Sunday, July 14, 2013

Hold their hand?


Indeed. Ever been dispatched for this patient?

60yoM cc difficulty breathing at 3am, gradual onset throughout the day & worsening tonight to a point that he can't breathe. You find him sitting on the edge of the bed, with a smoldering cigarette in the ash tray next to him. He is slightly diaphoretic, tripoding, sats 85% on RA, BP 172/96, pulse 102, resps 30ish. He has hx of asthma, COPD, CHF, HTN, DMII. He takes lasix, lisinopril, HCTZ, albuterol/atrovent, & spiriva among others. On exam, he has some pedal edema, lungs sound crackli/rhonchus/wheeze.

                            

So how do you treat him?

Do you go the COPD/Asthma OR CHF route? Albuterol/Atrovent nebs, etc OR Lasix & Nitro, etc?

The reality is that this scenario can be true for BOTH COPD/Asthma AND CHF... and frequently a combination of all of these issues into one sick patient. So where do you start AND which one do you treat first? Or do you treat both?

This is one of the most confusing patients, a scenario that I've experienced myself countless of times, and a common debriefing point with my fellow medics who were not sure if they were doing the right thing on this exact patient.

If you have a tough patient that has both a history of CHF and an obstructive resp disease such as Asthma/COPD, an easy trick to determine which one to treat first is to take their hand in yours. The question I asked you yesterday is why? And how would this help you determine the difference between these two very different respiratory processes?

But before I start, please note that:
1) I am omitting a lot of the detailed pathophysiology that goes into explaining this phenomenon, so if you want to know more, then READ about it.
2) I am also certain that a couple of you smarty pants will elect to provide me with detailed examples of their patients where this did NOT work or the many reasons for why this will not work. My response to you is, I don't want to hear about it. What I am about to present is a guideline, NOT a rule. This was taught to me by physicians dozens of times smarter than me, and much more well versed in medicine than I ever hope to be.

But I digress... so here goes.

CHF exacerbations will predominantly cause a hypoxemic problem and not a hypercapnic problem (high CO2). What the heck does that mean? It means that, when your lungs fill up with fluid, you become significantly short of breath, become very hypoxemic (the partial pressure of oxygen falls to dangerous levels) and you become hypoxic (tissues are NOT receiving the necessary oxygen that is required for them to proceed). Your body's natural response is to rapidly increase the RATE of breathing as a compensation for your hypoxemia & hypoxia. Since there is NOTHING obstructing the air from exiting the small airways, the CO2 that is exchanged for O2 is able to leave, so your CO2 level stays near normal or actually DROPS (normal is about 35-45mmHg). But why would the CO2 level drop from the normal?

The following may be a bit confusing... but try & read on.
Unlike in asthma/COPD, where CO2 rises because of the obstructive nature of those diseases, the hypoxia driven tachypnea from CHF causes the CO2 to be exchanged out much quicker than it can be produced. In asthma/COPD, however, the hypercapnea precedes hypoxemia (high CO2 comes before low O2)... the nature of this disease allows O2 entry, but prevents CO2 exit.

                                   

Think about it this way... in CHF, it is an EXIT only... the exchanged CO2 is allowed to exit, but O2 is denied entry.

While in Asthma/COPD, it is an ENTRANCE only... the O2 can enter, but CO2 is not allowed to leave.

So the key here is the CO2 production. An interesting property of CO2 is it's vasodilatory property. How many of you were taught at one point or another to bag your head injury patients to a CO2 level of around 30-35mmHg? The reason behind that is to constrict the brain vasculature permissively in order to decrease the swelling of the brain & potentially delay herniation.

The concept can be translated to the rest of body. When your CO2 rises to dangerous levels as in Asthma/COPD exacerbations, the high CO2 causes peripheral vasoDILATION. The hands are the most sensitive to the high CO2, and they turn WARM or even HOT. The face is also very vascular and can appear unusually red & warm.

However, when the CO2 falls slightly as in the marked tachypnea associated with CHF (remember the tachypnea is driven by HYPOXIA from hypoxemia, washing out the CO2), the hands will be cold because of the vasoconstriction from low CO2 (same concept as with the head injury from earlier example).

                                 

Now, remember all of this goes OUT the window, if the patient is circling the drain/impending code. Asthmatics/COPD patients can have remarkably good sats... 88% may on the surface "not look so bad" per se... but their CO2 may be 90mmHg or even 100+mmHg, and they are on the verge of respiratory arrest... at which point the O2 will finally precipitously drop into critical hypoxia level as they stop breathing. Whereas CHFers will have very LOW sats from the beginning, that can initially be rapidly corrected per se with just high flow O2... but will also rapidly decompensate unless immediately treated, at which point their CO2 will also rise as they tire out & code.

In summary, if the hands are WARM, treat Asthma/COPD, you are dealing with HIGH CO2... if they are COLD treat CHF, you are dealing with LOW CO2.

Hope this helped! Stay safe!

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

~EMSDoc911


Thursday, June 27, 2013

The backboard controversy.



This was NOT my call, but does bring up an interesting controversy. The following is a call that one of my avid followers has had recently... and his question was did he do the right thing?

"64yo male ran over by a tractor. On our arrival we had an alert 64 yo male laying in a right lateral recumbent position, in NAD, speaking full clear sentences, aox4, GCS 15. 

Pt said that the tractor ran over his right hip, denied pain upon palpation of his C Spine and spinal column. Negative for step off or deformity. Pt complained of right hip pain, 5/10. Negative for deformity or crepitus. Legs of equal length, negative rotation. Pelvis stable, negative crepitus.

Pt stated he did have a 5/10 discomfort in his lumbar region secondary to a fusion he had a year ago. This discomfort is not new. The pt was rolled onto a BB to lift him to the stretcher. He complained that his pain intensified on the BB. I opted to REMOVE him from the BB to avoid exacerbation of his pain and potential injury to his fusion. His pain resolved to a 0/10 in a supine pain on the softer surface of the stretcher.

The receiving physician was not happy and made it known. I defended myself and provided reason for what I did. He argued that all trauma pt should be BB and that the soft padding would cause flexion and injury. Both points he attempted to make I provided rebuttal.

Would you have placed this pt on a BB?"

Let me know what you guys think... Feel free to send me links to STUDIES showing the benefits OR harms of the backboard/immobilization use 


-------------------------------

Here is what I wrote back to the provider... with some modifications after reading your comments.

Giving the described MOI, I would have kept him on the board. Reasoning being, the risk vs benefit.

In this case, the risk of a lumbar fracture is great particularly with pain... and particularly with an old fusion which is much more prone to fracture post trauma... even though the pt states that the pain feels "old" the body has no idea... the pain fibers are the same whether it is a fracture or an old fusion, the brain will receive the same impulse... pain.

Furthermore, do NOT forget the mechanism of injury (MOI). If I was rolled by a tractor I'm sure my adrenaline would be through the roof, further dulling any real pain that may actually be there. Such injuries occur in a split second... the tractor probably rolled over him... do NOT trust the pt to fully state that it was "Just over my hip." Recall of actual MOI by a patient under the stress of incurred trauma & excruciating pain should not be deemed reliable. Remember, an orthopedic injury will be VERY painful and distracting to the patient... his concern is PAIN in his hip... YOUR concern needs to be all the other stuff that COULD have occurred in the process. If you think about the mechanics of this MOI, it is virtually impossible for a tractor wheel to roll over SOLELY over a hip.

