Wednesday, January 30, 2013

Walking on Water.



It's not that we necessarily walk on water, it is just that no one else is willing to try... everyone always turns & looks at the passing, screaming ambulance in wonder... where are they going? who is sick? someone dying... shot... stabbed? They look on... wishing for a moment to "walk on water" themselves... but yet something holds them back. Is it the fear? The complacency? The unknown? The blood... the guts... the decomposing flesh? Who knows... but as they stream home from their 9-5s... away from the city, they pass us, heading in.

It's not that we walk on water... we just make the water walkable... we don't sink, because we can't... if we sink, then who else will hold up the bloody, horrid, violent night? Who else will pick up the pieces of humanity & attempt to put them back together?... and as we limp home from our 5-9, they streak back in... unknowingly driving over a remnant of a bloody mess that was our ejection just hours prior... over the smear of vomit that was our drunken partier moments earlier... just past the house where we found grandma rotting for the last two weeks.

I'm not sure why I began this little chat of mine tonight, but being 6 states away & seeing a wailing ambulance pass me by, and watching the airport crowd turn & follow it in awe... just made me think, that I feel more at home in that little shiny, screaming, racing box, than I do anywhere else.

Be safe guys!

Saturday, January 26, 2013

The Elephant in the Room.

Many of us have struggled with weight control... some successfully... many not... and others continue to to this day... this is not a cheap shot at anyone honestly trying so if you are offended at me for pointing out the white elephant in the room, then do not read this post.

Had a middle aged pt not too long ago that got mad at me when I pointed out the Elephant in the room out when they came in with chronic b/l knee pain...

When I attempted to council them non-judgmentally & with compassion on healthy eating habits (like good doctors are supposed to do), they angrily replied at me:

"But I only eat one meal a day!"... ok... but you REFUSE to stop drinking TWELVE 250 calorie sodas per day!!! You have made that very clear to me that you will NOT be giving up your sodas... well ok... let's do the math:

12 sodas x 250 calories = 3000 calories/day that you consume in PURE SUGAR... DEAD calories!

Just FYI, a POUND of fat is equivalent to 3500 calories... soooooooooo technically speaking you take in ALMOST one pound of fat through soda per day.......... let's finish out this math.........

3000 calories per day X 365 days ~~ 1 MILLION extra calories per year.....

OR

312 pounds of weight gain per year... that is a fact... I did not make this up... the math speaks for itself.

Obviously your body has ways of compensating for this... such as slower metabolism (making it hard to lose further weight in the first place)... diabetes... aka pissing pure sugar every time you tinkle... etc.... and still they get mad at me when I try to council you on healthy habits...

"But how did I get diabetes???" They asked me with marked surprise... 1 million calories per year in Soda sugar that you refuse to give up... thats how... and again they get mad at me because I am advising them to start therapy for their high blood sugar.

The moral of this story is that we frequently forget how much we actually take in through the course of the day, especially in EMS. This pt was truly oblivious to her calorie intake... they were mad at the world, at their body for failing them in losing weight... but yet it was them all along. I've been guilty of this myself... a quick stop here, in between meals... a quick stop there, because I may not get to eat again... and when I do, I shove in as much food as possible, as this may be my only meal... a Red Bull here... a Monster there... 4 sodas through out the shift... lacing my Starbucks with enough fatty creamers to make up a whole cow... etc... been there, done that.

EMS & medicine is stressful enough for all of us, but REASONABLE healthy eating habits & lifestyle are within our control. If you are struggling with weight gain, keep a two week diary of everything that you eat/drink... EVERYTHING that goes in your mouth... you will be amazed at exactly how many calories are put into our bodies on a daily basis. A quick Google search will give you an exact calorie count for ANY food... Let's just put it this way... I was quite mind blown by how much I actually "ate" when I kept a log for two weeks... I was taking in enough empty crap calories to fill in almost 2 full meals... courtesy of my EMS lifestyle.

One of my endocrinology doctor lectures once said, "you can't make fat out of air... it has to come from somewhere." We truly are oblivious to what we put in to ourselves over the course of the day... especially given the demands of EMS and medicine... until WE ourselves take control of the Elephant in the room... the white one... the one that has been here the entire time... nothing will ever change.

This patient left our office that day with a better appreciation of her own habits... a MILLION calories per year sounded very scary to them... but it is a fact... now whether they decide to do anything about it... well that's up to them... up to you... and up to me.

Wednesday, January 23, 2013

Laws of the House of God!

1) GOMERS DON’T DIE.
2) GOMERS GO TO GROUND (referring to patient's, usually the elderly, tendency to fall or fall out of bed)
3) AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4) THE PATIENT IS THE ONE WITH THE DISEASE.
5) PLACEMENT COMES FIRST.
6) THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
7) AGE + BUN = LASIX DOSE.
8) THEY CAN ALWAYS HURT YOU MORE.
9) THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10) IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
11) SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12) IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13) THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

Amen.

Pain.... it's not going anywhere.

Here is a good example of why people continue having pain after having hardware put into their bones. When you have this much metal stuck in your bones... it is not unusual for you to still have some sort of pain once in a while... the picture speaks for itself. Albeit this pain may be significantly less than whatever issue you had this put in for in the first place...



