Street Watch: Notes of a Paramedic: April 2012

The number one treatment change in EMS in the last twenty years is the increased emphasis on painmanagement and comfort care.

Albert Schweitzer said, “Pain is a more terrible lord of mankind than death himself…. We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege.”

Like many I began in EMS with visions of saving lives everyday and then having grateful reunions filmed by the crew of the old TV show, Rescue 911.

Now over twenty years into my career, I know that true life-saving calls are few and far between. And many of those few life-saving calls you really don't do much more than you are taught:

Show up on scene, find recently collapsed patient, apply defibrillator, shock, feel restored pulse.

Show up on scene, find cool, clammy patient with chest pain, do 12-lead, see obvious STEMI, call hospital to activate cath lab, transport.

Show up on scene, find child in anaphylactic shock, eyes swollen shut, airway closing off, no blood pressure, stick them with epi, and watch them return to their normal self.

Some patients are just waiting there for us to save them.

And on other calls, you can work your tail off, do heroic things and the patient doesn't make it. It was just their day to die.

Today, I see my job not as a lifesaver, but as a comforter.

My EMT instructor told me the emergency ends when you arrive on scene, or at least that's what you have to make the patient believe.

Today, my reinterpretation of her comments is this; once I am on scene, the patient is no longer alone. I am there to care about them, to provide whatever comfort and care I can, and to try to keep them safe from further harm.

I do that hopefully with a calm voice, a caring touch, understandable words, and with if they are in pain, with everything from pillows and ice to morphine.

"My great and ever new privilege," as Schweitzer says, "is to take care of people's pain."

I can do that, in one way or another, on an almost daily basis.

When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year. And for vomiting patient, I never once gave an antiemetic.

“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.

It's a new day.

Last year I gave Fentanyl over 50 times, more than any other drug except Zofran, which I gave close to 100 times.

I gave Fentanyl for hip fractures, and ankle fractures, and shoulder dislocations and wrist fractures, for amputated fingers, burns, for kidney stones, and for all sorts of abdominal pains. Did I get scammed a time or two by a drug seeker? Likely I did, but you know what? I don't care. I can say I didn't deny anyone in legitimate pain medication for fear they were drug seeking.

Why is pain management important? Because pain is destructive to the human body. Its only purpose is to alert patients to injury to help eliminate the source of the injury and halt damage to the affected tissue. Untreated, pain stresses the body, damages the immune system, hinders wound healing, and can lead to chronic pain. Not to mention the emotional suffering it causes.

"Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.” – Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006

Nearly ever study ever done on the issue has showed widespread under use of analgesics in EMS systems and emergency departments across the country.

But times are changing.

When I started as a medic, on-line medical control was required to give morphine. Today, for a 220 pound patient, I can give up to 20 mg of Morphine (over 20 minutes) on standing orders and up to 300 mcgs of Fenatnyl. Morphine for abdominal pain was prohibited. Today I can give Morphine and Fentanyl on standing orders.

I may not be able to save a life everyday, but everyday I can treat my patients with respect and dignity, and if they are in pain, I can ease their suffering.

The oldest mission of medical healers is to treat pain. I accept that mission.

And I praise paramedics and EMS systems across the country for coming to recognizie this.

# 2 AEDs

The first code I ever did I hadn’t been an EMT but a few months, and my partner had been an EMT but a few days. The man had collapsed in his kitchen. He had gasping respirations. We got him on a board and out to the ambulance, where my partner did compressions and bagged while I drove. This was in the late 1980’s, twenty years after this country had put a man on the moon. I don’t know what rhythm the man was in the field. He was asystole at the hospital -- asystole, blue and with a bloated belly. Not only did we not have an AED and no paramedic intercept, we didn’t have any intercept. We were in fact trained to do two person CPR, not two person CPR like they teach in CPR class, but two person load the patient onto a stretcher and get him out to the ambulance, load him in the back and have one EMT do CPR while the other drove to the hospital kind of two man CPR. I remember shouting to my partner the whole way “15 and 2! 15 and 2!” Our small service couldn’t afford to tie two ambulances up for one patient.

Even later, when I worked as a paramedic for a larger service, while I had a Life Pack 5, our BLS crews didn’t have defibrillators nor did the police department who was the reluctant first responder. We considered it good form if a first responder was doing CPR when we showed up as opposed to standing in the doorway, saying "he don’t look too good." For many years the only bystander CPR I saw was when someone dropped in sight of a volunteer EMT or a boy scout.

