TBD: Think Before Denying

Newguy and I are inside the home of a delightful lady who was complaining of chest pain, at least according to our dispatchers.

Our intrepid local first responders are huddled around the patient, in a mad dash to save her from the throes of death.

They seem to be succeeding at preventing her imminent demise, and also are sucessful in their attempts to create a large pool of blood all over the patient’s hardwood floors.

It’s a win/win situation so far.

One of the patch-wearing heroes rattles off some vital signs, and they are all better than mine, with the exception of her blood sugar: 331. Alas, she is a diabetic.

I really enjoy when the pieces of the puzzle assemble themselves.

Our infirm female has said several times now that she needs to “tinkle,” and asks if she can go. Newguy wants to get the 12-lead first, so he asks her to wait just a minute or so. It’s normal, by the way.

“Okay then, can I have a glass of water while I wait? I’m really thirsty.”

“Nothing to eat or drink until you see the doctor” the intrepid hero reflexively replies.

Newguy is nonplussed. “Why can’t she have anything to drink?” he asks.

“I don’t know” is his reply. Clearly, he has no idea.

“Were you guys going to put saline in that IV over there?”

“Well, yeah…”

 

Why don’t we think about these things? Don’t we all recognize what is going on here? This lady is hyperglycemic, and polydipsic and polyuric. Because her blood sugar is ridiculous. Granted, I’ve seen higher, but she’s going to get a large amount of fluids in her IV on the way to the hospital, so is there really any harm in giving her a glass of ice water?

A post about a comment on a post

So I posted what I found to be a humorous exchange between a first responder and a paramedic that I witnessed not too long ago.

As he is wont to do, TOTW posted a comment on my post. Some times, I think he and my mother are the only ones who actually read my blog, and I enjoy his comments. (Mom never has much to say. She really doesn’t read, anyway.)

He says:

There’s a difference between knowing what’s going on with the monitor and what’s going on with the patient. Unfortunately, a lot of people don’t see that.

And he is right. Absolutely right.

I have always viewed the cardiac monitor as a tool to aid in my diagnosis and treatment, rather than as something that guides my treatment. There is a difference there. A slight and subtle difference, but one that I think is very important.

Really, it is the difference between a cook and a chef.

A cook follows directions, and adds a certain amount of ingredients to a dish at certain times. A chef knows how foods and ingredients interact with each other, and is not afraid to experiment and let the dish guide how he prepares it.

Now I’m getting hungry.

I used to work with this guy. He was a huge jerk. A stereotypical, 50-something Jersey Shore jerk. He used to wear his shirts with several buttons undone so he could show off his manly chest mane, and his gold chains. No, I’m not kidding.

But he was a great clinician, and took very good care of patients.

One day, I asked him if he wanted me to put the monitor on a particularly sick patient.

No, I already know what it is going to say. No need for the monitor just yet.”

That confused me. It confused me a lot. I was a fairly young EMT at the time, and I thought things had to be done a certain way, and here was this guy who was doing it his own way. But what he said later when we talked about it made sense:

“A good assessment will tell you what the monitor will say. A person complaining of chest pain, presenting with Levine’s sign, with pale, diaphoretic skin and weak pulses is going to have a sinus rhythm, perhaps with a first-degree block. Then the 12-lead will show ST elevation. And if it doesn’t, I will be surprised. Granny, with her 47 bottles of medications and nausea and vomiting with an irregular heart beat will be in atrial fibrillation.”

Granted, there are no absolutes in EMS, and people won’t always present the same way. But there is a big difference in reading the monitor and knowing what the monitor will say.

Well, there is one absolute in EMS: nobody will be critically injured in an MVC in which the cars have pulled into a McDonald’s parking lot.

Traffic by Tom Vanderbilt

Burned-Out Medic wrote a post a little over three years ago about a book he suggested everyone read. Traffic:Why We Drive the Way We Do (and What It Says About Us).

I always enjoy a good read, and usually have two books in rotation.

Lately I’ve been a fan of Malcolm Gladwell and Gavin de Becker. That is also where I get ideas for the next book to read: from authors citing books in their writings.

Somehow, Traffic: came up in a conversation, and I remembered the post from Burned-Out Medic.

So I bought the book.

And I can’t put it down.

