Sunday, December 23, 2018

Manual Versus machine Blood Pressures

 

How do you want to be known as a Paramedic/EMT?

A. Reliable
B. Frequently wrong

According to a recent article in JEMSDitch the Machine to Improve Accuracy in Blood Pressure Measurement and Diagnostics, "automated blood pressure readings are frequently inaccurate."

Is this a surprise to anyone?

Yet, many of us continue to relay on automated BP cuffs to direct our clinical actions.

In a March 2016 article in the Journal of Clinical and Diagnostic Research, Which is More Accurate in Measuring the Blood Pressure? A Digital or an Aneroid Sphygmomanometer:, digital devices:

  1. should be used with caution, doubt and suspicion
  2. are not up to standard
  3. (can cause many people to be) wrongly or misdiagnosed
  4. may prove disastrous

Powerful words.

The JEMS article points out that even the manual for the Physio-Control Lifepack 15 contains this warning:  

"shock may result in a blood pressure waveform that has a low amplitude, making it difficult for the monitor to accurately determine the systolic and diastolic pressures."

Got that.  Your Lifepack 15 is not capable of providing reliable blood pressures if your patient is in shock.

Cardiogenic shock
Hypovolemic shock 
Anaphylactic shock 
Septic shock 
Neurogenic shock

Your machine BP is unreliable when addressing these conditions.  It is frequently wrong.

How are you going to make clinical decisions with bad data?

You need to take manual blood pressures.

As an EMS Coordinator, I see run forms with blood pressures like these:

158/71
210/190
143/84
95/87
170/119

All for the same patient.  With no explanation.

As a paramedic, I have had my patient in afib brought into a level one medical room because the triage BP machine said my patient had a blood pressure of 79/40.   Why are we in here? the doctor asked as he looked at my calm, warm, dry patient.

Because the triage system at this hospital relies on digital blood pressures. 

Don't relay on machines to take a blood pressure in patients with atrial fibrillation.

Here are my guidelines:

  • Make your first blood pressure manual
  • Treat your machine pressures as an inexperienced partner
  • Before making a critical clinical decision, take another manual pressure.

Make certain you know how to take a proper blood pressure.

Here are some good articles to help us improve our manual blood pressures:

Taking a Manual Blood Pressure: Techniques & Pitfalls

Blood pressure reading tips and tricks for EMS

 

I get it.  It is hard and nearly impossible sometimes in EMS to obtain optimal conditions for taking a blood pressure.

Just know that the blood pressure you obtain under those impossible conditions (using short cuts) may not be accurate.

Don't let inaccurate and unreliable readings cloud your clinical judgement.

Take a manual, and if you can't hear, palpate a blood pressure.

 

 

 

Tuesday, December 18, 2018

Balance

December 8, 2018: This weekend, I am in Worcester, Massachusetts at the New England Short Course Meters Masters Swimming Championships as a member of the Connecticut (CONN) team. Last year, we shocked many of the other teams by taking first place. Points are awarded based on place finish in individual and relay events. Each swimmer is only allowed to swim a maximum of six events a day or 13 for the entire meet. Friday evening is distance day (800 Free), Saturday and Sunday are for the relays and the main swimming events. Last year I scored 119 points swimming 12 events despite having a pretty severe chest cold. I also swam in three of the four relays. I came in second in the men’s 55-59 200 Meter Butterfly and earned 15 points for it. I was second out of 2 swimmers. Last year I finished 25th in the nation in that event in my age group. 25 out of 25. Still I was proud as it is a difficult event, particularly for someone who did not know how to swim the stroke five years ago. I am swimming it again this year, and if all scheduled swimmers swim, I will likely finish 5 out of 5, but maybe some of them will scratch (drop out) as it is the last individual event. Last year I swam the full 200 meters without stopping. This year I may hang on the wall and catch my breath at some point along the way. I have not trained as much this year as last. My best event is the 50 free, but I will not come close to my best time of two years ago. Again, lack of training time and intensity. Plus Father Time sapping some of my strength.