Think about the anatomy of the pelvis (immediately attached to the hip)... pelvis is a bowl attached to the sacral spine in the back... so the pressure from the wheel on the hip will transmit that pressure to the pelvis & hence the spine... where the old fusion is... the patient does NOT necessarily know that... but we as paramedics do... risk of lumbar fracture is GREAT.

But..... is backboard right here? I'm not saying it necessarily is or is NOT... let's think of the alternatives:

1) You backboard AND pain management - not the BEST option... but the risk of paralysis in his case is greater than the 5/10 pain that could have been successfully controlled by fentanyl/morphine/etc... remember until the precedent of backboarding changes, it is still the STANDARD of care.

2) Scoop stretcher - move the pt directly onto the soft stretcher with the scoop... would have been reasonable in my opinion.

Do I think that you were detrimental to his care or that you exacerbated his injury further? No, I sure as hell don't... but the problem is, a lawyer for this pt will see this in a whole different light... they will ignore the obvious fact that a damn tractor broke his f-in back, and instead blame it on the paramedic who didn't put him on a backboard... irregardless of mounting evidence against use of boards to begin with... but lawyers will use the slimiest way, not the up to date way.

Remember, crap rolls down hill... and EMS is at the bottom of that hill. You did not necessarily do anything blatantly wrong, probably actually helped him & his pain... but sometimes doing the right thing for the pt is not doing the right thing for yourself or your career... remember you are in a profession where there is no black & white... you are swimming in a murky sea of maybes... choose the path that is the best for everyone involved, your career being a priority... I wouldn't risk mine if I had a valid alternative of pain management. It would have been the wrong thing to do to just leave him there & not give him anything for pain, but I doubt that's what you would have done.

For example, I received a phone call from a fellow EMT a couple of years back asking me for advice. Their elderly relative was transported back from the hospital to the SNF that they were residing at... upon arrival, the staff called EMS back to transport the same patient back to the ED for "hip pain." The pt subsequently turned out to have a hip fracture... so how did this patient get a hip fracture between her hospital stay, EMS transport, and then SNF stay? Who the hell knows... but the hospital blamed the EMS crew for handling the patient "too rough" when moving them over to the stretcher... see @#$% rolls downhill.

It seems to me the ER doc was out of line in chewing you out in the matter that he did, but it is what it is... this won't be your last time getting chewed and that's OK... it just means you are thinking outside the box & doing your job.

Lastly, if you choose one option, then try to STICK with it... if you've backboarded this patient, then keep him on the board and manage his pain. Putting him on the board, then taking him off puts him at much higher risk for exacerbating his injury than if he was just left alone on it. I understand that every EMS call is dynamic, and always changing... and we have to be good at adapting... but in this case, stick with one option... it is easier to defend.

Hope this helped! Stay safe!

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

~EMSDoc911

Sunday, May 26, 2013

BLAST INJURIES: ESSENTIAL FACTS


In lieu of recent events, I contemplated doing a post on this completely myself, but the more I read, the more I realized that it would be re-inventing the wheel on my part as there are EXCELLENT resources out there on this topic. Below you will find one of the best, down and dirty reviews on BLAST injuries, their treatment, monitoring, and disposition courtesy of the CDC. It is a fairly long review, so feel free to browse through it, read only parts of it, and share it away. I modified this slightly by highlighting the key points with my own comments after them.

Any EMS, public safety or medical personnel need to be aware of at least the following basics when dealing with blast patients:

1) Key Concepts:

- Bombs and explosions can cause unique patterns of injury seldom seen outside combat
- Expect HALF of all initial casualties to seek medical care over a ONE-HOUR period
- Most severely injured arrive AFTER the less injured, who bypass EMS triage and go directly to the closest hospitals
- Predominant injuries involve multiple penetrating injuries and blunt trauma
- Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with GREATER morbidity and mortality
- Primary blast injuries in survivors are predominantly seen in confined space explosions
- Repeatedly examine and assess patients exposed to a blast
- All bomb events have the potential for chemical and/or radiological contamination
- Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the RISK OF EXPOSURE to caregivers is SMALL
- Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers... this means that you need to wear it!
- For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current)

2) Blast Injuries:

- PRIMARY: Injury from over-pressurization force (blast wave) impacting the body surface resulting in:
TM rupture, pulmonary damage and air embolization, hollow viscus injury

- SECONDARY: Injury from projectiles (bomb fragments, flying debris) resulting in:
Penetrating trauma, fragmentation injuries, blunt trauma

- TERTIARY: Injuries from displacement of victim by the blast wind resulting in:
Blunt/penetrating trauma, fractures and traumatic amputations

- QUATERNARY: All other injuries from the blast:
Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness

PRIMARY BLAST INJURY:

1) Lung Injury:

-Signs usually present at time of initial evaluation, but MAY BE DELAYED up to 48 hrs
- Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso
- Varies from scattered petechiae (pin-point hemorrhages of the skin) to confluent hemorrhages
- Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast
- CXR: “butterfly” pattern
- High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube
- Fluid management similar to pulmonary contusion; ensure tissue perfusion but avoid volume overload
- Endotracheal intubation for massive hemoptysis, impending airway compromise or respiratory failure... common sense here, if you suspect airway deterioration of the pt, then tube them while you still can!
- Consider selective bronchial intubation for significant air leaks or massive hemoptysis
- Positive pressure may risk alveolar rupture or air embolism
- Prompt decompression for clinical evidence of pneumothorax or hemothorax... remember it is better to decompress if you suspect a tension PTX than NOT... if the pt turned out to have a HEMOthorax, then you will only get blood back! That is OK, put a stopcock on it, and move on, at least you now know the cause of their hemodynamic collapse!!!
- Consider prophylactic chest tube before general anesthesia or air transport... this is CRITICAL for those of you working in smaller outlying hospitals to which patients may show up for INITIAL stabilization... if you are a flight crew or an EMS transport agency picking this patient up, make sure this is done!
- Air embolism can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, claudication
- High flow O2; prone, semi-left lateral, or left lateral position
- Consider transfer for hyperbaric O2 therapy... know where your hyperbaric hospitals are, many cities only have ONE or none!

2) Abdominal Injury:

- Gas-filled structures most vulnerable (esp. colon)
- Bowel perforation, hemorrhage (small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture
- Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia
- Clinical signs can be initially subtle until acute abdomen or sepsis is advanced

3) Ear Injury:

- Tympanic membrane MOST COMMON PRIMARY BLAST INJURY!
- Signs of ear injury usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, bleeding from external canal, otorrhea)

4) Other Injury:

- Traumatic amputation of any limb is a marker for multi-system injuries... this may seem common sense, but we all too often TUNNEL VISION on these injuries due to their graphic & horrifying nature... throw a tourniquet, and move on with your primary assessment! Once you stop the external bleeding, it is the other stuff that will kill them... PTX, head injury with increased ICP, internal bleeding, perforated organs, etc... don't forget that!
- Concussions are common and easily overlooked
- Consider delayed primary closure for grossly contaminated wounds, and assess tetanus immunization status
- Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings
- Consider possibility of exposure to inhaled toxins (CO, CN, MetHgb) in both industrial and terrorist explosions
- Significant percentage of survivors will have serious eye injuries

DISPOSITION:

- No definitive guidelines for observation, admission, or discharge
- Discharge decisions will also depend upon associated injuries
- Admit 2nd and 3rd trimester pregnancies for monitoring
- Close follow-up of wounds, head injury, eye, ear, and stress-related complaints
- Patients with ear injury may have tinnitus or deafness; communications and instructions may need to be written

Please see the full resource text for further info at:
http://emergency.cdc.gov/HAN/han00346.asp

I would like to thank the CDC website and Epocrates for this detailed summary.

