Playing with the monitor. Or; “Someone is about to have a cow”

I like playing with the Lifepak 15 settings. Local Ambulance Service has had the 15s for about 8 months now.

They are pretty cool. The monitors and LAS.

I will occasionally do things in the settings, like change the print speed from 25mm/sec to 50mm/sec.  It helps to widen out complexes on 12-leads occasionally.

I’ve also been known to change the format in which the 12-lead is printed. Did you know we could do that? It’s called the Cabrera format. I don’t know who or what Cabrera is, so please don’t ask. I suppose either one of us could Google it.

The standard 12-lead ECG printout looks like this:

We are all familiar with the standard printout by now, at least I hope we are.

Cabrera is a little different. It starts by reversing the polarity of lead aVR, giving the complexes upright waveforms. Cabrera then rearranges where the leads print on the strip, grouping together anatomically contiguous leads. Cabrera looks like this:

I apologize if the pictures aren’t snazzy enough. I use MSPaint, as opposed to Photoshop. Plus, it’s late at night, and I’m tired.

Classic inferior infarcts show elevation in II, III, and aVF, with reciprocal changes in I and aVL. So we are normally looking for changes in the bottom left-hand corner of the strip. Cabrera, by grouping the leads anatomically, will show an inferior infarct in the entire second column.

The difference looks like so:

versus

I think if we had been taught to interpret using the Cabrera format, we could be better clinicians.

Cabrera also allows for an easier look at the frontal plane.  The leads are laid out in order on the hexaxial system from +150 (aVL) clockwise to -60 (lead III).  Looking at the leads this way will make it easier to recognize a shift in electrical axis.

But that’s too deep. There’s probably 5% of us that understand and care about electrical axis.

I use capnography. A lot. Virtually every patient that I transport is placed on capnography. Even the BLS patients.

Instead of actually having to scroll to the section of the screen, select “waveform” and choose my “source” to see the EtCO2 waveform, I simply set up the monitor to always display the waveform on the bottom of the monitor. Plus, on the 15, it’s in pretty colors as opposed to that ugly orange on black.

I still have the option to select “trend” data on either one of the two remaining display lines, and I use that option frequently on longer trips.

Really, what’s the point of “monitoring” in three leads anyway? Isn’t lead II good enough for just normal transports?

I have also been known to turn off the interpretive statement on the monitor. No more “reading” a 12-lead by reading what the computer “thinks it is.” The algorithm inside the LP15, while marginally better than the 12, still sucks.

I had a patient with a pretty clear 3rd degree block several months ago, and the interpretive statement read “Sinus bradycardia with a sinus arrhythmia.” Stupid machines.  I would rather have nothing printed up there.

Can you imagine the looks on the faces of some providers when they run a 12-lead, and nothing is printed at the top?

Priceless.

The tail wags the dog. Again.

So it’s getting cold again. Nights are crisp, and one’s breath is easily visible in the morning air. With Halloween costumes and football jerseys come the classic seal-bark cough of croup. Anyone who has worked on an ambulance more than several months, and virtually any parent of a toddler, or child who once was a toddler, has heard that classic sound.

I like to use the term laryngotracheobronchitis. But only because using big words makes me look smarter. Or at least that’s my perception. And perception is more of what I do than much else.

Croup is an acute viral infection of the upper airway. This infection leads to swelling in the airways, which produces the classic sounds. Agitating the child, or making the child cry will worsen symptoms. I typically will ask the parents to make the decision which will keep the child most calm. Be that transport in the back of my ambulance, or in the back of their car. Whatever keeps the child the most calm and without distress is best. Whenever I have heard stridor at rest, I have always made it a point to encourage transport in my ambulance.

While I am sure this is nothing new for most anyone reading this blog, well, frankly, most of EMS is not made up of blog readers. There are lots and lots of idiots out there who sucessfully passed a test, and blew enough smoke up the ass of a Field Training Officer, walking around with Paramedic patches on their sleeve. I tend to think highly of my colleagues. Sometimes too highly.

So I walked into the nurse’s breakroom at Local Hospital to snag a soda, which they are so kind to provide to the heroes such as myself, when I overheard a conversation between several nurses. They were lamenting the treatment of a young child who was brought into the pediatric section of the emergency room. This child was apparently very sick, and the paramedic who was the subject of the banter was quite the idiot.

