases of greatly prolonged down time prior to initiation of CPR or cases of massive pulmonary embolism where blood flow to the lungs is completely blocked. Also, in patients in arrest, CPR is neccessary to generate a waveform.

Caution: In patients with a prolonged down time, the ETCO2 reading may be so low (sometimes less than 6mm HG) that some monitor's apnea alarms may go off even though the monitor is still providing an ETCO2 reading and a small wave form. If the apnea alarm goes off and you continue to bag without resistance and have equal lung sounds and negative epigatric sounds, do not automatically pull your tube. A small but distinct square wave form along with even a marginal EtCO2 reading is still verification the tube is in the trachea.

ETCO2 can also be used to assist in difficult intubations of spontaneously breathing patients.

Paramedics can attach the capnography filter to the ET tube prior to intubation and, in cases where it is difficult to visualize the chords, use the monitor to assist placement. This includes cases of nasal tracheal intubation.

You're out (missed the chords).

You're in.

Paramedics who utilize this method during cardiac arrests with cardiac compressions continuing while they intubate may see CPR oscillations on the monitor screen immediately upon intubating, replaced by larger wave forms once the ambu-bag has been attached and ventilations begun. The oscillations provide proof that compressions alone can produce some ventilation.

Note: You must still assess for equal lung sounds. Capnography cannot detect right main-stem intubations.

Capnography can also be used for combitubes and LMAs.

Paramedics should document their use of continuous ETCO2 monitoring and attach wave form strips to their PCRs. Print a strip on intubation, periodically during care and transport, and then just prior to moving the patient from your stretcher to the hospital table and then immediately after transfer. This will timestamp and document your tube as good.

Continuous Wave Form Capnography Versus Colorimetric Capnography

In colorimetric capnography a filter attached to an ET tube changes color from purple to yellow when it detects carbon dioxide. This device has several drawbacks when compared to waveform capnography. It is not continuous, has no waveform, no number, no alarms, is easily contaminated, is hard to read in dark, and can give false readings.

Paramedics should encourage their services to equip them with continuous wave form capnography.

3. Measuring Cardiac Output During CPR

Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to measure the effectiveness of CPR.

In 1978, Kalenda “reported a decrease in ETC02 as the person performing CPR fatigued, followed by an increase in ETCO2 as a new rescuer took over, presumably providing better chest compressions.” –Gravenstein, Capnography: Clinical Aspects, Cambridge Press, 2004

With the new American Heart Association Guidelines calling for quality compressions ("push hard, push fast, push deep"), rescuers should switch places every two minutes. Set the monitor up so the compressors can view the ETCO2 readings as well as the ECG wave form generated by their compressions. Encourage them to keep the ETCO2 number up as high as possible.

“Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac output....The extent to which resuscitation maneuvers, especially precordial compression, maintain cardiac output may be more readily assessed by measurements of ETCO2 than palpation of arterial pulses.” -Max Weil, M.D., Cardiac Output and End-Tidal carbon dioxide, Critical Care Medicine, November 1985

Note: Patients with extended down times may have ETCO2 readings so low that quality of compressions will show little difference in the number.

Return of Spontaneous Circulation (ROSC)

ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses.

End-tidal CO2 will often overshoot baseline values when circulation is restored due to carbon dioxide washout from the tissues.

A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before settling into a normal range

.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8

Note: Each bar represents 30 seconds.

“End-tidal CO2 monitoring during cardiac arrest is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients.” - American Heart Association Guidelines 2005 CPR and ECG

Loss of Spontaneous Circulation

In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a person with ROSC, immediately check pulses. You may have to restart CPR.

The graph below demonstrates three episodes of ROSC, followed by loss of circulation during a cardiac arrest:

4. End Tidal CO2 As Predictor of Resuscitation Outcome

End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the likelihood of resuscitation.

"An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the initiation of advanced cardiac life support accurately predicts death in patients with cardiac arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may reasonably be terminated in such patients.” -Levine R, End-tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 1997

Likewise, case studies have shown that patients with a high initial end tidal CO2 reading were more likely to be resuscitated than those who didn’t. The greater the initial value, the likelier the chance of a successful resuscitation.

“No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived. Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital signs....The difference between survivors and nonsurvivors in 20 minute end-tidal carbon dioxide levels is dramatic and obvious.” – ibid.

“An ETCO2 value of 16 torr or less successfully discriminated between the survivors and the nonsurvivors in our study because no patient survived with an ETCO2 less than 16 torr. Our logistic regression model further showed that for every increase of 1 torr in ETCO2, the odds of surviving increased by 16%.” –Salen, Can Cardiac Sonography and Capnography Be Used Independently and in Combination to Predict Resuscitation Outcomes?, Academic Emergency Medicine, June 2001

Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg.

Asphyxic Cardiac Arrest versus Primary Cardiac Arrest

Capnography can also be utilized to differentiate the nature of the cardiac arrest.

A 2003 study found that patients suffering from asphyxic arrest as opposed to primary cardiac arrest had significantly increased initial ETCO2 reading that came down within a minute. These high initial readings, caused by the buildup of carbon dioxide in the lungs while the nonbreathing/nonventilating patient's heart continued pump carbon dioxide to the lungs before the heart bradyed down to asystole, should come down within a minute. The ETCO2 values of asphyxic arrest patients then become prognostic of ROSC

.-Grmec S, Lah K, Tusek-Bunc K,Crit Care. 2003 Dec

5. Monitoring Sedated Patients

Capnography should be used to monitor any patients receiving pain management or sedation (enough to alter their mental status) for evidence of hypoventilation and/or apnea.

In a 2006 published study of 60 patients undergoing sedation, in 14 of 17 patients who suffered acute respiratory events, ETCO2 monitoring flagged a problem before changes in SPO2 or observed changes in respiratory rate.

“End-tidal carbon dioxide monitoring of patients undergoing PSA detected many clinically significant acute respiratory events before standard ED monitoring practice did so. The majority of acute respiratory events noted in this trial occurred before changes in SP02 or observed hypoventilation and apnea.” - -Burton, Does End-Tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices, Academic Emergency Medicine, May 2006

In the graph below, the respiratory rate decreases as the ETCO2 rises, and the patient suffers apnea, all the while the SPO2 remains stable.

Note: Each bar represents thirty seconds.

Sedated, Intubated Patients

Capnography is also essential in sedated, intubated patients. A small notch in the wave form indicates the patient is beginning to arouse from sedation, starting to breathe on their own, and will need additional medication to prevent them from "bucking" the tube.

