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!”

 

 

Napping in EMS

 

Do you nap on your EMS job?

While many EMS organizations prohibit sleeping on the job and others allow it only in designated areas, a safety panel empowered by the National Association of State EMS Officials recently issued recommendations that included encouraging napping as a way to mitigate the adverse effects of fatigue.

Recommendation 4: Recommend that EMS personnel have the opportunity to nap while on duty to mitigate fatigue.

The panel determined that current evidence supports the use of naps while on duty as an effective strategy to positively impact fatigue-related outcomes. Naps improve alertness, reduce sleepiness, and improve personnel performance (e.g., reaction time).

I recently posted about a picture put up on our employees only Facebook site where a crew was blasted for being photographed while sitting in their ambulance, the driver with eyes closed, and the passenger slouching in his seat.  I found some links to fatigue on the job, but did not get around to reading them in their entirety until later. I was surprised and pleased to find the pro-napping recommendations. In the document they directly address the issue of public misunderstanding of sleeping EMTs.

The general public may perceive EMS personnel napping on duty as unacceptable. The panel concluded that the benefits of improved alertness on duty, and ultimately improved patient and personnel safety, are a commonsense justification to this anticipated undesirable effect. Additionally, it is common knowledge that many EMS personnel and other first responders work long duration shifts requiring nighttime sleep when not on a response. Policies and protocols that clearly describe the appropriate use, structure, and benefits of naps on duty may be useful toward educating the public and reducing potential negative opinion.

I have been working EMS for almost 30 years, and have worked all types of shifts, overnights, 24s, 16s, 12s, and have never had a shift, where I did not occasionally on some days catch some rest with my eyes shut.  It could be in a designated bed with my cheek on a pillow and the blanket pulled up to my neck, in a comfy armchair with my feet up, on the stretcher or bench seat with my legs stretched out, or simply in the front seat with my head against the window and my mouth, hopefully closed.

I have always found the power nap restorative.  The only issue I have ever had with sleeping on the job was when I did overnights in places where you could sleep in a bed, and I would get a call in between the hours of 3:00 AM and 4:30 when I would wake and find myself driving down the road having no idea where I was or where I was going.

EMS conditions most responders to listen for their number and hear it even in a sound sleep.  I have never failed to respond to a call for my number when I was dozing on the job. I have had partners however who have fallen asleep so deeply that they needed a shake.

Many, many years ago when I was on overnights (and EMS was still the wild west), I did a call for a patient on a street corner who wanted to go to detox.  While my partner slept soundly in the back (he was logging 100 hour plus weeks), I had the man sit in the front seat and we drove the half mile down the road to the detox facility.  My partner was still asleep when I came back out.

It has been years since I have done an overnight.  Today I work 12 hour day city shifts and my only napping is of the head against the window power variety (or the head nodding forward and jerking me awake as just happened while writing).

The safety panel recommends for those services that use dynamic deployment that napping should only be done in the front passenger seat or the patient compartment, that the sleeper be seat belted, and the driver never engage to prevent him from waking up with sleep inertia, leading to impaired driving.

Makes sense to me.  It’s nice to know napping has the sanction of the experts.

Read the full report here.

Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services

Missing

 She frequented a neighborhood park near the hospital. I’d see her times smoking a cigarette while she sat on the playground swings. Many nights, she slept on cardboard by the fence, sometimes she tied a tarp from the fence down to the grass to provide shelter on rainy nights. She was tall and gawky with red hair and looked a lot older than her thirty odd years because she had lost most of her teeth. Nothing makes a person look older than when their gums recede. I first saw her one morning this summer when the temperature was already up into the 90’s and the humidity made it hard to breathe. I asked her if she wanted a bottle of cold water, which she did, smiling in such a way you could see her youth hadn’t completely been obliterated from her body from the hard living she had put it through. I also gave her an orange and a couple bucks. She had a tattoo of a blue pony on her neck. It was faded, but the pony looked like a magical kid’s pony -- the kind that could fly when it wasn’t being cuddled by a four-year-old.

I never found out too much about her. I knew her name Tammy and knew she was a heroin user. I didn’t know her back story of how she came to call the small park her home. She rarely came down toward Pope Park where we post sometimes in the ambulance and where I get to know many of the users walking east up Park Street to buy their drugs. I usually saw her as I drove past in the ambulance headed west.  She walked alone, going in and out of bodegas or standing on the corner lighting cigarettes. Even among the murals and store signs on Park Street, her orange red hair stood out like technicolor in the old movies.

Early on a cold fall morning when you could already start to see people’s breaths as they stood at the bus stop or hurried down the street to whatever job put subsistence in their pockets, we get called for an overdose on the basketball court in the park. My partner pulls the stretcher and I sling the house bag over my right shoulder, and carry the heart monitor in my other arm. The fire department responders stand in a semi-circle over a body. One of the guys gives the finger across the throat sign to say we won’t be needing the stretcher. As I get closer, I see two feet sticking out from under the blanket. I pull the blanket back and stare at the face. When someone dies their soul leaves and their face becomes almost unrecognizable to what they once were. Then I see the tattoo.  I look at her face again. It is white and waxen. She’s been dead for hours. Her limbs are cold and stiff. Her mouth is riggored shut. I run my six second strip of asystole.

A slow drizzle has started. I pull the blanket back over her face. We head back to the street, past the empty playground. The morning is black, white and grey.

 

 

 

Missing

 She frequented a neighborhood park near the hospital. I’d see her times smoking a cigarette while she sat on the playground swings. Many nights, she slept on cardboard by the fence, sometimes she tied a tarp from the fence down to the grass to provide shelter on rainy nights. She was tall and gawky with red hair and looked a lot older than her thirty odd years because she had lost most of her teeth. Nothing makes a person look older than when their gums recede. I first saw her one morning this summer when the temperature was already up into the 90’s and the humidity made it hard to breathe. I asked her if she wanted a bottle of cold water, which she did, smiling in such a way you could see her youth hadn’t completely been obliterated from her body from the hard living she had put it through. I also gave her an orange and a couple bucks. She had a tattoo of a blue pony on her neck. It was faded, but the pony looked like a magical kid’s pony -- the kind that could fly when it wasn’t being cuddled by a four-year-old.

I never found out too much about her. I knew her name Tammy and knew she was a heroin user. I didn’t know her back story of how she came to call the small park her home. She rarely came down toward Pope Park where we post sometimes in the ambulance and where I get to know many of the users walking east up Park Street to buy their drugs. I usually saw her as I drove past in the ambulance headed west.  She walked alone, going in and out of bodegas or standing on the corner lighting cigarettes. Even among the murals and store signs on Park Street, her orange red hair stood out like technicolor in the old movies.

Early on a cold fall morning when you could already start to see people’s breaths as they stood at the bus stop or hurried down the street to whatever job put subsistence in their pockets, we get called for an overdose on the basketball court in the park. My partner pulls the stretcher and I sling the house bag over my right shoulder, and carry the heart monitor in my other arm. The fire department responders stand in a semi-circle over a body. One of the guys gives the finger across the throat sign to say we won’t be needing the stretcher. As I get closer, I see two feet sticking out from under the blanket. I pull the blanket back and stare at the face. When someone dies their soul leaves and their face becomes almost unrecognizable to what they once were. Then I see the tattoo.  I look at her face again. It is white and waxen. She’s been dead for hours. Her limbs are cold and stiff. Her mouth is riggored shut. I run my six second strip of asystole.

A slow drizzle has started. I pull the blanket back over her face. We head back to the street, past the empty playground. The morning is black, white and grey.

 

 

 

Number 10 - Involve the Family

 Involve the family. When I started it was common practice to shoo the family out of the room. Not just on the scene, but in the ED. I no longer do that. I make certain to explain to a family member or members what we are doing and how things are progressing. If they choose to wait in the kitchen, I will keep them updated, but if they want to stand in the living room and watch, I will explain to them what we are doing. Sometimes, I will let them hold the patient’s hand or brush their hair.