It was mentioned that the paramedic gave continuous Albuterol nebulizers to the patient because “that’s all they have.” The nurses were adamant that this particular ambulance service carried racemic epinephrine, at which point I piped up and joined the conversation.

Ambulances around here don’t carry racemic epinephrine.”

“Yes they do.”

No, they don’t. I’ve been riding around on ambulances for greater than 10 years, and I have never seen racemic epinephrine.”

Well, you can make it.”

Not really, you can’t.”

“It’s the same thing.”

Now, I could continue with the way that our conversation went, but I won’t. Suffice it to say, I gave a short lesson on the difference in the epinephrine that we carry (30ml of 1:1000 solution and 10 10ml prefilled syringes of a 1:10,000 solution) and racemic epinephrine.

My point here being that there is a difference in the two. I will agree that they both have efficacy in the treatment of croup. Some studies have shown the increased effects of epi nephrine 1:1000 over racemic epinephrine.

Adrenaline 1:1000 4 mL (undiluted) should be given via nebuliser, preferably with oxygen. Traditionally, racemic (2.25%) adrenaline has been used to treat croup, but this is as effective as the 1:1000 preparation1

So, they are equally effective at the treatment of croup. But again, the vast majority of those reading this already knew that.

It’s really not that hard to nebulize epinephrine. I have seen it done different ways, and I have done it different ways myself:

  • 4ml 1:0000 nebulized
  • 5ml 1:1000 with 2-3ml NS nebulized
  • 3ml 1:1000 with 3ml NS nebulized

I prefer the first method. It delivers an effective amount of drug, and quicker, as it has the least volume. I don’t know exactly how long it takes to completely nebulize 1ml of a liquid with 8LPM of oxygen, and Google didn’t help much. I’m sure someone out there could come up with the math. I mean, fixed variables and all.

(Rogue Medic probably knows.)

What shocked me the most was the fact that the paramedic gave continuous Albuterol treatments.

Albuterol will do absolutely nothing for a child with croup, except to piss them off. Can you imagine being two years old, and some stinky man sticks a smoking mask on your face? I would be pissed off for sure.

Albuterol is over-used as it is. Albuterol is a Beta-2 agonist. It works on bronchospasm. It is effective in patients with asthma and bronchospasm. It is a bronchodilator. It does not reduce swelling. Period. The problem in croup is swelling.

Sure, sure, you could argue that, “well, perhaps the child was an asthmatic as well.” That’s not the point here. The paramedic continued to give the Albuterol because that’s all we have for croup.

Steroids and epinephrine are what fix croup. Not bronchodilators.

And certainly not dumbasses.

So now, we have to go through mandatory training on how to give nebulized epinephrine to children, because someone didn’t know how to give it, and because Local Hospital’s ER was angry enough to call all the Local Ambulance Services.

The stupid tail is wagging the dog again.

 

1: http://www.racgp.org.au/afp/201005/201005starr.pdf

Opposing the Devil’s advocate

In conversation with a colleague, Maverick, about the state of EMS, where we as a community could go, and how to get there, we both became markedly frustrated with each other. But, we had what we both believe was an engaging argument. Except for the way he argued.

Mind you, Maverick is not an idiot, like some of the others that I have mentioned before. This gentleman is intelligent, well-versed, and can speak in complete, cohesive sentences. I am roughly 10 years younger than he is, yet have 5 more years of experience. We both respect each other as quality clinicians, and frequently learn from one another. We both recognize that the other has the knowledge and experience to support their opinions.

Enough about that.

I dared mention the prospect of enacting a new protocol, or set of guidelines, to reduce the prehospital spinal immobilization practices, which caused a perceptible gasp. Had there been a can of soda in his hand, I am quite sure we would have been dealing with some aspiration. He had never heard of NEXUS, or the Canadian C-spine Rule, nor any of the various studies on the effectiveness (or lack thereof) of prehospital spinal immobilization. He is of the opinion that every patient who presents to the emergency room with complaints of neck pain receive a CT scan and X-rays. I disagree with his assertion, but generally don’t hang around long enough to see what tests are ordered.

Typically, what happens is this: I show up with patient immobilized to a backboard, move the patient to the hospital stretcher, the nurse palpates the cervical spine, asks a few questions, and log rolls the patient off the backboard, at which time the backboard is returned to me, and I return it to the compartment on the ambulance.

I won’t argue with my colleague’s opinion that each and every patient with complaints of neck pain receives a CT scan and X-rays, but I will disagree. And there is a difference in the two. I don’t necessarily believe his opinion to be accurate, for the record.