6. ETCO2 in Asthma, COPD, and CHF

End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the severity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce a characteristic “shark fin” wave form, as the patient has to struggle to exhale, creating a sloping “B-C” upstroke. The shape is caused by uneven alveolar emptying.

Multiple studies have confirmed the sloping shape correlates to bronchospasm and obstructive lung disease.

“The analysis of the capnogram’s shape is a quantitative method for evaluating the severity of bronchospasm.” –You, Expiratory capnography in asthma: evaluation of various shape indicies, European Respiratory Journal, Feb, 1994

Changing Asthma Values

Asthma values change with severity. With a mild asthma, the CO2 will drop (below 35) as the patient hyperventilates to compensate. As the asthma worsens, the C02 levels will rise to normal. When the asthma becomes severe, and the patient is tiring and has little air movement, the C02 numbers will rise to dangerous levels (above 60).

Successful treatment will lessen or eliminate the shark fin shape and return the ETCO2 to normal range (Patient below: capnogram on arrival, after start of 1st combi-vent, after two combivents).

Hypoxic Drive

Capnography will show the hypoxic drive in COPD "retainers." ETCO2 readings will steadily rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it has been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers without worry that they will hypoventilate.

CHF: Cardiac Asthma

It has been suggested that in wheezing patients with CHF (because the alveoli are still, for the most part, emptying equally), the wave form should be upright. This can help assist your clinical judgement when attempting to differentiate between obstructive airway wheezing such as COPD and the "cardiac asthma" of CHF.

(wave form of patient with cardiac asthma)

7. Ventilating Head Injured Patients

Capnography can help paramedics avoid hyperventilation in intubated head injured patients.

“Recent evidence suggests hyperventilation leads to ischemia almost immediately...current models of both ischemic and TBI suggest an immediate period during which the brain is especially vulnerable to secondary insults. This underscores the importance of avoiding hyperventilation in the prehospital environment.” --Capnography as a Guide to Ventilation in the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. The decreased cerebral blood flow may result in cerebral ischemia.

In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than those without ETCO2 monitoring (13.4%). Patients in both groups with severe hyperventilation had significantly higher mortality (56%) than those without (30%). –Davis, The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation in Patients with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Trauma, April 2004

8. Perfusion Warning Sign

“A target value of 35 mmHg is recommended...The propensity of prehospital personnel to use excessively high respiratory rates suggests that the number of breaths per minute should be decreased. On the other hand, the mounting evidence against tidal volumes in excessive of 10cc/kg especially in the absence of peep, would suggest the hypocapnia be addressed by lower volume ventilation.” – --Capnography as a Guide to Ventilation in the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless of any change in breathing. This has implications for trauma patients, cardiac patients – any patient at risk for shock.

In the study cited below, 5 pigs had hemorrhagic shock induced by bleeding, 5 pigs had septic shock induced by infusion of e-coli, and 6 pigs had cardiogenic shock induced by repeated episodes of v-fib. The pigs' cardiac output was continuously measured as well as their PETCO2.

“Cardiac output and PetCO2 were highly related in diverse experimental models of circulatory shock in which cardiac output was reduced by >40 % of baseline values… measurement of PetC02 is a noninvasive alternative for continuous assessment of cardiac output during low flow circulatory shock states of diverse causes.” -Xiahua, End-tidal carbon dioxide as a noninvasive indicator of cardiac index during circulatory shock, Critical Care Medicine, 2000, Vol 28, No 7

“A patient with low cardiac output caused by cardiogenic shock or hypovolemia resulting from hemorrhage won’t carry as much CO2 per minute back to the lungs to be exhaled. This patient’s ETC02 will be reduced. It doesn’t necessarily mean the patient is hyperventilating or that their arterial CO2 level will be reduced. Reduced perfusion to the lungs alone causes this phenomenon. The patient’s lung function may be perfectly normal.” --Baruch Krauss, M.D, JEMS, November 2003

9. Other Issues:

DKA - Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation causes their PAC02 to go down.

“End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical assessment, may help discriminate between patients with and without DKA, respectively.” –Fearon, End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes, Academic Emergency Medicine, December 2002

Pulmonary Embolus – Pulmonary embolus will cause an increase in the dead space in the lungs decreasing the alveoli available to offload carbon dioxide. The ETCO2 will go down.

Hyperthermia – Metabolism is on overdrive in fever, which may cause ETCO2 to rise. Observing this phenomena can be live-saving in patients with malignant hyperthermia, a rare side effect of RSI (Rapid Sequence Induction).

Trauma - A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent of patients with ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The median ETCO2 for survivors was 30.75. -

Deakin CD, Sado DM, Coats TJ, Davies G. “Prehospital end-tidal carbon dioxide concentration and outcome in major trauma.” Journal of Trauma. 2004;57:65-68.

Field Disaster Triage - It has been suggested that capnography is an excellent triage tool to assess respiratory status in patients in mass casualty chemical incidents, such as those that might be caused by terrorism.

“Capnography…can serve as an effective, rapid assessment and triage tool for critically injured patients and victims of chemical exposure. It provides the ABCs in less than 15 seconds and identifies the common complications of chemical terrorism. EMS systems should consider adding capnography to their triage and patient assessment toolbox and emphasize its use during educational programs and MCI drills.”- Krauss, Heightman, 15 Second Triage Tool, JEMS, September 2006

Anxiety- ETCO2 is being used on an ambulatory basis to teach patients with anxiety disorders as well as asthmatics how to better control their breathing. Try (it may not always be possible) to get your anxious patient to focus on the monitor, telling them that as they slow their breathing, their ETCO2 number will rise, their respiratory rate number will fall and they will feel better.

Anaphylaxis- Some patients who suffer anaphylactic reactions to food they have ingested (nuts, seafood, etc.) may experience a second attack after initial treatment because the allergens remain in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The wave form may start to slope before wheezing is noticed.

Accurate Respiratory Rate - Studies have shown that many medical professionals do a poor job of recording a patient's respiratory rate. Capnography not only provides an accurate respiratory rate, it provides an accurate trend or respirations.

10. The Future

Capnography should be the prehospital standard of care for confirmation and continuous monitoring of intubation, as well as for monitoring ventilation in sedated patients. Additionally, it should see increasing use in the monitoring of unstable patients of many etiologies. As more research is done, the role of capnography in prehospital medicine will continue to grow and evolve.