Joe Frazier used to say. “If you cheated on that (your roadwork) in the dark of morning, you’re going to get found out now, under the bright lights.” I have no cold this year, but I am a year older, and not in the shape I used to be. That lack of training is likely to be apparent. Still I am here as part of a thirty person contingent of people who I have come to call my friends over the years. No matter how fast or slow I swim, i always get high fives and good jobs. I doubt we will win this year. Charles River Masters, who we upset last year, showed up loaded with more swimmers. My goal is to score more points for my team than last year, which will be a little easier as I am swimming one additional event and I have moved up in age to the 60-64 division.

Here’s why I writing all this on my EMS blog.

I was talking the other day with a new medic trainee and we were talking about a number of the old career medics who were around when I started, and I told her of how many of them ended up broken. Here’s a roll call. Overweight, fired for poor behavior, dead of a heart attack. Fired for violating policy, seen a few years later in a nursing home with jaundice, dead not long after. Retired unceremoniously, dead within months of lung cancer, obit posted on the operation’s wall. Fired for undisclosed reasons, shot dead by police in a standoff -- suicide by PD. Left for undisclosed reasons, found dead in bed a few years later, obese, uncertain of heart attack or overdose. Not a lot of happy stories. Many say that the job will leave you bitter in the end.

I used to say that I wanted to stay at this until I am 72 when my youngest daughter is targeted to graduate from college. I don’t know if I can make it make it that long. I am hoping to at least stay full time until my middle daughter who is a freshman at college graduates. My goal is to get her through without any debt. In addition to my medic job, I also work as an ems coordinator at a local hospital. Between the two I am scheduled for 64 hours a week, but I often work longer. I try to keep Saturdays as a day for my youngest daughter and I to do things together.

My youngest is very into sports, and unfortunately, tomorrow, she has her first basketball game of the season, and I will miss it because I am here at the meet. She is playing in two leagues this winter, one with Saturday games and one with Sunday. Other than today, I will be at all her Saturday games, but because I work Sundays, I will only be able to see the Sunday games if I take off work. A part of me wants to go part-time on the ambulance so I can be free to see all her games, but with the middle daughter in college, I can’t really afford that yet. I debated not going to this meet, but last year I skipped several meets to see her games. The fewer meets I do it seems the less I train. This is the one big meet of the year, so I expected if I skipped it, my identity as a masters swimmer would pretty much slip away, and I am not yet ready to give that up. I need athletic competition to keep me healthy and maintain my image of myself as an athlete and a man still in prime health.

All these conflicts.

I used to never miss an ambulance shift. I prided myself on always being on time and always being there if my name was on the books. In twenty-five years I have only had to go home sick twice, and only called out sick about the same number. I have only been late three times, twice due to a time change and once due to my alarm not going off. I take days off fairly freely now. With my seniority, I get a ton of PTO, so I use it. I took off for Zoey’s soccer championships and I will certainly take off for her basketball championships if she makes those. My next swim meet is Superbowl Sunday and I am planning to take off for that, but only if it doesn’t conflict with one of her games. I’ll take that game over the local meet. Hopefully, I’ll be able to do both.

I enjoy my swimming friends, as I enjoy my EMS friends. And of course, I enjoy my family most of all. Between the three I hope to be able to maintain a balance that I have not always had. I don’t need to be on the ambulance everyday or at every swim meet or at every single one of my daughter's games. I just have to do my best to be there whenever I can, and ensure that I am healthy, and happy. I want to be there for the long run.

Postscript:

We came in 3rd in the meet. I had the eighth most points of any male in the competition, points mainly accumulated because I was one of a few who swam 13 individual events. I finished the 200 Butterfly only a few seconds slower than last year, and captured 3rd place. Out of 4.

My daughter won her game and scored 8 of her team’s 14 points. Hearing her recap of the game wasn’t as good as being there, but it was still great. Nothing much of interest happened on the ambulance that day, according to the guy who filled in for me, nothing unusual. I didn’t miss out on anything exciting.

The meet renewed my enthusiasm for swimming, so I have been hitting the pool hard this week. I saw my daughter’s game yesterday and it was great. They won and she played well, scoring 10 or 12 points in the win, including making both her free throws. Not bad for 10 years old.