If I am getting ready to cease a resuscitation, I will tell family members what is happening, and I will have them come in (if they are not already in the room) and say their goodbyes. The departing may be able to hear and take the voices of their loved ones with them.  If you need a reminder of why we do what we do, try this. Listen to the family’s good bye.

“Auntie May, I love you. I remember what you’ve done for me. Say hello to Uncle Jim. Tell him we miss him and we’ll be together again. I’ll take care of Jake and Mary. Don’t you worry. I love you, Auntie.”

 

Pearl #10 Involve the Family

 Involve the family. When I started it was common practice to shoo the family out of the room. Not just on the scene, but in the ED. I no longer do that. I make certain to explain to a family member or members what we are doing and how things are progressing. If they choose to wait in the kitchen, I will keep them updated, but if they want to stand in the living room and watch, I will explain to them what we are doing. Sometimes, I will let them hold the patient’s hand or brush their hair.

If I am getting ready to cease a resuscitation, I will tell family members what is happening, and I will have them come in (if they are not already in the room) and say their goodbyes. The departing may be able to hear and take the voices of their loved ones with them.  If you need a reminder of why we do what we do, try this. Listen to the family’s good bye.

“Auntie May, I love you. I remember what you’ve done for me. Say hello to Uncle Jim. Tell him we miss him and we’ll be together again. I’ll take care of Jake and Mary. Don’t you worry. I love you, Auntie.”

 

Number Nine- Don't Be a Prisoner to the Clock

 Don’t be held prisoner to the clock. Stay and work the patient as long as believe you have a shot. There is nothing magic about twenty minutes. I have on several occisions shortly after the 20-minute limit was talked about, gone into another room or out to the ambulance to call medical control for permission to presume only to return and find the patient has regained pulses. That’s epi for you. Our state protocols now, use a guideline of 60 minutes for some patients.

I met a man the other day who had survived 50 minutes of CPR, and while he said he felt mentally slower, he could walk, talk, drive a car, work a job, pay taxes, and live and love and enjoy his extended family. I worked with an old partner of mine who had been out of EMS and was back now. At 20 minutes, he started pointing to his watch. By 30 minutes, he finally, said, Pete, we gotta go, we’ve been here a half an hour. I looked at him and said, we’re not going anywhere. 10 minutes later we had pulses.

Not everyone who has extended CPR is going to have a good outcome, but people who get concentrated unhurried CPR are likely to have a better outcome that those who get strapped to a backboard and rushed down two flights of stairs with compressions on the landings.

Number 8 - Anticipate ROSC

 Anticipate LOSC (Loss of Spontaneous Circulation). Once you have pulses back with ROSC (Return of Spontaneous circulation) anticipate you will lose them and have your plan in place. Premix your epi or norepi-drip and have it ready to go. Don’t start moving the patient immediately after getting ROSC. I usually wait 5 minutes to get the patient secure and make certain they are stable before starting to carry them down that windy staircase. If they arrest on the staircase, it will difficult both to recognize the lost of pulses and then to start compressions. While most know that a sudden rise in ETCO2 during an arrest signals return of pulses as the restored circulation sweeps the buildup CO2 in the distal portions of a body up to the lungs where it is ventilated off, the reverse applies when a patient loses pulses. ETCO2 45, you have pulses and a blood pressure back, you are all slapping each other on the back on a great job done getting the patient back, when you glance at the ETCO2. It is down to 14. Better get back on the chest. ETCO2 signals the loss of pulses as well as regaining pulses. Check out this trend summary of a patient who arrested three times.

 

Pearl #7 Use ETCO2 to Predict Arrest Cause

 If two identical twins are standing next to each other at a family reunion, and one chokes on a sandwich leading to cardiac arrest, and the second suffers a simultaneous VF arrest, and two medics arrive exactly 5 minutes later, and both patients are intubated at the same time, will their ETC02 numbers be the same or different?

Despite being identical twins, they will have different ETCO2 readings.  The twin who went into VF arrest will likely have an ETCO2 in the 20s with CPR.  The twin who choked on his sandwich will have an ETCO2 much higher --likely in the 70s or more.  His heart continued to beat for awhile while he slowly died of hypoxia from an obstructed airway.  The pumping heart pumped CO2 to the lungs where it built up.  Cardiac arrests due to respiratory causes usually have much higher initial ETCO2s than those who suffered sudden cardiac arrest.  (Patient who are hypercapnic as their norm are an exception.).  Those who suffered respiratory causes of their arrest will see their initial high ETCO2 fall back to more normal levels after a minute of ventilation. 

Use ETCO2 to help predict the cause of the arrest (cardiac versus respiratory) and then treat accordingly.

 

Pearl # 6 Use ETCO2 to ensure CPR Quality

 ETCO2 measures cardiac output. The better the CPR, the higher the cardiac output.  The higher the cardiac output, the higher the ETCO2.

While the American Heart Association  recommends you switch compressors every two minutes during a cardiac arrest to prevent compressor fatigue.  A fatigued compressor can't maintain consistent CPR.  The compressor tires, the cardiac output declines.  Time to switch compressors.  Or so the AHA suggests.

I would accept this if you have two compressors of equal ability and talent at CPR,.  If on the other hand, you have two compressors of different strengths, go with the compressor who can achieve the highest ETCO2. I challenge my partners to do their best CPR and get the ETCO2 up as high as they can. Even if one compressor grows tired, if he is consistently hitting 28, while the fresh compressor can only get to 24, keep the strong one on the chest.

Use the ETCO2 level as your marker not an artificial two minute limit.

Pearl # 5: Preattach ETCO2 Filter to ET Tube

When intubating preattach the ETCO2 to the tube.  If you have a narrow stylet, this is possible.  Attach the ETCO2 to the monitor.  If I have trouble seeing the chords, I hand the tube to my assistant, then using my right hand apply crick pressure until I can see the chords, then I have my assistant replace his fingers where mine were, and I pass the tube.  Once the tube is passed, I look at the monitor.  If CPR is being done, this is what I will see.

The CPR is creating passive ventilation that registers on the monitor.  Once the ambu-bag is attached and the first ventilation given, the cpr wave form is replaced with the traditional form. 

Instead if you just see flat line (with CPR) you may not be in.

Unless you are certain the tube is good, don’t bother with checking belly and lung sounds just take it out and try again or insert a supraglottic airway.

Stay Tuned for cardiac arrest PEARL # 6  Use ETCO2 to Ensure CPR Quality 

PEARL # 3: Make space for your cardiac arrest.

 

You can’t work an arrest if you don’t have space to do effective CPR. I often come into a bedroom where responders are trying to work a code, and I will flips beds up on their sides, clear out couches, or if the patient is wedged in the bathroom, haul them out into the hallway, stopping so there is an open door in line with their chest.  Ideally you need room on both sides of the patient’s chest for compressors and room at the top for the airway management and space for your supplies.  Make use of your help.  In this age of stay and play for cardiac arrest, if you are going to be there for awhile, make certain you have the best conditions for an effective resuscitation.  

Stay Tuned for next cardiac Arrest Pearl # 4 CPR Coach

Pearl # 4: CPR Coach

 

Make certain the CPR and airway management are being done properly. When I started our protocol said to intubate immediately.  On arrival, I would turn my back on the code and take the two minutes it takes to get my intubation roll out, unzip everything, take everything out, open the packages, assemble everything and then finally approach the patient.  Now I watch the compressions and the ventilations.  If only one person is doing the bag valve mask (assuming we are not doing passive ventilations), I grab someone else to hold the seal while the other squeezes the bag.  Make certain they are not hyperventilating.  Try using a pediatric ambu bag instead of an adult.  Make certain a properly sized oral pharyngeal or nasal pharyngeal airway is in place and that the airway is held open.  

Watch the CPR.  Are the hands positioned properly? Are the compressions to an adequate depth and at the proper rate?

Since compressions are what matters most, make certain your team is doing them properly.  You are the coach.  You are in charge.  Bring that patient back to life!

Stay tuned for next cardiac arrest Pearl #5: Preattach ETCO2 Filter to ET Tube.