***

10 Things Every Paramedic Should Know About Capnography

Peter Canning, EMT-P

December 29, 2007 (Version 6.3)

Disclaimer: The information in this paper is gathered from textbooks, research articles, web sites, lectures and my own experiences. Paramedics should consult their medical directors and protocols for approved uses.

***

For more information on capnography, go to the site:

Capnography for Paramedics

Blogging

I occasionally have people ask me for advice about writing/blogging about EMS.

When I first considered starting a blog, I consulted with "the MacMedic," a paramedic who at the time was working in my state. He gave me some advice as well as directing me to a blog post written by Tom Reynolds, an English EMT, and author of the blog, Random Acts of Reality. (Reyonlds turned excerpts from his blog into the book, Blood, Sweat & Tea: Real-Life Adventures in an Inner-City Ambulance.

Here is Reynolds' post on blogging:

How To Blog And Not Lose Your Job

I followed Reynolds's advice, as well as advice given to me by the Macmedic, and made certain my employers knew I was writing a blog. I emphasized to them I valued my job and was open to any changes or suggestions to prevent any problems. My policy is not to rank on anyone or the company, or at least not in a hateful way. I occasionally rail against the system, but not against any individuals. Generic subjects can be fair targets; identifiable ones are not. While in my books I used the real names of my partners and coworkers believing they deserved credit for the fine work they do, I have chosen for the most part not to follow that course on the internet. Consequently sometimes my posts appear as if I am the only responder there or if I have a partner, they are largely faceless, unless the story is centered around their involvement on the call.

I have also taken great strides to protect patient confidentiality. In addition to changing identifying details, I often use a randomized method of selecting sex and age to further obscure any case that might be known to the public. In only a few cases have I not written about a call for fear that I would reveal personal details that could be readily identified. In other cases, I have written about a call months out of sequence. It is easier for me to write about calls when I am working in the city and can respond to any of a number of towns beside the city, than when I am working in the one suburban town to which I am assigned.

I think it would be very difficult to write a blog in a small town with a low call volume and still protect confidentiality. The greater the population you serve, the easier it is to safely write about a call. I have heard many stories of small town bloggers offending fellow crew members or even town residents. I would advise anyone writing about a small service to be extremely careful in what they write, as you should even in a larger service. Write as if you were standing in front of the town, giving a public reading.

The one area where people seem to get in the most trouble is with photos. When I first started, I was tempted a number of times to post a photo of an accident scene, even once going so far as uploading a photo of one mangled car very relevant to the story, but was unable to push the publish button out of fear I was crossing a line. A newspaper or TV station can show the pictures, but health care providers cannot. I would think the only way you could post the photos safely would be to show a photo that does not in any way identify a person or specific car or accident scene and post it at a date different than that on which it occurred. When in doubt I would always first check with your company’s policy. Many companies now have policies prohibiting both the taking of photos unless taken with an officially issued camera and then only for patient care purposes. If your company doesn’t have a policy, you might want to work with them to develop one.

AI occasionally have people ask me for advice about writing/blogging about EMS.

Here is Reynolds' post on blogging:

How To Blog And Not Lose Your Job

As important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.

As far as a personal policy, I would say this:

Don’t use writing to put someone else down, particularly someone who cannot properly defend themselves. Don’t be cruel. Write to elevate what we do. Write to elevate the spirit you have seen in people you have cared for -- in their worst and best moments. Write to share your human experience with those who can benefit from it. Record your stories, your thoughts, and your revelations. Use your writing to try to understand the world, not to condemn it. Share your victories, your defeats, your frustrations and your hopes. Write to show that you have walked down the EMS streets.

***

Some final thoughts. Blogging about EMS is an excellent way to stay fresh. By looking for material, I can see interesting things I might not have noticed. It keeps me from falling into a rut.

Blogging can be particularly useful for a new medic. Writing about a call can enable you to think about it in a new way, as well as to learn from the comments of readers. The experiences we have that can seem isolated to ourselves we learn are actually fairly universal.

Everyone should find their own angle so that they are writing about what interests them. Some blogs are story-centered, some medically centered, some are very introspective, and others go for the humor. Write what you enjoy.

It is not a bad idea if you are thinking of starting a blog to read the work of others.

I have quite a number of blogs listed in my blogroll. While I don't read them all everyday, I periodically check in on them to see how they are doing. They all have their own voice and are worth a listen. Find someone with a style that matches yours and learn from that blogger.

There are many others out there waiting to be discovered. If you start a new EMS blog, don't hesitate to send me a link, and I will add you to my blogroll.

Together, we, as EMS bloggers, are painting a fresh immediate portrait of what our work and world is really like that you can't find anywhere else. Our contributions help others; both fellow EMSers and members of the public understand our unique and extremely important profession.

Keep up the writing and stay safe!I occasionally have people ask me for advice about writing/blogging about EMS.

Here is Reynolds' post on blogging:

How To Blog And Not Lose Your Job

As important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.

As far as a personal policy, I would say this:

***

Some final thoughts. Blogging about EMS is an excellent way to stay fresh. By looking for material, I can see interesting things I might not have noticed. It keeps me from falling into a rut.

It is not a bad idea if you are thinking of starting a blog to read the work of others.

There are many others out there waiting to be discovered. If you start a new EMS blog, don't hesitate to send me a link, and I will add you to my blogroll.

Keep up the writing and stay safe!s important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.

As far as a personal policy, I would say this:

***

Some final thoughts. Blogging about EMS is an excellent way to stay fresh. By looking for material, I can see interesting things I might not have noticed. It keeps me from falling into a rut.

It is not a bad idea if you are thinking of starting a blog to read the work of others.

There are many others out there waiting to be discovered. If you start a new EMS blog, don't hesitate to send me a link, and I will add you to my blogroll.

Keep up the writing and stay safe!

Sunday, June 28, 2020

COVID Antibodies May Not Last

Ideally, if someone gets COVID-19, their body produces antibodies and they become immune from ever getting it again or they get immunity that lasts for several years. The answer to this is still unknown, but it doesn’t appear likely if we judge on the presence of antibodies in patients who have been infected.

A recent Chinese study showed that antibodies produced in response to COVID-19 may not last more than a few months, particularly if the infected patient was asymptomatic.

Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections

COVID-19 Antibodies Can Disappear After 2-3 Months, Study Shows

The study of 37 people with symptoms and 37 people with infection but no symptoms found after two months, 40% of the people without symptoms showed no antibodies while 18% of those who had symptoms with their infection showed no antibodies.

