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:

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"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."

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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?

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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.