Sunday, December 30, 2012

Weekly Word.

The following piece is written by a very good friend of mine that has his own educational material that he researches & distributes every week called the "Weekly Word." He has written over 130 of these & has an emailing distribution list of over 3000+ people & forwarded to another 8000+ with readers in 21 states & as far away as South America, Africa, Great Britain & Australia. These are random review topics that he researches & writes up himself. They are well worth reading as he breaks them down into easily read pieces & the topics are usually on things that we all have limited exposure to and/or need some serious review on.

If you wish to be added to his emailing list feel free to contact him at:
Brian Talty, btalty@raaems.org, 804-874-8724

So without further ado....





"~Vermiform, ever heard of it? Look it up. Too lazy? Cool, I’ll just tell ya, it comes from Latin and means worm-shaped. Would it be comforting to know that something in your body is called worm-shaped? First, get your mind outta the gutter and second think about the small pouch like thing in your abdomen that isn’t use but often will cause a problem. Too lazy to look it up again? Seriously dude? Fine, it’s the appendix, the often overlooked and never used organ in the body. It’s like your pinky toe, who needs it right?
~As humans evolve we develop the need for newer or stronger systems/organs as well as outgrow the need for some. The pinky toe is useless to us now, however, before we evolved into humans, when we were chimps, the pinky toe played a vital role in survival. The appendix is kinda the same, it is thought to have played a vital role in digestion back in the day when our diets consisted of raw meats, dirty greens and sometimes pebbles, dirt, bone or whatever else got into our food when in the cave. Since we have gone from spearing saber tooth tigers and eating them in the field to ordering processed, inspected and cleaned pre cut pieces of meat on our phones, we no longer need that extra piece to aid in digestion.

~Much like the useless son that still lives in the basement, the only thing the appendix brings is aggravation. It is located near the junction of the small and large intestine and connected to the cecum. The cecum is a simple, pouch like structure of the colon. The appendix is located in the right lower quadrant and averages 11 cm in length.

~The most common diseases of the appendix are cancer, tumors and most importantly to us is appendicitis. Anything that ends in “itis” means inflammation, so as you can guess, appendicitis means inflammation of the appendix. Pain will begin in the center of the abdomen and then localize to the lower right quadrant and is visceral in nature. Visceral pain is from thoracic, pelvic or abdominal organs and usually evokes pain that is referred to as distant, deep, squeezing and dull. A fever will begin to spike and there may be nausea and vomiting present. Field diagnosis can be obtained with the above info as well as the following 3 points; 1. Do they have an appendix, if it has already been removed than I’d say it’s a good chance they do not have appendicitis. 2. Rebound tenderness. This is pain elicitation upon removal of pressure rather than upon application of pressure. 3. The rebound tenderness is usually found along McBurney’s point. This is a specific location 1/3 of the way along a line drawn from the anterior superior iliac spine to the umbilicus. Draw a line from the bony tip of your pelvis that is near your side to your belly button, now 1/3 up from the hip is McBurney’s point. Fun fact, that’s also how you impress the ladies while taking body shots ;)
~So what do we do? Proper assessment is imperative since a missed appendicitis can rupture and will lead to peritonitis which will then lead to sepsis, shock and death, all in a rather short time. Keep your patient in a position of comfort while keeping their transport safety in mind, no fetal position on the stretcher like a saw roll through the doors a few weeks ago……….Oxygen as needed, IV and fluid bolus is a must and if you carry antipyretics (fever reducers) or antibiotics it would be a good idea to get those going. Appendicitis is painful so be humane to your patient and give them analgesia (pain control) with liberal use of narcotics to keep them comfortable. The days of not giving pain medicine for abdominal pain are over. Back in the day EMS was not advised to give pain medicine for abdominal pain because when the surgeons would come to examine the patient the medicine would mask the actual pain and distract the doctor from what was actually going on. This could lead to misdiagnosis or missed/delayed surgeries that were needed. For some reason this notion is still around today and I still hear new medics say it. Nowadays surgeons’ use extremely advanced diagnostic equipment to confirm suspicions. The goal is to reduce pain and make them comfortable, not to completely eliminate it. The definitive treatment will make it go away completely.

~Once in the hospital and once confirmed by a surgeon or whomever needs to sign off on what the you already told the patient 3 hours ago the patient will undergo an emergency appendectomy. This is a routine surgery now and the patient will usually be up and back to normal in a few days.