I am at work now, posted on a street corner in the December rain, drinking hot tea with honey.  I am hoping the next call will be an interesting one.  I hope that I get out on time so I can swim at the pool.  I hope that when I get home, I will sit in my armchair and have a cold glass of water, while my wife sits on the couch and laughs at Will Ferrell in the Wedding Crashers in a way that brings warmth to my heart.  I hope that my daughter will be dribbling her basketball back and forth between her legs.  I hope that she looks up at me and says “Dad-Catch!”

 

  

Thursday, December 06, 2018

Not My Addiction

 

This is great film, made by EMS for EMS, to help us understand addiction and the stories behind our patient's lives.  The 37 minute film tells the story of four addicts in their own words, including one who was once in EMS.  Listening to these four tell their stories helps people understand how easy it is for a person to fall into the grip of opioids and how hard it is to get out.  As I mentioned in another blog post, I recenly heard a mother describe her daughter's descent into opioids, which ended in her death, as "an innocent entry and an impossible exit."

I met two new young people this week who were ex-addicts struggling to reclaim their lives.  One was a former army medic, who told me he became addicted in Afghanistan. His squad often found caches of heroin, hidden by villagers. It was hot there and they were always hydrating themselves with IVs.  One day they added a few grains of heroin to the IV.  Three days of this and he found himself coming down with a horrible flu.  It took awhile for him to realize he was in opioid withdrawal.  When he came home, he found himself in Hartford, a land where a bag of heroin is only $4.  Two years of hell later, and scared by two fentanyl overdoses, he finally got on suboxone, which is working for him.  Still he's a homeless vet, and he has a long way to go to truly be back home.

The other young man got hooked on prescription pills after an injury.  He followed the usual course, buying on the street when his prescription ran out, and switching to heroin because it was so cheap.  The death of so many of his friends got him onto methadone, and that too, is working for him, although like the soldier, he is homeless and living in the woods.  We talk for a long time, and I tell him how my views on addiction have changed over the years and how I now recognize it as a disease.  "You should talk to my parents," he says.  

Watch the film.  Educate yourself.  Talk to people.  There are a lot of lost souls out there who can use our help.  

Not My Addiction

Review: Documentary film takes EMTs, paramedics inside the pain of opioid addiction

Wednesday, December 05, 2018

Opioid Crisis National Roadmap- EMS Comment

 

EMS Encouraged to Comment on Opioid Crisis National Roadmap

These are my comments on the draft report developed by the Fast Track Action Committee (FTAC) on Health Science and Technology Response to the Opioid Crisis.

People who have suffered a nonfatal overdose are at the high risk of suffering a fatal overdose. A recent study out of Massachusetts suggested that one out of ten of these patients will die of an overdose within a year.(1) Since EMS has contact with these patients at a pivotal time in their live, EMS has an opportunity for intervention either through educating them (and their families)to rehab options or where to obtain naloxone and clean needles for those who are not ready to quit. Some EMS services even leave naloxone with users and their families.
The manner in which EMS treats these patients is also critically important. If EMS treats them as people who are suffering from a chronic disease as opposed to people with character flaws, then they can help reduce the stigma that any opioid users face that can be a barrier to them seeking help. Improved education for EMS personnel into the science of addiction is needed if EMS is going to play a role in helping people toward recovery.

Harm Reduction should be emphasized in EMS education and in EMS Treatment. In area of high intravenous drug usage, designated EMS vehicles or stations could function as a needle exchange site, providing users with clean supplies as well as information about rehabilitation. Clean needles and supplies will not only help the spread of disease such as AIDS and Hepatitis C, it can prevent endocarditis and other infections that are rampant in the user community.

EMS data offers as unique look into the epidemic and can provide real-time data surveillance and early warning of spikes in overdoses and bad batches if done properly. A study from North Carolina has shown the naloxone is a poor surrogate for tracking opioid overdoses because many overdoses do not need naloxone and that naloxone is often given to people who turn out not to have opioid overdoses. (2) A better way is to require EMS to install the data element “suspected opioid overdose,” and track this. In Connecticut, we have conducted a pilot study of using our Poison Control Center as a repository of EMS overdose information. In the pilot, EMS responders in Hartford called poison control shortly after each overdose they responded to, and answered a series of questions about the overdose, including patient demographics, place and route of overdose, whether naloxone was needed and in what dose, and identification of any paraphernalia. (4) The project is expected to slowly expand statewide, and will eventually be linked to the HIDTA (High Intensity Drug Trafficking Area) OD map software to show location of overdose. (3) The project was able to identify unique heroin brands linked to overdoses as well as information about users who thought they had bought cocaine, overdosing on opioids.

