Handsome Boy

 A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster--is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

Where I Stand (Today)

I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student's own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service's medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again. 

King of the World

 I work Sunday, Monday and Tuesday, 12-hour city shifts. I took the day off today (Tuesday) to go to the monthly regional EMS meetings for my clinical coordinator job that fall on the 2nd Tuesday of every month. I was excited for the meeting because we were going to be voting of our new spinal immobilization guideline to limit the use of long boackboards for certain patients, but the meetings were cancelled due to the storm we had this past weekend. Friday night we were hit with a blizzard that dumped anywhere from two to three and a half feet on towns in the area. The storm plus the nightmare of cleanup stressed enough of us with backlogged work and still messy road conditions that the meeting was put on hold.

I woke up Saturday morning to this site in my driveway:

Fortunately, I had a good helper with the shoveling.

Sunday and Monday at work were challenging as many of the streets in the city had yet to be plowed. We got as close to the call locations as possible and then either hiked in or had the patients meet us on street corners. The mother with the sick kid and the woman with the full body rash met us on the corners, the unresponsive hypoglycemic and the weakened dialysis patients who missed their scheduled appointments we had to go get.

Monday was complicated by people trying to drive to work and by a cold rain that turned the streets to slosh and ice. We dealt with more blocked streets, and cars that were stuck on ice with skidding wheels that we had to get out and help push out of the way. All day long, it seemed I was stepping out into snowbanks and doing crazy arm whirling balance dances when my own boots failed to grip the ice.

So a part of me was relieved that instead of dealing with more of the mess today, I was in my warm office at my computer, weating a comfortable sweater and reading run forms on the computer instead of doing the actual calls myself.

…instead of doing calls myself!

I do like my office job with the nice state benefits and great boss and chance to work on systems issues, but I also like doing calls myself. Really there’s nothing like it.

I found myself daydreaming, remembering the day before, how on one call to keep from blocking the road completely and leaving room for the arriving fire truck, I was wedged up against a giant snowbank. I squeezed out of the passenger door, and started climbing. I climbed to the very top of that snow bank. I was up higher than the ambulance roof, higher than the big fire truck. I was higher than everyone on the street. I could look all the way down the avenue, at all the life of the winter city digging out. I stood on the snowbank a moment, and pounded my chest like old King Kong. I was the King of the World! Then I climbed down to follow my paramedic preceptee and our EMT partner into the apartment house where on the third floor we took care of an old man with swollen legs, carried him down in a stair chair, and out through the snow and into our warm ambulance and transported him safely to the hospital.

Homemade Soup

I am conflicted. I am having doubts about some of the benefits of medicine. Let me be more specific. In our state, we are told to advise a patient at least three times to go with us to the hospital before we can accept a refusal of care against medical advice (AMA). (For legal purposes all of our refusals are considered AMA). On the other hand, as a medical professional, we are bound by the fundamental tenet, first do no harm.

Sometimes I feel that my required recommendation of transport is actually against the patient’s best interest. (Examples to follow.) In these cases, I may say, “I am required by law to advise you to go to the hospital three times. My advice by requirement is always to recommend transport to the hospital for evaluation by a doctor.” Other times clearly I ardently believe the patient needs to go to the hospital and I will use every trick in my book to get them to go. “I believe you will die a horrible death if you don’t get to the hospital, so we are going to take you to city hospital, okay?”

So why am I losing faith in medicine and in the benefits of patients going to the hospital? Clearly, I am not in every case, but in others, I do have my doubts. The history of medicine is not a stellar one. Think blood letting and hospital acquired pneumonias. Even in my years as a paramedic, it turns out that many of the things we were doing that we thought were helping patients were harmful to them. MAST trousers, high volume fluids in trauma, lasix. A recent study of spinal immobilization in penetrating trauma showed that for the one out of every 1200 patients we were possibly helping we were likely killing one out of every 68.

1999 Institute of Medicine Report, Too Err is Human, estimated that 44,000 – 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS. I also think this seriously undercounts people who may die from medicine contributing to their morbidity. What about people with unnecessary operations? What about people put on meds that may not have been necessary? The tendency in medicine is always to do something. That is what we get paid for. We don’t get paid for recommending against unnecessary treatment.

Now I understand that I am not a doctor and that I do not have the battery of tests that are available at a hospital not the extensive medical education and experience of a physician. It is just that I see so many people taken to the hospital and getting workups that don’t show anything or that show what any one else could see. A patient has the flu, the patient has a GI bug, the patient is dehydrated, the patient has a muscle strain, the patient is old and has wobbly legs.