Pearl # 2 Precharge your Defibrillator

 

Charge your defibrillator before looking at the rhythm. Whether you and your partner are the first person at the patient’s side or first responders or laypeople are already doing CPR on your arrival, initiate and/or keep CPR going while you apply your pads.  Then with CPR still continuing, charge the defibrillator.  Only then stop CPR to look at the rhythm.  VFIB or VT, shock!

If its not a shockable rhythm, simply dump the charge by pushing the speed dial button.

https://youtu.be/awdZoE0O_wM

Make certain to tell the compressors you will not shock them as you charge.  When you order them to stop so you can see the rhythm, you want your gun loaded.  If you were a hunter and had a deer in your sights, you would want a bullet in your rifle, not to have to stop and load.  This should be the process all through the code.  Charge while CPR is in progress.  At the 1 minute fifty second mark, charge so that at two minutes when you see VF or VT, you can shock, instead of starting another ten seconds of CPR before being able to fire.

Limit interruptions to CPR and limit  the pauses pre and post shock.

Peri-shock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest

Stay Tuned for Cardiac Arrest Pearl #3: Make space for your cardiac arrest.  

#1 Recognizing Cardiac Arrest

  

Cardiac Arrest.  Pearl #1  Recognize cardiac arrest.

This sounds obvious, but it is not always so.  Early cardiac arrest can present like a seizure or syncope.  The patient’s eyes may be open and they may have agonal breathing.  Get the pads on!  Too many times I have shown up on scene to see first responders tell me the patient just had a seizure or they are breathing, and everyone is standing around.  I admit when I first started, I didn’t always instantly recognize what was going on.  When I was precepting, we had a patient with chest pain who all of a sudden he started seizing.  I reached for the valium (our benzo at the time).  My preceptor shook his head.  "Look at your monitor," he said.  VF. 

Get the pads on!  Even if the patient snaps out of it before you can act, always get them on the monitor.  Be vigilant.  Several times early in my career I have had witnesses tell me the patient had stopped breathing and needed CPR before coming around.  Those reports did not seem consistent with the alert, talking patient I had in front of me.  I poo-pooed their stories, only to have the patient suddenly rearrest on me.   Any patient with syncope or seizure needs the monitor on and a self-resolved cardiac arrest should be considered

Check out these two blog posts for great videos that show early presentations of cardiac arrest, many that self resolve only to rearrest later.

From EMS 12-Lead

What it Looks Like: Cardiac Arrest 

Pay particular attention to the video "Diagnosed Seizure," which shows a female going into cardiac arrest while on an EEG and EKG monitor.  You can her rhythm go into torsades and her breathing turn into only an occasional gasp, yet the observers fail to recognize she is in cardiac arrest.  

https://youtu.be/YV3b9Dcy_2A

The video of basketball player Hank Gathers shows him collapsing, briefly getting up, and then collapsing again, and never receiving CPR.

https://youtu.be/Kia8j3TDyL4

From EMS Basics

What it Looks Like: Cardiac Arrest and CPR

Bottom Line:

Any active syncope or seizure, consider the patient might be in cardiac arrest.  Any resolved episode of seizure or syncope, consider that the patient might have suffered a self resolved cardiac arrest.  Get them on a monitor, and be ready to slap the pads on.

Stay tuned for: Pearl #2 Precharge your Defibrillator

Cardiac Arrest - Pearls

 Paramedics all take ACLS every two years, and we all have roughly similar protocols. We all know that the key to resuscitation is high quality CPR and early defibrillation. I love this graph I found on Rogue Medic's blog a number of years ago.

This graph is the answer to the test. We read about the latest gizmos and approaches over the years – everything from high- dose epinephrine, the ResQPOD, CPR machines, double sequential defibrillation to the latest head up CPR, but despite their early promises, few innovations make a difference beyond the basics. Those basics will likely always be good CPR and early defibrillation.

What I will offer in a series of posts is not a new way of doing CPR or a new device, just some pearls that I have learned to include in my resuscitations over the years that work for me.

Pearl #1  Recognizing Cardiac Arrest

Two Man dead Lift

 

This was sent to me by an old medic.  This is how stretchers were when I started in 1989.  In the days of the dead lift, careers in EMS were much shorter than they are now.  I remember each new stretcher innovation as they arrived, and fought against them all, but within days was sold on the new technologies, from the one man to the new self-loading I tried for the first time a week ago (on another service's ambulance).

In my thirtieth year in this profession, only now battling my first back issue, I am grateful to the innovators for allowing me to last as long as I have.  Hats off to to the inventor of the tractor stair chair.

Maybe someday someone will invent a way to prevent stress, PTSD and other mental injuries so many of our coworkers struggle with.

Peace to all.

 

Note: I wasn't able to track down the original source of the cartoon, but thanks to the artist for great drawing.

Fentanyl Test Strips

 

Mark Jenkins of the Greater Hartford Harm Reduction Coalition passes out fentanyl test strips as part of his mobile needle exchange. He has set up on a Sunday in the parking lot of 1200 Park, a shopping plaza/strip mall across from Pope Park where users often congregate.

Once the users see him out there, word spreads, people come from under the highway overpass, cars pull up and users step out. It is a Sunday and the local needle exchange van only operates Monday through Friday. Many have already run out of their supply of fresh needles, so this is a welcome event. The users hand over their old needles counting them out as they drop them in the sharps box and Mark hands them new syringes ten to a package.

One of the advantages of needle exchange is users pick up used needles, knowing they can exchange them for new ones. They use some of the needles for themselves and sell others a dollar a needle to other users. Mark also provides them with clean tourniquets, small cookers which look like quart bottle caps, a saline bullet, an alcohol wipe and little bits of cotton. They pour their heroin in the cooker, squirt in the saline water, stir it up, and then they draw the mixture up through the cotton ball which serves as a filter to help keep out impurities.

Mark has another product for them today. Fentanyl test strips. “Stick the strip in your cooker,” Mark says. “If one line turns red, there is Fentanyl present, two lines, it’s negative. You can choose not to use or if you do just do a test shot. Do two bags instead of five. Have someone with you.”

In the summer of 2017 Mark collected heroin bags across the city, and tested them for fentanyl. Nearly ninety percent of the city’s bags tested positive.

“It’s about informed choices,” Mark says. “They can choose to avoid the fentanyl or much more likely, if they use it, they at least know it’s there and they can take steps to stay safe, having someone there with them, having naloxone available, using less than

Sunrise on Albany Avenue

 

Back on the Rise

 After a slight decline in 2018, overdose deaths are projected to hit an all-time high in Connecticut in 2019.  

94% of the deaths were caused by opioids with fentanyl being the biggest culprit.

For full breakdown, click here:

Connecticut Accidental Drug Intoxication Deaths Office of the Chief Medical Examiner

Judge Rules for Safe Unjection Site

 

A federal judge ruled yesterday that a nonprofit group in Philadelphia's effort to open a safe injection site where people can use drugs under medical supervision does not violate the federal crackhouse statutes prohibiting the operation of a space "for the purpose of manufacturing, distributing or using controlled substances." 

U.S. District Judge Gerald McHugh wrote: "The ultimate goal of Safehouse's proposed operation is to reduce drug use, not facilitate it." 

The federal government has not only vowed to appeal, they have threatened to shut down anyone who attempts to open such a site.  Deputy Attorney General Jeffrey Rosen said, "Any attempt to open illicit drug injection sites in other jurisdictions while this case is pending will continue to be met with immediate action by the department."

Ten years back I would have thought a safe injection site was a foolish idea, but after witnessing the sorrow, devastation and death caused by the opioid epidemic, I have come to see these spaces as essential.  The evidence from safe injection sites operated legally in countries around the world shows that they work in reducing death and the spread of disease as well as increasing the number of people getting into treatment.  They are a common sense solution to a major problem.  Today users in Hartford shoot up in public spaces, leaving drug paraphernalia (open needles) on the ground, and many of them die behind dumpsters, in public bathrooms and in their battered cars because they are found too late to be revived.