The authors concluded: "Together, these data might indicate the risks of using COVID-19 'immunity passports' and support the prolongation of public health interventions, including social distancing, hygiene, isolation of high-risk groups and widespread testing."

The study raises into question whether or not herd immunity (where enough of the population has had the disease and remain immune so that disease runs out of hosts to pass the germ onto) can ever be reached.

COVID-19 could well be with us forever (lacking scientific breakthroughs) just like the common cold, although with much more vicious (lethal) symptoms.

As a personal side note. I had an antibody test in early June, four months after my two week illness that left me with lingering shortness of breath. The test showed I had no antibodies, but I guess this study means I still cannot rule COVID out as the cause.

Seroprevelance of Antibodies

The CDC (Center for Disease Control) has just released a study of the seroprevelence of antibodies to SAR-CO-2 (COVID-19) in Six U.S. states, including Connecticut between March 23 and May 3, 2020.

The study estimated that these states had between 6 to 24 times the number of reported cases.

Commercial Laboratory Seroprevalence Survey Data

In Connecticut the seroprevelence (percentage of people in the population with antibodies) was estimated at 4.94%, which would mean the state at the beginning of May, had six times the number of reported cases.

New York City Metro region had the highest estimated seroprevelance at 6.93%, or 12 times the number of reported cases.

Missouri had a seroprevelence of only 2.65%, but this represents 24 times the number of reported cases.

The CDC will be conducting this study in additional states as well as retesting these areas.

South Florida, for instance, likely has a much higher seroprevelance now than when the study was taken in April.

The reason for the underreporting of cases, according to the authors, was likely "people may not have been counted because they had mild illness or no symptoms and did not get medical care or testing."

The authors emphasize that we still don’t know how long antibodies last or if they prevent someone from being reinfected.

Rt Numbers

Connecticut has the second lowest Rt number in the United States, behind only Massachusetts and the District of Columbia. Rt number is the average number of people who become infected with COVID-19 by an infectious person. If it’s above 1.0, COVID-19 will spread quickly. If it’s below 1.0, infections will slow.

In March, Connecticut’s Rt number was above 3. By April 1, it had fallen to .99, and is now estimated to be at .76.

In contrast Nevada has the highest Rt number in the country at 1.52. It began March at 2.17, fell below 1 in April 1 when its shelter policies started, dipped as low at .71, but then when the state reopened, the number has climber back to 1.52.

You can check out your state here:

Rt Number COVID-19

Bottom Line: If you practice physical distancing and wear masks in public, this germ can be beaten back, but crowd into bars or packed churches with poor ventilation, and disregard the use of masks, then the germ will have the upper hand and people will die.

Thursday, June 25, 2020

A Lull

Today in Connecticut there are only 124 patients hospitalized with COVID-19. This is down from a high of over 2,000 hospitalized. Connecticut has had 4,287 deaths. Yesterday only 1% (14 new cases) of the 1175 tested for COVID were positive. I did have contact with a COVID patient, a SNF resident who was COVID positive in April, tested negative in May and then appears to be positive again. The explanations for this – either the negative test was a false negative, like some patients, she continues to shed virus, or she was reinfected. We don’t know enough yet to know if people can be reinfected. We don’t know how long it can remain in a person, but we do know that tests can show false negatives. In talking with other medics and through my work at the hospital, it seems the only new EMS COVID patients anyone is talking about are those who have been living in the same household with COVID patients, or those who may have had COVID and are now feeling unwell enough to be hospitalized for COVID or other medical related reasons.

I would be celebrating the near vanquishing of COVID, but I read in the paper that COVID cases are hitting new highs – mostly in states that have loose restrictions and where wearing masks seems to be a political issue. I do get frustrated with Connecticut. The state has allowed pools and gyms to reopen, but neither my pool nor my two gyms have done so. The hoops are still not back up on the public basketball courts in our town. I know many restaurants have balked at the new permissions to open indoor dining at reduced capacity. I do see people violating physical distancing and mask wearing, but on the whole, they are isolated cases. It remains to be seen whether our slow reopening will spark more cases or if the protests will have any role in an increase, although early nationwide data on protests seem to show little role in the spread as most protesters have been wearing masks. In reaction to the states where cases are skyrocketing, Connecticut yesterday joined New York and New Jersey in putting a quarantine order on anyone coming into the state from an area with increasing cases.

Gov. Ned Lamont announces new restrictions on visitors to Connecticut arriving from 9 states with COVID-19 outbreaks

It was 90 degrees the other day when I had to gown up in my isolation gear – N95, surgical mask over it, face shield, gown and gloves -- and it wasn’t pleasant. My face shield fogged up, I felt like I couldn't breath, my glove kept falling off my shoulders. At least we are having to wear our gear much less now that the virus seems to be so sparse in these parts.

I am of the belief now that the virus will be with us for a long time, but that we can live with it if we are careful. My daughter has started her softball practices and it is great to see her and her teammates running the bases and enjoying the outdoors. Her first game is next week and the softball complex were the games will be held has a detailed list of safety rules. Temperatures will be taken on entry. The umpire will stand between the pitcher and second base, the girls will wear masks when not actively on the field. Instead of sitting in the dugout, they will sit outside the fence spaced six feet apart. There will be no high fives. Parents must bring their own chairs and sit outside the fence from beyond first base out along the outfield all the way over to third. Balls will be regularly decontaminated, kids must use their own equipment and not share water bottles. Only one parent per child with no other spectators. If a player or any member of their household tests positive, that player may not play for fourteen days.

FASTPITCH NATION PARK POLICIES & TOURNAMENT RULES

I am worried about a reemergence in our state when the colder weather comes and people have to be back indoors where the virus may be more likely to spread. But for now, I am going to try to enjoy each day, and hope that the lull here lasts. I’ll wear my mask in public and when I get the 911 calls, I will add my face shield, and add the gown when necessary.

Stay safe all.

A Boy

In 1999, I wrote a letter to the editor of the Hartford Courant about a police shooting in the city. The newspaper reported that an unarmed 14-year old black boy had been shot in the back by a white police officer. They put the story on the front page under the headline Family, Police Want Answers: No Weapon Yet Found At Scene Where City Officer Fatally Shot 14-Year Old

The New York Times also ran a story on the shooting: Unarmed Boy Is Fatally Shot By the Police In Hartford

What motivated me to write the letter to the Courant was the photo of the victim the Courant put on the front page. Here’s what is looked like a little larger.