Medicine rarely offers a "cure" without some side effects and/or occasional pain... it is what it is. Our bodies are not designed to have random crap stuck in them permanently, so do not be surprised if you still continue experiencing some sort of a discomfort long after your procedure... however, if the pain/discomfort is unbearable, you should probably follow up with your physician... i.e. use common sense... no one knows your body better than you... but don't come back to us saying that your pain is now a 2/10 after the operation from a 8/10... because fact of the matter is ... it may always remain a 2/10.

Medicine as in life... nothing is ever 100% perfect.

Saturday, January 19, 2013

Any personal EMS/hospital experiences with this? Trivia of the Week: Lazarus Phenomenon


Lazarus phenomenon - the return of Spontaneous Circulation AFTER cessation of resuscitative efforts (SROC). An extremely rare occurrence that is covered more in non-medical literature rather than published in actual medical literature... i.e. it has been witnessed but not necessarily written about. The pathophysiology of this phenomenon is not really known, but has been attributed to "autopositive end-expiratory pressure, hyperventilation and alkalosis, hyperkalemia, delayed action of drugs and unobserved minimal vital signs." Literature review recommends passive observation of patients for ~10min post calling the arrest... not exactly sure how many of us would OR actually have done this... I know I haven't...

but...

This occurred to me once for an asystolic patient that I just received orders to cease resuscitation, and upon hanging up with the doc, I rechecked the pulse again "just to be sure" (my mistake on that) as the pt turned out to actually have one... well damn... so when I turned the monitor back on, the pt went from asystole to perfusing VT.... long story short, she got transported, coded & uncoded with me several more times & was later re-pronounced by the same ED physician that gave me orders to confirm her in the first place.

So my question to you is, has this actually happened to you at some point in your career? Did you guys resume resuscitative efforts AFTER already calling the arrest?

Wednesday, January 16, 2013

EMS Case #3. A crappy time to be a DNR.

So here is a dilemma. This actually happened... sadly on 2 separate occasions to two different patients... one occurred ~30min after I left at a facility I was working at, and found out about it the next day... the other was ran by a good friend of mine several years prior, a practically identical situation... I disagreed 110% with the care/treatment/rationale that was done on/for this patient, and hence why this is a good post.

You are dispatched to a nursing home for a 62yo pt in active choking. On arrival you find a male at a cafeteria on the ground, apneic & pulseless... blue from the nipple line up... the pt is in full arrest. The nursing staff is performing abdominal thrusts...ish. They inform you that the pt was "just fine and eating" when he began chocking on a roll... Heimlich unsuccessful... pt collapsed, and is found as described.

Only medical hx is the pt has diabetes, HTN, and "some" mental "disability".......... oh yeah the pt is also a dDNR/DNI........

So..... do you work him? Or not? Do you Magill fish 'em out? Or not? Would you cric him if fishing failed? Or not?

Remember the pt is a DNR/DNI........... Would you work him if I told you the hospital was across the street (shared a driveway) with this facility? What about if the ED was 30+mins out?



Crappy time to be a DNR... the response.

I apologize ahead of time if this is lengthy... we in EMS tend to be a bit ADD & lose focus... but it's your choice to read this or not.

2/3rd of you wanted nothing to do with this arrest DNR means "dead is dead"... fair enough.

1/3rd of you would work this pt based on the circumstances of his arrest... choking, short down time, etc.

A small portion of you wanted to either BLS him until med control was contacted OR contact med control first for direction.

If you can take anything out of this post, note the following points... whether you agree with them or not is irrelevant... you at least need to consider them when you are out on the street...

#1) And the most important one in my opinion... a HUGE portion of you indicated that you would honor "the patient's wishes"... this is a common mistake... the DNR is not always "the patient's wishes"... a good portion of DNRs are made by the pt's power of attorney (POA)... whether it be family... friends... or legal representative of some sort if neither available. Please do NOT forget this fact... many people do NOT make any desires for NO resuscitation ahead of time... prior to some sort of event that makes them incapacitated to make a decision for themselves. We see this often in the hospital setting when a catastrophic event causes a pt to be on the verge of "getting the plug pulled" and it is up to the family to make the tough decision to do so...

Some families prefer to say goodbye... others wish they were never put in the situation in the first place.

This in no shape or form negates the legality of the DNR... it is what it is... however, please do NOT misinterpret it as a "patient's wish"... DNR wishes are made by a good portion of patients either directly themselves or to their family.... however another good portion of pts never express any desire either way... and this tough decision to place or NOT to place a pt on a DNR is left up to the caregivers... who may not always have the best of intentions.

Case in point. Our above pt. The pt had a hx of some "mild" mental handicap... making him unable to make his own decisions. The DNR was placed for him by some distant family member in a different state... those particular family members have not visited our said pts in years... but the DNR was valid... was in date... but was what "family" if you can call it as such wanted... not necessarily what the pt actually wanted... either way we will never know.

However, if you can take ANYTHING out of this post... take this... just because the pt has a DNR does not necessarily mean this is the pt's wishes... I know legal document, blah blah, blah... but to say that that is what EVERY pt would want who has a signed DNR is invalid.