As Mark Jenkins of the Greater Hartford Harm Reduction Coalition often says, we have plenty of public drug consumption spaces in this city already today.  The restrooms of McDonald's, Subway, Burger King, the public library,  not to mention sidewalks, alleys, and public parks are all commonly used to as public places to inject drugs.  But these sites are far from safe for the user or the public.

A safe consumption space provides a clean environment where users not only get sterile supplies, they get counseling and access to social services.  They are treated by people who care about them and recognize them as fellow human beings who are afflicted with a severe chronic disease.  They are not stigmatized as scumbags and degenerates.  

We can't forget that nearly all of these people are trapped in a vicious addiction that often began through an injury or illness and a visit to their doctors.  Their doctors prescribed them dangerously addictive medications that the pharmaceutical companies were making billions off of, while hiding their addictive dangers. Even those who began their drug use through experimentation don't deserve the horror that addiction inflicts.   If you take addicted opioid users and put them in an MRI, the imaging will show the damage done to their brains as surely as it will show the damage done to hearts injured by cardiac disease, or lungs by respiratory disease.  

Heroin destroys and rewires the brain's reward pathways.  For many, the damage is so severe, recovery is not possible, all that can be hoped for is periods of remission.  The job of harm reduction is to keep people alive and minimize the ill effects of their drug use.  It is about being our brother's keeper.

Judge rules Philadelphia supervised injection site does not violate federal law

Former Philadelphia mayor calls approval of safe-injection site 'hugely important'

Peace to all.

Water

 

The next drug to add to the EMS formulary should be water. That’s right. H20. How many times have you been on a call and the patient has asked for water only to be told by every EMS responder in the room, “No! You can’t drink anything!”

Really?

The reason we don’t let people drink water is so they don’t throw up and aspirate while the anesthesiologist is trying to intubate them at the start of surgery. This all comes from two cases in the 1950’s where pregnant woman aspirated during delivery. If you are going to have scheduled surgery, the surgeon will often tell you, no liquids after midnight. The problem with this was they were telling this to old ladies who go to bed at seven at night.  Their surgery wouldn't be until three in the afternoon.  They were going into surgery dehydrated and hypoglycemic.  Nowadays, many progressive surgeons just say no liquids for two hours before surgery.

Research Suggest Drinking Before Surgery Helps Recovery

New Rules: Eating, Drinking, Anesthesia

Research shows people who are allowed to drink water, apple juice or Gatorade do better than those who are required to abstain. They are not dehydrated. Their stomachs may even be emptier due to the fluid moving things through their system and they spend less time in the hospital.

Translate all of this to EMS.

Why do we keep insisting our patients can't drink water, and only the kindest among us get them ice chips to suck on?

How many of our patients who are asking for water are candidates for emergency surgery? Maybe the guy with the bullet hole in his abdomen screaming out for water like the soldiers in the movies shouldn’t be given a drink, and certainly it shouldn't be given to anyone vomiting with altered mental status as the result of a head injury or someone having a stroke who can’t swallow. No water for them. Fair enough. But most patients can quite comfortably drink some water without any ill-effects. And even for those who may have surgery like those with hip fractures, how many of them are going to be under anesthesia within two hours of when they ask you for a sip of water? Not many. Two-thirds of hip fracture surgeries take place more than 24 hours after the patient’s arrival in the ED.

Timing of Hip Fracture Surgery

The "nothing to drink before surgery" mantra should not apply to all EMS patients on the oft chance that a rare individual patient will have some type of unexpected surgery within hours of their arrival.

Old woman feeling weak. Her apartment is hot and has poor airflow. She wants a drink of water. "NO!" nine of the ten responders (Police, fire and EMS go to every call in some towns) in the room shout. "No," you say, calmly.  "It’s okay." (If she calls her doctor instead of calling 911, he is going to tell her to drink fluids.) "I’ve got a cold bottle of water in the ambulance. You can sip on it on the way to the hospital."

"You can’t drink," I hear medics say all the time.  "But I am going to give you water right into your veins instead."

Maybe water or Gatorade might be a better, safer, and less invasive intervention for certain patients than an 18 gauge needle in their AC.

For hypoglycemics we are taught that if they are are able to swallow, we can give them some orange juice to drink if there sugar is low.  Better than putting in an IV and running the risk of extravasation or hyperglycemia if we push Dextrose.

Our state hyperthermia protocol actually does allow us, if the patient is alert and oriented, to "give small sips of cool liquids."

Many people don't know that.

I always carry extra water with me in the ambulance. On hot days I even carry a cooler of ice and water. It comes in handy.

We pick up a schizophrenic man who has been shouting at his demons. “Would you like a cold bottle of water?” I ask. Talk about an immediate way to civilize someone. The British had tea. We have water. We toast each other and chat on the way to the ED.

Have some water with me. Works like a charm, although one patient did pour it all on top of his head.

Woman sitting on a bench in the sun waiting for the city bus has trouble getting up.  She's alert and oriented, but diaphoretic and very tired.  Here drink this.

It's not quite like the TV commercials where Bobcat Goldthwait eats a Snickers bar and turns into Mariah Carey, but it works.  She perks up.

Everybody loves cold water.

Homeless person fell and cut their knee. We clean and bandage it up. He doesn’t want to go to the hospital. Okay, he is alert and oriented. Thank you for your signature on the refusal. “Would you like a cold bottle of water? And how about an apple? You have a bad tooth? Take an orange instead.”

Yes, sometimes we carry fruit. I don’t let them eat on the way to the hospital. I’m not that radial yet. Maybe after I get the water added, I will ask for fruit.

It’s not like we don’t let some patients eat and drink. Hypoglycemic? Have some orange juice. How about a peanut and butter jelly sandwich?

We have a big homeless population in Hartford. They are all hungry. Maybe some day I can give them crackers to eat while we wait in the triage line. I confess sometimes my partner and I take turns going into the EMS room to get some fruit and crackers for ourselves while the other waits with the patient for a nurse to call our turn to come to the desk. Our patients are hungry too.

Every morning we stop at Cumberland Farms. They give us free coffee, tea or soda. It normally costs 99 cents. I don’t feel comfortable getting stuff for free so I always buy something to go with my free drink. Lately, I buy a bag of ice for $1.99. I put the ice in my cooler which is filled with water from the case I bought at the Stop and Shop the night before for $2.29.  On baking hot days, with the sun beating off the blacktop, my partner and I are water philanthropists. Ed Newman has his prize patrol. Bill Gates writes checks all the time to deserving charities. We drive down the street on 90 degree summer days with an eye peeled for people who are sweating, tongues hanging out, trying to find shade in the tiny shadow of street posts. “Hey!” We shout. We lean out the window and hand them glistening cold bottles of Aquafina. “Have a good day!  May the force be with you Peace be with you!”

Talk about a feel good treat.

And good public relations for your service, too.

Sit down with your medical advisory committee and work out a list of who it is okay to let have a drink of water.

It’s a kind gesture.

 

Two Boys

 

We are called for an unconscious and find the man out cold on his feet near Pope Park.  He is a tall man in his early thirties with a ghost white complexion, standing there on the side of the road, his head nodded forward, arms hanging down swaying.  Another drug user on the nod in Hartford.  I shake him and he opens his eyes and says he is fine, but then he drifts back out.  My partner wheels the stretcher over and we gently push him down onto it.  He wakes enough to again, say he is fine, but he drops back out.  In the ambulance, I check his ETCO2 and his pulse saturation.  The numbers are 66 and 90.  I can stimulate him and the numbers come up a little, but if I leave him alone, he doesn’t breathe well enough on his own.  I put in an IV, which he doesn’t feel.  I take a 10 cc syringe, squirt out one cc, then add 1 cc of Naloxone to the syringe.  I slowly give him one cc of the mixture, delivered 0.1 mgs of Naloxone, a tiny dose.  When he doesn’t respond, I give him another 0.1 mg dose, and soon he is talking to me.  He doesn’t even know I have given Naloxone to him.

“I don’t need to go to the hospital,” he says.  “What time is it?   I have to get back to work or I’m going to lose my job.  I‘m on my lunch break.”