Everyone should read this book.

 

Those are all Amazon links, but I’m not an affiliate or anything like that. I don’t get paid if you buy those books through my link. But you should buy them anyway.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”

“Yes.”

I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”

A conversation about plethysmography

“What’s that?” asks a student on another ambulance, pointing to my cardiac monitor.

“It is the plethysmograph” I replied, most likely butchering the pronunciation.

“What’s it for?”

—–

After dropping my patient off, I made my way back to the EMS room where I found the student. It turned out he is a paramedic student, just finishing up his intern rides. He has a few weeks to go before he takes his exam. He has been an EMT for roughly 4 years, and by all accounts, is a good student, and a fast learner.

The fact that he asked a paramedic whom he didn’t know bodes well for him. He is engaged, and wants to learn.

We spent the next 15 minutes or so discussing the plethysmograph and its usefulness in assessing patients. What struck me most about our conversation was the fact that he had no idea whatsoever that there was even such a thing, much less that it could be used to assess patients.

We talked about how vasoconstriction can cause an increase in amplitude, and what could cause vasoconstriction. We talked about how vasodilation would cause a decrease in amplitude, and the causes of vasodilation.

We discussed how waveforms would change in a hypertensive patient with chest pain to whom we were administering nitroglycerin. The mechanism of nitro’s action, in decreasing systemic vascular resistance through causing vasodilation. It seemed to make sense how waveforms would change, and how that was directly related to afterload.

My patient happened to be septic, and I could show him how plethysmography could help confirm that diagnosis. My patient was an infirm older woman who had a mildly altered mental status, hypotension, and some mild tachycardia. The fact that she had a chronic Foley catheter with cloudy urine in the bag made the diagnosis of a UTI fairly easy, but the plethysmograph showed a very deep, prominent dicrotic notch.

He asked, appropriately, how the waveform would help me in my assessment, and I explained that the deep dicrotic notch showed me a low SVR, and there was no need to assess orthostatic vital signs.

He was receptive, inquisitive, and it was a refreshing conversation.

—–

I’m just a regular paramedic, and nothing special. I only learned about this stuff because I asked and because I wanted to learn. I enjoy showing students, and other EMS personnel, things that I have learned along the way, and I enjoy learning from others. Our education doesn’t stop when we get that paramedic patch, it begins.

What is disheartening is the fact that a paramedic student, only weeks away from testing to become a paramedic, had never heard of a plethysmograph, a dicrotic notch, and did not understand the relationship between waveforms and vascular resistance.

We have a very, very long way to go in the education of our paramedic students.

 

Phone calls

FEM/22YO/BLEEDING FROM MOUTH” says the MDT.

We arrive on scene to find a pleasant looking female, approximately the age stated on our mobile dispatch terminal thingie. We don’t notice any obvious trauma or distress, but we haven’t made it to the apartment door yet.

Slimm takes point.

Good morning, ma’am. What seems to be the problem today?” he asks.

I’ve got this thing on my mouth and it burns.”

And then we see it.

A cold sore.

I bet that burns and hurts. How long have you had it there?”

I woke up with it this morning.” (and decided that a call to 911 was in order, apparently…)

Have you tried putting anything on it?” Slimm asks, knowing full well the answer will be a resounding ‘duh, of course not.’

I don’t know what it is! Shouldn’t I see a doctor or something?!”

Well, ma’am,” Slimm replies, being the consumate professional that he is “it appears to be a cold sore. There are lots of treatment options at the pharmacy.”

What is a ‘cold sore’?”

It is a type of herpes infection. They are pretty common, actually. They usually go away in a few days, but they can come back at any time really.”

Sometime in the past few days, Slimm has become a dermatologist.

I HAVE HERPES?! ON MY FACE!?”

It really isn’t that big of a deal. Most people get them…”

OhmygodIhaveherpesonmyface!”

We are sliding quickly down the slope towards an anxiety attack.

Am I, like, contagious?

Well, yes ma’am. If you share utensils, or drinking glasses or straws, or kiss, or have oral sex, you can pass the virus to the other person.”

A gasp audible from ten yards escapes her mouth.

I need to make some phone calls…”

We make our way back to our ambulance and climb in. Slimm turns to me. “I wonder who she is going to call?”