~You’re day is now complete because you have done what you should do everyday, learned something.

~An education is expensive but knowledge is free, please feel free to distribute this to whoever you like.

~The person that knows HOW will always have a job, the person that knows WHY will always be their boss.

~Remember to always act in your patient’s best interest, always use sound clinical judgment and always follow your protocols.

~Brian Talty, btalty@raaems.org, 804-874-8724

~Sources:
1. http://www.innerbody.com/image/dige03.html#anatomy-term-bottom
2. http://en.wikipedia.org/wiki/Vermiform_appendix
3. http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis

*This is supplemental educational material that is researched and distributed by Brian Talty. I attempt to ensure accuracy but there may be some instances of incorrect facts or material or grammatical errors that mislead the reader. These are written from experience, EMS books in my library and research done on the internet. These are meant to bring out things that you have forgotten in the back of your brain and to encourage critical thinking. The base of the subject is given here but the core must be researched on your own and application is pursuant to your agency protocol. These in no way replace your protocols and should never jeopardize patient care. Please remember that I try to ensure 100% accuracy but I am human and mistakes may be sent out. If there is something that does not look right, question it or research it on your own to eliminate confusion. I may be reached at 804-874-8724 or by email, btalty@raaems.org. *

Wednesday, December 26, 2012

Infant cardiac arrest.


At 3am on a non-busy, Sun night we are all sitting around the ED just BS-ing & not doing anything productive, when the local fire dept rolls in through the door performing compressions & bagging a 4mo pt.  So here we go from 0-60 in a blink of an eye.... this was not my show to run, but I made some substantial contributions with this pt, and made the following observations... worthwhile mentioning.  Here is the deal, this happened at a busy, inner city, teaching hospital... so if the following mistakes can happen here, this can happen anywhere.

As we worked the code, this is what I have observed... and corrected to the best of my ability:

1)  EMS critique - first off, I understand the stress that comes with working a peds arrest in the field... been there, done that... on more than one occasion sadly.  However, there if no excuse if you are an ALS unit to at least NOT do the following:  vascular access.  The crew did a good job of performing continuous compressions & bagging (def a better job than the ED)... however, the call was run completely BLS.   The child had a long-standing history of congenital issues, and was found down for a possibly extensive period... all in all this pt sadly should have been a DOA, but was rightfully worked (you better have a pretty damn good reason to NOT work a kid like that... however, using our common sense & our gut sense we all knew this pt was not going to make it).  Give this information, this should have been a perfect case for doing an IO... if anything for practice only... but it was not done.  We in the EMS have a tendency to scoop & run especially when it comes to running with kids... however, let's not forget, we will not always be able to do this... there may be times when we may actually have to perform life-saving procedures on critical kids... that's a fact.  Starting an IO on this pt would have made no difference in the outcome... but practice on a real pt during an actual real world, stressful scenario is worth its weight in gold when compared to practice on a mannequin.

2) The 1st attempt at an IO was done by one of the docs & it immediately blew... I did the 2nd IO, this one worked... remember when performing the tibial IO, you find the tibial tuberosity, then go directly below to the tibial plateau... place your non-dominant thumb on the plateau directly below where you would drill with the IO while holding the leg in the same hand... the thumb & the hand will stabilize the leg, allowing you to drill/screw the IO in.  Aspiration is preferable, but not necessary... and remember always flush before attaching fluid... but flush slow... flush too fast & the IO will infiltrate like it did in our case.

3) When you are administering code meds & you flush saline afterwards... try to be conscious of how much saline you are flushing... I had to stop the nurses from rapidly flushing 10cc of saline after every drug administration.... on a 4kg child, those little 10cc flushes can mean a huge fluid bolus.... @ 20cc/kg x 4kg = 80cc of fluid for a bolus only to be repeated 1 more time when hypotension is suspected... this child did not need fluids.  2-3cc of fluid is more than sufficient to flush a code med through a saline lock or one of the closest IO ports.  Do NOT overdo it!!! Just because 10cc works on an adult... it does NOT on a 4kg kid!