Stay safe!

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

~EMSDoc911

Monday, May 20, 2013

A pregnant conundrum?


20yoF ~9mo pregnant (aka due any minute) called us for labor in progress... pt is a G3P1011 (this indicates 3 pregnancies, with 1 term births, 0 preterm births, 1 induced abortion or miscarriage, and 1 living kids).

Pt indicates that she is having strong contractions every 2-3mins apart lasting ~30sec ever since her water broke ~30min prior... she delayed calling 911 or having anyone take her because she wanted to "check" with her OB/GYN as to what she should do... who told her to come in to the hospital immediately as the pt is status post 1 C-section already, and has been scheduled for another one 1wk from now.... per her doctor the pt absolutely CANNOT have a VBAC (Vaginal Birth After C-section) because of some unknown complication that occurred with her first birth putting her at higher risk for uterine rupture... and most certain maternal & fetal death.

The problem.... her doctor's hospital is 25mins away Lights & Sirens or 45mins through rush hour traffic non-emergent... vs. the closest Obstetric Hospital which is 5mins away. The pt absolutely refuses to go to any other hospital other than the one where her physician is...

For anyone that knows me, if there is any chance of a delivery... I get off the scene quicker than if this was a trauma... aka... I'm on scene 5mins or less usually... so approximately 5mins into on scene time, and despite exhaustive efforts at convincing pt (visibly uncomfortable from her contractions) that it would be the safest to take her to the closest facility, the pt gets off the stretcher starting to walk back out of my ambulance & indicates that she will REFUSE if I take her anywhere other than her hospital. My partner offers to have our supervisor meet us on scene (eta ~15min) to see if he can remedy this situation.

So my question to YOU is...
1) Do you take her to her hospital of choice, knowing that you may be risking a vaginal delivery in the truck on the way there? And/or the possibility of uterine rupture?
2) Do you wait for your supervisor to show up & settle this?
3) Do you get her family involved, and try convincing her further to go to the closest hospital?

Any other suggestions?

__________________________________________________

First off, I must say that this may have been one of the most commented on posts (on EMSDoc911 Facebook page) that I've had in a while... which is great, because my intention for posting these cases is to stimulate a flow of ideas between the many professions that are within the realm of EMS and medicine.  It is always very interesting to see the variety of approaches to the same issue at hand... because how a paramedic may handle this may not be the same as a nurse or another professional... there were even a multitude of different/contradictory responses by paramedics that are of the same certification level.

This case was NOT clear cut... EMS rarely is... so the way I approached it, you may disagree with, and that is OK.  The last thing any of us need is a medic that second guesses you or me from the comfort of his couch.  Learn, don't second guess.

But to the case...

The one thing that I will never be able to adequately describe to you is the true feel of the scene, the gut feeling while in it, and the chaos of the real world.  Even though my call may be very similar to yours, every scene is dynamic, and never exactly the same.  My patient was in pain... but not too much pain... she looked like she was going to deliver... but not right now... she needed to be taken to the hospital... but the closest one? Not yet. Did I feel comfortable risking a 25min drive in rush hour traffic?

I was.

The most important point out of this is the fact that taking her to the closest facility AGAINST her will... is kidnapping, plain and simple.  Several of you suggested doing this... this is against the law.  It is NEVER ok to drag somebody to a facility without their explicit consent (unless implied consent of course)... this would be an ambulance chaser lawyer's dream.

Air transport from the scene is RARELY (if ever) utilized when intra-city, particularly when there are more hospitals scattered in the city than the local 711s, hence risks of flight/landing itself outweigh any benefits of expedited transport by this mode.  Any time you consider AIR transport, ask yourself this, what is the benefit that this patient will be receiving?  If you are 20-30mins away by ground from the facility of choice, is it really quicker?  If not, then what would this patient be gaining by flying?

Let's take our case, if I was to activate a helicopter:
2min from my call to activation of the flight crew
3min for warming of heli & crew readying
5min flight to scene (we assume heli is close... not always)
5min for scene time: pt packaging, take-off, etc
5min flight to hospital
5min from safe landing on the roof, pt extrication out of heli, elevator to ED or L&D

Total time:  25min!  And this is on the LOW end!!!

Exact same time that it would have taken me to transport this pt emergent to the EXACT same hospital... WITHOUT the extra utilization of fire/ems units for landing site prep, shutting down traffic, dangers of flight itself... and the exponentially higher bill for the air transport... for what?  Benefit?

Some indicated that it looked like she had "a while before delivery" as her contractions were still far apart... remember, the BEST place for a delivery to take place is in the comfort of a L&D dept, and not our MRSA infested trucks.  When was the last time you honestly deconed your ENTIRE truck after EVERY patient?  Furthermore, when deliveries go bad, they go REALLY bad... there is no in between.  Err on the side of caution, particularly with higher risk deliveries, and not the complacency of her "contractions are still far apart," we have NO fetal monitoring equipment in EMS... and by the point WE realize fetal distress, it is usually too late.

Others of you wanted to involve the patient's OB/GYN physician... a wise choice at first glance, but impractical when you have limited time.  Calling AND getting a hold of a physician that will ALSO give you a time a day can be worse than getting a customer service representative from a cell phone company.  In my opinion, it is time wasted when time counts... however, a wise choice when you have the luxury to play with time.

Calling med control.  Even though you will get an ER doc much quicker on the phone, don't forget that you may be on hold for a while as well... they may be busy doing a procedure, in with a patient... all too often I have been asked to call back OR have been on hold for up to 10-15mins waiting to get an attending to pick up... again time wasted, when you don't have much to spare.  Furthermore, unless the physician you are calling has a decent professional relationship with you, trusts you, I would bet that they would be hard pressed to offer you any other advice other than TAKE HER TO THE CLOSEST HOSPITAL.  A sentiment you already knew, and your patient rejected.  By the looks of my patient, some random ER doc telling her the same thing I did, would not have cut it.

Remember, that in that moment, you are attempting to relinquish the responsibility for making the tough, "life & death" decision by calling the ED doc... but this goes both ways... it would take a LOT for me as the doctor to take on that liability from you, if I was on the receiving end.  If this is the first time that I have ever spoken to you, and you ask me whether you should/should not take this pt to the closest facility AND/OR getting me to talk to the patient... yea, I will be erring on the side of caution, I'm not there on scene with you, I don't have the full picture... and will tell you the SAFEST thing to do... which may NOT be the BEST thing to do.  Makes sense?

My patient was determined to go to her doc, and I was NOT going to stand in her way OR waste time.  For those of you that frequent the inner city populace as your patients, do know that heated scenes can explode in seconds.  This was one of those times.  Everyone was outside, everyone was yelling, everyone was putting in their two cents, and everyone wanted to get in my truck.... ummm no.  Family help has its merits, this wasn't one of those cases.