Having read Rogue Medic’s posts, Ambulance Driver’s posts, and several others, along with a few different studies on the practice and use of spinal immobilization, I agree with virtually every assertion:
We are causing more harm than we are doing good.

In our discussion, Maverick mentioned that (and I paraphrase, mind you) “every one gets boarded because it’s the national standard of care, and we live in a litigious society.” He did concede to my argument that way too many people get boarded, and it probably hurts more than it helps. He is of the opinion that the only way to change the way we use immobilization is to get our medical director on board, and that our medical director will never agree to the because of the threat of a possible lawsuit. He said “not immobilizing a patient with a suspected spinal cord injury would be negligent.”

Forgive me, but isn’t causation, or actus reus, or one of the main components of negligence?

So, for example, we arrive at the scene of a motor-vehicle accident, and find a patient complaining of neck pain. The patient has no distracting injuries, no neurological deficits, no posterior midline cervical-spine tenderness, and is not intoxicated. We elect not to perform spinal immobilization, and the patient is helped to our stretcher. Later, after several tests, the patient is found to have a fracture to one of her cervical vertebrae, and requires surgery. Could that patient sue the EMS provider for failing to immobilize him or her? Sure they could. Anyone can sue anyone, as long as they can find their way to the courthouse, and fill out the paperwork.

Would that patient’s lawsuit go anywhere? No.

I was of the opinion, and offered as such, that a medical director who won’t read and study material presented, as a suggestion to take better care of her patients probably isn’t the type of medical director an EMS service needs. Mind you, I have no idea what my particular medical director would have to say to this. I have had several conversations with her, and believe that she would likely be open to suggestions, and would certainly want to do what is best for our patients.

Maverick continued, in his own words, playing “Devil’s advocate,” which began to frustrate me. His assertion that there was some “National Standard of Care” baffled me. I have yet to see such a thing. I am familiar with standard of care as it pertains to tort law, however. Standard of care was described in Vaughan v. Menlove as whether or not the individual “proceed[ed] with such reasonable caution as a prudent man would have exercised under such circumstances.” Wouldn’t refraining from causing further injury be considered “prudent?” And we certainly aren’t talking about haystacks and cottages here.

Now, medical standard of care is a medical or psychological treatment or guideline. From Wikipedia:

In legal terms, the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances… …The medical malpractice plaintiff must establish the appropriate standard of care and demonstrate that the standard of care has been breached, with expert testimony.

Am I a less prudent professional simply because I have read more literature on the risks of spinal immobilization than Maverick has? Or is the failure somewhere between where he and I are on this issue? Perhaps I am more prudent, and he is less prudent. So, the plaintiff’s attorney must establish that the procedure I did not perform would have harmed the patient, and that the patient was harmed by my not performing that procedure. (I would certainly call Rogue Medic as my expert witness…)

We did, of course, discuss more than simply spinal immobilization. But perhaps I can save those for another post.

**********

While I can understand the necessity of a Devil’s advocate, I hardly see the necessity. Perhaps I am a bit myopic here, though. Historically, the position of Devil’s advocate, or advocatus diaboli was a lawyer appointed by Catholic authorities to take a skeptical view of a subject during the canonization process. The Devil’s advocate opposed God’s advocate.

In the 396 years after Pope Sixtus V created the office of Devil’s advocate, there were 98 canonizations. Since Pope John Paul II abolished the office in 1983, there have been over 500.

Some would argue that the position of Devil’s advocate prevented the over-canonization of people, and served to prevent those who weren’t worthy of such an honor from receiving it. Some might argue, as would I, that the Devil’s advocate, while maybe serving a minimally valid point, actually prevented progress.

Making arguments to continue doing things the way we always have is pointless. Tradition has it’s place, but that place is not necessarily in the back of an ambulance. It’s place certainly isn’t in discussions about how to advance the future of EMS.

And really, that’s what it’s about for me: the advancement of EMS. We aren’t going to get anywhere by perpetuating the status quo, simply because that’s the way it’s always been done.

 “He who rejects change is the architect of decay. The only human institution which rejects progress is the cemetery.”

-Harold Wilson

First-day jitters

I originally wrote this as a college English assignment for school, the subject being my “Moment I Entered Adulthood.”  While some specific details have been changed, the story is largely the same.  My paper got an A.