Yes, Community Medics

I’ve been low on blogging inspiration, so a big thanks to Mr. Morse for his post on Community Paramedicine. He seems not to care for it much, and lists 10 of his top reasons why.

My reply to his ten reasons:

  1. I may not know much about insulin pumps and how best to maintain proper insulin levels, but I want to learn. I don’t care to learn about how to perform high-angle rescues, but I won’t put down the person who wants to learn how.
  1. The emotional well-being of our patients should be a priority of ours. This includes counseling drug addicts, or at least referring them to the persons who can provide them with adequate psychological care. When we revive a heroin overdose, do we just spend the next several minutes ignoring the patient in the back of the ambulance? Or do we initiate a conversation with the patient?
  1. See #10. Why are we afraid to learn about drugs and therapeutic regimens?
  1. “Ambulance” is not synonymous with “Paramedic.” If a registered nurse can provide the same level, or higher level of care than a paramedic, then why are we concerned? Isn’t the care of the patient our foremost concern?
  1. I don’t see this as a “cradle to grave government funded approach to healthcare” at all. Even though Congress and our President would disagree with me. But I also work for a private service.
  1. It probably takes more thought to learn how to counsel people on how to avoid things that may trigger allergic reactions. We might as well stick with what we know, right? See # 10 and # 8.
  1. I also like nurses. Especially pretty ones who smile and talk to me. Nurses like what I do as a community paramedic, because I can reduce their workload. If I can prevent one readmit to the Emergency Room, that makes triage times quicker, allows nurses to focus more on their patients since they have less of a workload, and can raise reimbursement rates for the hospitals.
  1. At least 80% of our job consists of responding to non-acute problems. But yes, we should forget about that 80 percent and instead focus on the remaining 20. I work in a very busy area of the country, and probably run one or two true emergencies per month.
  1. Why would the concerns of another group be a concern of the community paramedic? There is a void in healthcare, and nobody is stepping in to fill it. Paramedics already work in the community, and are a logical solution to the puzzle.
  1. Ah, yes, the image of EMS.  Maybe, just maybe, members of the community will see the paramedics in a different light: perhaps they will have the image of the paramedic that is willing to make appointments to follow-up, check-up, and to help them meet their healthcare needs.

He is right, we should “be excellent at what you do, and respect those who are excellent at what they do.” Mr. Morse seems to only focus on one-third of the initials in our profession: the “E.”

Emergencies is what we do. But we also do Medical Services. There is a huge gap in our healthcare system, and we are positioned to fill that gap.

We should be more invested in the health and well-being of the members of our community. We should be proactive and prevent emergencies from happening, instead of reacting to them.

Community Paramedicine isn’t just about checking insulin pumps or reconciling med lists. It is about preventing the little old lady from the fall, and answering questions, and so much more. It is about keeping people from needing the trip to the Emergency Room. I believe community medicine will play a large part of the future of EMS and healthcare in general.

We can either lead or follow.

Those who don’t want to lead, and aren’t willing to follow, should simply get out of the way.

What is said and what is heard

What it said is “treat the patient, not the monitor.”

What I really hear is “I don’t know how to accurately interpret the monitor, so I can just ignore what is on the monitor.”

For example: your patient is a 73 year old male. He is pale, cool, and diaphoretic. He has normal mentation and complains of weakness. His heart rate is 40, and weak at the radials.

Do we seriously not base our next treatment off the interpretation of the monitor?

He could be in symptomatic bradycardia, and might need a little atropine. He could be having a humongous inferior MI and need a large bolus of diesel. He could be in a complete heart block and need to be paced. He could be in ventricular bigeminy and need some oxygen and a fluid bolus.

But no. You treated your patient, and not the monitor.

What is said is “I know he doesn’t have neck or back pain, but I’m going to board him anyways because of the mechanism.”

What I really hear is “I totally have no idea that immobilization causes harm, and besides, I don’t know how to perform an accurate assessment anyways.”

For real. If you are going to immobilize someone to a spine board, at least have the cojones to say “I was legitimately concerned about the possibility of an unstable cervical spine fracture, so I performed the immobilization.”

We shouldn’t base any treatment based on mechanism alone. Should every victim of a gunshot wound get bilateral lines, oxygen, and transport to a trauma center?