Waiting for the sup?  As you can probably already tell, that would be an incredible waste of precious time... I will let you fill in the blanks as to why I think that is a bad idea.

After unsuccessfully attempting to reason with my determined patient, I agreed to take her to her hospital 25mins away under the following conditions:

1) If there was ANY worsening (sudden bleeding, imminent delivery, significant vital sign deterioration), I would divert to a closer OB capable facility, there were going to be TWO that we were passing on the way, ~10mins apart, giving me ample buffer in case I needed to divert.
2) I would be the judge of her deterioration if any, and my decision would be final.
3) She would be signing a refusal acknowledging the fact that she disregarded my medical advice at the potential risk of harming her unborn fetus AND herself.

The patient agreed to all terms.  The transport was uneventful, and she delivered a healthy baby boy later that afternoon by her doctor.

Moral of this long, dragged out post, if you made it this far reading it... sometimes what you feel is the best for the patient, is in reality what is actually best for you, and not necessarily for your patient.  Our job is not easy... our patients are not always reasonable with what YOU want (even though sometimes it may be what is best for them)... but a compromise can usually be obtained if YOU are reasonable to their demands.  We are here to serve THEM... even though the patients sometimes may not want to serve themselves.

Her actions could.... key word COULD... could have been disastrous.  But they were HER actions, and we must respect that... to a degree.  My rule of thumb is:

The more UNSTABLE a pt is, the LESS bargaining power THEY have.

The more STABLE a pt is, the LESS bargaining power I have.

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT DO NOT DISREGARD YOUR COMMON SENSE.

Stay safe!

~EMSDoc911

Wednesday, May 15, 2013

The monitor is deceiving... no, I was just lazy.

Yup, precisely that... I was too lazy to reach over the stretcher & press the PRINT button... even though I have made it a habit to try and do so... but occasionally we get lazy, tired, frustrated, annoyed, or whatever... so we don't do what we "always" do... and we get burned... as did I one night.

55yoM found unconscious on the side of the street... highly intoxicated or so I stereotyped him given the time of day, the location, and the plethora of empty ETOH containers around him. Upon loading him up & doing the usual VOMIT protocol (Vitals, Oxygen, Monitor, IV, transport), I noticed that his heart rhythm was borderline brady & a bit irregular... those were my first and last two clues... but again, I was lazy, tired, de-caffed, or whatever... he had a good pressure, and otherwise stable, other than his inebriated status bordering on needing a tube... he was just peachy... so I did NOT print out a strip.

How many of you have ran that or a similar type of call? How many of you have ignored your better judgement because you decided to slack off a bit... or cause you woke up from that deep 3am sleep still trying to figure out how you even got to the call? If you have been doing this long enough, it has happened... if it hasn't yet, just wait.

I took the patient to the local non-specialty hospital ED that was 0.6mi away (aka 6 blocks)... vs taking the pt to a referral facility 2.5mi away. Upon arriving at the ED, giving my turnover report to the staff, and the patient being hooked up to their monitor... a 2nd degree type II block came out clear as day.........

**facepalm** this time it was on me.

My point in describing this little story is that it happened to me... I got too comfortable on my own bench seat... this happened recently... not when I was a new medic... so if it can happen to me now, it can and will happen to me again... and can happen to you as well. I let my guard down... and I got burned... the pt did fine, was fine... but I was not fine... he should have gone to a cardiac facility, and it was on me... I deserved every crooked look that the nurses gave me.

EMS... emergency medicine... public safety... will grind you till you can't go any further... but the pt's don't know that, and they don't care what faze of your sleeping cycle you were in when they called... or how much caffeine you've had or did not have... they don't care if you just broke up with your boyfriend/girlfriend/husband/wife or if your dog died or you wrecked your car... they will call you expecting you to be at your BEST from the moment you show up... no matter what is going on in your life, at that moment... they are a PRIORITY... we are there for them on their BAD day... no one cares about our day.

I will continue having patients like this that will slap me upside the head & pull me out of whatever slumber or lazy haze I am in at that moment... but I hope to minimize those instances... never let your guard down... that is when we get burned.

Stay safe.

~EMSDoc911

Tuesday, April 23, 2013

A missing lung.

This may be an obvious one, but still, what are your guesses? MOI? Alive or dead? 


This patient presented to our services for a completely unrelated complaint to his obviously demolished L lung. The patient was a self-inflicted GSW from a shotgun to the L chest over TWENTY years prior... that is correct... the following patient is alive & well 20+ yrs after attempting to shoot himself.

A couple of you picked up pretty quickly on the discrepancy between his CXR and the lack of radiographic life support apparatus such as ET tube, chest tube, etc... if this patient presented acutely, the CXR would have contained ALL of the above & more.

So the lessons out of this:
1) Always look at your patient & not just your monitoring or diagnostic equipment... if the patient is flatline on the ECG but is talking to you... it is probably not asystole. If the patient is BLUE & not breathing, but his sats appear to be 98%, you should probably still bag him.

2) The human body is a very fragile AND a very resilient thing... I have seen ricochete 22s kill a man... and you have now seen a man missing an entire lung on a CXR with over a dozen pellets still in him be alive and fine 20yrs later. This is why we WORK some trauma patients that may still have a pulse, but yet may appear unsalvageable to us... this patient is a living testament to that. The initial scene of his shooting would have probably been quite gruesome & I can only imagine being the medic responding to that... my initial thoughts would have been that this pt will not make it... but alas.

When I post medical material... whether it be an ECG, an xray, a write up or something else... it is almost always a patient or a case that I had direct interaction with and because it caught my eye for some reason. Many of you subscribe to dozens of medical sites that recycle the same medical themes over & over... as cool as an AMI may look like on a 12-lead, it does tend to look near about the same anywhere else... I will not waste your time with the obvious.

Thanks for following & feel free to share anything I post, and as always message me with feedback or any questions!

~EMSDoc911

Monday, April 22, 2013

The importance of staging.

I'm working my last street night shift for the month tonight, when one of our crews was dispatched for an unknown problem at a local residence with no additional info. Upon arrival with PD and entering the scene, an armed assailant shoots two of our police officers. Both are ok, as is our crew... the standoff has ended with a murder & suicide... however, this ambush could have been infinitely worse. Our crew was lucky that PD beat them there... otherwise today may have had a much different ending for my fellow EMS crew... or myself.

Wherever you are working... wherever you do EMS, don't be a hero... heros get shot. Please stage until you are cleared to go in by your local PD... we never know what kind of a situation is awaiting behind those closed doors.

This has been a bad week for public service ... today could have been a lot worse... close to home as one of my own.

Stay safe, the night is young... you never know what it may bring to you or I.

~EMSDoc911

Wednesday, April 10, 2013

This is for you.

This is for all of those that have said our job is not special. This is for all of you that have said we are like everyone else. This is for all of you that have told me in person & on this page that our job as EMTs/paramedics/firefighters/police is no different from anyone else.

Today is justifiably yours... the events of today have truly shown that we in public service are no more special than anyone else.

Today, a man pulled a gun on a police officer just over a mile from my house... an officer made a life & death decision, and pulled a trigger that took a gunman's life at 330pm, today... just over a mile from me... while I was playing outside with my child in this beautiful weather... an officer was fighting for his life... I heard the incessant wail of sirens... and I wondered where they were going... knowing all too well the dangers that lurked behind every wail of the siren... only to find out a short while later that the wails were for the gunman... a desperate man that tried to take an officer's life, only to see the end of his.