4) Review your code meds & their dosages:  epi 1:10K is 0.01mg/kg... which equates to 0.1cc... as in 1/10th of 1cc!!!  So for our pt this should have been only 0.04mg or 0.4cc of epi... the pt almost mistakenly received 10x more of epi than called for until I stopped them... and even after the nurses wanted to argue with me that I was wrong... nope... not so much... so again... please know your code meds & their dosages... if you do not, use a reference like the Broselow tape... even then, in our pt the Broselow tape was used, but they incorrectly calculated the dosages & then wanted to disagree when I told them tehy were wrong.... so when using the reference, make sure you do the math correctly :)

5) Amiodarone has no role in an asystolic cardiac arrest of any kind... especially in a pediatric pt!  I attempted to politely correct the code team, but was overruled... make sure you know your meds indications when you give them... don't just give them for shi+z & giggles b/c you "think" they need them... know why you are doing this!

6) The small ED room was wayyyyyy overcrowded for my liking... I understand this may be hard to do at a teaching facility, but please note... there is no place for 3 nursing students on top of the 4 nurses already in the same room... the 2 techs... and the 3 docs... tooooo many people!  Tooooooo many chiefs & not enough Indians as well.  This goes the same for your EMS truck... you need two people in the back to work an adult code (if you have an automated compression device) or 3 people tops if you have no automated compression device... 1st provider:  compressions, 2nd provider: bagging, 3rd provider: the medic to run the meds & the code.  Anything more than that is too much, too crowded.  There is always time & a place to teach... but when the pt to student/provider ratio is 1:12... that's too much.

In summary, this code was run less than perfectly, partly due to the chaotic nature of the infant arrest... but also b/c the room was full... random orders were thrown out by too many people that were not heard and/or not followed... the personnel in charge of meds did not know what they were doing... etc... if these issues can occur at a well respected facility... this can (and/or already has more than once) happen at your place.  So learn from your mistakes... critique your calls/run/shifts/patients... and teach it to anyone who will listen... because the next patient, may actually be the one that has a chance... and the patient before it, the one that didn't make it, but the one you learned from... the one your practiced on... may have actually saved someone else's life... through you.

Saturday, December 22, 2012

ECG Case #2: "Stroke like symptoms"


30yoF flown in to the ED from scene.  Pt had a sudden onset of L sided weakness & speech slurring.  On cursory exam, the pt is extremely diaphoretic with minor lower lobe rales & + cc of profound "weakness."  We were in the room a total of maybe 5mins when while obtaining the PMH and getting a 12-lead which is below, the patient suddenly goes into a VT cardiac arrest:


What does this 12-lead make you very suspicious for?  Treatment (for this condition... not the arrest he is in... I know CPR, defib, blah blah blah... what else)?  What other differential diagnosis would you have?





Summary:
So I left out a very crucial little piece of information on purpose, because if I've had divulged it, then it would have given it away. Differential would have been hyper K vs. tox vs. AMI, otherwise. 

The pt is on dialysis and missed only his "last session"... yea okkkk.... K+ of 9.4.... like the last month of his dialysis.... so having known the fact he is on dialysis prior, we zeroed in on the hyper K which at that point we have not yet had the labs back. 

When you have the full story: dialysis pt who missed his session and has a T-wave that can poke your eye out with QRS prolongation and absent P-waves, he needs Calcium IV ASAP. 

Forget about BSI, scene safety, labs, whatever other BS you can come up with... you say hi to him or her, and then you open the crash cart or your drug box & give him calcium, don't wait for labs, don't order it & wait for the order to register with the nurses, because its gonna take WAYYYY to long to get it on board, while all the while the pt is an imminent code. If you sat on the T-wave & it poked a hole in your butt, good chance it's hyper K especially if pt on dialysis. End of story. Do it. He got calcium & his QRS shrank, T wave dropped some, and he was successfully resuscitated.

ECG Manifestations of Hypo & Hyper K+:


EMS Treatments:  
Albuterol continuous +/- insulin & glucose +/- Sodium bicarb +/- Calcium

Take away points:
1) High suspicion of HYPER K+ given the right clinical circumstance = Give Calcium!!!
2) Remember Calcium only stabilizes the myocardium, it does nothing to the actual K+ level = temporary measure to hopefully prevent the pt from coding.
3) Redistribution treatments:
    Albuterol continuous & Insulin + Glucose redistribute the total body K+ by pushing the extra cellular K+ back into the cell, thereby decreasing the serum level... but doing nothing to the TOTAL K+ = these are stabilizing measures only!
5) Do not take weakness in a renal patient lightly!  They should all warrant an ECG & a 12-lead.

Wednesday, December 19, 2012

I doubt that's what they meant.