It is three-thirty in the afternoon.  I ask him where he works and he says he is a house painter.  He asks where we picked him up, and after I tell him, he tells me he is painting a house a few blocks from there.

I tell him the doctors will look at him at the hospital, and after, watching him for an hour, will let him go.

“Dude, I can’t wait that long,” he says, “I’ll lose my job.”

I feel for him, but we had to take him in.

His name is Keith and he lives in an upscale suburb of Hartford.  The street is familiar to me.  I did an overdose there maybe a year before. I remember the mother sobbing at the sight of her son on the bathroom floor, even though we were easily able to revive him.  I sensed she was at her breaking point.  He had already been through rehab four times.

“You didn’t give me Narcan, did you?” Keith asks.

“Yes, I did,” I say.  “Just a little, enough to keep you breathing without me having to shake you every minute.”

“Fuck, I’m going to lose my job.”

“You have to be careful if you are going to use,” I say.

“I only did a half a bag.  I just haven’t used.  I got out of a program last week.”

“Your tolerance is down.  If you are going to use no matter what have someone there with you.  Have Narcan around.  Do you have it at home?”

He nods. 

“Who do you live with?”

“My Dad took me back in.”

“Does he know how to use it?”

“Yeah.”

“You have to be careful with the fentanyl around.”

“I know my friend Marty died a month ago.”

The name rings a bell with me.  “What was his name?

“Marty Harris.”

“I took care of him before,” I say.  “That was a year ago.”  Marty was the young man I remembered.  The news of his death, even though I barely knew him shocks and saddens me.  Marty and Keith were the same age

 “He got out of jail after nine months and he oded and died.”

“I’m sorry.”

“Man, I’m going to lose my job.”

Once we get to the hospital, he gets even more anxious, and he ends up pulling his IV out.  I try to get a nurse to come over.  I give the heads up that he wants to leave.  The nurse says he’ll get a doctor to look at him.  The doctor comes over and the doctor and Keith end up in a shouting match.  The doctor tells Keith he obviously doesn’t care about his own life because he is doing drugs that may kill him.  The young man tells the doctor to fuck off and walks out, swearing that he is going to lose his job and he has to walk all the way back to the job site.

 

That night I google his friend Marty’s name and add obituary and the name of the town to the search.  And there he is – a picture of the other young man.  There is nothing in the obituary that mentions drugs.  It just says he died too soon and what a kind heart he had.  He was a high school swimmer, an avid soccer fan and an accomplished cook.  He liked to camp with his family in the Adirondacks.  There is a long list of family members he left behind.  I read the comments.  One poster says how he remembered him so fondly as a little boy playing in the neighborhood.  There are even pictures of him when he had to be about five.  One shows him with another young boy, and I wonder if it is the man who I transported today.

Another poster writes:   “He is no longer in pain.”

Draft ILCOR Advanced Airway Recommendations: Banning Paramedic Intubation-What System will be the First?

 

The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR), the group that forms the basis for the AHA ACLS guidelines, has released a new draft guideline on Advanced Airway Management During Adult Cardiac Arrest.  The guideline is available for public comment until April 2, 2019.

Advanced Airway Management During Adult Cardiac Arrest

The recommended guideline takes into account the latest literature, including The Pragmatic and AIRWAYS-2 trials:

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome The AIRWAYS-2 Randomized Clinical Trial

Here areILCOR's the key draft recommendations:

Treatment Recommendations

• We suggest using bag-mask ventilation or an advanced airway strategy during CPR for adult cardiac arrest in any setting .
• If an advanced airway is used, we suggest a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success.
• If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate.

While they do not specifically define what low versus high intubation rates are, they write the following:

We have not provided a precise value or range of values for low and high intubation success rate, nor an agreed definition. Studies have used different definitions of tracheal intubation success. Using the individual study definitions, we considered the Wang and Benger RCTs (Benger 2018 779, Wang 2018 769) as having a low tracheal intubation success rate (51.6% and 69.8% respectively) and the Jabre study (Jabre 2018 779) as having a high success rate (97.9%).

In other words, if your service has an intubation success rate of 69.8% or less, then you are should be using a supraglottic airway instead of tracheal intubation.

(Intubation success should not judged on whether or not the patient eventually comes in with an ET tube place (after multiple attempts), but your rate per attempted laryngoscopy.)

When I began as a medic in 1993, ET was the standard for prehospital care.  We did not even carry supraglottic (backup) airways.  Today supraglottic airways, and even bag value mask, are considered acceptable alternatives.   As research continues to show that tracheal intubation does not lead to improved outcomes and may lead to worse, medical directors are going to start pulling intubation from their medics’s arsenal.  To date, I am not aware of any who have done so.  What system will be the first?

 

Our work is different.

https://www.facebook.com/bo.israeli.myname/videos/10161541225365174/?t=10

It speaks for itself.

Please share.

Austin Eubanks

 

I attend the Department of Public Health’s 2019 Connecticut Opioid & Prescription Drug Overdose Prevention Conference on May 2.  The featured speaker is Austin Eubanks, a survivor of the Columbine shooting. He and his best friend were golfing and fishing buddies. He shows us pictures of the two of them smiling, no idea what fates life had in store for them. In the school library, they hear an odd sound from out in the hallway. Another student says it sounds like gun shots. But they are in a school. Guns aren’t allowed in schools. (This was of course the first mass school shooting, while today students drill for such occurrence).  Then more commotion and a teacher bursts into the room and says “Everyone get under the tables!” Even with that they stand around for a moment, thinking “really?” Then the gunmen, armed with shotguns and automatic weapons, enter the library. His best friend and he hide under a table as the shooters walk through the room systematically executing their fellow students. They are under the last table. His friend is killed instantly, while Austin is shot in the hand and knee.

He survives only by playing dead. He tells us how detaches himself from the scene. Later when he is rescued and meets his father, he bursts into tears, the emotion finally ripping through him. But then he is medicated for his injuries. Doctors prescribe him heavy doses of very powerful drugs. He is seventeen years old and has never drunk a beer or smoked marijuana.

He tells us that what the opioids he is given do best is not affect his physical pain, but they take away all his emotional pain. They enable him to block all his emotions. While his physical pain subsides in a matter of days, his emotional pain is still off the charts. He keeps taking the medicine --at times more than he is prescribed -- because it is working for his emotional pain -- blocking the horror of what he has been through and the thought of all his slaughtered friends. The pills provide an escape that quickly leads to addiction. Within a matter of months he is not only drinking alcohol, but as his tolerance for opioids has increased, he is now obtaining pills and illicit drugs on the black market.

He uses all these substances for years to manage his emotional pain, which is not addressed by any of his doctors. Because he is able to put a tie on and go to work, he fools people, he tells us, but his life eventually unravels completely. He uses heroin, methamphetamine and other pills to keep his emotional pain at bay and to keep from feeling the sickness of withdrawal. He loses his job, his family -- he is married now with a son-- breaks apart.  After more than a decade of struggle, he finally makes it though multiple recoveries and finds his way home.  He reunites with his son and becomes good friends with his ex-wife, remarries and has another son. He becomes a committed advocate and travels the country speaking about the opioid epidemic, offering messages of recovery and hope.  He tells us how important his family is to him now, how grateful he is to have found his way home.

 He tells us about the difference between feeling better and being better.   He urges us to pay close attention to people's emotional pain.  He brings the message that those addicted are not junkies and scumbags, but our brothers, sisters, parents and friends.  He receives a standing ovation from our packed conference crowd of nearly 300, all people dedicated to battling the opioid epidemic.

Three weeks later, I open up the newspaper to see the headline Columbine Shooting Survivor Found Dead.  His family issues a statement:

"(Austin) lost the battle with the very disease he fought so hard to help others face.”

Was he using when he spoke to us. Were we fooled because he had a tie on and spoke without slurring his words?  Or did he relapse after? It doesn't matter.  The point is the battle is never over.

I wonder what would Austin's life have been like had he not gone to school that day twenty years ago?