Emergency Medical Services, which has been underutilized in the fight against the opioid epidemic, can be a leader in the fight contributing surveillance, data collection, and early warning alerts, as well as education and harm reduction to the traditional role of emergency treatment.

1. 402 One-Year Mortality of Opioid Overdose Victims Who Received Naloxone by Emergency Medical Services
Weiner, S.G. et al. Annals of Emergency Medicine , Volume 70 , Issue 4 , S158

2. Joseph M. Grover, Taibah Alabdrabalnabi, Mehul D. Patel, Michael
W. Bachman, Timothy F. Platts-Mills, Jose G. Cabanas & Jefferson G. Williams (2018)
Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid
Overdoses in a Large U.S. EMS System, Prehospital Emergency Care, 22:3, 281-289, DOI:
10.1080/10903127.2017.1387628

3 https://www.hidta.org/odmap-training/

4. https://www.courant.com/news/connecticut/hc-news-hartford-overdose-tracking-numbers-20180912-story.html

 

 

Down Time

 

A few days ago on our employees only Facebook page, someone posted a picture another person had taken of one of our crews while they were parked by the side of a street. The driver leaned against the window, arms folded, eyes closed.  The passenger had his eyes open, but he was slouched down in his seat. They were clearly in rest mode, but it wasn't like they needed Narcan.  The comment was if they wanted to sleep, they should find a more secluded spot than a downtown street. The concern was every crew represents all of EMS, and the poster thought this crew looked unprofessional.

A fair point, perhaps, but I admit I felt bad for the crew to be shamed by a few fellow employees (the comments mainly agreed with the poster).  There are few days I have worked when either myself or my partner have not been guilty of shutting our eyes at some point in the shift. I can’t say there hasn’t been snoring at times. (Most in EMS work either mega-overtime or multiple jobs in addition to trying to raise families and fatigue in EMS has been well-documented in the literature). It's why I like to find out of the way spots. Not that we get a lot of downtime. Our service utilizes system status management so we are constantly on the go. If you are not on a call, you are headed to a posting location to wait for a call, and sometimes sent to another location as soon as you arrive at the first one. At least our management is not too rigid about where we post as long as we are in proximity to the stated posting location.

I am six-foot-eight and sixty years old so it is almost impossible for me to sit folded up in the passenger seat for too long. I have to get out and stretch. I bring a basketball with me and sometimes will find a court to shoot on (my radio on my belt), or I will just stand outside the ambulance practicing spinning the basketball on my finger. I took my daughter to see the Harlem Globetrotters last year and have challenged myself this year to master the finger spin. My goal is to have my picture taken with a Globetrotter with both of us smiling while spinning basketballs, during the pregame photo session. I have already purchased the “Magic Pass” tickets.

The other day, my partner and I were in Bushnell Park (covering downtown) and a local TV cameraman showed up to take some footage of the park ambiance and scenery. When he was done, putting his camera back into his truck, which was parked right behind us, he told me the film was for the weather segment. He said not to worry. He didn’t take any footage of me spinning the basketball as he imagined if my boss saw it, my boss would call me into his office and ask me to bring my basketball.  He thought he was doing me a solid, but I was disappointed. I had imagined calling my daughter and saying be sure to watch the weather tonight, you’ll see a basketball superstar doing tricks. The cameraman didn’t understand. The fact that I am standing outside the ambulance spinning a basketball doesn’t mean I am lazy or goofing off. It's just what I do sometimes while waiting for a call.

I feel the same about the crew that was getting some rest. What matters to me, at least, is not whether they are sitting bolt upright in the seats, eyes open, hands on the steering wheel and the map book ready to respond, but that when their number is called, they hear it, answer the radio, respond quickly and safely, and treat their patients with skill, kindness, and empathy.

Peace to all.

Fighting Fatigue in EMS

Fatigue in EMS

Harlem Globetrotters Magic Pass