I am a gun owner. I am a paramedic, and in 5 months a doctor. I have dedicated my life to treating & saving the life of the sick, injured, and the helpless... but I would not think twice to pull the trigger on an armed burglar in my own home to save the life of my own family... I would also not have a problem pronouncing them myself right there on my living room floor.

However, given the recent events, if you disagree with the fact that things need to drastically change, then you are living in a delusion of the 2nd Amendment.

It is so easy to begin the finger pointing game from both aisles... it was the mental health system... the psychiatrist should have known... it was the mother... the friends and the family should have noticed the warning signs... if only the kid was not bullied... it's the guns... the legislature is to blame... the media frenzy is at fault... it is the lack of religion in the schools (seriously?!). We as a human society always have to have a scapegoat irregardless of what the issue is. We will not rest until we have successfully singled out the single cause or persona and crucified it to the fullest. Yet we fail to recognize that human emotion and behavior is a complex interplay of all of these things. It is impossible to pick out one single cause responsible for a tragedy such as this. It is never that simple.

The fact is that the mental health system did fail on some level; people are rarely this unstable without somebody in the healthcare system at least noticing something... at one point or another. Friends and family are usually the first to recognize the warning signs, but either blow it off as "he's always like that" or are ignorant to the true potential of their unstable family member until it is too late. Then there is the overwhelming media frenzy surrounding each event... yet in their defense, it is impossible to not cover something as horrific as this... how could they not cover this? We need to know this... how can we deny the fact that each & every one of us was glued to the television looking for updates and answers to this heart breaking event? But yet, restraint is not exercised... we throw lights, dozens of cameras & screaming reporters directly into the faces of teary eyed kids & bystanders minutes after the horrific event... we exploit the victims for the story. Sickening. We broadcast the name of the perpetrators for everyone to see... we expose their entire lives... "Who was he?" ... "he was a shy kid," "he was very intelligent,"... we post the murderer's photos... effectively locking their notoriety for all eternity to see... giving them EXACTLY the fame they so desired & that they never got in their former life........ and thereby providing the motivation & aspiration for that next unstable human being to take the extra step towards their own infamy!

These are all aspects of a complicated puzzle that will never be solved, no matter how much time, effort & blame we put into this. But several burning questions remain in my mind... why do we make it so easy for them to carry out the carnage? When our Constitution was written & the Founding Fathers put in our 2nd Amendment... did they ever foresee the America that we live in now? I doubt it. Did they ever think outside the box that one day there may be automated "muskets" that could hold 30+ "musket balls" & could be unloaded on dozens of human beings in a matter of seconds? I doubt it. When they wrote our 2nd Amendment, did they think that the "muskets" and rifles for which they wrote the protection for all Americans would be translated into protection for handguns, AR15s, AK47s, Uzzis, and practically into anything that shoots a projectile out of a barrel? I doubt it. When they all convened round table & discussed securing their right to weapons so that they could ensure they would be able to protect themselves (as there was no formalized & effective police force like we have today)... and solidifying their ability to hunt (as hunting was a significant source of food)... do you think that they would ever expect that by writing this Amendment they were giving us Americans 250 years into the future a "carte blanche" to own whatever the f@#$ weapon we wanted? I doubt it.

Why is it that I need to have a background check done to work as a paramedic... as a doctor... that I need a license to drive a car... that I fill out more paperwork adopting a mut from the SPCA... but yet... if I want an assault rifle, I just need to bring me, myself, and I to a gun show? How is it that in the "greatest country on earth," I have to have a licence and a background check for anything I do, yet I can obtain an AK47 with about the same ease & lack of documentation as if I was in Somalia. How does that make any sense? Why is it ironic to me that I have responded as a paramedic on more than one case to a shooting in my own town where an assault rifle was used... where the f@#$ am I living? How is it that I am comforting 6 screaming children & 4 adults from a house that sustained >100 rounds from an AK47... how nobody got hurt baffles me to this day...

"But me carrying my own gun gives me protection if someone armed attacks me!"... tell that to at least three (that I can remember off the top of my head calls to which I personally responded) grieving families of victims that tried to pull their own gun... only to have the attacker be a split second quicker.... one murderer that was caught stated that he was just defending himself after the victim pulled his own gun... sigh... what a f@#$ed up paradox egh?

How is it that I have had cop friends mention more than once how even they feel outgunned sometimes? Seriously?! Where the f@#$ am I living? An industrialized 1st world country or a 3rd world?