Today, another man... several states away from... took several Georgia firefighter/paramedics hostage... another desperate man... in a desperate situation... yet a happy ending for us.

Today, one of my local officers went home wondering how things could have played out differently if he had hesitated... if he had been too slow.

Today, a group of our friends & public service colleagues are going home with a fresh look and perspective at life... their wife's kiss, their child's hug will be extra sweeter today... and will be extra sweeter from this day on.

So this is for you... to all of you that have said we in public service are no more special than anyone else. You are right. We are not. We are the same people... the same flesh that you are... the only difference between us and you, is that we put on a uniform and head out work on this beautiful night, knowing all too well that tonight may be our last night.

Today was a good day... we went home. Tomorrow, is a different day, and who knows what it will bring.

Stay safe.

~EMSDoc911

Monday, April 8, 2013

The other half of EMS.

A good portion of my EMS audience has been from the US... but I must say that I do also have a decent overseas following. Recently I received a message from a South African EMS provider that was... well... very heartfelt... and I thought it was prudent to share.

We have all worked in the most austere of conditions... providing the best possible care that is within our abilities... and we do it well... yet, turn to any EMS page or blog and you will find the rants about how hard our profession is & how we all have to do MORE with LESS. Unless you are a system that is EXTREMELY well funded... which is few & far between given the recent budget cut days... we all do the best we can with what we got... ironically, while we complain about our conditions here in the US, there are thousands in other countries that have to do even MORE with even LESS. This is NOT a stab at the lack of funding & the hardships that we all face here, so please do NOT post any comments about how hard we have it... I know, trust me, been there, as have many others following this blog.

I have been fortunate enough to have had the ability to create this page... and in doing so, have networked with many EMS providers overseas... a feat that even 9mo ago seemed crazy even to me.

Below is a link to a movie, just under an hour in length, about an EMS agency in South Africa. The movie takes you on a real life, 3 day journey, to the heart of Johannesburg and its surrounding areas... alongside the EMS crew... it chronicles their struggles, and challenges that they face... ones that ironically only few of us have ever experienced. I have included a 1min 30sec trailer... as a teaser to the real thing.

I watched the entire movie... and have decided to profile it for a good reason... it was not only powerful, but also opened my eyes to the herculean task that it takes to bring EMS to the farthest corners of this Earth.

Just over 400 paramedics serve the entire province of South Africa (an entire county or city department for some places in the US)... and in my opinion they are some of the BEST trained providers in the world... join them for a ride, you won't be disappointed!

Full movie:
www.tellmemovie.com or also available on Netflix

Trailer:
http://www.youtube.com/watch?v=DajZsgW3yLg

A series of black and white photographs, depicting a day in the life of a paramedic:

http://www.youtube.com/watch?v=AOsGIE56g5M&fb_source=message

~EMSDoc911

Saturday, March 30, 2013

A dangerous road.


A veteran trauma nurse of 18+yrs of ED experience (40yrs as RN) messaged me today in regards to second guessing herself for not stopping after witnessing a bad wreck.  As I have a wide variety of followers on my page, not just EMS background, this may be a worthwhile read.  My response to her is below her message:

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

"Last night on my way to work, driving down a long straight highway at 70 +/_mph, I observed in my distant rear-view mirror a largish pickup truck somersault in the air and land on it's roof on top of some other vehicles. I saw smoke. I think it was the truck that was smoking in the air, I'm not sure.

My thought at the time (discounting my urgency to get to work on time) was that the fire department probably needed to deem the area safe before health rescuers went in. I thought my presence would probably be useless. Then again, I don't know what I would have found.

Should I have turned around to help? Should I have crossed the (wide, muddy) median strip to turn around? Should I have backed up along the shoulder in my lane? (many hundreds of yards distance)
I continued driving to work, but I'm sure my call to 911 was the first the dispatcher received.

I'll get more follow-up tonight. So far, I've learned there were four injuries. Since my current ER - a rural/tourist/non-trauma hospital didn't get any of them, that means they were all bad enough to go to the local trauma center, 30 miles away.

What do you think? I'm obviously second-guessing myself and I don't know if my judgment was wimpy or sound."

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

Here is the thing... take it in perspective.

Safety being first... are you willing to stop on the side of the highway & potentially become a victim yourself? Did you have reflective vest to make yourself noticed if you HAD to stop? How safe would it have been for you to cross a muddy median strip without causing an accident yourself? If the answer is no, then you did the right thing.

Helpful bystanders whether they have medical experience... such as doctors, nurses, etc or if they are just average Joes are not always helpful... FD and EMS are trained in spotting the hazards that an untrained eye may not notice. We have seen hundreds of wrecks up close & personal, and are well in-tuned as to whether that green looking leaking fluid signals imminent danger or is ok... is the slight smell of the gas normal after a wreck like this or not.

When we step out on the side of the interstate, we (usually... should) have reflective clothing... my head normally is spinning 360 non-stop... I am not only worrying about the patient, but also about the hazards (fluids, gas, unstable vehicle, terrain, inclement weather, other morons on the road, etc), the bystanders, my partner, and most importantly myself. I have seen first hand the dangers of "trying" to help because you feel the obligation to help, and the sad reality is that most of the time those "helpers" are only in my way OR they have done something that have DRASTICALLY jeopardized patient care... unknowingly, only because they were trying to help.

I have seen severely injured patients yanked out of cars by a DOCTOR because he thought the car may be catching on fire... it was the steam from the engine & the airbag. He was only trying to help... true... but was detrimental to the overall outcome. I have seen bystanders cut themselves while on scene being in my way... I have responded for bystanders being secondary patients from a secondary wreck by ogling morons that refused to slow down... the list goes on.

Furthermore, remember no one knows how one may respond when confronted by a gruesome scene of multiple trauma patients (particularly if the patients are kids)... I've seen some lose it, even though they were in the medical field... seen others have significant PTSD after trying to "help"... most of the time bystanders just bear witness to these scenes without really adding much to the actual care, other than carrying the nightmarish memory with them for life.

Everyone has a role in this... even you, and I think you did what you thought was appropriate... hindsight is always 20/20.

Would I have stopped if I had been the one that witnessed this?

Yes, I would have... but I know what to look for... I know what the hazards are, which ones to avoid... I know how to safely (as possible) clear the interstate when I try to make a U-turn in the middle of it without letting the adrenaline get the best of me... done it before, have been trained for it... I have a reflective vest... I know where to position my car in regards to the wreck... I know how to approach multiple trauma patients & how to triage them appropriately under the stressful circumstances that are bleeding, screaming family/friends/bystanders & the roar of the interstate right next to me... all without losing my cool.  I don't only know the dangers of stopping to help, but I am also painfully aware of them... I know that once I stop on the side of the road in my car, it may be my last time trying to help somebody... and I am ok with that.

However, in some instances, I would not have stopped... for example, if I had my child in the car with me... or if the interstate was bustling so badly that there would be no safe way for me to either get to other side... or if the dangers of stopping would have outweighed the benefits of "saving" someone. It is what it is... sometimes it is better to leave those dangers to the flashy ambulances & fire trucks and the men & women in them... after all, nothing does a better job of blocking 3 lanes of traffic than a ladder truck... my Ford POS would be but a speed bump to an out of control tractor trailer barreling at 70mph into the scene.