Our pt was very mobile... had many friends at the NH... was very outgoing, and even went out into town often... he had no true family or friends other than the staff and the residents of said facility..... yet the decision for his life was made by "family" that no one has ever seen... or ever heard off... keep this in mind.

#2) Half resuscitation... some of you wanted to do something along the lines of doing just BLS airway... or just trying to remove the obstruction and see what happens... please note... this can be a very slippery slope... there are only 2 options in this scenario: 1) work him, 2) honor the DNR... there is no happy medium in between.

If you wish to honor the DNR... then case closed... done deal... the pt is EOT.

If however you wish to work him, then do not "half" work him and see what happens just because he is a DNR... WORK him... throw the kitchen sink at him. If you pass the threshold of "I am going to work him"... then do so. Treat this pt no different than you would any other choking pt without a DNR. Magill him... tube him... cric him... code him... whatever you need to do... but do it right... do not half it just cause of his code status.

Moral of the story, if you are honoring the DNR, then do it. If you decided to proceed with resuscitation, the do so, utilizing all available options that are within your scope of practice.

#3) Calling medical control... this is a good option... when in doubt, seek help... fair enough. However, do note... not all systems have immediate access to medical control. I have been on hold for an attending physician for cease resuscitation orders for over 10 mins... what if you had to hold for a doc for 5... 10 mins to get an answer for what to do? All the meantime the pt is actively choking and in a code situation? What would happen if you added another 5mins of hypoxia doing only BLS to this pt only to have the med control tell you to work it? Well now we truly have a vegetable that well deserves his original DNR status.

Working this pt or NOT working this pt is an incredibly tough decision... but it is what it is... that is the path we chose... to make tough... impossible... and often conflicting decisions in a split of a second. You have to be comfortable making such a decision, and sticking with it... because med control may not always be there to help you... or even they may not know what to do... they are human just like you... so it truly is up to you.

#4) Load & go... the hospital is "just around the corner" ... "let them make the decision to work him or not." So what happens if they decide to work him???? I don't know about your SNFs, but mine are usually multi-layered with several floors... or extremely convoluted hallways that stretch for ridiculous distances... so lets calculate this out:

6min down time/your response to the NH ...
3mins to get to the pt from you getting on scene (you know the loading the cot/getting it out/waiting for the staff to open the locked doors for you... you fill in the blanks of whatever your SNF does to you)
2mins to assess the pt & "load and go" him...
3 mins to get back to the truck/load him up/get behind the driver seat & pull off... another
3mins to maneuver through the parking lot, across the street, and to the ED entrance
3mins to unload him & get him inside & onto an ED bed & for the ER doc to make up his mind to ALS him or NOT.
-------
Total hypoxic time prior to a definitive ALS intervention:
20mins --> you may have as well left him dead on scene as a DNR... If I was the ER doc & you brought me a 20min hypoxic tomato for which you have done NOTHING than dump him on my doorstep for me to make the decision... that would not make me very happy.

As whatever you get back out of him at this point is going to spend the rest of his life in the ICU in vegetative, anoxic brain injury state... he would have been better off where you found him.

So my point is... you either WORK him as ALS or you DON'T, that decision is up to you... you do not have to like it... but respect it.

Lastly, I would have worked this pt to the full extent of my training... my reasoning in addition to the above reasons:

1) DNRs are usually (key word usually, some of you pointed out that you have no med issues & have DNRs... fair enough) written for people approaching end-of-life time and/or extreme of ages and/or when facing terminal illnesses. Some of you would point out that "it is a legal document" ... it is "patient's wish" and "we need to respect it"... fair enough........ but this felt wrong..... my gut told me this was wrong...... and if I learned anything from EMS it is that my gut is never wrong.

2) I would rather err on the side of caution & TREAT a pt for an immediately REVERSIBLE condition (6min down time secondary to a dinner roll choking is about as reversible to me as it can get)...

A good lawyer can spin this in either direction... "you should have worked him sir, this pt clearly had a reversible cause of his cardiac arrest for which YOU refused to provide care that was within your scope and power... as you know sir, most DNRs are written for end-of-life, terminal illnesses... not a CHOKING" VS.
"Sir, this pt clearly was a DNR... it was valid, it was presented to you, you went against this family's wishes"

Damn if you do... damn if you don't.

Whether you agree with me or not is irrelevant. You are not wrong... and neither necessarily am I... the sad truth is the fact that we are BOTH wrong... we just each chose the lesser of the two evils... in our own opinion humble opinion.

The patient btw died... he was pronounced dead prior to any resuscitative efforts by EMS by the SNF doctor that happened to be in house at the time of the event.

***DISCLAIMER: everything I have written is for EDUCATIONAL purpose only. I do my best to research what I write to the best of my ability... but I am also human like you... and I can and will also make errors/omissions so it is on YOU to double check any and all information that you read, particularly from verified, peer reviewed sources. It is NOT a substitute for your protocols or medical direction. Lastly, be careful what you read on the internet... especially from some random guy claiming to be a paramedic doc :)

Saturday, January 12, 2013

Some thoughts... and questions.