How is it that multiple national tragedies are occurring back to back... yet all we are shoved down our throats is a blanket "it's my 2nd Amendment." I am fairly certain that that's not what our Founding Fathers meant when they wrote our 2nd Amendment for the protection of their right to bear arms in a fairly lawless country dependent on hunting for their livelihood. If our Founding Fathers were to write our Constitution today... I highly doubt that the 2nd Amendment is what they would mean as it is written today.

I am a gun owner. I would not think twice to use it to save my own life or the life of my family... but I do not think it is unreasonable for me to go through a background check to obtain my gun. I have nothing to hide, if you object, then maybe you do... in which case, you should probably not own a gun in the first place.

Thursday, December 13, 2012

Like a boss.

So I was randomly going through my stuff, and I came across this practice question that I had when I was taking my physician boards certification aka USMLE (US Medical Licensing Exam)... I saved it for a reason (the ECG was go
ogled as I was too lazy to look for one of my own).

The following is a patient's ECG on a telemetry unit that suddenly went unresponsive.




Which of the following is the BEST NEXT STEP in managing this patient?
A. Amiodarone

B. Digoxin
C. Defibrillation
D. Epinephrine
E. Echocardiogram immediately
F. Lidocaine
G. Magnesium Sulfate

Please note that only 77% of soon to be physicians got this question right!!! (as in those medical students that have less than a year before they become doctors....)

Sadly more soon to be "doctors" got a question right about which antibiotic to prescribe for a sinus infection (86% right), than when to defibrillate a patient.

I am however pretty certain, that NOT a single paramedic (or most EMTs) would have missed this ECG question. So the next time you get reamed out for no good reason by one of the brand new, freshly minted docs, just think, could she/he have been one of those 23% that got that question wrong?

On that note, don't ever let anyone downplay your EMS education. Everyone has a role in the great playground of medicine. When I have a sick, I go to my PCP. When my tooth hurts, I go to the dentist. When I end up on the floor of a hospital, I want a damn good nursing & internal medicine team to work with me. When I need my appendix out, I want a damn good surgeon......... but if I ever code/get shot/MI in the field, I want an EMT & a paramedic... not a doctor..... until they bring me to the ED, then I want a doctor.

Wednesday, December 12, 2012

All egos aside.

So it is clear that my earlier two posts on the Narcan discussion have stemmed some heated exchanges. Here is the deal. There was no wrong answer here. If you wish to argue that anyone person was wrong or out of line for suggesting what they would have done, then I would strongly recommend you take your ego's somewhere else. My comfort level may not be the same as yours in regards to patient care,
 but that is because of where I am now in my career.

Likewise there are plenty of you here that comment who are EMTs, paramedics, nurses & above. So with that said, keep your comments friendly & professional. In addition, if you post something on here, and I reply to it explaining to you why your reasoning may be wrong given your explanation, I am trying to better you by teaching you something. That is all. I created this page for the sole reason of making a down to earth, no BS, educational site for EMS professionals, nurses, and whatever else you may be... and to share some stories that encompass our difficult profession. It has been my experience that many difficult topics are poorly explained in the medicine world. I have attempted to break them down into simple understandable concepts.

Furthermore, a little about me so that there is no confusion. I am just a random paramedic that decided to go to medical school. I did a decent amount of paramedic & critical care training and teaching during my career. I also did my undergraduate and graduate studies in biology, physiology & cardiology BEFORE I ever went to medical school. And now that I am almost done (5mo left before I'm a doc), I have elected to share some of my knowledge that I gained during my long career & road through medicine. I can assure you of a couple of things: I take special care to back up my comments and posts especially when it involves patient care. So if you elect to "argue" with me on topics that you think you know something about, great, but back up your comments/posts. On that note, many of my friends, colleagues and other EMS/hospital professionals are also on this site, and I can vouch for their knowledge first hand as well... so try & not make a fool of yourself by arguing for one thing or another when multiple people point out why that reasoning is wrong.

I have appreciated your comments & discussions on my Narcan post. I made the post for the sole reason of how difficult of a choice this can be when you are in the heat of the moment of a call. This choice is much easier when you are reading out of a textbook or making it from behind a desk. But unless you have been there yourself, experienced the blood/vomit/verbal abuse and the cacophony of the actual call, do not second guess anybody. I never second guess my medics, I only debrief them. I posted my own debriefing for this call for you to share, and gave my reasoning for what I did. You may have done it differently, and that is absolutely OK.