How different it is today. This year alone there have been five successful cardiac arrest resuscitations where the patient has walked out of our hospital with full neurological function. Four of those patients got bystander CPR from laypeople, three of them had pulses back before the medics even arrived thanks to the first responders’ defibrillators. The other two needed a shock from the medics before coming around after initial AED shocks. All of the five patients had pulses back before the medics intubated or put in an IV.

The 2nd most important change in EMS treatment in the last twenty years for me has been the introduction of defibrillators to all ambulances and to first responders, not to mention the widespread appearance of public access defibrillators. I wish I had one all those years ago.

# 3 STEMI Care

When I started in EMS we had Life Pack 5s, which showed only one lead at a time in a tiny window. When I went to paramedic school, no one taught us about 12-leads. Paramedics didn't do them. Early on, we did an experimental project where we had a giant 12-lead machine in our ambulance, but it was so big and we were so uncertain about how to do a read a 12-lead that we never used it (or at least I didn't) and the project soon died.

Later, another medic taught me how to do a modified 9-lead ECG. This involved putting the machine in lead III and moving the left leg electrode across the chest in the V1-V6 positions, while being certain to print in the diagnostic mode. We then had to cut and paste the strips onto a sheet of paper. We labeled the newly aquired views as MCL1-MCL6.

The first time I did one (the day after I had been taught how to do it), I had a healthy young man with crushing chest pain. His skin was warm and dry. His vitals were BP 120/80, HR-64, RR-16, SAT-100% on room air. As a lark, I tried the 9 lead ecg. When I put it in MCL4, it showed tombstone elevation. Curious, I thought. I showed it to the triage nurse, who was dismissive, but at least instead of putting the patient in the waiting room, she put him in a regular room, where the room's nurse found him in cardiac arrest when she went in to assess him. He was defibrillated successfully, taken to the cath lab and found to have a 100% blockage of his LAD.

I can remember many times when I walked through the ED waving my 9-leads, and then even later after we got 12-leads, waving those, trying to get a doctor to look at one. The regular procedure was put the patient in the room, have the nurse come over, assess, do a 12-lead and have the nurse show it to the doctor. We all soon learned to be aggressive with our 12-leads, calling in saying the 12-lead showed an MI (sure, sure, they thought), and then using the 12-lead as a ticket to the head of the triage line. Excuse me, see my 12-lead, mind if I cut ahead. Take a look at this. Where's the doctor?

Nowadays, of course, it is so much different. We see a STEMI in the field, we call the hospital from the patient's bedroom, talk directly to a doctor and activate the cath lab from the field. We often bring the patient right up to the cath lab on our stretcher. Progress.

Here's a post I wrote on STEMIs.

STEMIs

STEMIs (ST-Elevation Myocardial Infarctions) are my favorite EMS call. I like them as a paramedic and I like them as an EMS coordinator. They are a great test of your both your ability as a medic and the ability of your EMS/hospital system to function well. They require clinical acumen, speed, skill, and coordination of resources.

If done well, you can save a patient’s life, if done poorly, a life could be lost (although sometimes lives are lost even when everything is done right). And the lives we are talking about here are usually people in the prime of their life. These aren’t asystole codes of 95-year-old ladies whose ribs break at the first push of CPR. And these aren’t trauma patients whose bones can’t be unbroken, whose head injuries can’t be easliy unbled.

It is simple. Recognize a possible STEMI, do a 12-lead, interpret it, notify the hospital/and hopefully get the people in the cath lab ready. Think of yourself as the 911 dispatcher for the cath lab. As important as all the skills you will do is getting the cath lab team sliding down their bat poles and getting their superhero suits on and having them there ready to work their miracles when you come through the door with your patient.

Transmit the 12-lead as soon as you identify it. If you can’t transmit, call it in, as soon as you can (not after you have done your two IVs and given ASA and 3 NTGs) — as soon as you see it is a STEMI.

Give 02 if the patient is hypoxic (AHA says no longer does every STEMI get the nonrebreather).

ASA if there are no contraindications.

IV – two is best, the bigger the better.

Nitro — unless it is a inferior STEMI with right ventricle involvement or any MI with low BP.

Morphine — if pain is not controlled by NTG.

Zofran — if the patient is nauseous.

Take their clothes off if feasible. Hospital gown on top, sheet over the pants (this will save time at the ED).

Get your registration info so they can get him into the system.