We have all seen videos & heard stories of bystanders doing heroic things... and they do, occasionally... right place, right time happens for some... but more often than not, bystanders (ironically more times than not, particularly ones with medical experience) are a hindrance to the rescue efforts... and sometimes, those bystanders are at the wrong place at the wrong time, and they pay the ultimate sacrifice themselves.

You did the right thing.  Stop second guessing yourself.

Hope this helped,

~EMSDoc911

Thursday, March 28, 2013

The Arrest Cluster... a brief CPR/code review.


Managed to walk in on a cluster of a cardiac arrest in progress... a young pt in VF & hyperkalemic, missed dialysis... two of the critical interventions that should have been done FIRST or early, were NOT done AND then done late approximately 20min into the code... miraculously after I suggest those two things, the patient got a pulse back, and was waking up in the ICU an hour later.

What were those two things that I politely suggested 20min in that I am 100% certain saved their life?

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

I am peacefully minding my own business when an overhead call goes out paging for a code blue in the ED... the two rotating residents rush over there... I stay back... why?  Well because I KNEW that it was going to be a cluster @#$%... I have refused to voluntarily attend any more codes in the hospitals that I rotated with because they just make me angry... and a lot of times I am powerless to do anything about them as my "student" role is often looked down upon.

The attending I'm rotating with knows I'm a paramedic (his son is one too, only reason I told him I was... I normally never tell anyone), so he didn't bother making me go to it.  Sadly about 15mins into the code, we get paged to report stat to the ED to assist with the code.... sigh.

So we stroll over there, and here is what we find:

1) CPR performed was done abysmally... recoil was pathetic if any.  Full recoil of the chest is IMPERATIVE for adequate circulation... so if you are PUMPING the chest at the correct rate, but do NOT allow it to recoil fully to its natural position, then you are doing it WRONG.

This phenomenon is called LEANING, and a lot of times is observed when refreshed providers first come on the compression cycle... Leaning is detrimental to the critical threshold of 15mmHG of Cerebral Perfusion Pressure (CPP) that is needed for Return of Spontaneous Circulation (ROSC) to occur.

In layman's terms, if you LEAN, then you are NOT allowing chest recoil, which prevents the blood from adequately circulating, hence you do NOT perfuse the brain ... aka you be dead.

Lastly, the amount of CPR interruptions was unacceptably high... remember, compressions should be stopped ONLY for critical procedures such as defibrillation (still questionable for intubation).  When the interruption in compressions is 5 seconds or greater the CPP drops to zero, and it takes sometimes up to 15 compressions to bring it back to minimum CPP of 15mmHG.

I recently co-authored an article on CPR interruptions that will be coming out soon enough in one of the EM journals... I will link it once it is out.

2) Defibrillation?  Why do it... sigh.  Ok guys... if the patient is in COARSE VFib... the definitive treatment is defibrillation.  Period.  I should NOT have to remind you to DEFIBRILLATE a patient in coarse VFib that has been in said rhythm for OVER 6minutes since last shock... I mean WTF?!

3)  Calcium chloride/gluconate is the FIRST med that should be given in a very hyperkalemic or SUSPECTED hyperkalemic patient.  So which patients should you suspect it in?  A dialysis patient that tells you that they "missed last dialysis" and then CODES... is a candidate for Calcium... ASAP!  Or a dialysis patient that codes period.

I walk 20min into the code.... and I have to be the FIRST person that mentions CALCIUM and DEFIBRILLATION?!

Within two minutes of calcium administration & after I noticed that they have not defibrillated this patient, I suggested politely to defibrillate them... the patient was defibrillated into a perfusing rhythm.  Was waking up in the ICU an hour later.  Was extubated the same evening, and appears to have near full neurologic function on cursory exam (pt A&O x 3, not event).

This is a life save, hands down... and ironically it was because of me... the sad, little 2-mo-out-from-being-a-doctor med student that was **facepalming** himself in the background.

The above two interventions are absolutely CRITICAL to a hyperkalemic arrest survival, period.  I am NOT smarter than any of you, or anyone else for that matter... what I mentioned above & suggested be done is STANDARD of CARE... nothing less.  Please at least meet the minimum... and strive for the maximum.

Please see my Hyperkalemia & Calcium Case Review from a while back by clicking on either the shrunk FB link below:

http://on.fb.me/YIX25I

Or go to my Blog for the case:

http://emsdoc911.blogspot.com/2012/12/ecg-case-2.html

**The attached picture is a good pictographic description of the different potassium levels & the associated ECG findings.**

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT ALSO YOUR COMMON SENSE.

~EMSDoc911

Saturday, March 16, 2013

Can NITRO cause a stroke in a HTN crisis? YES!

Watershed infarcts.


One common way of causing a stroke (about 10%) is by knocking out the watershed areas of the brain. A watershed area is an area that is supplied by two separate, distal parts of arteries... as in it lies on the borders of where the blood supply of two major arteries meet. For example, an area located between the anterior AND middle cerebral arteries OR the middle AND posterior cerebral arteries.

As these parts of the brain are only supplied by terminal blood flow, it is therefore very sensitive to marked drops in BP as during HYPOtension or with vasodilatory meds. The watershed area is the 1st one to suffer... if I may make an analogy... think of a marsh that is supplied by a creek or a river... when the river or creek water level drops, the first area that dries up is the marsh... same thing in the brain (and in several other parts of the body, most notably the gut, heart and kidneys).

Patients who are EXTREMELY hypertensive over a long period of time are particularly prone to CVAs... when they throw stroke, they are going to be even more hypertensive, and our knee jerk reaction as clinicians is to immediately attempt to control their blood pressure via the massive array of BP control meds at our disposal.

However, if the BP is dropped too fast, the brain will paradoxically infarct because the watershed areas will suffer... and patients that have lived on BPs of 190/110 for years, will suddenly see their BP at 150/80... which is HYPOTENSIVE for them... and hence they stroke.

This is the reason for why there are strict guidelines for how fast you can decrease someones blood pressure from a very hypertensive patient... below are just a couple of them:

1) Acutely lowering BP for clinical neurologic situations other than hypertensive encephalopathy, acute ischemic CVA, acute intracerebral hemorrhage, and subarachnoid bleeds is controversial & generally should be avoided.

2) In hypertensive encephalopathy, the treatment guidelines are to reduce the MAP (mean arterial pressure) by 25% over 8hours.

3) For acute ischemic stroke, WITHHOLD anti-HTN meds unless the SBP is >220 or DBP >120, unless the patient receives fibrinolysis then goal of <185/<110 should be maintained, and <180/<105 after treatment for 24hrs.

4) For acute intracerebral bleed, MAP <110 or SBP <160 WITHOUT ICP... if ICP suspected maintain MAP <130 or SBP <180... a couple of studies suggested a slightly lower pressure.

As you can see, the guidelines promote blood pressures much higher than we would typically think would need to be maintained for someone that is having a stroke or a bleed... but remember... in many cases the HTN is the body's way of FIGHTING against the obstruction... by dropping the blood pressure, you have taken away the only way it has to fight. If you look at it that way... it is not surprising why a stroke may worsen or a new one develop because of our AGGRESSIVE management.

Hope this helped! Remember, do NOT be over aggressive... if you are not sure, look it up... or ask someone that knows!