They used a picture of a ten-year-old boy. I knew the EMS responders on the call that night and they thought the shooting victim was a man in his early twenties.

I knew the officer who had shot the boy. He was far from one of my favorites. He was one of those cops who was a cop and let you know it. Still I felt he was getting a bum deal. The photo of the child was incredibly biasing against him, and I scolded the paper for it. It apparently made little impression on them as it was never published.

Clearly my mindset back then was different than it is today. (I had completely forgotten about this incident until the other day when it flashed into my mind). Not that I still don’t think it was shoddy journalism to put a picture of the victim as a ten-year-old, but I did truly believe then that the victim was a criminal, a thug and up to no good and that he likely deserved what he got. I don’t know whether the fact that he was black or not figured much into it. In the north end of Hartford, 95% of the population is black. If I worked in a city that was 95% white and a cop gunned down a 14-year-old I might have felt the same, but maybe not. Maybe if he had been white, the cop would have let him keep running or not believed the boy might be reaching for a gun and it would never have been a story.

There was much community unrest over the shooting. An all-star panel investigated the incident and exonerated the police officer.

The Aquan Salmon Report

The Hartford police chief during the incident had taken a leave of absence, and was replaced by a respected black officer, Deborah Barrows. Her standing in the community is credited with preventing riots when the report was released.

AQUAN SALMON, HARTFORD'S POLICE AND DEBORAH BARROWS

The report stated the boy was one of four youths who “rented” a white Cadillac from a drug addict for $15 so the addict could buy crack. While joyriding in the drug addict's ride, they brandished “guns,” tried to mug a 41-year old woman, who Salmon hit over the head with his "gun"and then on being chased by police, fled the vehicle. When the lone officer chasing them through a dark back yard commanded the boy stop, the officer allegedly heard a gunshot, he thought he saw the victim reach into his belt and turn. That was when he shot him -- a shot more through the side than in the back (consistent with turning) it was later determined. No gun was recovered, but a cigarette lighter that looked just like a gun was found at the scene, and another one was recovered in the car. The youths had apparently bought several of these gun-lighters earlier in the evening. These were the "guns" they had been brandishing on their joy ride.

That incident occurred at 2:30 in the morning on a school night, and the fourteen-year-old victim had a home confinement bracelet around his ankle. Despite the bracelet he had apparently not been home for two weeks.

I wonder now if the same event occurred today, how we (I) would be reacting. Maybe there would be video footage that would tell a different tale. Maybe it would show a boy running and an officer taking aim, and the boy turning with hands up to surrender, and the officer still firing. Maybe it would show exactly what the report concluded.

Maybe Hartford would be on fire.

Reading the papers from back then makes me incredibly sad about the lack of progress in our country today.

Barrows said she hopes Aquan's death has awakened the city to issues it can no longer ignore -- namely homeless teenagers in trouble with the law, who have trouble succeeding in an ordinary school setting...."It's time to stop talking. What are we going to do? Aquan Salmon's death should have awakened everyone . . . If the Aquans of this city aren't safe, my kids aren't safe," she said.

-Chief Deborah Barrows

I still feel that the picture of the 10-year-old Aquan Salmon was biased against the police officer as it made people think he had gunned down an innocent child rather than a troubled manchild with a model gun that looked real who was indeed up to no good in the late hours of the night.

Maybe better training or more experience would have kept the officer from pulling the trigger, but that is just speculation. Who am I to judge someone who had to make a split second determination that means the difference between life and death between yourself and a stranger, between going home to your family at night or them laying a wreath on your grave?

But I have changed my mind about one thing. The ten-year-old boy in that photo is a victim. He was a victim, not of a rogue police officer, but of a system and a society that failed him and many others like him. He grew up in a poor, dysfunctional family, many who were in or spent time in jail. He had no role models, no one to steer him in the right path. The schools in Hartford are far from the schools of its suburbs. Here in Connecticut, the quality of your education is determined by the zip code you live in and the wealth or poverty of your neighbors, not a child’s needs.

AQUAN SALMON'S LIFE OF CONTRADICTIONS

The Connecticut I grew up in was far different than the Connecticut Aquan Salmon knew. The Connecticut many minority children are growing up in is different than the Connecticut many poor children in Hartford grow up in. We can talk about black versus white, but it is really opportunity versus none. It is about the disenfranchisement of our inner cities. Some people say get what is yours and pass it on to your own. Others say use your time on the earth to make the world a better place for all.

It is easy to put a Black Lives Matter sign on your freshly cut suburban lawn, to applaud the end of the Confederate flag or confederate statues being torn down, but what will matter in the end, is our country's support for a deep and committed redistribution of educational opportunity so that each kid growing up in our country has the same chances, the same preparation to make the most of their individual lives and not get lost at so young an age. If you live in a rich suburb and don't want to give up the quality education your child receives, then don't fight against taxes on the more advantaged to provide the same opportunity for the children of the inner-city or poor rural areas.

Aquan Salmon would have been 35 years old this year. Maybe he might have found the path. Statistically, he would have been more likely to end up in prison, certainly on the path he was headed. Maybe he would have gotten out of prison and become a community leader, helping others avoid the mistakes he made, or maybe he would have been arrested for buying cigarettes with a counterfeit $20 bill. Maybe he would have ended up on the pavement in some city with a policeman’s knee on his neck.

I hope that 20 years from now when we look back on 2020, that it won’t be the same old story. I hope we will look back with pride on the actions and commitments we made to right the world.

I hope that we make a safe, nurturing place for all children to grow up in.

I hope this movement in the country is real and lasting.

Peace and justice for all.

Power to the People.

Wednesday, June 24, 2020

Room 134

I hadn’t noticed this before, but my partner said it is true for many nursing homes now. Since visitors aren’t allowed, the nursing homes put room numbers on windows so the family knows which room their loved on is when they come to visit.

Another sad feature of many homes. In the lobby they often have pictures on the wall and the newspaper obituary of recently departed residents under titles like “Gone by Not Forgotten” of “In Memory of our Dear Friends.” In one home I count twenty-three notices of the departed.

In Connecticut 63% of all COVID-19 deaths have been in nursing homes.