Thirty-seven-year olds die of opioid overdoses daily in this country. How do people think of them? Are they scumbags and abusers?  Are they the unclean?  Or are they members of our community? People to be cared for and shown love and mercy?

How close we all are to our lives suddenly falling apart. I think of all my patients who look up at me with irrepressible sadness as they say, "I used to normal once." 

The scenarios are there for misfortune to knock on any of our doors.

 

https://youtu.be/SP_q3cW672s

 

Columbine and addiction survivor Austin Eubanks made his last speech at a Connecticut opioid conference. He was found dead in Colorado last weekend.

 

 

Connecticut SWORD

 In Hartford, EMS personnel call the Connecticut Poison Control Center (CPCC) after each opioid overdose they encounter, and answer a series of questions.

The specialists (CPCC) log the data and also input in into federal OD map software which produces a near real time map reporting overdose locations and types, and can automatically send spike alerts to local officials when certain county wide thresholds are reached.

This map which records ODs down to the block level can be accessed by local public health departments in Connecticut.

Additionally, data collected by the CPCC specialists can generate other alerts based on identification of bad batches or unusual events such as cocaine contaminated with fentanyl.

Specialists also follow up with the hospital for transported patients to record their outcomes.

The project began as a pilot in Hartford last May, and now after a year of data gathering and data sharing with the public health and safety community, has been expanded. On April 1, the North Central Region began reporting with the rest of the state set to join in on June 1.

For the first time Connecticut is able to track non-fatal overdoses, gather valuable demographic data and trends and provide near real time alerts.

The program now called SWORD (Connecticut Statewide Opioid Reporting Directive) is funded by the State Department of Public Health (using federal grant money), and the Office of Emergency Medical Services who issued the reporting directive in accordance with a new state law mandating opioid overdose reporting.

EMS calls to poison control are HIPPA protected under a federal waiver. The CPCC can only share deidentified information with state and federal health agencies.

Here is a video on the program put together by UConn Health, which was one of the original sponsors of the project.

https://youtu.be/8Fyoj0EbUFc

 

Hartford Opioid Crisis Interview

One of my EMS coworkers and a budding journalist Sean Freiman interviewed me recently about Hartford's Opioid Crisis with a focus on the heroin bags.

Click on the picture to view the interview.

  

INSIDE LOOK AT LIFE AS AN EMT

 

I recently participated in a project to describe the daily routine of an EMT to help people considering a career in EMS.  The final product was published this week on the website below.

INSIDE LOOK AT LIFE AS AN EMT

Here is an excerpt:

5:30 AM:

I punch in and checkout my equipment, my house bag which contains my medications, IV and airway supplies, my heart monitor, and then the equipment on the ambulance shelves, while my partner checks the ambulance to see that the siren and emergency lights are working and that we have plenty oxygen to make it through the shift. He also checks the oil and engine fluids.

Then, we sign on with our dispatcher and already there is a 911 call for us. No time for coffee. A 68-year-old woman has been vomiting all night. I feel her forehead she is burning up. Her tongue is also dry and cratered. I give her Zofran for her nausea and IV fluid for her dehydration. We transport her to the hospital.

6:23 AM:

I am writing my PCR (Patient Care Report) on my laptop computer in the hospital EMS room when my pager goes off “Can you clear for a Priority One?” We head out lights and sirens for the report of a person unresponsive in a car. Before we can get there, we are cancelled. It turns out the person was merely sleeping. Dispatch has another call for us. A motor vehicle crash by the highway entrance ramp. Both drivers are out of the car inspecting the damage, which is minor. One driver has arm pain, but refuses to go by ambulance to the hospital. We have him sign a refusal of care, and then clear the scene.

7:04 AM:

Report of another person not responsive. A woman stands by the front door and we can see she is crying as she flags us down....

To read the rest, Click here

Draft ILCOR Advanced Airway Recommendations: Banning Paramedic Intubation-What System will be the First?

 

The Consensus on Science with Treatment Recommendations (CoSTR) from the International Liaison Committee on Resuscitation (ILCOR), the group that forms the basis for the AHA ACLS guidelines, has released a new draft guideline on Advanced Airway Management During Adult Cardiac Arrest.  The guideline is available for public comment until April 2, 2019.

Advanced Airway Management During Adult Cardiac Arrest

The recommended guideline takes into account the latest literature, including The Pragmatic and AIRWAYS-2 trials:

Pragmatic Airway Management in Out-of-Hospital Cardiac Arrest

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest A Randomized Clinical Trial

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome The AIRWAYS-2 Randomized Clinical Trial

Here areILCOR's the key draft recommendations:

Treatment Recommendations

• We suggest using bag-mask ventilation or an advanced airway strategy during CPR for adult cardiac arrest in any setting .
• If an advanced airway is used, we suggest a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success.
• If an advanced airway is used, we suggest a supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate.

While they do not specifically define what low versus high intubation rates are, they write the following:

We have not provided a precise value or range of values for low and high intubation success rate, nor an agreed definition. Studies have used different definitions of tracheal intubation success. Using the individual study definitions, we considered the Wang and Benger RCTs (Benger 2018 779, Wang 2018 769) as having a low tracheal intubation success rate (51.6% and 69.8% respectively) and the Jabre study (Jabre 2018 779) as having a high success rate (97.9%).

In other words, if your service has an intubation success rate of 69.8% or less, then you are should be using a supraglottic airway instead of tracheal intubation.

(Intubation success should not judged on whether or not the patient eventually comes in with an ET tube place (after multiple attempts), but your rate per attempted laryngoscopy.)

When I began as a medic in 1993, ET was the standard for prehospital care.  We did not even carry supraglottic (backup) airways.  Today supraglottic airways, and even bag value mask, are considered acceptable alternatives.   As research continues to show that tracheal intubation does not lead to improved outcomes and may lead to worse, medical directors are going to start pulling intubation from their medics’s arsenal.  To date, I am not aware of any who have done so.  What system will be the first?

 

Moral Injury

 Check out this powerful You-tube video

https://www.youtube.com/watch?v=L_1PNZdHq6Q&feature=youtu.be

When I see another provider who is burned out, my reaction has always been:

"Get another job.  You have no business doing this kind of work."

Until I saw this video, I never really considered the concept of moral injury.

If a fellow paramedic hurts his back lifting or wrestling with a patient, I would never thing to say, "Get another job.  You don't belong in this work work anymore."

Companies take great precautions to make our work physically safe.  There have been great innovations in stretcher design (when I started we used a two man dead lift), stair chairs, safety nets, and driver safety systems.  And while most services have employee assistance programs, I can't think of any preventative measure routinely taken in EMS to prevent moral burnout.  Long shifts, holdovers, too few cars on the road, 911s holding, order-ins.

Meat in the seat.

There is always a new hiring class to pick up the fallen stethoscopes and take their places on the front lines. 

It is hard to change things overnight.

I am glad there seems to be an awakening ahead.

 

An Underappreciated Attribute

There are many qualities I appreciate in a BLS partner (Our system pairs either each paramedic with an EMT.)  These are my ideal attributes:

1. Strong, can lift.
2. Solid EMT.
3. Knows where they are going.
4. Pleasant disposition.

Over the years I have worked with partners who are missing some of these.  I have learned to work them.

If a partner can’t lift, I make use of first responders.

If a partner is not a good EMT, I never rely on them.

If a partner doesn’t know where they are going, I can direct them because I know the roads.

But if a partner isn’t pleasant, there is nothing I can do suffer. 

All

 

I’m on scene of an overdose. A fifty year old man in an unkempt apartment went unresponsive after sniffing two bags of heroin. His neighbor found him, giving him 4 mgs of Naloxone IN, and then called us. The man is alert and oriented by our arrival and does not wish to go to the hospital. The neighbor says he will watch the man. He still has another Naloxone in case the man goes out again. He says he gets his Naloxone from the local harm reduction agency.

The cop on scene shakes his head and says, “They’ll give out Naloxone for free, but kids have to pay $800 for an Epi-pen.”

This is an argument I hear quite often. "They’ll give a drug addict free Naloxone, but my wife, who is a school teacher, has to pay $1000 for her Epi-pen.”