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT ALSO YOUR COMMON SENSE.

~EMSDoc911

Monday, March 11, 2013

Severely hypotensive/pre-code from anaphylaxis... still IM epi?

This was a paramedic test question that presented a patient that was severely hypotensive/pre-code from anaphylaxis... and they wanted the answer of IV EPI drip, and NOT IM EPI as I have preached in my last post... I disagree.

Let's look at it from the common sense... real world application perspective, and not the academic/textbookperspective... which sadly the two tend to wildly differ, particularly in medicine.

The writers of this paramedic question attempted to write a real world example of a patient but using a textbook answer, which sadly you cannot do...

As all of us that work the street know, it takes MUCH longer to start an IV AND do an epi drip... than to shoot an IM dart full of epi, FIRST.... then IV, drip, etc. The reasoning behind their answer is that when the pt is vasodilated enough, extremely hypotensive, pre-code, etc, then even IM epi will not be absorbed appropriately.

My rebuttal to this is two fold:

First off, SOME of it still will be absorbed (particularly if you are injecting into a large muscle mass like the thigh), albeit not the whole dose. Hence, a HIGHER dosage like 0.5mg IM would be indicated & should be given... hopefully whatever is absorbed will keep patient hemodynamically intact long enough for you to have time to get IV access AND then do the drip... whereas if you just went first for the IV and then the drip WITHOUT giving epi IM first, then that pt may be a code on you by the time you get around to giving him any epi via drip/IV... at which point this conversation is pointless, as you would be just working a code. Makes sense?

Secondly, as I alluded earlier, I can shoot a dart much faster than I can start an IV AND try and remember how to do an EPI drip. I would love for someone to realistically present a valid argument where they can say that they can start an IV, do an EPI drip in same/less time than popping an IM in the thigh. This is a REAL world application for a REAL world problem. The writers of the above question wanting EPI drip as the answer clearly have forgotten how the street life actually works.

On the flip side, if my patient already has an IV in place, and has NOT received IM epi for whatever reason... and they are unstable/pre-code/etc, then yes IV epi would be much faster in such case... obviously!

But if you are first on scene starting the care of the patient from scratch, then EPI IM is 1st line period!

If the patient is a CODE when you find them, then this conversation is mute, as you would be giving them epi via IV or IO anyways.

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT ALSO YOUR COMMON SENSE.

~Thank you for following, reading, and learning. As always feel free to share this. Be safe!

~EMSDoc911


#EMS #Paramedic #EMT

Anaphylaxis: top 10 things to remember

1) IM epi is the drug of choice AND the thigh is the site of choice! 

Must be given at onset of anapylaxis!!!

Dosage: 0.2-0.5mg (0.2-0.5ml) of 1:1,000 or 0.01mg/kg in kids with max dose of 0.3mg for kids

This may be repeated every 5mins. It has been shown that IM epi injections provide a more rapid absorption & higher plasma epi levels in both adults & kids when administered into the thigh than into the arm or via SQ route.

2) Give rapid IV fluids & always transport... don't delay transport for any reason particularly if the pt is refractory/non-responsive to initial Epi dose.

3) A combo of diphenhydramine AND ranitidine is superior to just diphenhydramine alone. So if you are an agency that carries both, then both need to be given.

4) Consider glucagon for those patients that are on Beta Blockers.

5) Food is the most common cause in outpatients, and accounts for ~30% of FATAL cases of anaphylaxis.

6) Biphasic reactions can occur in ~1-23% of patients... as in initial period of response followed by secondary anaphylaxis.

7) Symptoms (secondary anaphylaxis) may recur hours (usually within 10hrs) AFTER resolution of the initial phase.

8) Each patient is an individual!!! Some biphasic reactions may occur quicker and some longer in each patient. There are NO reliable predictors of a biphasic reaction. Case in point, if you started an on scene treatment of a patient in severe allergic reaction and/or anaphylaxis, and they get markedly better from your treatment, do NOT let them refuse... the 2nd part of this biphasic reaction will bring them down!

9) ALL patients discharged from the ED must be prescribed an auto-injectable Epi! This is crucial for patient education as they must have it with them at all times... every subsequent reaction is going to be worse!!!

10) Do NOT hesitate to reinject the pt with another dose of Epi if you show up on scene and the pt has already used their auto-injector BUT still looks unstable!

In summary, one of my immunologist professors in medical school said that he would have everyone at his office be responsible for giving epi... there were pre-filled syringes on the wall in EVERY room... he said that if the pt even sneezed wrong, they got epi... and anyone that worked in that office, whether it be a janitor, a nurse, a tech, or a secretary could give it.

The point that he was trying to make is that, the MOST effective EARLIEST intervention in impending anaphylaxis is IM epi!

**The following information was gathered from the Joint Task Force Guidelines and from "The diagnosis and management of anaphylaxis practice parameter: 2010 update," Liberman P et al. J Allergy Clin Immunol 2010 Sep;126(3):477-80.e1-42

AS ALWAYS I TRY TO ENSURE THE ACCURACY OF MY MATERIAL, BUT MISTAKES HAPPEN AS I AM HUMAN. IT IS YOUR DUTY TO DOUBLE CHECK ALL INFO, PARTICULARLY THAT FOUND ON THE INTERNET. PLEASE FOLLOW YOUR LOCAL PROTOCOLS BUT ALSO YOUR COMMON SENSE.

~EMSDoc911


#EMS #Paramedic #EMT

Saturday, March 9, 2013

Every damn night.

A tonight's question raised by Nocturnal Medics: how many times has your life been threatened on the job?

So it got me thinking... and there is no good answer, but every flipping night... every time I wear my uniform... every time I get in the front of my truck.

Every time you fail to pull to the side while I'm working the drunken fool crashed on the interstate.

Every time you call for a stubbed toe and hang up, refusing to give any additional info, forcing my dispatcher to keep this call a priority... and me hauling a$$ across town to "save" you.

Every time I go through a red light while you keep your music blasting chattering on the cellphone & ignoring my airhorn.

Every time you decide to get in my face yelling obscenities and splattering your HIV infected blood from your busted jaw into my clean face.

Every time I walk into the projects at 2am for your "emergency" and the gang of two year olds in diapers running around my ambulance pointing & screaming "Po-Po!!!" in unison... alerting them of my badge that I foolishly forgot to take off.

Every time my partner has to slam on his breaks while I'm in the back unrestrained performing an advanced procedure... because you elected to slam on your breaks as a flashy ambulance approached you.

Every snowstorm... every severe weather outbreak... every hurricane... every damn state of emergency... while you are hunkered down at home with your family, I am away from mine... praying for mine... hoping they are ok... hoping my house is still there when I get home... I'm rushing to save yours.

Each and every time you get in my face waving your gun screaming "you betta do everything for my momma"... yes your mom... the one sitting there in rigor mortis... frozen in her dead state... as if your 9mm in my face is going to bring her back?

Every time I have to show up for that abdominal "pain" that turns out to be a stabbing... and the crowd surrounds me & my partner... with cops nowhere in sight.

Every IV that I start... knowing that a clumsy slip of my hand may shower my blood stream with whatever god foresaken blood disease you may have.

Every time I knock on your door from the side... wondering if this may be the night that you blow a shotgun round through the front door because you "just had enough."