I hate beating the same ole topic to death, but some of these questions that were brought up by one of you in regards to the Narcan & my blog, I felt necessary to address (see the Narcan discussion from Dec 10th-12th for reference).

1) "Why not ask what do your protocols call for in this situation where you are at?"

The thing is that would be a boring response on my part... protocols are for the most part near about the same across the board as they are written to mirror the ACLS & standard of care guidelines.... my blog would be extremely uninteresting if I asked them that. On that note, patients do not read books nor protocols nor guidelines, they are ALL different... and even when two patients present identically they may require drastically different treatments. There was no wrong answer necessarily in this post, but a shlew of potentially right answers with some >right than others... medicine is a shlew of greys & maybes... we make up protocols & guidelines for the 90% of patients, or at least try to... but even then not all of them fit in.

2) "I can see how the med dirct can be peeved when we don't follow off-line orders bc quite frankly thats his ass"

Completely agree. Follow your protocols, your best judgement, and your common sense... but do NOT disgard your gut feelings... if something feels wrong, it most probably is. Every agency has different protocols... some more lax than others... some more "Mother may I?", etc... my blog or whatever you wanna call it, is here to augment your knowledge... I wish to give you a couple of extra tools for your toolbox when you go out there day in & day out treating patients in some of the most austere & violent conditions... I am not here to disgard your protocols... I do not practice where you practice, so what may work for me or my place, may NOT work for yours... read what I write, agree with it or not, but at least learn from it, and apply some of the knowledge to wherever you practice.

3) "Maybe u should have paid more attent but I don't believe I recall you saying if you actually ran this call or if it was a teaching scenario"

I did run this call as stated at the top of my post... I will rarely if ever post "hypothetical" scenarios, they are boring AND never mimic real life... I will only post stuff I actually ran and/or saw. As a student, I detested the stupid implausible scenarios with the ridiculous answer choices... egh... not gonna happen on my posts.

4) "Did anyone get a d/stick bf narc admin"

I'm pretty certain I included that in one of the follow up posts, but I cannot recall completely. D stick was done & was normal. However, do note... from the pt presentation... everything fine to sudden collapse and cardiac arrest, the chance that this was HYPOglycemia precipitated would be extremely unusual. Pts do not have sudden unanticipated cardiac arrests from HYPOglycemia... can hypoglycemia be a cause of cardiac arrest? Absolutely, but the history would usually be more supportive of it. For our pt, something catastrophic like a massive AMI, huge saddle PE, narc OD, congenital heart issue, etc was more likely.... of course you need to check the BG at some point, that's a given, but was not my suspicion for the cause of this arrest.

5) "RSI drugs?" We do not carry RSI where I am at.

6) "um guys you had a ff in the back for this scenario have him sit (maybe literally) on your pt bc thats what sucs and etomid is for....just sayin why not hsve those drugs ready bf you narc him"

This is a very dangerous endeavor... we frequently underestimate how much force we are putting in to "restraining" our pt... the only times when this amount of force should be necessary is when the pt is a literal danger to you and/or to themselves & should only be used briefly until they can be soft and/or chemically restrained. Furthermore, the pt "fighting" your tube is a VERY, VERY bad thing... the amount of baro trauma to the airway that this pt can sustain is enormous... not to mention pulling the ET tube out with the cuff still inflated can irreversibly damage the vocal cords...

If the patient is fighting your tube, one of two things need have occurred:
1) they probably did NOT need the tube in the first place, hence extubation, and
2) they need to be sedated if they really need the tube. NEVER fight your patient if they have a tube in place... you are right to point out the fact that we should be ready for this with drugs, but NOT physical force. Let me reemphasize, you either sedate them OR pull the tube out, period.

Lastly, remember we all do things differently, but not necessarily wrong. Some of my best preceptors taught me the best of the tricks that I know... and many of my worst preceptors taught me probably my most important lessons... what NOT to do, and how NOT to do it... there are some things that I modified to fit my own style, but few of the tools in my toolbox I came up with on my own... this blog (or whatever you wanna call it) is just a resource... use it as such if you wish.

DISCLAIMER: everything I have written is for EDUCATIONAL purpose only. I do my best to research what I write to the best of my ability... but I am also human like you... and I can and will also make errors/omissions so it is on YOU to double check any and all information that you read, particularly from verified, peer reviewed sources. It is NOT a substitute for your protocols or medical direction. Lastly, be careful what you read on the internet... especially from some random guy claiming to be a paramedic doc :)

Monday, January 7, 2013

EMS Case #2. To Pace or Not to Pace.




Ran this call not too long ago. Dispatched on a random evening for a 54yoF with a syncopal episode with no additional info. When I got there, I found an average size female supine on the floor in her night gown. She appeared ill, but non-toxic (ill as in... she looked like she felt like crap... but non-toxic as in did not appear like she was going to die on me in the next 5min). She was extremely pale, and very diaphoretic, but A&Ox4.