What is the implication behind the officer’s remark. Is this man’s life less worth saving then a kindergartner who mistakenly eats a cookie with nuts in it?

Last year over 70,000 Americans died of accidental overdoses. Only about 150 people die a year from fatal food anaphylaxis.  3,000 die from any type of anaphylaxis.* Each of these deaths were preventable. Were the 70,000 who died of overdose all scumbags who willfully chose to become addicts? Were those  Americans who died of anaphylaxis all a higher class of citizen?

"Well, the junkies made a choice to use illegal drugs," an EMT says.

In EMS we talk all the time about the lack of respect we get as a profession. What makes us professional?

Is it the 120 hours of the EMT class we took? Or even the 2,000 hours paramedics get?

Is it how spick and span our uniforms are? How shiny our badges?

Or is it the way we treat our patients? The compassion in our hearts that recognizes the humanity of all our people no matter their circumstance?

Recently a local fire department in its annual CPR lifesaver awards ceremony, chose not to honor its members who had saved overdose victims from cardiac arrest, alongside those who had achieved ROSC in victims of heart attack or other “medical” cause.

There is too much hatred in the world. There is no place for it in EMS.

We should never pit patients against each other.

We should embrace programs like community Naloxone in the same way we should embrace efforts to hold pharmaceutical companies responsible for price-gouging families for the costs of Epi-pens.

We should teach people how to properly use Naloxone with the same fervor that we should teach people how to properly use epinephrine.

***

*In many cases people die of anaphylaxis not from absence of epinephrine, but from failure of medical professionals and/or families to administer it.

When Should I Use Epinephrine? Why Am I Afraid of it?

The Proper Use of Epinephrine for Anaphylaxis

EMT Administration of IM Epinephrine via Syringe

 

Connecticut, following the leads of states such as New York, has just expanded the scope of practice for EMTs to include injecting medications. This means instead of carrying two $600 Epi-pens, EMTs can now draw up 0.3 mg of epi from a $5 vial and administer it to a patient suffering a severe allergic or anaphylactic reaction.  Services who wish to provide this alternative need authorization from their sponsor hospital, but all EMTs in the state will be taught the skill as part of their regular training.

Here’s a link to Connecticut's training program:

EMT Administration of IM Epinephrine via Syringe

Background

Unfortunately, the rising cost of the injectors and their short expiration periods create a significant financial burden on the EMS agencies. King County Washington EMS system, which uses the “Check and Inject” program, estimates they have saved $335,000 annually by switching to a syringe method. According to a recent survey, 13 states have training programs to allow BLS to inject epinephrine and 7 others are considering it. 

Basic Life Support Access to Injectable Epinephrine across the United States

Evidence/Value of Safety of BLS Syringe Injection

“EMTs successfully implemented the manual “Check and Inject” program for severe allergic reactions and anaphylaxis in a manner that typically agreed with physician review and without any overt identified safety issues..”

- “SYRINGE ADMINISTRATION OF EPINEPHRINE BY EMERGENCY MEDICAL
TECHNICIANS FOR ANAPHYLAXIS.” Prehospital Emergency Care; January 15, 2018, Published Online (1-7)

Syringe Administration of Epinephrine by Emergency Medical Technicians for Anaphylaxis

“Based on the results of a State Emergency Medical Advisory Committee (SEMAC) demonstration project, the New York State Emergency Medical Service Advisory Council (SEMSCO) approved Syringe Epinephrine for Emergency Medical Technicians (Check & Inject NY) at the September 14, 2016 meeting. The project established that EMTs, with the appropriate training may administer the proper dose of epinephrine for a patient experiencing a severe anaphylactic reaction using a specific 1cc syringe. Additionally, the project realized a significant cost saving over maintaining epinephrine auto-injectors.”

- Bureau of Emergency Medical Services and Trauma Systems POLICY STATEMENT 17-06, May 24, 2017

I am all for this program.  Some have argued that this is a skill that should be reserved for paramedics, but to me, it is a skill easily taught.  EMTs can administer this drug safely in life-threatening situations and the cost savings can be used to improve other aspects of the EMS system.

How We Feel Versus What Dispatch Hears

 It has been busy at work lately and the crews have been getting pounded.  An EMT posted this video (found on the internet) on our employee Facebook page.  I laugh every time I think of it.  If you have never worked commercial EMS in a high volume system, you might not appreciate it.  I can only say, over thirty years, I have witnessed similar scenes hundreds of times with scores of partners.

https://www.facebook.com/savageparamedics/videos/406029299966649/

Here's a link to an interesting article about working conditions in commercial EMS:

Can EMTs, paramedics catch a break?

Connecticut Overdose Deaths 2018

 The official death numbers for 2018 are out from the Connecticut Medical Examiner's office.

Connecticut Accidental Drug Intoxication Deaths

1017 people died in Connecticut of accidental overdoses, down 21 from 2017.  This is the first decline (albeit minor) after six years of escalation.

746 people died in Connecticut due to the presence of Fentanyl, up 71 from 2017.

Still  much work to go before we can rest.

***

Here's a town by town breakdowns of deaths by residence and deaths by overdose location.  95 of the fatal overdoses occurred in Hartford.

CT Drug Overdose Deaths Town-By-Town In 2018

Connecticut Overdose Deaths Plateau

 Overdose deaths are declining in some states, and they appear to be plateauing in Connecticut.

Overdose Deaths Fall in 14 States

In data released by the CDC, covering the time period July 2016-June 2017, 14 states showed a decline in overdose deaths, while nationwide deaths rose 14 percent. The data showed an 15.9% increase in Connecticut, but even more recent data released from the Connecticut Medical Examiner’s office tells a more promising story. 

Number of Connecticut overdose deaths surpassed 1,000 in 2017

While deaths increased by 11.7 percent in Connecticut between 2016 and 2017, the last six months of 2017 showed a 8.7% decrease from the first six months of the year.

This is still a horrendously high level of overdose death, and it may only represent a temporary lull before escalating, but it does reflect what I have been sensing lately.   Over the last several months, 911 calls for overdoses are still abundant, but they don’t seem to be getting worse.

As to why the death rate may have plateaued, it is an open guess. The increased availability of community Naloxone may be a contributor. Also, perhaps, the knowledge that much of the heroin in Connecticut is either heroin (and cut) laced with Fentanyl  or just plain cut and Fentanyl, has caused users to use more caution, doing test shots and making certain they are using with someone else, and have Naloxone available.   Without better data, it is hard to say for sure.  At any rate, the decline in the latter half of 2017 is at least promising.

Graphs by P. Canning based on Medical Examiner's data and published news stories.

(Note:  These graphs were updated on March 1 to refelect Medical Examiner's official number released on this day.  They were slightly different from previously published news reports.)

Calendar Years 2012 to 2017 Accidental Drug Intoxication

Connecticut Drug Deaths Top 1,000 Last Year; Fentanyl Jumps As Heroin Declines

Common Cardiac Arrest Mistakes: Sodium Bicarbonate

This is the second of three posts about common cardiac arrest drug mistakes some EMS personnel make on a routine basis.

You have been working a cardiac arrest for a 54-year-old male with no prior medical history who collapsed after grabbing his chest.  You shocked him twice for fine vfib, but now he is in a PEA. It’s been 20 minutes since you started ALS interventions and another medic suggests you try sodium bicarb.  What do you do?

Remember it 2019, not 1979, 1989, 1999 or 2009.

Unless the patient has preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressenat overdose, (which this patient clearly does not) sodium bicarb is not recommended by the AHA.  In 2010 sodium bicarb was made a Level 3 Recommendation.  Level 3 means it is not helpful and may be harmful. In 2015 that recommendation was reviewed and maintained.

While you should always follow your protocols and your local medical direction, in Connecticut, sodium bicarb in cardiac arrest is reserved for “suspected pre-existing metabolic acidosis, suspected or known hyperkalemia (dialysis patient), known tricyclic antidepressant overdose, or suspected excited/agitated delirium.”