Every time I drive through your projects & you pop off a round at our ambulance... just because...? Did we not work hard enough to save your buddy shot from the night before? I'm sorry but I can't save exsanguination from a femoral artery... 45 cals tend to do that.

It is a funny question to be asked... how many times our life has been threatened? Every flipping night. Every time you & I put on our uniform... whether you're are a paramedic, EMT, a cop, a firefighter or a soldier... we all full well know that tonight may be our last... whether we accept it full heartedly or deny it... that fact remains.

Never take what you do for granted... I have listed off just a handful of the moments out of my 13yr career... more than a dozen more have come rushing into my mind as I am writing this... but you guys can fill in the rest. We are not anymore invincible than anyone else... we bleed the same... we are just as fragile... but yet we sometimes forget that we are just as vulnerable.

So please, slow your ambulance down... that stubbed toe can wait. Put your damn seat belt on... that starburst your last patient made, your head will make a similar one. Wear gloves when you do an IV... cause who knows... that glove may be the only thing that stood between you & the needle accidentally nicking you. Don't talk smack to a room full of pissed off family members... it may not end well for either one of us. Wear your traffic vest... because that idiot that was ogling the accident scene otherwise may have not seen you from his F150 as he blazed on past us.

Oftentimes our best weapon against the idiots that fill this world... the ones that we have to traverse through to get to our patient... our best weapon is our common sense & our experience.... so use it.

Be safe!

Thursday, March 7, 2013

Going to medical school motivation.

For those of you wanting to go to medical school... whether it be from scratch, or from EMS or nursing or another profession... here is some motivation for you.

I keep receiving ER physician recruiting emails now on a weekly basis... one of them stands out, partly because I get the same one multiple times a month.

ER physician needed at a small sized, economically depressed city. Sign on BONUS: $30-90K based on 1-3yr contract. Starting salary $200/hr for 10 shifts/month.

Let's do the math:
If I work 3 shifts/wk x 52wks = 156 shifts
156shifts x 12hrs/shift x $200/hr = $374,400/year

$374,400 +$30,000 Sign On bonus = $404,400 annual salary!

Now Uncle Sam is going to take 40% of that, but still that leaves me with clean cash of:
$242,640!!!

This job offering is within a 2hr drive of me... so not on the other end of the world or in the middle of nowhere.

PREP Time:
*2-4yrs of college (depending on if you already have a bachelor's degree)
*4yrs of medical school
*3-4yrs of Emergency Medicine residency

Total prep time before seeing a paycheck:
~ 9-11yrs

And another 5-8yrs before paying back ~$250K-$350K student loans... I will be in my early 40s before my loans are at ZERO, and I can start saving the $$$ I make.

Now I only have about 3yrs before I can take such a job, but the light is at the end of the tunnel.

My point in showing this to you is that this is achievable, but it takes quite a bit of effort AND dedication on your part to stick with this journey. If I did it, YOU can do it, that I promise you. So if you have a burning desire to go to medical school, I hope this is a bit of motivation to start it up. It will be a long road, but I must say I am very thankful that I started it.

Good luck & stay safe out there on the street! 

Wednesday, March 6, 2013

Coronary Ultrasound Camera.




The following is a unique screen shot of an ultrasound video that we shot looking through the LAD artery.  As you can see the artery is well opened, thanks to our stent which is in the cobblestone pattern that surrounds the interior portion of the artery.  If you look a little closer, above the stent, mostly on the upper portion, you can tell that there is some calcified plaque.

The patient came in for a non-emergent cath and was found to have a 99% occlusion of his LAD which we subsequently stented.

Interesting how we can make a camera that can look through the inside of someone's coronary artery... yet we are still stuck mucking around with the darn ECG lead wires... I think it is about time for me to invent wireless ECG leads.

Wednesday, February 27, 2013

ECG Case #4: SOB & Cough x 2wks



70ish yoM presented to our ED & to our cardiology service with the following ECG. The pt has had a "cold" x2wks with cough & SOB, he was seen by his PCP about 1wk ago for same & was given antibiotics that have "not helped much."

The pt was brought in by EMS as he walked up to them complaining of worsening SOB & the fact that he could not get a ride to the ED.

If you were the crew, would you STEMI alert your ED to activate the cath lab? Is this a STEMI? An MI but not necessarily an AMI? If not, what else could be going on?

Thoughts? 


*** Answer below ***
-----------------------------------------------------------

The following patient sustained a significant anterolateral AMI at some point in the past, most likely within the last couple of weeks. To reference my prior chart from this week, the LAD occlusion would cause this type of distribution.

The old AMI is evidenced by:
1) pronounced deep Q waves in all anterolateral leads
2) poor (virtually non-existent) R wave progression of precordial leads - what does this mean? It means that as you go down from V1-V6, the R wave should progressively get bigger while the S wave gets smaller, with the transition point being somewhere around the V2/V3 or V3/V4 mark. There is none in this ECG, further suggesting an old MI.

Now what about the marked ST elevation with T-wave inversion in anterolateral leads as well as some in inferior leads? How come this is NOT new onset MI? Well given the very deep Q-wave in the said leads would indicate dead, scarred tissue which would be unlikely to reinfarct as it is already dead. The more likely explanation, and another cause of ST elevation, is a ventricular aneurysm.



A ventricular aneurysm is one of the many sequela of an untreated MI. The scarred, dead ventricular wall can no longer contract, yet it still experiences the fluid pressures that the rest of the working ventricle deals with. This weakened area balloons out creating an aneurysm within the ventricular wall, as evidenced by the above image (not mine, ECG was).

This aneurysm rarely ruptures as the scar tissue is elastic and is able to support the stretch; the more deadly complication however is the creation of a stagnant area of blood within the aneurysm that eventually clots... the clot can grow, and then dislodge emboli into the brain or other parts of the body. The brain usually takes the hit first because of the direct, straight off-shoot of the common carotids off the aorta.

The 2nd complication of LV aneurysm are the development of arrhythmia foci that may lead to VT and/or VF. A growing of the aneurysm over time will cause progressive heart failure, and eventual death.

On the ECG the manifestation is usually in the presence of persistent ST elevation with mildly if any elevated troponins. These patients are usually monitored over time, and if growing of the aneurysm is causing significant failure, then reduction surgery may be necessary.

Our patient had just that. The "cold" and SOB symptoms had truly nothing to do with his presentation, and were a red herring in this case. His cold probably was not getting much better given the fact that he was very slowly recovering from his heart attack weeks prior. Remember, a patient with an MI may also have a cold... those things are not mutually exclusive.

We did an echo on our patient which showed marked apical wall motion abnormality with a developing aneurysm and a well defined clot within it. His ejection fraction was currently preserved at ~50% (lucky man so far). He will be anticoagulated and followed closely by our cardiology service.

Learning point from this, the 12-lead looked atrocious at first glance. But if you break it down into components you can tell that this was old stuff... we were looking at an OLD MI, and the unfortunate sequela that can go along with it. Our patient could not recall any episodes of acute onset CP, SOB, syncope or any other worrisome symptoms that could pin point as to when he had his MI... he was just more weak than normal. This is another very important learning point for us... everyone that is elderly (particularly diabetic and/or female) presenting with atypical symptoms that may be mimicking an MI deserves a 12-lead... who knows what you may catch when you least expect it.

I hope this was helpful... as always feel free to share & spread the word. Knowledge in my opinion should be free... who knows one day you may be responding to my side...