Pt states that she has had "the bug" for the last couple of days with multiple nausea, vomiting, diarrhea and "sweats" episodes all day. Pt's only cc is "dizzy," lightheaded," and "weak." Per pt and the "friend" that was present on scene, the patient had a moment when she felt like she "was going to throw up again " but "I could only retch." So the pt was being assisted to the restroom during her "retching" and had a complete syncopal episode lasting ~1-2mins as witnessed by "friend." No seizure activity, no incontinence.

We arrived on the scene within ~7-8min of dispatch. On PE other than what already described above, the pt had absent radial pulses & only a very faint carotid (but still mentating appropriately... able to give us her PMH, HPI, etc).
PMH: Hep B/C, currently not on treatment, HTN
Meds: HCTZ, others non-contributory
Allergies: none

Vitals: BP 60/palp (fully supine with palpable brachial once in the truck), pulse: extremely weak ~20-30/min (carotid only palpable initially on scene), resps: 14, SpO2: unobtainable, BG & temp: normal
ECG: pronounced sinus brady w/out ectopy

So my question to you is:
Would you pace her? or Would you give her meds? Both? If so, what meds and WHY?

Again no wrong answer.

****************************************************
Explanation Below:
****************************************************

First off, thanks for all of the comments and discussions that was provided on this topic to everyone on my FB page. It is quite amazing to see our minds try and attack this case from every angle, but for the most we all reached the same conclusion:

~1/4th of you wanted to pace immediately
~1/4th of you wanted to do atropine first
~1/4th of you wanted to give fluids first before pharma/electro tx
~1/4th of you wanted to either do something else like dopamine and/or aggressively hit them with meds, fluids and/or TCP

None of these answers are by any means wrong. The fact of the matter is that I presented you a patient (that yes I actually ran) but one that YOU, the reader, did not run making it impossible for you to judge this patient clinically, visually, to assess them on your own, etc... it's very admirable of the many of you to put in your treatment plan in writing and stick with it... this becomes actually much harder when you do have a real breathing patient in front of you... and I have no doubt that many of you may have done things a bit differently if you had the actual patient in front of you and not one that you just read about... reading is not the same as actually doing it, but it serves it's own teaching point... anyways... here is what I did and WHY I did it.

As stated earlier, the patient looked quite sick, but NOT toxic... as in my puker was prepped to puker in case it needed to puker but it did not puker. As she was a lady of manageable size, my partner and I scooped her up pretty quick & loaded her into the truck... I always rapidly move any "sick" patient to the truck... to my well lit, comfortable & safe environment... plus if she went down the tube, everything I need is within an arm's reach... including the gas pedal.

Given her clinical presentation, and the history that she gave me of "the bug" I came to the following conclusions while assessing & treating her: 



***please refer to the above image when reading the below explanation***

1) Empty Container (orthostasis): vomiting + diarrhea + decreased PO intake = automatically put her in fluid deficit (she was also on HCTZ which will further deplete the tank... I should have included that from the get go in the case, but my bad) 

2) CN X: Retching/vomiting episodes are an incredible source of vagal stimulation, not only b/c of the gagging directly stimulating the vagus nerve but also the increased intrathoracic pressure during gagging further stimulates our vagus friend (Cranial Nerve X)... this is analogous to you telling the patient to "bear down" when trying to do a vagal maneuver on them during SVT --> result bradycardia.

3) Bezold-Jarisch Reflex: kind of complicated but the gist is as follows...... if the patient rapidly stands up, why do some of them pass out? and others of us don't? 

When we are supine or dependent, and then we are rapidly tilted up/stood up as in the case of our patient when she was assisted up to get to the bathroom to continue her puking episode... the blood is pooled in your dependent areas, and it takes a bit of time for it to reenter the main circulation back to your heart... but in the brief moment, your vasculature (carotid sinus baroreceptors) sense a MARKED drop in your systolic BP ... duh you stood up... and they send out an immediate signal to the heart to INCREASE the heart rate AND contractility... 

This would be a good thing, if there was fluid to pump......... but our patient is fluid depleted (dehydrated + diuretics)..... the heart is rudely & rapidly forced to squeeze whatever is left in it's ventricles NOW... it immediately responds (as it is stimulated directly by a nerve)... the pressure within the heart RAPIDLY rises (albeit momentarily)... this SUDDEN rise in pressure is sensed by the L ventricle, and the L ventricle sends an immediate response back out saying "TOO MUCH pressure!!!"..... and the response back is well then SHUT DOWN... and that is exactly what it does... the sudden, marked but brief rise in pressure, flips the heart back into protective mode from the super high pressure it itself created by IMMEDIATELY bradying down & decreasing its contractility --> this results in sudden & profound drop in BP.....on top of the already crappy BP and low fluid status that our patient had!!!! 

To summarize the Bezold-Jarisch Reflex, think of it as two siblings getting into a fight... one sibling is the vasculature, the other is the heart... if you've ever seen a brother & a sister fight, they go from best friend-->worst enemy in a blink of an eye... same for the vasculature->heart and heart->vasculature. Vasculature punches the Heart, the heart's immediate response is to punch the vasculature back, and the vasculature returns with another punch... both end up hypotensive and bradycardic... and crying in the corner mad at each other.