Bipartisan Women’s Caucus wants answers from Gov. Lamont about why so many people have died in nursing homes

Sunday, June 21, 2020

Molly, Mushrooms and Mayhem

I just read an advance copy of Molly, Mushrooms and Mayhem,written by paramedic Jim Bollenbacker, who after a long career as a lawyer became a paramedic working concerts in the Midwest. He has many interesting tales of his experiences and those of others covering the craziness of music festivals from the EMS perspective.

Here in Hartford we have an outdoor music venue (Originally called The Meadows, now called the Xfinity Theatre) that our company does the EMS for. It is right off the interstate near the junction of I-91 and I-84 and draws concert goers from many neighboring states. I don’t like doing festival standbys, but over the years I have done a number of calls in and out of the venue as our on-scene crews call for ambulances. There have been times in the past when we have done over 100 transports out of one concert. Our company sends out notice to all the area hospitals beforehand to urge them to put extra staff on. It's a regularly scheduled mass casualty. Most patients are young, many underage drinkers, and depending on the concert there are also some drug overdoses. In the summer on hot days, heat exhaustion (often exacerbated by alcohol consumption) is common. But mainly its drinking. Drinking and vomiting. We have had kids so drunk we’ve had to intubate them. And many didn’t have any id on them believing if they got drunk, no one could call their parents.

Xfinity Theatre To Pay For Additional Police Following Mass Hospitalizations

I am a liberal parent, but I wouldn’t let my daughter go until she was at least 18, and warned her not to drink or take any drinks offered by others. I often wondered what the general public would think if they could see what we saw at these concert scenes: drinking to oblivion, a few young people openly having sex, people higher than satellites, pure craziness.

I have done calls into the venue where we have a triage tent and a line of ambulances rolling through, and calls in the outside parking lots where there are tent cities full of drunkeness and debauchery. The city of Hartford and the police have clamped down on the tailgating considerably in recent years. In the early days of the concerts there (I believe it was a Jimmy Buffett concert), I got sent one night for "a cardiac arrest" in one of the massive parking lots. We tried to find the call, but had no luck. Drunk teenagers continually walked right into our ambulance despite our whirling red lights. We couldn't go more than two miles an hour through the oblivious crowd. The parking lot was like a large neighborhood with each row being a city street where people sat in couches or in makeshirts pools or in the back of their pickups, drinking, smoking, tripping. Fires burned in trash cans. People wandered the streets like stoned zombies at a crowded block party. We drove around and around and couldn’t find anyone. The next morning, after all the cars had left, and all that remained were smoldering couches, I had a vision of someone still doing CPR amid the wreckage, only now visible.

When I was assigned to an actual concert, I couldn't take it. I think I saw the Charlie Daniels Band and the Outlaws. It was sparely attended, but even then the music was so loud I couldn't hear my radio. Some of my fellow employees love it and work the standbys almost exclusively. If you love music, you can see all the hottest acts. Over the years the events ranged from big time acts like Dave Mathews and Pearl Jam playing a stage with arena seating and additional seating on a large lawn to multiple stages with multiple acts throughout a full day, tours like Lollapalooza, Rage Against the Machine, the Warped Tour and others. If your favorite band was coming to town, you could put in a request to do the standby although most times there is little chance for people to enjoy the music they are so busy with the medicals.

DAMAGE AT MEADOWS ESTIMATED IN THOUSANDS

ROWDY CONCERT FANS FACE THE MUSIC IN HARTFORD COURT

Bollenbacker came to love the musical festival scene and appreciate the party-goers as well. His has some funny stories that ring true and I found it an enjoyable read about a little known aspect of the EMS experience.

Here’s a link to the book’s website:

Molly, Mushrooms and Mayhem

Saturday, June 20, 2020

Juneteenth

Worked the city yesterday. It was a beautiful day, a little on the hot side. There was another large protest at the state capitol with the people later marching to city hall and then the police station. People seemed to come from all over, white black, young and old, most carrying hand made signs. The police blocked off streets. I don’t think I’ve worked a day where there hasn’t been one rally or another. I am glad it is continuing, that we are coming together as one people.

Thousands gather at state Capitol on Juneteenth

While the rally was going on, I was buzzing back and forth across the city responding to emergencies. Increasingly there are people filming us on their smartphones. I wonder if they are truly concerned or are hoping to have the next viral video. A kid on PCP, who instead of making a racket and taking his clothes off, was just enjoying his dissociation, a man who fell and cut his leg, and another person with dehydration from the march, vomiting -- all captured on bystander’s iphones. Not much to see here. When I pull it to a call, I have to put the car in park, sign off on two radios, put my surgical mask and face shield on,attach my portable radio to my belt (the car is so cramped, I can’t wear it while I drive) get out and go around to the back and grab my gear (monitor, house back and isolation bag. It seems like it takes me forever to do all this. All the while I am on multiple cameras. I walk over and set them down next to the patient and introduce myself. I’ll do a quick assessment and get some demographics on the patient while waiting for the ambulance. No big drama.

I did do one call that might have made for some good video had it been outside. Instead it was in a dark dusty apartment where a large and very strong half naked woman with low blood sugar, cold and diaphoretic, shouted and yelled and rolled about on the floor. We had to try to hold her down so we could treat her. Low blood sugar can turn even the most mild mannered person into a potential world wrestling federation star as their brains, depleted of sugar, can make them lose normal consciousness and go crazy. She was shrieking and battling us. Between the fire department and the ambulance crew we had four people on top of her. She had poor IV access so I had to go for an EJ (external jugular vein)in his neck. That meant I had one person on each leg, another holding his shoulders down and the fourth holding her head to the side stiff-armed to the pillow we’d put under it while all the while she was struggling against us. I stuck a big needle in her neck, and then had to tape the IV down and hold it, as her neck was too sweaty for the IV tape to hold. I held my hand against her neck to keep the IV from pulling out as a firefighter held the bag of D10 I handed him and it ran into her neck as she fought us like a woman possessed with demon strength. I started with a surgical mask on and a face shield, but the shield got knocked off, and the mask started to slip to. I was just inches from the woman’s face and turned my head and closed my eyes to keep the spittle from getting into my eyes, and hoped to the good lord she didn't have COVID. And then just like that she stopped fighting opened her eyes and was back to herself. Someone filming it might have thought their footage was going to go nationwide of uniformed people beating down an unarmed defenseless person, but then it was all over. The patient was back to normal, smiling and thanking us for helping, apologizing for being difficult and signing a refusal of transport AMA. We made certain she had something to eat and someone to monitor here, and then we went back to our vehicles and on to the next call.

Happy Juneteenth all!