Switch O2 to the stretcher tank and mount the monitor on the stretcher so there is no delay packaging once you arrive.

Hit the curb and out you pop.

Oh, yeah, and have defib pads ready in case your patient codes. The natural progression of a STEMI is to VF and cardiac arrest. We are talking high risk here!

The hospitals have been practicing their pit crew techniques on STEMIs as well. Hospitals are being rated now on Door-to-Balloon (D2B) times meaning time from when the patient hits triage to when the balloon crosses the blockage/lesion in the cath lab.

The three big hospitals in our area have been battling with each other for STEMI patients and all of them are recording both excellent door-to-balloon times and great patient outcomes. Most of these patients who may be withinin minutes of cardiac arrest walk out of the hospital in a matter of a few days with clar stented arteries, on some new meds and told to eat heart healthy diets. Years ago they would have planted in the ground. Much of the improvemt is due the medical system recognizing and encouraging the important role EMS plays. Years ago I used to have to walk through the ED waving a modified 9-lead strip trying to get a doctor’s attention that my patient was having an MI. Now the MD knows and the ED and cath lab are already readying even before I leave the patient’s house.

***

A new study in the American Journal of Emergency Medicine published in April of this year, Hospital-based strategies contributing to percutaneous coronary intervention time reduction in the patient with ST-segment elevation myocardiaI infarction: a review of the “system-of-care” approach, concluded among 8 primary strategies for reducing hospoital door-to-balloon times, “2 have substantial evidence to support their implementation in the attempt to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), including emergency physician activation of the cardiac catheterization laboratory and prehospital activation of the STEMI alert process.”

#4 CPAP

This morning we had a call for a 70 year old man with dsypnea and found him guppy-breathing with a BP of 210/100, HR – 144, skin ice cool and clammy, unable to get a SAT, ETCO2 of 50, RR of 32. Wheezes and crackles in lungs. Upright CO2 wave form.
He was sitting on his front steps, probably hoping the fresh air would help, but it wasn’t. We threw him on the stretcher and got him in the back of the ambulance quick.
We put him on CPAP — first time for me (we’ve only had it a couple weeks) — and started pounding in the nitros and in no time he was warm and dry. RR down to 24, ETCO2 down to 34. HR down to 132. He was still full of fluid, but at least we weren’t having to intubate him. Neither did the hospital. They put him on bi-pap and a nitro drip. His PH was 7.25 on arrival. The doctor said he probably would have coded if we hadn’t gotten there and started treating him as soon as we did.

I was trying to imagine how the call would have gone if we didn’t have CPAP. The nonrebreather wouldn’t have helped much. We had it on for about a minute before we got the CPAP out and he was tearing it off gasping that he couldn’t breathe. We would have had to start bagging him and maybe dropped a tube – certainly much more invasive than putting the CPAP on.

I saw him later in the hospital and they had him down to a Venturi mask and he was sleeping comfortably.

I made sure to thank our medical control doctor and clinical coordinator for helping us get CPAP. It certainly made a big difference — just as advertised.

In the five years since we first got CPAP, I have used it probably two dozen times, with many just as dramatic as the above. As a region we have expanded our use of CPAP from just for pulmonary edema to any severe dyspnea. If it works, keep it on. If it doesn’t, take it off. My least favorite calls were the severe dyspnea where you had to battle with the patient just to help them, but CPAP has made it so much less stressful. We can also give Ativan on standing orders now to patients with anxiety due to their dsypnea. It makes it much easier to get them to cooperate.

Studies have shown that the use of CPAP prehospitally reduces the need for intubation by 30% and reduces mortality by 20%. – “Out of Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial.” Annals of Emergency Medicine. September 2008

So the number to treat to save one life is 5. That means for every 5 times you use it, you are saving one patient who might have otherwise died. That speaks for itself.

In Connecticut we are pushing to make this a BLS skill with medical control approval.

#5 Capnography

Before capnography, there was nothing.

Sure, we could verify the placement of an ET tube the old fashioned way – visualization, your partner feeling the tube pass just beneath his fingertips as he gave you crick pressure, absence of epigastic sounds, positive lung sounds, mist in the tube, chest rise, and ventilation compliance. But even that was not always reliable (except for the partner feeling the tube pass). And the real problem wasn’t always just getting the tube in the right place, but keeping it there. Once you had a tube and it was good, it was nerve-racking maintaining it – and let’s say it did slip, let’s say when you arrived at the hospital and an crew anxious to help, grabbed the stretcher and yanked it out as soon as they opened the back doors for you, while you were carefully bagging, or let’s say a first responder knocked it while he was bagging for you (bad decision), you were constantly checking and if found out the tube was no longer in the right place, how long was it not in the right place? With capnography, as long as you see that beautiful wave-form, you are feeling good because you know the tube is good, and the patient is being protected.