I'm sorry if this is a bit of a drawn out explanation, but try re-reading it at some point later if it is confusing to you now.

So I loaded her up, I gave her bilateral 18gg IVs, and while getting atropine ready, she received ~500cc of fluid... before I could give her any atropine, she markedly perked up just from the fluid... radial pulse returned to ~90, and BP went up to 108/60. I finished out one bag, and KVOd the other. Total fluid given prior to ED 1250cc... no meds, no atropine thanks to the miracle of a normal saline bolus. Now you may wonder why did I prefer atropine vs pacing? In this case, the overwhelming issue was two fold: low fluid status coupled with pronounced vagal tone secondary to the retching & the Bez-Jar Reflex... the antidote to a cholinergic dump from the vagus nerve is an anti-cholinergic Atropine :) 

For example, in pediatric patients their vagal response is not yet fully matured, and it tends to go overboard when even mildly stimulated, hence they occasionally get pre-treated with atropine prior to intubation to prevent them from vagaling down during our tube attempts. If you did not know why the protocols/PALS advise to give atropine as first line in cases of severe pediatric bradycardia lieu of epi when high vagal tone is suspected, well now you know.

If you did pace this patient, you would not have been necessarily "wrong" as the protocols do state unstable, bradycardic patients get the juice... but here is a perfect example of where thinking of "outside" the box can make a difference. The pacing would have sped up the heart, it also would have given her considerable pain & anxiety --> raising the sympathetic drive, and probably correcting the bradycardia all by itself, but not necessarily addressing the fluid problem. Now I know you would have given her some sedation & started an IV and maybe given her some fluid... yada yada... but "sedation" should only take the edge away & would not do much for her sympathetic response from the pacing... and a lot of us can get tunnel visioned when performing an advanced task such as pacing.... completely forgetting to open up that fluid... the miracle drug.

I hope you learned something from this case.... feel free to share it... print it out... re-read it with a fresh eye if it is too confusing... whatever works for you. Remember we all make mistakes... questionable judgement calls... and sometimes not necessarily the best treatments... but the onus is on us to learn from these mistakes. Making mistakes is ok, not learning from them however is inexcusable.

DISCLAIMER: everything I have written is for EDUCATIONAL purpose only. I do my best to research what I write to the best of my ability... but I am also human like you... and I can and will also make errors/omissions so it is on YOU to double check any and all information that you read, particularly from verified, peer reviewed sources. It is NOT a substitute for your protocols or medical direction. Lastly, be careful what you read on the internet... especially from some random guy claiming to be a paramedic doc :)

Heart axis tutorial.

Heart axis... had one of you ask me for help with heart axis... so here is my little tutorial... may be confusing as hell to you... my bad then, don't read... I tried to simplify it. 
I've done a fairly good job of explaining axis to students in person... but never in writing through a message... so bear with me here. I've attached a pic that you should memorize if you wish to know the heart axis. When it gets boiled down to it, they are quite simple, as long as somebody explained them to you correctly... don't worry, it took me a little while to get them myself... so look at my pic when I explain it to you:



So when you think of leads, think of them as observers or bystanders witnessing an event. Picture yourself standing in the middle of an interstate facing traffic... that is what a lead really is... you are seeing oncoming traffic coming directly at you... leads just see a rush of electrical activity flowing AT them or AWAY from them... hence a POSITIVE deflection for AT them or a NEGATIVE deflection AWAY from them... for example, take Lead I... it is arbitrarily labeled as 0 degrees & then lead AVF is +90deg & so on for the other leads (as labeled)... no rhyme or reason for this labeling, just know that it is what it is.

If someone has "normal axis (-30 -> +110 deg)" ... let's say that their axis is +60deg... then Lead I AND Lead AVF should both be POSITIVE as they would both be seeing electricity coming at them.... why is that the case??? Well in a NORMAL heart the majority of the electricity will be coming INTO the LEFT ventricle.... which what leads look at???? Lead I for the lateral part of the LEFT ventricle (or it's side in layman's terms)... and Lead AVF for the INFERIOR portion (or the bottom of the L ventricle). If you take that reasoning into play, then you should EXPECT as to what the other leads should show you... for example, take lead AVR... it is like an observer that is facing AWAY from traffic, so it would be seeing everything going AWAY from it since the other leads are seeing traffic coming at it... hence, it should be negative :) Now if you continue that reasoning, Lead II is exactly at +60deg, hence it should be the MOST positive lead. So out of ALL the leads, lead II would have the HIGHEST positive inflection... period.... that's it.

Why would lead I or lead AVF not have a higher inflection than lead II, you may ask??? Well think it about it this way... would you be scared $hi+less more if you were standing in the center lane of an interstate looking at a semi coming STRAIGHT AT YOU... or... would it be a little bit less scary if you were let's say sitting in the right median looking at a truck traveling in the far left lane... the truck is technically still coming towards you, but it is NOT coming straight at you... does that make sense??? Lead I and Lead AVF are still positive because the electricity coming into the left ventricle is still coming at them, but from an angle so it is not as intense, whereas Lead II which is at +60deg sees it coming DIRECTLY at it.....