What is said is “I have to do treatment x because it is protocol.”

What I really hear is “I’m just doing what I’m told, and may or may not know better. I might be interested in changing the protocol, but probably not.”

If your medical director wrote a protocol that instructed EMTs to apply a brown paper bag to the face of any tachypneic patient, would you do it?

If your medical director wrote a protocol that instructed you to perform spinal immobilization on every patient who might have a head injury, would you strap down the old demented lady with kyphosis who rolled out of bed on the wrong side?

Or would you stand up for your patients, and for your profession, and point out the wrongs?

I guess I’m just irritated.

That duck can pull a truck

The call is for a middle-aged man with “altered mental status not breathing normally.” I’m responding with the ambulance crew and a fire crew to the apartment complex address listed on the MDT.

I arrive on scene as the ambulance crew is making their way inside. I know the medic fairly well. He did all of his intern rides with Slimm and I, and he is good at his job. I know he won’t need me, but I would like to see him working on his own. The fire crew has been there several minutes.

I walk in to see the fire crew taping down an IV in the patient’s arm. “It’s a white-out, C” says Ashley the medic, with his thick drawl. “Suggah is thutty.”

(Think Kevin Bacon in JFK. Not Costner, because his attempt at a southern accent was piss-poor.)

I see Ashley and his partner spiking a bag of saline while a fire crew member is reaching into his bag for the D50.

“Hey, b’fore y’all go ‘head and push that dee-fifty, let’s mix it up in this bag right here.”

“But he needs the sugar. His glucose is really-”

“I know, I know, but we should mix it up in this right here bag instead’a givin’ it straight in the vein.”

“That doesn’t make any sense-”

“Look, now. If I tell you that duck can pull a truck, then hook that duck up! Lemme show ya’ ” Ashley replies, grabbing the syringe, attaching a needle, and mixing it into the bag of saline.

“Now, what we got here is dee-ten. It’ll wake’em up just tha same, but it’s just less shockin’ to tha system” he explains.

I know exactly what he is doing, because that is my preferred method of dextrose administration.

The patient wakes up quickly, and I glance at the bag. About 100ml are in so far. Somebody repeats the glucose stick. “Eighty-nine.”

“Now see, he’s had a hunnid of dee-ten, and he’s already awake. Ain’t that suggah better’n givin’ tha whole amp and jackin’ it up to tha three hunnids?”

Apparently, when a Southerner tells you that a duck can pull a truck, you are supposed to shut up and hook that duck up.

Learn something every day.

Disaster averted

Admittedly, the portion of paramedic school that covered the care of the newborn was short. We didn’t learn much aside from managing either a perfectly normal baby, or a baby that was terribly abnormal.

A friend of mine was relating a story recently. He was telling me about a call he ran that morning in which a mother delivered a baby at home. Apparently the mother wanted a home birth, but the HMO’s obstetrician insisted the baby be transported to the hospital after delivery, going so far as calling 911 for the new parents.

My friend Jeff* was explaining that he arrived a few minutes after the local first responders, and walked into the house about 5 minutes after they did. The first responders apparently cheated by having a station less than half a block away from the house, and also cheated by having their vehicle parked outside, doing their morning truck check-off when the call came in.

Jeff was saying he walked into the house to find a first responder putting the finishing touches on an IV that they had established on the baby. The IV that was established before any vitals were obtained. With the exception of a heelstick glucose.

He mentioned that the baby appeared “completely normal and content.” The parents had already given the baby a cursory bath, and clamped and cut the umbilical cord. The baby was born about 15 minutes before Jeff walked in. The baby was full-term, but had not begun feeding yet.

He didn’t say what the cord was clamped with, and I should have asked.

Another first responder on scene was holding an ampule of dextrose. Not D5 or D10. Not even D25.

D50.

The baby’s heelstick glucose was 49.

They were about to administer, according to Jeff, “half an amp of D50 through a 24 gauge IV of saline.” Until they were stopped by my friend.

The first responder who was about to administer the dextrose had recently finished paramedic school. One would think he would know better, but he wasn’t taught.

Who is responsible for errors when the paramedics that we put on the street ‘don’t know what they don’t know?’

 

*Not his real name, of course.