Friday, June 19, 2020

A New Team of Professional Crisis Workers

The mayor of Hartford Luke Bronin is proposing “a new team of professional crisis workers who would respond instead of or alongside police to calls involving mental illness, emotional distress, trauma and addiction.”

Hartford mayor commits to creating civilian crisis response team to handle certain emergency calls instead of police

As he says in the article in the Hartford Courant, "police should not be the first or only ones to respond to some calls for help."

Hmmm.

How about EMS?

No, wait, we already do it.

He just didn’t know because of our special powers of invisibility.

Now, to be truthful, here’s how it works in Hartford.

Resources are dispatched depending on the way the call comes in.

Let’s talk about these categories. EDP (Emotionally disturbed person). Violent EDP, Overdose, Shooting, Stabbing, Assault.

Many years ago when I started in Hartford, we were sent to these calls and we just went. In time, we started to do something called staging. We respond, but wait for the police at a safe distance. Today, a nonviolent normal EDP, we don’t stage. We stage for a violent EDP. We stage for shootings and stabbings. Sometimes we stage for an assault and sometimes we stage for an overdose. I understand why they have us stage for a some assaults in case the assailant is still there, and I can see us staging when we are sent for an overdose when the overdose is a large muscled man on PCP climbing naked on cars. I don’t understand why sometimes they have us stage for an apneic heroin victim, but staging for such calls is rare.

Let’s say the call is a violent EDP. The police enter and we wait for them to call us in. Sometimes, they bring the patient out in handcuffs, sometimes they come out and say misunderstanding, but most times we go in, talk to the patient and convince them to come with us to the hospital. We often do a good guy bad guy routine. They want to get away from the cops so they go with us. Sometimes, they are holding the patient down, and we sedate them, and then they help us get them on the stretcher and follow us to the hospital. Usually, when I sedate a violent EDP, they are snoring by the time we get to the hospital.

On the heroin overdoses, sometimes the cops show up and try to force the patient to go to the hospital when they refuse. I once had a cop say, “Either you are a victim of a medical illness, in which case you are going to the hospital, or you are a criminal, in which case you are going to jail.” I am against these forced transports. If a patient is alert and oriented, I will take a refusal after giving them a full discussion of where they can get help and how to stay safe. For the most part, the cops will defer to whatever EMS decides is right for the patient.

I have noticed on some overdoses lately harm reduction people have shown up on scenes, often getting there before us. (They listen to scanners). They are helpful and never in the way. I can see how dispatching them formally would be a good thing. I am also not opposed to mental health professionals going. This has happened sometimes in the past. They can be helpful, but they can also just make things worse. I have waited on scene for extended periods while they have conducted their assessments. I prefer that we say to the patient, how about we give you a ride to the hospital and you can talk to someone there who can here you out? That usually works.

I am all for keeping the cops on calls where they are most needed. Sending them for a violent eight-year old or an apneic heroin overdose or a fifty-year old who told her friend she doesn't want to live anymore might not be the best use, but they do certainly need to still go to the shootings, stabbings and crazed people on PCP.

Dribble for Justice, Dribble for Change

Tonight I participated in Dribble for Justice. Dribble for Change. I made a top score of 279 (trying five times and worked up quite a sweat).

It is a part of a basketball training App called Home Court special BLACK LIVES MATTER activity.

As part of the event, I also made a donation to the Equal Justice Initiative in memory of Kevin Andrews.

The Equal Justice Initiative is committed to ending mass incarceration and excessive punishment in the United States, to challenging racial and economic injustice, and to protecting basic human rights for the most vulnerable people in American society.

We can make our world a better place for all!

Thursday, June 18, 2020

Reopening

Connecticut reopened its gyms and swimming pools today along with indoor dining. Unfortunately, neither my pool or the two gyms I go to reopened. Nor word yet when they will. Bummer.

I had no desire to celebrate the phase two opening by going to a restaurant to dine indoors, so tonight i am in my backyard grilling hamburgers and in a little bit I will get in my small hot tub that I just paid $600 to get the leaks fixed in and a new motor after a few years of unuse, I will also likely have a couple of hard seltzers even though I find they interfere with my sleep.

Connecticut has been doing great as evidenced by the map below. We are one of the few states in green, meaning we are a state making progress in our battle against COVID. Part of the reason we are in green is we were hit so hard in the first wave that made its biggest initial impact in our neighboring New York, spreading into New Jersey to the south and Connecticut to the north. Our state made some good choices early on and for the most part people have followed physical distancing protocols. I use the term physical distancing now because that is really what it is all about. We should never socially distance.

How We Reopen Safely

While the reopening and the fact that today Connecticut has less than 200 people hospitalized with COVID down from a peak of over 2,000 in April, is cause to celebrate, the more I read, the more realistic I realize I and we all need to be about the future.

The interview below with Dr. Michael Osterholm, noted epidemiologist and author of Deadliest Enemy: Our War Against Killer Germs, a great book that is clear-eyed in its appraisal of what we face.

COVID-19: Straight Answers from Top Epidemiologist Who Predicted the Pandemic

Only 5% of our population has been infected.

Covid-19 has no reason to disappear.

Unless we have a vaccine, which is no sure thing, COVID will burn until 60-70%of our population is infected, and will likely kill 800,000 to 2 million american in the next two years.

Chances of a successful vaccine that prevents COVID are not good.

Our darkest days he says are still ahead of us.

He recommends avoiding prolonged contact with others in indoor spaces with poor ventilation and cautions that cloth masks offer only limited protection in such situations.

What we must do is find the safest ways we can to live the life closest to what we have loved about our society, and if we have strong leadership that speaks the truth to us, we will get through it.

Please read the interview, and if you are looking for a good read, try the book. It in nonfiction, but reads like an adventure story. It covers everything from Ebola to the flu.

Be safe out there.

Wednesday, June 17, 2020

Harm Reduction

Connecticut's harm reduction workers are out on the street everyday trying to make the world safer for those caught in substance use. This is particularly important in this time of COVID-19. I am often questioned whether or not harm reduction - syringe services, community naloxone, overdose prevention sites, drop-in centers-- are not just enabling users.

The video below offers a great explanation of the benefits and role of harm reduction.

https://youtu.be/w7vptIKGOKo

Monday, June 15, 2020

Kevin Andrews

With all that is going on these days, I thought of Kevin Andrews, one of my first partners in EMS.

I first posted this in January of 2011.

***

In EMS, we cannot help but be shaped by our earliest partners. They are the ones who show us the way. I was lucky in that regard.