So to apply this reasoning, if you look at the limb leads (Leads I, II, III, AVF, AVL, AVR), and then pick the MOST positive lead (so the sum of the boxes above the isolectric line minus the boxes below = positivity or negativity of the lead)...

Lets say that out of all those leads, the Lead that has the MOST positive boxes is lead AVL, well then you KNOW that your axis must lie somewhere NEAR lead AVL or near -30deg because AVL is seeing the most crap (ehem... electricity) coming at it!!! .... now the question is going to be well is it still normal axis or is it now LAD??? How do you tell???

Look at the Lead that is the perpendicular to Lead AVL... which lead is that??? Lead II :) Every single lead, has a buddy lead... a perpendicular lead... whenever one lead is super freaking positive (or negative)... there will be another lead that for the lack of a better word... a lead that just doesn't give a crap... the chill lead... the lead that don't want to do no work... it don't wanna be positive or negative... a perpendicular lead... this lead will always be ALMOST isolectric (or neither negative or positive overall OR both positive AND negative, but the +boxes cancel out the -boxes... sorry if this is confusing, it's easier for me to show in person).

So anyways... look at the PERPENDICULAR Lead... the buddy lead... the don't give a damn lead.... the "I don't wanna be positive or negative lead" aka the isolectric lead:

Lead I = buddy lead is AVF, & vice versa
Lead II = buddy lead is AVL & vice versa
Lead III = buddy lead is AVR & vice versa
All of these leads are separated by exactly 90deg, hence perpendicular (sorry, you gonna have to pull out some 10th grade geometry outta your butt for this one)

Ok... going back to my original question... is it LAD or is it normal axis???

If the buddy lead is "slightly" more Positive, then you KNOW it has to be NORMAL axis.... sayyyy whattt???? Ok... if the buddy lead, is a bit positive... just a bit... that means that it is witnessing some of the electricity coming towards it, hence the ONLY way for that to happen is if the axis is less negative than -30deg or somewhere between -15deg & -30deg... hence still in the NORMAL axis range.... (on that reasoning if the axis was between -15deg and 0deg then lead I would have been MORE positive than AVL, but AVL is more positive in this case)... so...

If the buddy lead was "slightly" more Negative, then you KNOW it has to be LAD ... because why????? It means that the buddy lead (Lead II in this case) is seeing the electricity going AWAY from it... hence the axis has to be MORE negative than -30deg... hence in the LAD range.... clear as mud? or did I confuse you even more???? This is so much easier done in person.

Now if you get this concept that I just described above....... and this may take SEVERAL re-readings... or further questions & me clarifying... egh whatever, we'll get through it, but it should make a bit more sense.... all you have to understand is the fact that the only purpose of "leads" is to LOOK AT THE ELECTRICITY = if the lead is positive, the electricity is coming TOWARDS the lead, if it is NEGATIVE, AWAY from the lead.
The lead with the MOST positive or the MOST negative means it is seeing the ELECTRICITY DIRECTLY COMING TOWARDS or AWAY!!!

There obviously is memorization with this.... I did not invent the labeling of the axis and the degrees... that jank was done before me, so it is what it is... so memorize it if you care to know axis:
Normal axis: -30deg to +110deg
Left axis deviation (LAD): -30deg to -90deg
Right axis dev (RAD): +110 to +180
Indeterminate axis: -90 to -180

When each axis may present (a guide, not a rule):

LAD: L ventricular hypertrophy (LVH), L anterior fascicular block (LAFB), inferior MI, L bundle branch block (LBBB), congenital defects, V-tach, WPW syndrome

RAD: RVH, L posterior fascicular block (LPFB), RBBB, dextrocardia, V-tach, WPW syndrome

In all honesty... the axis are COOL to know, but not super useful in clinical practice as a paramedic or nurse... if you want to shine as a medic/nurse, then sweet, learn the axis, but it will not really alter your patient management.... do you really care if the patient has a LAFB ??? in most cases not really... but damn it is pretty cool to pick up.

Hope this helped some.... if not... my bad.

Wednesday, January 2, 2013

It's our fault.


As I am wheeling in a patient through the bay doors of an urban ED, I pass a local crew coming out of the hospital with their empty stretcher.  The provider is middle aged, morbidly obese & disheveled... his partner is young, thin and wearing a crooked baseball cap of some random sports team... they both have a cigarette already out ready to be lit.  One of them is wearing jeans... the other blue pants with some resemblance to EMS pants, but not quite... one has tennis shoes on... the other a pair of aging boots.  Both of their shirts are untucked.. both are covered in fast food grease... and both have been long divorced from their washing machine.

This is what a typical EMS crew looks like.... this is what I look like to the ED department... to the family to whom I respond... and to the rest of the world that sees me day in and day out.  Because once you have seen an EMS crew looking like that... we all look like that.  Yup... sad, but that is the way it is.  My shirt is tucked in... it is clean... the only stains on my uniform are the blood/vomit crap that my pt managed to fling at me today.  Yet... when I roll in and turn over my patient to the ED nurses & docs... guess what... that image of the previous EMS crew is seared in their minds... the damage is already done.  It is irrelevant as to how professional I look... how much I have done for this patient... and how much I may or may not know.  Period.