And then there is return of spontaneous circulation. The End Tidal CO2 suddenly shoots up and walla – you have pulses! The ETCO2 suddenly drops and oh sh---!, you have to start CPR again. The key is you know right away, not at the two minute check point or longer.
There is so much capnography offers us – for both intubated and non-intubated patients, it is hard to remember what it was like without it.

#6 Termination of Resucitation Protocols

I always had a problem with it. The patient was dead. Everyone knew he was dead. He hadn’t been seen since the night before when he’d asked for a cool glass of water. They found him in the morning in his bed, still as can be. He wasn’t breathing and he had no pulse. He looked peacefully there, his head on the pillow, the half-drunk glass of water on the bed stand. He was eighty-nine years old with inoperable cancer. He’d refused hospitalization just two days before. The problem was while there was a little bit of rigor in his jaw, there was no lividity. The room was warm – how he liked it. The family knew he didn’t want any extra measures done to save his life, but they called us because they didn’t know what else to do.

How many times did this or similar scenes play out? The patient ripped from the bed, laid on the hard floor, compressions breaking the chest, tube down the throat, IV, drugs, strapped to a board, carried out of the house to the ambulance in the rain, raced lights and sirens to the hospital, only to be dismissively called dead on the stretcher on entry to the code room. And then later, unseen to us the family received bills for ambulance transport and for ED care.

Everyone was worked and everyone was transported unless they had a DNR bracelet or met the criteria of rigor mortis in the major joints with dependent lividity.

We finally instituted some changes in our system. Medics were encouraged to use their judgment and call medical control, explain a situation and get permission not to intervene. If they did work the code and the patient was asystole, we could work a patient for 20 minutes, and then cease the resuscitation at home, call the patient dead, remove the tube, lift the person back up, put them back in bed, pull the sheet up to the neck, and have the family come in to say goodbye.

For a number of years, we could presume the patient on our own, but then once we developed statewide guidelines on termination, in the interests of solidarity with the other regions, we agreed to require our medics to call a physician for permission to cease. I have never yet had a doctor disagree with my request to cease. I am somewhat bothered by the requirement that we have to initiate CPR until the doctor gives the final concurrence, although I suppose that protects us if the doctor were ever to say, no, I want you to work the patient and bring him in. It has happened to others.

Sometimes, I have the family come into the room while we were still doing CPR, and have them say goodbye before we stop. What a sight that can be. A family one by one saying good bye to the 100-year old aunt in the room where she has lived the last ten years of her life. The love you see, the things they say, the tenderness. "Auntie Mae, I'm going to look out for Junior, for you, you know that." "Auntie Mae, I love you, I love you my whole life." "You going to rest now, Auntie Mae, you going where the fields are green." Sometimes, they just give a kiss, and whisper something into the ear. A husband says, we'll be together again. Wait for me.

I have seen this scene play out a number of times and I have always considered myself privileged to be there to witness it.

We do all we can. The families know when a loved one's time has come. Their spouce, or mother or father or sister or brother, grandparent, aunt or uncle, dies at home, surrounded with their love and thoughts in their last moments, with some kind of dignity.

The National Association of Emergency Medical Physicians has termination of resuscitation rules that have a 100% predictive value for determining death. A study done at Yale showed that 54% of cardiac arrests brought into their ED met national guidelines for being called at home. They were all declared dead in the ED.

I understand that sometimes there may be reasons to transport dead people and that every scene is different. But as the American Heart Association said in its 2005 Guidelines:
“Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable.”

Termination of Resuscitation Protocols is # 6 on my list of best treatment changes in the last 20 years.

7. Decreased Use of Lights and Sirens

Ambulances in this area drove faster twenty years ago than they do today. We had some wrecks. People were killed, other injured. It happened. The longer I worked, the more unnecessary it seemed. Drive half way across the city lights and sirens only to wait half the day in the triage line with the same patient. What was the point?

The worst drivers were young men in their early twenties, all full of testosterone and invincibility, wearing bullet proof vets, but not using seat belts, much less wearing crash helmets.

