Monday, October 28, 2019

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.”

 

Sunday, October 27, 2019

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.

Saturday, October 26, 2019

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.

 

Friday, October 25, 2019

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.

 

Thursday, October 24, 2019

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.

Tuesday, October 22, 2019

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 

Sunday, October 20, 2019

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.

Friday, October 18, 2019

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.  

Thursday, October 17, 2019

#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

Wednesday, October 16, 2019

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

Friday, October 11, 2019

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.

Thursday, October 10, 2019

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

Friday, October 04, 2019

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.