I guess what I am getting at is in the larger scale on a risk benefit ratio, I am curious the number of people who benefit from their evaluation versus those who may be harmed by the evaluation.

Here are three cases in point all that happened in one day.

A frail old man has grown weaker over the last day and has fallen twice in the last day. His family wants him evaluated, but more than that, they want our advice. We, of course, tell them the weakness could be a sign of any of number of serious illnesses, and that he should be taken by us to the ED for full evaluation by an emergency room doctor and hospital specialists. But the family really wants our advice. They are worried that if he goes to the hospital he will get the flu from all the sick patients already there (like the two we brought in earlier).

The the truth is I see their point. What if we bring him in and he does get the flu or another infection that further weakens him? What if he gets put on other meds to battle whatever irregularities they find at the hospital and he dims because of them?

If he is my father, what would I want for him? In this case, with these symptoms, I would want him to stay home where I would care for him, feed him, and see that he rests in his own bed. I would be more patient. I would wait before sending him to the emergency department. I suppose I would wait for what I saw was a true acute emergency. I think his wife and his daughter are capable of providing such care. This is what I want to tell them, but instead I am bound to follow my script. I am not upset when they decide that they will keep him home, and only call if things change.

An 88-year-old Vietnamese man passes out at the pharmacy. He lives just a few blocks away. he walked over to get his meds, but had to stand in line for over fifteen minutes. He felt woozy and was helped to a chair. He barely speaks any English. His vital signs are good and his 12-lead is normal. He doesn’t want to go, but due to language it is hard to communicate. When we finally get hold of a family member, who, on our advice, tells him he has to go, he agrees to let us take him. Maybe he has had a cardiac event and will walk out of the hospital on many wonderful meds and perhaps with a pacemaker. But maybe he just has the flu, and would better benefit from being taken care of at home by his family and hand-fed hot soup.

Nearly the same scenario plays out later in the day with a Croatian woman who collapses at the post office while waiting in line. She is old and looks pale, but everything checks out okay. We still end up transporting her for an evaluation after getting hold of an English speaking nephew. Maybe she won’t get sicker in the hospital, maybe she will be better able to rest there than in her own bed, surrounded by her family.

I know this is unrealistic, and we do need to pay for gas, ambulances, equipment, mine and everyone else’s paychecks, as the hospitals also have to pay for their staff and physical structures. Still I wonder about runaway health care costs. I wonder about the scientific evidence and if it would show we are truly making a difference but universally urging transport.

I want what I do-- what we do--to matter, and I know it does in many ways. There are just those times where I think it might be better if we could just transport someone home, set them in their own bed, with their family now gathered around them in a familar setting, and perhaps we would leave with some homemade soup as payment for our kindness. 

Risk Assessment

 This post is inspired by a book I am reading – Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb. In this fascinating book Taleb discusses risk. Take this example which I am modifying from his book:

Would you get on an airplane if there was only a 5 percent chance that the plane would crash?

While the odds may be in your favor that you will likely not crash, the outcome of those small odds is so catastrophic that you would be a fool to board the plane absent astonishing circumstances requiring your seat on the plane (to save a loved one, to prevent a war from starting, to collect a trillion dollars). The possible benefit of getting on such a risk prone plane—is insignificant when compared to the possible drawback of crashing – losing your life.

Most bets we make, according to Taleb, are asymmetrical. The amount to be gained or lost is not equal. If you are going to bet, you want to bet where the losses are minimal and the payoffs far exceed the downside. Position yourself to avoid catastrophe.

While Taleb talks a lot about economics and other subjects, let’s apply this simplified concept to EMS.

***

“Why wasn’t a 12-lead done?”

“I didn’t think it was cardiac.”

***

So your patient has syncope with a recent history of dehydration. You brought the lady in yesterday after a similar episode, and the ED sent her home after hydrating her. She is 80 and appears ill. You have been a medic for twenty years or perhaps you are a cocky brand new medic. Your gut tells you it is not cardiac. In fact you are 95 percent certain it is not, so you don’t bother with a 12-lead...

Your EMS coordinator or training officer pulls you into the office and says your patient in fact had a STEMI and went into cardiac arrest on the way to the cath lab after sitting in a room for 20 minutes until the ED did a 12-lead and spotted the anterior STEMI. If you had spotted the STEMI, the patient would have likely been cathed before going into arrest, and while resuscitated, she likely will have a significantly diminished ejection fraction as a result of the arrest and delay in treatment.

What was the gain from choosing not to do a 12-lead and going with your gut?

You didn’t have to exert yourself to do a 12-lead.