In time we got mandatory seat belts and were required to come to complete stops at all intersections when responding lights and sirens, and we had the black box technology to enforce it. You “fob” in to drive so the computer knows you are driving. If you don’t wear a seatbelt, drive too fast, take a corner too sharply, or stop too suddenly, you lose points and have to listen to the ambulance beep when it happens. I resisted the black boxes at first (not the seat belts, which I always wore), and in time, I came to think they were great. People definitely drive better now.

The role of lights and sirens is much less now. EMD, which I am not a big fan of, has at least, contributed to the downgrading of some responses.

We even have a statewide policy now to help limit the use of lights and sirens. The general rule of thumb now is only go lights and sirens to a hospital if the hospital can do something for the patient that you can’t in the amount of time you would save going lights and sirens over flow of traffic that will make a difference in the patient’s outcome.

I rarely even go lights and sirens to the hospital now. Despite this, I think lights and sirens are still overemphasized. Too many town and municipal contracts are based on on-time performance as well as outcomes. All these contracts measure is what time the ambulance arrives, not whether a medic is there or not or how good the care is. How about these for performance measures instead of response times? Percentage of patients 55 and over with hip fractures, who receive pain meds, % of STEMI patients who get ASA and have their 12-lead done and successfully interpreted or transmitted to the ED, CHF patient who receive CPAP and nitro?

When I started, the Golden Hour ruled, but it has been discredited over time. Quality Care and Safe Transportation are the new watchwords. I hope this trend continues.

# 8 Selective Immobilization Guidelines

8. Selective Spinal Immobilization Guidelines

I remember this scene from a hospital triage line vividly. It is eight-thirty in the morning. A woman in her middle thirties in a nice business suit is on a backboard with a tightly applied neck collar, two body straps, and her head is immobilized with thick duct tape going from the top ends of the board, down around her collar, cranking her neck back. Her problem, besides the poor job of spinal immobilization is she needs to pee. She has been drinking coffee since she woke up and got her kids off to school, and was drinking it on the way into work when she was rear ended in traffic. She has some minor back pain. “Please,” she says for the third time to the crew and triage nurse, Let me off this board! I need to use the bathroom. Please, I can’t hold it any longer!”

The triage nurse snaps at her. “Hold still, unless you want to be paralyzed. You have to stay on that board until the doctor exams you!”

I have seen similar scenes. Triage nurses,EMS, even doctors shouting at people that they could be paralyzed unless they submit to being immobilized.

Come on, people! What about the patient? Does anyone really think that letting this lady get up to pee is going to paralyze her. Does anyone think that her jerking around on the board is good for her supposedly injured spine?

If we really cared about keeping patients still, everyone we immobilized, we would also sedate. Got neck or back pain from a minor MVA? You get spinally immobilized, and then given 5 of Versed and 100 of Fentanyl. Hell, why not RSI them all?

Actually, this is probably a bad idea because most alert people with spinal injuries have their muscles tense up, which helps them self-splint the injury to limit movement.

I remember once I was called for a motor vehicle victim in a Chinese restaurant. The patient had been in an MVA on the highway, fled the scene and finally called from the Chinese restaurant. I tried to immobilize him. He wanted no part of it. I had two cops with me. Somehow they ended up wrestling with him to try to get him to submit to being immobilized. One cop had him in a head lock. It occurred to me then that maybe it would be better for his spine if we didn’t try to force him into the collar.

We used to immobilize everyone. Every motor vehicle, every fall over three feet, every shooting. We immobilized to protect the spine based on mechanism of injury, not based on assessment. There was no science behind it; just the conjecture that keeping people with possible spinal fractures still would prevent them from suddenly becoming paraplegics with the slightest movement. In our state basics continue to c-spine everyone. Paramedics are able to follow criteria to selectively omit spinal immobilization. There is a plan that is slowly progressing through the channels to extend this to basics.

The science of spinal immobilization is more extensive than I can cover. While there is evidence that spinal immobilization causes back and neck pain, leads to decubitis in elderly and can hinder breathing, and delays transport of critical patients increasing their risk of death, to date, there is no evidence that it does what it claims to do – protect the spine. It may, in fact, make it worse.

The study I like to cite the most is the one where they studied all spinal fractures in New Mexico brought in by EMS immobilized and all those from Malaysia who were thrown into the back of a donkey cart (I am joking here) without immobilization and taken to the hospital . The patients in New Mexico did worse. Did the study prove spinal immobilization was bad? No, but it clearly did not provide any evidence that spinal immobilization was beneficial. No study ever has.