What I wanted you to take away from this is the fact that tough decisions under even tougher circumstances are impossible to be correctly second guessed by others. Remember that there will always be people just as smart as you and I, and just because your way is how you do it, it does not mean that your way is the highway. I realized that pretty early in my career. I will re-emphasize again: medicine is an art and a science... we all make mistakes along the way, but you better damn learn from them. Treatments change over the years, but they are supported by the evidence NOW, and may be refuted later. That is the reality of medicine.

All egos aside, I hope you learned something from this... interesting topic.

Please remember though you are reading a random page, from a random guy that claims to be a paramedic/doc. Many of you know me personally, many of you don't. But please remember one thing, follow your common sense, and your protocols. I write to teach & share... but I am human, I can and will make mistakes along the way. I do my best to double check what I say, but I am not infallible.

Tuesday, December 11, 2012

Narcan question that I received.

"How would he have "recoded from [you] NOT giving the narcan?" Wasn't he intubated, and didn't you have control of his airway?"

Opioid OD not only has profound respiratory depression aspect but also a marked cardiac depressive effects. Therefore by NOT administering narcan, you are NOT reversing his respiratory depression in addition to maintaining depr
essed cardiac function. Given the fact that he may (or may not) have just came out of a cardiac arrest, the importance of enhancing his cardiac function & reversing the immediate cause of his potential cardiac arrest is paramount. Hence, narcan, which addresses both, the resp AND cardiac depression.

As I've explained earlier, the patient may NOT have been a code (but damn sure looked like it when I first got there), hence the chances of him re-coding are significant b/c of the cardiorespiratory depressive effects of his narcotic OD. I may have truly NOT felt a pulse because he was so hemodynamically collapsed that his blood pressure may have been 50/poop, thus no carotid pulse... and PEA. The two minutes of extremely effect compressions could have gotten his blood pressure up just enough for his heart to catch back up. True I had his airway secured, but that is only one component of this very complicated equation, albeit probably the most important one.

Narcotic OD codes usually have a 3 part component:
1) respiratory arrest leading to cardiac arrest,
2) cardiac arrest precipitated by profound cardiac depression AND/OR
3) hemodynamic collapse 2/2 histamine release that is accentuated by stimulation of endogenous narcotic receptors within the body.

Administration of Narcan would counteract the first 2 causes by reversing resp depression, increasing the inotropic activity of heart (yes narcan actual has inotropic properties, I re-looked it up for you :), and releasing catecholamines all contributing to improvement of the patient's hemodynamics. Narcan however does nothing on the massive histamine release that the opioids already did (analogous to a milder version of anaphylactic shock)... that damage is already done. Hence, the further importance of improving his cardiovascular function.

So in summary, just because the patient has an "intact airway" says nothing for the rest of him which is still reaming from the effects of his AyRhone. I hope this answered your question.

~Reference: "Naloxone in cardiac arrest with suspected opioid overdoses" by Saybolt, MD, et al.

EMS Case #1. To Narcan or not Narcan.

Ran the following call, and am interested to hear your opinion. Let me know whether you would have Narcan'd this pt or not and WHY... I will then let you know what I did. Just FYI, there is absolutely no wrong answer, so don't feel stupid if you disagree with someone else, it's all good.

Dispatched for a 50ish yo witnessed cardiac arrest, CPR in progress on my arrival.
 The pt was pulseless in brady..ish PEA with agonal respirations. He received ~2min of CPR by us when we got a pulse back. Intubated, IV, no code meds as we never got around to it. Per bystanders, the pt "started crying, then collapsed into a code... we got there in <5min.

As I started doing my secondary assessment in the truck, I noticed on my neuro exam that the pt has pinpoint pupils. So to Narcan or NOT Narcan???

Note: the pt is 250+ lbs, intubated, with IV, yada yada yada... we are 12min from ED, and it is just me & a firefighter in the back.


********************




Here is what I did, and why I did it: 



********************

The one thing that I cannot convey to you in a post is the actual, visual clinical impression of the patient, which makes all the difference in our treatment decisions.

The call was in a very public place, and the scene was a bit chaotic with screaming family, kids, and bystanders. Compressions were already in progress, the pati
ent was blue, and my priority was to get the pads on him as I was initially thinking arrest of cardiac etiology. The patient had a very fat neck, and I initially could not feel a pulse... or so I think.