Kevin Andrews was one of my first partners. This was back in 1989. I was a spanking new EMT — so fresh I didn’t even have my certification yet. Due to an EMT shortage I was working on a waiver that let EMT class graduates work pending the outcome of their state exams. I even wore a “whop kit” – one of those pouches that attach to your belt and hold your tools of the trade. Mine was small and conservative by some standards. I had a penlight, trauma shears, bandage scissors, and a window-punch.

We worked for Eastern Ambulance, a mom and pop ambulance company in Springfield Mass that had the 911 contracts for three suburban towns in addition to backing up calls in the city and doing transfers. On a good day we only had five ambulances on the road. On most we had three. Some of the ambulances had brown bondo on the sides and in one, you could see the road through a hole in the floorboards. On Fridays, we use to all race down to the bank to try to cash our checks. The last to get there often found theirs would bounce. We didn’t have paramedics, just basics and intermediates. We didn’t even have defibrillators then. But we were a close-knit group, and there was more to the job than money.

Kevin was an EMT, but he was respected as any of the intermediates. He’d tried to take the EMT-I exam a couple times, but kept just missing it. He was very street smart, but had trouble overthinking the tests. I, on the other hand was book-smart, but had no clue about the street. With the wrong partner, my life at work could have been made miserable. I was always glad to find myself working with Kevin.

We were both thirty then, but our backgrounds couldn’t have been more different. He grew up in a large family in Springfield in a neighborhood where the drug trade flourished. I was from an upper middle class suburban family and my most recent job was working for a United States Senator until his loss had send me on this personal quest to learn how to help people in person rather than from behind a policy desk.

Kevin was a big strong man with a shaved head who a instructor and black belt in karate. Still he was gentle and soft-spoken, with a ready smile. I never saw him raise his voice or become excited on a scene. He had that calm about him that for all the occupations I have worked in, I have only ever really seen in certain EMS responders — an unperturbed always in control manner that seemed to deescalate any panic around him from patients, bystanders or partner. He always knew what to do, and if he didn’t, he never let that on.

Sometimes we used to stop at his mother’s house where she always made sandwiches for us and we would visit with his youngest brothers and sisters before heading back on the road. He was their clear pride. Out on the street, Kevin would point out to me the drug houses and dealers. What I might have thought was an innocent boy of twelve on a bike, was instead a drug-dealer’s lookout. It was a new world for me.

My clearest recollection of a call with Kevin was on a cold sleety morning in winter when we responded for a woman who had slipped on the ice on the top steps of a church. I could tell right away her arm was broken. I palpated it through her coat and it felt almost as if it were in two separate pieces. I had my trauma shears out in a jiffy, but before I could make my first cut, Kevin had a soft but strong grip on my arm. “This might be the only coat she owns,” he said quietly. “Let’s see if we can ease her arm out of it.” Which is what he did, taking his time not to cause any pain. The woman’s winter coat was preserved and her arm was carefully splinted and he talked to her in a reassuring way that caused me to feel only awe at what I was witnessing. It made me see that EMS wasn’t really about blood and guts and bad car wrecks and doing CPR. It was about taking care of people.

The company went bankrupt a couple years later. By that time I was only working one overnight shift a week. I was back behind the policy desk as the ex-Senator after a year in exile had run for Governor and won. Despite the full-time government job I was not only hooked on EMS and had to get my weekly fix, but I felt like I was a part of a family at Eastern Ambulance and I didn’t want to lose that connection. I hated to see Eastern close. Kevin and most of the others we worked with went to work for another ambulance company in Springfield while I joined a volunteer service in Connecticut.

I saw Kevin periodically over the years. We had a few Eastern get-togethers. Another time he and his girlfriend brought their kids down for a picnic at the condo in Connecticut I shared with my own girlfriend at the time. I visited him in the hospital when he got a bad infection and had to get IV antibiotics. We’d talk on the phone sometimes and get caught up on how all the people we worked with at Eastern were doing. He told me he was honored when I mentioned him in my first book. I was honored to be able to write about him. Whenever he’d call, even if we hadn’t talked to each other for a couple years I’d say “Kevin” recognizing him at the first sound of his voice.

The last time I talked to him was three years ago right around the birth of my daughter. He’d mentioned there was going to be a new get together of some of the old people we knew. I wrote his number down, but in the confusion of the time, misplaced it. I have always been somewhat of a recluse. I work all the time and I’m not the best about keeping in touch.

A month ago I talked to a woman who’d also worked ambulance up in Springfield, starting shortly after I had left the area. When I mentioned I had worked for Eastern, Kevin’s name came up. She said she knew him and that he was helping teach basic EMTs at the college where she also taught. I said to say hello. Later in a New Year’s Day phone call, she told me she had talked to him and that he had been excited to hear she had spoken with me. He told her about the good times we’d had as partners. She’d given him my cell phone number and he’d said he was going to call me. She wanted to know if he had ever gotten a hold of me. He hadn’t. And now he won’t be. The reason for the call was to tell me he had passed away suddenly. She didn’t know the details. The rest of the conversation was a fog. I kept thinking. What do you mean? He passed away?

I have always found it hard to believe people I have known are gone. I have to see the obituary in the paper. I found it and there is was in print. Kevin Andrews, 52.

I am not one who believes in heaven or an afterlife. I believe when you are dead, you are dead. There is no place where you go to sit with others or wander among the clouds. Your conciousness is no more.

But what I do believe in is memory. I can close my eyes and see Kevin sitting right next to me in the ambulance, telling me a story. I can see him standing there in his mother’s house smiling watching his brothers and sisters play, and then years later, sitting on the back deck watching his own children play in my yard. I can see the true friendship in his eyes and feel his warm handshake when he says “Keep in touch.”

And I can still see him taking care of that old woman on the church steps as clear as if I were still there. I watch his hands and I want my hands to be able to soothe someone as his do.

***

Kevin shaped me as a caregiver and as a person. He helped make me the paramedic I am today. If I am gentle toward a patient, than Kevin’s spirit is in me, Kevin’s touch is in my hands. If watching the way those of us who were influenced by Kevin treat their patients, others are now gentler with the sick and injured, then Kevin’s hands and heart are also in them. His breadth widens. This is what becomes of him. This is how Kevin is passed on, from one caregiver to the next. Let this be how he is remembered.

The great church doors open to the icy weather. Outside on the cold steps, an EMT caring for a patient.