Out-of-hospital spinal immobilization: its effect on neurologic injury.

As a clinical coordinator, both at my hospital and in conversation with other coordinators, I do know of many cases where patients with cervical fractures were not immobilized (usually elderly victims of low falls), but I know of no cases where harm was done to the patient from not being immobilized. I have had several patients with cervical fractures who I did immobilize. Every one of them had significant neck pain.

Since we were able to omit spinal immobilization, countless people have been spared torture. I am unawre of any patient who suffered neurological injury from not being immobilized in our system. I would like to see the current guidelines extended to basics and I would like tto see the guidelines rewritten for paramedics to make spinal immobilization indicated only for suspicion based on assessment. If in your clinical judgment, the patient may have a spinal injury, then immobilize, and immobilize fully and properly. If you don’t believe they do, based on your assessment and judgment, don’t immobilize.

9. Alternative Airways

When I started as a paramedic – all we had was the ET tube. You brought in a code, the first question you were asked in the EMS room was “Did you get the tube?” If you got the tube, you got an approving nod. You didn’t, after you left, the other medics would shake their head. Of course, if you got the tube, nobody asked how many tries it took you to get the tube. You might hear the medic’s EMT partner later commenting it was a "hard tube,” which meant there were multiple tries. Familiar with the term “A Pass the Larengyscope Code?” I have been at a few of those and heard of many more.

Nowdays, we have alternative airways – The LMA and the Combi-tube. We may soon get the King LT. And we have limits on the number of times a paramedic or any combination of paramedics can attempt an ET. Two tries for the first medic and one for the second. No more than three tries total. And, most importantly, you don't have to try at all. You can just go to the alternative airway to start if you think it gives you the best chance to quickly secure the airway.

Here are some old posts describing my first LMA and my first Combi-tube, as well as a post called "The Battle" describing my beginning mindset when contemplating what airway to use.

LMA

Combi-tube

The Battle

I can tell you this now, based on the medical literature, and on my experiences with the LMA and Combi-tube, I no longer hesitate to use an alternative airway as my first line airway.

The goal is not to impress other medics, but to effectively ventilate the patient, and in cases of cardiac arrest, not to interrupt compressions. I can do both of those quite well with an alternative airway.

10. Chemical Restraint

I pride myself on my ability to talk to psychs. I saw a movie once about a hostage negotiator called “The Voice.” I would flatter myself that I, too, was "The Voice." I could talk anyone down, make any madman set down his hammer, sword and WWF delusions, and come peacefully. Once I was trying to talk down a kid on angel dust. I am very patient, but other responders there were not so much so. While I was talking this guy down and making what I thought was steady progress, a medic from another division, who was up helping us handle a particular rowdy concert, had had enough and jumped the guy wrestled him to the stretcher and with his partner roughly four-pointed the boy, who fought and spit and screamed all the way to the hospital. I was torqued. It seemed there was a certain class of responder who got into restraining/beating up people. I’m not saying I was always able to talk them down, but most of the time I could. If I couldn’t, sure I’d end up using the physical restraints, but I have never liked that part of the job.

Then we got Ativan and Haldol. Things are different. No more driving to the hospital with four people fighting a patient all the way to the ED. If I can’t talk them down, sure we may have to hold them down for five minutes, but I load'em up and they sleep baby dreams to the hospital.

***

This is my favorite Ativan/Haldol story - Sleepy Boy or Fetch My Dart Gun:

We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.

A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal's office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.

When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.

I am not.

Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.

Six people, I think, right. Talk about overkill.

I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.

"You're just one crew?" the cop asks. "You have restraints?"

***

Now when I first took my EMT class many years ago, I wasn't too keen on the section of the course where we practiced restraining patients. I mean I wasn't certain I wasn't going to vomit at the first sight of gore, and I wasn't certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.

I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouldn't get called for the big guy who wanted to kick my ass.

I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn't work on. That's why we have cops, but cops don't like to get worked up any more than paramedics.

In recent years, restraining patients has also gone somewhat out of favor due to some tragedies -- patients dying of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title "Chemical Restraint."

***

"We're going to sedate him," I say. (If this was movie, I would have said to my partner, "Fetch my dart gun.")

2 mg Ativan and 5 mg Haldol IM.

He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.

Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.

Ten minutes go by. He is still angry and yelling.

I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. "By all means," he says.