So if your patient is a dialysis patient or laying next to an empty pill bottle of amitriptyline, you can go ahead and give sodium bicarb.  Make certain the patient is getting excellent CPR and is well ventilated.

Just don’t give bicarb to “routine cardiac arrest," only use bicarb for special situations.

Here’s an excellent article on this issue:

Sodium Bicarbonate Does Not Work in Cardiac Arrest

As the author writes: “The literature behind using sodium bicarbonate in undifferentiated cardiac arrest clearly shows it does not work and may even be harmful. The AHA recommends against its routine use. So stop using it.”

https://www.sciencedirect.com/science/article/pii/S0300957217303337

Here's a recent journal article, which examined the "association of SB administration and survival and favorable neurological outcome to hospital discharge," and found in "OHCA patients, prehospital SB administration was associated with worse survival rate and neurological outcomes to hospital discharge."

Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest

Next: Naloxone in cardiac arrest. 

Sepsis

 EMS has focused on trauma, stroke and STEMI in recent years with resulting improvements in outcomes.  Many health care systems are now turning attention to sepsis care and the considerable role EMS can play in early recognition and treatment.

Here in Connecticut we have Sepsis Alerts, which while rarely generating the full response of Trauma, Stroke and STEMI Alerts are important to help hospitals be able to quickly recognize sick people on entry and devote them more immediate attention than they might otherwise receive.

EMS can start the treatment soonest with aggressive fluid resuscitation for those who meet the indications.

Great material on sepsis is available at this web site:

Sepsis Alliance

Check out this excellent video:

Learn to recognize sepsis:

IDENTIFICATION OF POSSIBLE SEPTIC SHOCK

Suspected infection – YES

Evidence of sepsis criteria – YES (2 or more):

o Temperature < 96.8 °F or > 100.4 °F.

o Heart rate > 90 bpm.

o Respiratory rate > 20 bpm.

o Systolic blood pressure < 90 mmHg OR Mean Arterial Pressure (MAP) <65 mmHg.

o New onset altered mental status OR increasing mental status change with previously altered mental status.

o Serum lactate level >4 mmol/L if available and trained.

-From Connecticut EMS Treatment Guidelines

 

Goals and Globetrotters

 Saturday night saw one of the pinnacle achievements of my life.  Twelve months before, while attending a Harlem Globetrotters game with my daughter, I announced that I was going to learn how to expertly spin a basketball on my finger just like the Globetrotters do.   Ever since then, I have carried a basketball in the ambulance.  In between calls while at posting locations, I have taken the ball out and practiced.  At home I have a basketball in every room of the house.  I even found a heroin addict in Hartford who for $5 a pop would give me spinning lessons. He was an ex-basketball player, who I am pleased to say now has a handyman business and is no longer on the street. (At least that was his plan when a few months ago, he told me I wouldn’t be seeing him around anymore, and true to his word, he disappeared no longer to be seen at his regular haunts.  I can only hope he is doing well).  I practiced so much I developed tendinitis in my elbow and had to suspend all spinning for a month. The elbow is much better and I can spin again without pain.

When I received notice that the Globetrotters were coming back to Hartford for their annual visit, I purchased Magic Passes for my daughter and I as well as third row seats at mid-court.  As a returning attendee, I took advantage of the 50% deal when the tickets were offered in a special pre-sale.  The Magic Passes entitled us to attend a pre-admission event where we could meet the players on the court, shoot baskets and spin basketballs.

Thanks to my daughter, my tryout was recorded for posterity.  Behold!

We had a great time, the Globetrotters stormed back from a 9 point deficit in the 4th quarter and beat the hated Washington Generals in a thrilling victory.

My daughter met "Swish,"a female Globetrotter.

While I was not offered a contract, I did have the opportunity to buy an official game ball for $60 and a Washington Generals t-shirt for $25.  I spoke briefly with the Generals and told them should “Cage” their 7-foot starting center and noted villain leave for other opportunities, I would be available to don the black mask.

I write all of this because my ability to devote a year to spinning a basketball is one of the great side benefits of being in EMS.  Over the years, EMS has allowed me to pursue a variety or hobbies and interests while at work getting paid simply to be available to respond to emergency calls.  In the 30 years I have been involved, I have read the works of Shakespeare, written five books and countless blog posts, learned to play poker (and when it was legal to play on-line, made a fair amount of extra cash), trained for triathlons and Tough Mudders (when I was assigned to a contract town, I was able to ride my bike on a 0.7 mile loop around the industrial complex where the ambulance base was located -- my longest at-work ride was 26 miles), learned to speak Spanish, failed in an attempt to learn Vietnamese, wrote a food blog on take-out food in Hartford, trained to perform a 100 push-ups in a row (okay, so I only got to 79, and started cheating at 57), amassed one of the nation’s premier heroin bag collections, and now have learned to spin a basketball.

So what’s next?  I think I will work on my balance with a goal of standing on one foot for ten minutes.  My longest time on 10 tries today was 1 minutes and 49 seconds on my left foot and 1 minute and 36 seconds on my right.  I am six foot-nine and sixty years old, so not only is my balance not great, with each advancing year it becomes less so.  I need to improve upon it if I am going to be able to keep at this job I love.

Wish me luck.

Common Cardiac Arrest Mistakes: Naloxone

This is the third in a series of posts on common drug mistakes some EMS responders make during cardiac arrests.

You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

You set your monitor by the man’s head and connect the fire department’s pads to your monitor, while your paramedic student quickly places an IO in the man’s tibia. As you approach the two minute mark, you charge the monitor, and then order stop CPR. The patient is in asystole. “Continue CPR,” you say, as you harmlessly dump the charge by hitting the joule button.

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

What drug do you give?

***

Epinephrine.

According to the 2010 AHA Guidelines

There is no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.

Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms

Naloxone has no role in the management of cardiac arrest.

Opioids bind to brain receptors that suppress respiration. The patient, if not treated in time, becomes hypoxic and may soon go into cardiac arrest. Giving the patient in asystolic arrest Naloxone will do nothing to restart the patient’s heart. The patient is in the same condition as someone who has suffered an airway obstruction. Hypoxia is the killer. The patient without a heart beat will not be able to breathe on their own without restoration of the heart beat. You are already taking care of the breathing part with your bag-valve mask.  The priority is getting the heart restarted. That is what epinephrine does.   This patient needs good CPR. Ventilation with a bag-valve mask and epinephrine to get his heart started.

***

Case # 2

You are a basic EMT. You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

You feel for a pulse, but find nothing. “Continue CPR,” you say.

What do you do next?

***

Naloxone.

Why? Because even though you can’t feel a pulse, the patient may have a hard one to palpate. He may, in fact, just be in respiratory arrest. You can give Naloxone while you provide CPR. If the patient is in a narrow complex rhythm, they may resume breathing on their own. If you are a medic in this situation and you find a pulseless man with a narrow complex rhythm, you should give Naloxone, while continuing to perform CPR.

The AHA Guidelines for BLS state:

Patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients.

Standard resuscitative measures should take priority over Naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). (Class I, LOE C-EO)

In October 2015, the guidelines were updated to add:

It may be reasonable to administer IM or IN Naloxone based on the possibility that the patient is not in cardiac arrest. (Class IIb, LOE C-EO).

I have had a couple calls this year where I could not feel a pulse in an apneic patient who I suspected of opioid overdose.

We initiated CPR. I had a narrow complex rhythm on the monitor. I gave Naloxone IM, and after several minutes, the patient regained a respiratory drive. We were able to feel pulses and so stopped CPR. In both cases, I suspect the patients simply had weak or hard to palpate pulses in the first place.

Bottom Line: Focus on good CPR and proper BLS/ALS care.   Give epi for cardiac arrest.  Give Naloxone for respiratory arrest. 

And as always, please follow your local medical control treatment protocols and guidelines.

***

For more on the controversies surrounding the use of naloxone in cardiac arrest, read the multiple and excellent columns by Rogue Medic

The Myth That Narcan Reverses Cardiac Arrest

Naloxone and Cardiac Arrest

***

Portions of this post appeared in a previous blog post.