When I roll up on scene in the middle of the night, and the first responder EMS/fire crew rolls up behind me with their pants half way pulled up... uniform shirts not even on... the radio mic clipped to their ripped undershirt... my confidence in that crew is next to zero.  You can't even tuck your damn shirt in... how do you expect me to trust you with bagging?

It is ironic... but having lived & breathed the dark side of EMS for the majority of my adult life... I now get to experience the other end of the equation.  I get to sit in the seat where the turnover is now given over to me.  And I promise you... when you roll in through the door... looking like absolute hell... if I confuse you with the local urban explorer that you have on your stretcher... if your a$$ is selling more crack than the city ghetto... if your patient from the pits of the projects looks cleaner, more put together than you... I am going to have a very hard time trusting anything that comes out of your mouth.  You want me to sign for your IV??? I'm not even sure if you put the blanket on this patient right.......



And I have LIVED and BREATHED EMS for the majority of my life... I know how tough and sucky and sleep deprived and food famished you are.... been there, done that... and yet that is how I view you!!!  Can you imagine how the rest of the world views you?  Or views me when I roll in wearing my squad uniform.... and not my clean white doctor coat.  The other docs... nurses... hospital staff... family... still call us ambulance drivers... they think we are all just a bunch of trauma junkees that scoop... run... and do a bunch of procedures we should have no business doing.  Why is it that as a profession we receive so little recognition as compared to our fire & police comrades?

Now many of you may disagree with me as that is "not how my agency works"... good I am glad... that's how it should be... or "I don't know where you ride... but we don't have crews like that"... well that would be a pretty big fat lie that you are telling to yourself.  I have seen up close & personal over a dozen high paced inner city (and probably twice as many rural) agencies bringing in patients all over the East coast... and guess what... we all look like that as a majority... sadly.  Just look around...

So when the next time you complain to me... to your supervisor... to your partner... or just in general as to why our profession is undervalued... underpayed... and never mentioned... take a long hard look at yourself... and pull up your pants... tuck your shirt in... wash the french fry grease out of your uniform... shave... don't chain smoke in front of the ED entrance... cover your patient with a blanket... bring them in feet first... put the C-collar on the right way... small steps for an EMT/Paramedic... but giant leaps for the rest of us in EMS.

Tuesday, January 1, 2013

Did you forget your BLS, Mr. ALS provider?

So as a paramedic 1st, doctor 2nd, I spend a good majority of my time in the ER defending you guys to my fellow non-EMS colleagues for whatever the hell-of-a-crazy-shi+ that your black cloud brought in. The majority of the reason is because unless you did EMS prior, the rest of the world has no freaking idea as to WHAT the hell or HOW or WHY the hell we do it. It is rare for me, to call out my fellow street medics.... however.... even I could not explain this one. 

So without further ado, if you are bringing in a trauma alert into a busy Level 1 metropolitan hospital there are a couple of things you should do to NOT look like an idiot (speaking from personal experience AND from defending you in the ED):


1) Immobilize any suspected spinal injury patients... hmmm... sounds like a DUHHHH to me... but for one crew that wanted to argue the point with the trauma doctor, not so smart.
If you have an adolescent female patient that wrecks her scooter at an unknown velocity to a point where she breaks her leg, has multiple abrasions on various parts of her body... and you find her down unable to walk... then you should probably immobilize her. I have nothing to say in your defense if you bring in this patient sitting up & screaming in pain, fully clothed, and without BLS thingeeess like backboarding or collaring done on her.... wtf guys?! seriously wtf?! Quite frankly I don't give two shi+z that you gave her an 18gg in her arm & 2mg of morphine with medical direction, whooopteeee freakin' dooooo, you should have done that... maybe even 10mg of morphine would have been better by the way the leg looked! However, when I have to fully immobilize her MYSELF, and then CT scan her entire spine..... hmmmm............. I hope whatever crew did this reads this post, and whatever crew thought about doing this tonight will not. This brings me to point #2.

2) If the patient buys themselves a 60mph ride to the Level 1 Trauma & a 1 bed with lots of gowned up people, please bring them in FULLY EXPOSED! That way you don't look like an idiot for missing that giant cut that did not bleed through their jeans... or that "missing" bullet hole. Cover them up with a sheet or a blanket or their cut up clothes when you bring them in so everybody doesn't see their goods, but for flips sake, cut that crap off before you roll into the trauma bay.

3) When you eff up, admit it, don't argue with an attending or a trauma doc... because more likely than not, they are golf buddies with your OMD, and I can bet that you will be the very first topic of discussion over a Miller light & some very long 18 holes.

So, done with my rant, however I deserve this rant as I defend you guys 99.9% of the time, and must point out the stupid crap other crews make so that YOU do NOT make it... we all get lazy during our shift... been there, done that, but negligent?... I may let you slide for not starting an IV on an abdominal pain that turns out to be appendicitis... eh whatever, you got them here, all good.... but I have little ground to stand on defending your lazy a$s for not immobilizing a patient such as this... because I know what is said about you in the ED after you leave (damn that was a badas$ crew vs. what a bunch of idiots)... this post is for you.