Andy nearly throws everyone off him when I hit him in the other thigh.

I sit back down in a chair and wait.

A staffer asks what the plan is now.

"I'm going to sit here until he's asleep," I say.

Five minutes later, he starts to snore.

One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.

He snores all the way to the ER.

#12 No More Lasix

In our 2012 Regional Protocols, Lasix has been removed from our med kits. I stopped using it several years ago -- even when I was reasonablely sure my patient had CHF. I had CPAP and I had nitro and I relied on them, as I do now.

The first rule of medicine is "Do No Harm." Lacking chest x-rays and the ability to do BNPs in the field, time and again, EMS (myself included) has done harm to our patients by giving patients we thought we in CHF, Lasix when in truth they had sepsis or pneumonia.

Below is excerpted from a 2010 post about Lasix.

Dear EMS Medical Control-

I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. "Stop the Horror! Ban Lasix!" I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.

Respectively
Patient X.

***

As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services's trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and won’t be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We don’t want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.

In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.

Evaluation of prehospital use of furosemide in patients with respiratory distress.

For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.

Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school don’t always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didn’t have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.

I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. D’oh!

When I was a newer medic in the last 1990’s, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didn’t give Lasix at all.

Several years back, we added the following caution to our regional protocols:

CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.

Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient's respiratory distress is severe.

With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.

13. Permissive Hypotension

In the mid 1990s and before then, you were a stud if you could swoop down on a shooting victim, toss him on a board, get him in the back of the ambulance, and take off before the mobile TV news crews arrived (even better if you were gone before the PD arrived). Then in the three or four minutes you were in the back of the ambulance as your partner flew (we’re taking airborne on the rises) to the Level one trauma Center, you slammed in two large bore IVs and had the fluid running fast and wide. Two 14’s was an A plus. A 14 and a 16 was good. Two 16’s was border line. Anything less was not worthy of the patch on your shoulder. You were a god if the 1000 liter bags had less than 100 cc by the time you hit the trauma room.

It really sucked if your victim had bad veins. A 20? That was all you could get? A 20? But in most cases your shooting victims were young strong males with bulging pipes, who just happened to be on the wrong street corner doing nothing at the wrong time.

I remember one time I put a 14 in a man’s AC and the fluid ran like Niagara Falls. I noticed then the cot was soaking wet under his upper arm. He had another huge bullet hole there that had completely taken out the vein. The fluid entered the AC, run upstream for four inches and then ran right out tinged with pink. Pink was often the color on the sheets after we’d unloaded the patient. And back then, we didn’t just run the fluid when the BP was low. We ran the fluid regardless of the BP. We were medics and aggressive and taught to stay ahead of the game. We ran fluid in anticipation of the BP dropping.

Many medics started the day by hanging and prespiking two 1000 cc bags of fluid. One of Saline; one of Ringers. Some medics hung the bags, but just taped the drip sets unspiked to them. I usually just laid two bags on the bench seat, ready to open and spike. A few medics may have just left the fluid in the cabinets until needed. I guess it all depended on what degree of spark you were.

Of course we know better today. Aggresive fluid resucitation in absence of controlled bleeding can damage the body's ability to clot off the bleed, create hypothermia, and impair the delievery of oxygen. While there is still some discussion about just how much fluids trauma patients should get prehospitally, permissive hypotension seems to rule the day. Our regional protocols calls for blood pressure to be titrated to 100 systolic. I know some would argue that blood pressure limit should be much lower – just enough to produce a pulse and no more.

14. Expanded Medication Routes, Less IV Emphasis

When I was going through paramedic school (1982), another student told me, if you can’t get an IV, you can’t be a paramedic. If your IV skills are not second nature, you will spend too much time worrying about getting an IV, he said, and not be calm enough to keep the big picture in mind. Plus, he said, if you can’t get the IV, you can’t fully treat the patient or give most of the medications you carry.

I worked hard on my IVs during school, taking many extra shifts on the IV rotation where I accompanied the IV nurse around the hospital and jumping to do every IV I could on my ED rotations. I was already an EMT-Intermediate, but I worked for a small volunteer service and was lucky to get three IVs a month. When I was cut loose as a paramedic (now working for a city 911 ambulance company), I was assigned an EMT-Intermediate as a partner for my first six months as a condition of my medical control. On my calls, I insisted on doing most of the IVs and I put IVs in most of my patients. My reasoning was if the person was going to get an IV in the hospital, I was going to give them an IV in the field. At the time, we also drew four tubes of blood for the hospitals, so bringing in a patient with an IV and labs drawn was a great way to earn nurses’ favors.