What really struck me as odd, was the fact how quickly we "got him back," with no therapy other than just some compressions.... yea okkkkkk... that crap never happens... just compressions for a miracle ROSC... hmmmmm... That was my first clue as this may NOT have been a cardiac arrest from the get go, however given the fact that this pt's sats initially were quite shi++y, and his fat neck & huge tongue were given us issues, I chose to put in the airway.

What also struck me as very, very odd, was how "perfect" the post arrest his vitals were, BP 113/70, pulse 78... this just doesn't happen. Once in the truck, I only took one ride along as I only needed somebody to bag, I could do the rest... more than 2 people in the back, and everyone starts getting in my way. As I started my secondary head-toe assessment, the first thing I noticed were the pin point pupils.... voila! At that moment, I was pretty certain that this was most likely never a code... but either his fat neck vs. my crappy pulse taking ability vs. hypotensive episode 2/2 hypoxia, and that the real elephant in the room was just a bit of "ehhRone" that he did.

So I now had 2 options: Narcan or Not.
1) Not - benefits: he is intubated, self sedated, not causing any trouble, all around a pleasant patient. Pitfalls: when I bring him into the ED, I'm going to look like an absolute moron for missing the OD right off the bat, and/or look like a moron for NOT giving him the narcan after recognizing that it is an OD.
2) Narcan - benefits: I actually "fix him," and he is talking & crap when I get him to the ED, this is the definitive treatment that he needs. Pitfalls: he is flipping tubed... he'll flip out when he wakes up... puke all over my damn truck... its just me, myself, and I ... and a lonely ff in the back... hmm....

What I did:
I gave him Narcan.... why ? I was feeling adventurous for one. For seconds, I felt pretty dumb for "working an arrest" when it most likely never was one (even though it damn looked & felt like it then), I also did not want to look like a moron in front of my future potential doc co-workers, this was the definitive treatment for a now highly suspected narcotic OD... and lastly, I knew that I had plenty of help if need be (the cops were following me).

So I prepped my suction, had the deflated syringe ready, and was prepared to sit him up if need be for vomit. Gave him Narcan, he promptly wakes up & goes for the tube, I deflate the cuff, and assist him with self extubation, I suction him (he never pukes thankfully), and sit him up. He looks at me, and I at him.

"So how much heroin did you do tonight buddy?" I ask.
"Just one pill man." He hoarsely replies.
One pill my a$$ I think... but ok. His second phrase was "Man I fu#$ed up tonight."
"Yup, you sure did there buddy." I reply.

In the end, a happy ending. Could I have kept him sedated the way he was? Absolutely. It would not have been wrong to do so by any means. Reversing his respiratory arrest however was also not wrong especially given the fact that I knew I was properly prepared for it. I can paint a 100 more similar scenarios when I would NOT have given him the narcan as comfortably as I did there.

So the moral of the story, given the right clinical suspicion & scenario, the comfort level, and the resources that I had around me, I felt comfortable enough to proceed with my treatment. If I was by myself in the middle of the projects on the 3rd floor still surrounded by 20+ excited bystanders, my decision would have been different.

I brought him into the ED, fully talking, answering questions, on a NRB with great vitals & sats of 100%....... on the flip side, this could have also gone horribly wrong... he could have puked, aspirated, re-coded, etc... then again... he could have "re-coded" from me NOT giving him the narcan (the treatment that he needed)... so damn if you do, and damn if you don't. This is medicine... no black & white answers, but a shlew of maybes & areas of grey... sometimes there is no absolute right answer, but answers may be more right than others... on different occasions for different patients. Welcome to EMS :)

Lastly... his first words to the ED nurse "why is my throat so sore?"... my bad on that man... my bad.

Saturday, December 1, 2012

The power that we possess.

"Why deny it, that for a moment there - why deny that for a moment there, God was you?" ~Frank Pierce from BOTD

After reading Nocturnal Medics's recent Facebook post about what "humbles you?" that stemmed from his adenosine -> 7s asystole experience, I got to thinking... and me thinking at 0130 am normally leads to a post.

As a newly mint EMT fresh out of green school, I came 
out with the knowledge & expectation that:
1) everyone gets O2 via NRB @ 15lpm or 4lpm via NC,
2) everyone that goes boom gets a backboard,
3) Paramedics were gods.