What was the worst possible outcome of not doing a 12-lead?

The patient would be having an undiagnosed STEMI and due to the delay in diagnosing her, she could die before she could be reperfused in the cath lab.

Thus the decision to withhold the 12-lead is in Taleb's view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong.

Now for those of us who cast a wide net with our 12-leads, this may seem like much ado about nothing. There is no way despite our guts, this patient is not getting a 12-lead, but let’s apply this same reasoning to another scenario.

***

Why did you spend so much time trying to get an ET tube on that lady instead of just popping in a combi-tube?

“I thought I could get it.”

***

Obese female grabbed at her chest, and went unresponsive five minutes before your arrival. She was fortunate enough to get bystander CPR, but it doesn’t look like they are doing it very well. The seconds on her survivability clock are ticking quickly down to zero, unless you can intervene quickly and with great skill.

You put her on the monitor and see she is in a fine v-fib so you shock her X 1 and resume CPR. You want an advanced airway so you can do continuous compressions (instead of 30:2) as well as secure her airway – get more oxygen in and more CO2 out. You have two choices – an ET tube or a combi-tube.

You choose the ET tube. Why?

Well, it may be a better airway. It is the airway the hospital will use if you get her back and she remains unresponsive (under sedation) whereas if you put in a combi-tube, the hospital will eventually pull it and put in an ET. Also, you like intubating. It is a paramedic skill and one you don’t get to do as often as you’d like so you don’t want to pass up on the opportunity. Plus, when you talk about the call later, everyone will ask if you got the tube. If you are a new medic people want to know these things, and you want to show them you are worthy of the rocker on your shoulder. If you are a 20-year medic people will expect you to get it.

And most important of all – you think you can get it. You think there is perhaps an 85% chance you will get it, or maybe scale that down to 75% as you do notice, she has a thick short neck and protruding teeth. Still, you think the odds are in your favor. You go for it!

So what are the risks and benefits?

If you get the tube quickly you are a stud and the ED won’t have to switch out tubes as long as your crew doesn’t yank it. If you can do it without much interruption in CPR, all the better. Now the studies do show that ET attempts cause many interruptions of CPR, and you know that is true, but not in all cases, and sometimes you do intubate flawlessly and with great skill. No interruptions in CPR – even when checking lungs sounds. You can do it!

Now how about the risks?

If you don’t get the tube flawlessly, there could be problems. You will look bad for trying three times and not getting the tube. But wait a minute, we are not really concerned with you, we are concerned with the patient. That’s who the real risk is too.

If you are a medic working by yourself, it takes longer to get out all your equipment to intubate than it does to rip open and insert a combi-tube. If you can’t sink the ET tube on first look, CPR may be interrupted or the patient may not be ventilated well. CPR may be interrupted while you intubate, and your patient who is already on the brink of death may go to the darkness while you dick around trying to get the tube. It may not happen every time, or most times, but some tubes are, shall we say, challenging.

Reward you get the tube. Risk you cost the patients seconds if not minutes that they may not have. An asymmetrical bet. Small upside, big downside if the bet goes wrong.

Given that this patient is likely already on the razor blade edge between imminent tissue death, imminent anoxia and chance of full neurological recovery, I think we have to do everything to obtain immediate airway (oxygenation/ventilation) relief with no delay in compressions.

When seconds count, seconds should count. The risk of the most difficult airway I think is too great in this particular described patient. It is not a 75% versus 95% proposition. It is a possible loss of 10 to 60 seconds when a patient may not have those seconds left.

Wouldn’t it be great if every patient we showed up to in cardiac arrest had a visible life clock hanging on the wall above them. 0 seconds remaining, we don’t even have to go through the motions. 2 minutes remaining, we can take our time rolling up our sleeves and taking control. Or maybe 20 seconds remaining when we have to act fast and with that great skill. Deliver that jolt. Pound those compressions – they must be excellent. Secure that airway.

It doesn’t matter how well packaged the patient looks when we bring them into the ED doing CPR. ET tube, 2 IVs, run through the entire ACLS algorithm. It matters if we can get them back before that last grain of sand falls in their life clock.

We might save a human being who would otherwise pass. So what if they have to change out the Combi-tube to an ET tube later. Big upside, low downside.

***

Now I may be butchering Nasem’s points, and his book is certainly more complex and well thought out and argued than my meager post. The point is reading the book has made me look at a situation that I have struggled with in a new way. I don’t think I was adequately assessing the risks. When a life is at stake, I should err with whatever is more likely to avoid a catastrophic outcome.

Alternate Airways