Back then, if a patient was in status epilepticus, we had to have an IV to give them Valium. If a patient was in CHF or having an MI, we had to have an IV to give them nitro. If they were in pain, we had to have an IV to give them morphine. Even most heroin ODs got an IV. True, if you had a patient in cardiac arrest, you could give drugs down the tube if you didn’t have an IV, but even then, we did not think that was the most effective way to deliver the drugs. And, of course, trauma patients didn’t just need an IV, they needed two large bore IVs so you could run the fluids wide open.

Things are very different today in 2012. You still need to be good at IV to be an effective paramedic, but there are more drug delievery options, which is better for the paramedic and, most importantly, better for the patient. Also, the IV has less importance in cardiac arrest and trauma as studies have shown IV meds don’t improve and may worsen outcomes in cardiac arrest and the old practice of pouring fluids into trauma patients was, in fac,t helping kill some of them.

Today with a patient in status epilepticus, we can give Versed not just intramuscularly (IM), but intranasally (IN). Same with patients in pain. IM, or even better IN with Fentanyl. Heroin ODs get Narcan IM or IN as well. We can give patients with chest pain NTG without an IV as long as we use caution. Someone sick and vomiting, we can give Zofran IM, and very soon, we may be able to give it sublingually. With Benadryl we now have a PO option. And for those patients who absolutely need an IV, no more sweating and shaking hands, the eyes of everyone on you as you poke and poke and fail to get an IV on a critical person who continues to deteriorate or who may already be dead, you now have the EZ-IO drill to fall back on.

I want to thank all the thousands of patients who let me put IVs in them over the last twenty years and who helped give me the confidence I have today in my IV skills. I no longer follow the rule that if a patient is going to get an IV in the hospital, they will get one from me in the field. I still do my fair share of IVs – but I now appreciate there may be times when it may be necessary in the ED, but it is not as necessary for us prehospitally to do it. There is also that factor that some hospitals routinely either DC prehospital IVs or put in their own. Some have said it is for infection control reasons, others have said it allows the hospital to add another charge to the bill. I don't know, but when transporting a patient to a hospital following such a policy, I tend to be more selective about when I establish IV access.

15. Narrower Use of Narcan

When I started we used narcan for opiate overdose and coma of unknown etiology. Today we only use narcan for respiratory depression or inadequate ventilation associated with opiate overdose.

The following is excerpted from a post "That Narcan Shit" from December of 2008.

When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie's IV, and slamming the Narcan as they'd go through the ED door so the junkie would sit up and puke all over the medic's nemesis -- the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.

I did, however, slam Narcan into lots of junkies and wake them up. When I say slam, I'm not taking about pushing the Narcan in like I push Adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.

I'd slam it. They'd puke, curse, rip their IV out and stalk off. One guy I found in an abandoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the Narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push Narcan. I'd had no idea.

Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the Narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.

Slamming a full dose of Narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.

It used to be if I was called for an OD and the patient had used Heroin, they got Narcan even if they were breathing okay. As long as they were slightly altered, I'd hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.

"Did you do drugs?"

"No."

"Then why do you keep dropping asleep?"

"I didn't do drugs."

I'd push the Narcan. They are wide awake and puking. Stupid. Them and me.

"Did you do drugs?"

"No."

"Then why are you wide awake now and puking?"

I don't give narcan now as much as I used too because I don't work in the city nearly as much, plus now, like I said, I only give Narcan if I suspect an opiate overdose and the patient's respirations are extremely depressed. Sometimes I bring Heroin users in to the hospital and the first thing the hospital staff does is give the patient Narcan. Wake them up and make them puke. I shake my head. That's just no way to treat people. Put them in a hallway and let them sleep it off -- as long as they are breathing okay.

We also used to give Narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.

Here's two cases where I gave narcan to coma of unknown origin with bad consequences.

1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did -- living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills -- opiates -- I zapped him with Narcan. So now I went from a patient in a semi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I'd just zapped all the pain medicine he needed to tolerate living into the ether. My bad.

2. Called for a possible stroke, I found an 80-year-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her Narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn't find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Strange. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her Narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.

Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of Narcan.

Narcan Solves the Riddle, Part I

Street Watch: Notes of a Paramedic

Saturday, April 14, 2012

EMS Changes -16 Biggest