And then I hit the streets... not just any streets... but the city project streets... My fresh EMT patch was still leaking ink when I ran my first cardiac arrest. My hopes, wishes & desires were violently shattered in a matter of minutes. The city was brutal... to my patients & to my idealism... how could all these patients still die despite our best effort? I was humbled.

Upon getting my medic several years later, I was a more humble preceptee than that young EMT I vaguely remembered myself as. Having had a decent amount of BLS experience under my belt, I was able to pick up ALS...ish concepts pretty quickly... my medic preception was not too long... it also was not too short... but it was too quick. Still to this day, I was never so terrified as the day that I was released to practice as a medic on my own... that was it. It was now only me... and the fresh-faced, newly minted EMT sitting right next to me... the dynamic duo. The EMS gods screwed with me big-time on my first shift... they gave me 1 call in a 12hr shift... a damn lift-assist... something that was unheard off in our system was to run 1 call in a shift, but I did it. During my 2nd shift... as I am stuffing a burger down my throat... I get my 2nd call... a 40yoF witnessed cardiac arrest.

Poetic justice... EMS gods testing me? Nah... they are laughing their a$$es off up there. I all of a sudden felt so small... so damn inexperienced... where is my preceptor? There I was... barely 20yo... not old enough to legally drink alcohol... yet old enough to now hold the power of someone else's life directly in my hands. Somewhere on scene was a family frantically screaming at the dispatchers wondering where the effin ambulance was?! Not far... it's here... right next to the burger joint... just chilling there... calmly idling & looking at me... I swallowed the burger that I still had in my mouth... felt the color return to me... and jump back in the truck. That was humbling. It was officially me & no one else... don't get me wrong this is not a snipe at all the EMTs/FFs/First responders that came with me... not at all... but the sad reality is... when we showed up... all eyes were on me... on me the medic... this was it. I ran several BLS codes by myself before... but ALS was usually shortly behind us. There was no-one else coming. It was me.

Ironically, this is the same kind of "oh $hi+ moment" that I see many brand new, mint doctors getting when that first code roles through the door... or when they are paged to the floor for a crashing patient. I however marvel at the fact that that was my experience... 10 years ago... on a truck in a city far, far away. However, we did it... in less than optimal lighting... with screaming family... in their home... with cockroaches holding hands cheering us on... on the floor covered vomit... this patient's life was now in the hands of a juvenile not yet old enough to make a responsible decision of how much alcohol to consume... but responsible enough to remember when to restart compressions... how to tube... and which drug to give for that asystolic rhythm... people twice... even thrice my age were all around me... eyes on me.

I was recently asked by a partner of mine do I still get the "oh $hi+" moments... occasionally... but they are getting much less frequent. The more experience one acquires over their career... the better we are at tackling a new, unfamiliar issues or patients that presents to us. The "oh $hi+ moments" will humble many of us... but sadly not all of us. It is still amazing to me to see medics bring in homeless "drunks" with 14gg IVs in their hands just because "they pissed me off"... or cardiac arrests with obvious coarse V-Fib on the monitor that I can see all the way from the ambulance bay... "shock them damn it!" I want to scream... don't just look perplexed at the monitor as you are getting your patient out... the lack of you raising your finger to press the "defibrillate" button may have just cost someone their life... the lack of you controlling your emotions may have just cost someone 1wk of hospital admission for IV antibiotics...

Upon going to medical school I realized what kind of a true life/death power I had in my hands... how the 30+ meds that I carried in my box as a paramedic & the dozens of skilled procedures that I could do on a patient then could do so much harm... cellulitis from a botched IV... uncontrolled bleeding from that Aspirin I gave... damaged vocal cords from intubation attempts... I was humbled having saw the aftermath of what we do... I still do it without reservation. I do not hesitate to start an IV... or to drill them... I do not hesitate to tube... but I do take extra care... knowing all the while the power that I now truly hold in my hands.

In the words of Frank Pierce, "Why deny it, that for a moment there - why deny that for a moment there, God was you?" We in the medical field play god every day... every time we push adenosine & that asystole showed up on the monitor... we did that... every time you defibrillate a patient from V-fib to NSR or asystole... we did that... we make people's lives come back... or go away everyday. Be humbled by that. Mistakes happen... we did them... learn from them... the onus is on you if you don't. And the next time you do a procedure... or give that med just cause you "haven't done it in a while," stop and think... do they really need that... sometimes our patients are better off as is... keep them that way.