**********

What am I doing here? I am way in over my head.

Yesterday, I was a kid living at his parent’s house, where Mom did the laundry, and Dad enforced the curfew. Today, I’m in a strange house, interrupting a family dinner, doing chest compressions on a man who is not much older than my father. There is all sorts of food coming up out of this man’s mouth. Dinner was obviously nearing an end.

I wonder who said the prayer before dinner. I wonder if anyone prayed before dinner. My Dad always said the prayer. I never really listened.

Lift the man, lift the stretcher, wheel it outside, lift it in the ambulance.  Damn, we do lots of lifting in this job, don’t we?

Start an IV? I’ve only done that once, in class. Well, I did it when I worked in the hospital as an ER tech, but really it was different. I really only drew blood, and once the blood was drawn, the nurse would somehow make it an IV. I don’t know what they did. I probably should have paid more attention.

Damn, I blew that IV. Not that I blew a vein, I just totally missed.

“Relax, kid. You’re doing okay. There isn’t much that we can do to help this guy anyways. Why don’t you switch places with me, and I’ll get the line.”

Wait. How do I use this BVM? I remember this from class. That’s right. Squeeze it 20 times a minute, enough to make the chest rise. Good, that’s better. At least I can manage that. You want me to get you what? Epinephrine? Where is that in the drug box? Yeah, that’s right. Here it is.

CLEAR!

Oh, I’m clear alright. I’ll be up in the front seat if you need me. I’ll make sure to tell Tony how to get to the hospital, even if I have no clue where it is. I’ll be up there helping him. Okay, nevermind, I’ll switch places with you again, and do chest compressions.

“That’s good CPR. Keep it up, kid.”

My back is on fire. How the hell am I supposed to ‘keep it up’ when I can barely stand up? I think I’m going to vomit. Then my vomit will be mixed with this man’s vomit all over the floor, and that will probably make Billy vomit, and now I have to clean up three times the vomit after we get to the hospital.

Just how far away is this damned hospital, anyway? I know I was there at least once before, during orientation a few weeks ago. But I don’t remember orientation. Hell, I didn’t know where this county was a month ago.

Why, oh why did you guys hire me? Who in their right mind would pay me to screw up this bad?

Thank god we get to switch places again. It’s my turn to bag him again. Atropine? Yeah, that’s in the purple box, right? There it is. Let me connect it for you. You want me to push it? I remember that much, I know I have to pinch the line before I push it, then let go, and let the medication flush.

Why is this man that color of blue? That doesn’t look very good. I think he had some sort of chicken and pasta bake for dinner. I see green peas. It smells terrible, and I think again that I might vomit.

What’s that beeping? Oh, the backup alarm! Great! That means we are here!

Thank goodness some strange hospital worker opened those doors, and Tony came around the corner just in time to take the stretcher out.

Switch the oxygen over to the tank on the stretcher. Keep squeezing. “I’m ready, go ahead and take the stretcher out.”

Switch places again. How am I supposed to do chest compressions when the stretcher is moving? The dummy was always on the floor when we did CPR in class!

“Stand on that bar, kid, it will be easier for you. I’ll hold on to you so you don’t fall off.”

This is how I do it? I thought this was one of those Hollywood dramatic license things. We seriously stand on the stretcher while it’s going in the hospital, doing CPR? Damn, I bet I look cool. If only my friends could see me now.

“One, two, three, MOVE!”

Now we are on the hospital bed. That was fast. Back to compressions. Switch over the monitor. Someone bag. How many rounds? I don’t know. Billy knows, ask him. Can you not tell that I have no clue what I am doing here?

“Call it. Time: Nineteen-oh-eight.”

Call it? But we just got here. My back is on fire from pushing on his chest, my hair is soaked with my sweat, and I still think I am going to throw up. How can you just give up?

“I’ll start the paperwork. I’ll meet you in the truck after I get my signatures, and help you clean everything up.”

I guess that’s my cue to go fix the mess we caused in the ambulance.

It is completely trashed. There are cardboard boxes, and tubes, and metal things with lights on them, and wires, and cables, and needles, and cut clothes all over the place. Needles are supposed to go in the sharps containers, not the floor! Well, it was kind of busy back here. I guess that is to be expected. At least I haven’t vomited yet. But I still might.

The metal thing with the light coming from the end looks expensive. I won’t throw it in the fancy red trash bag. Pick up everything that looks like trash. His family might want his clothes, even though I can’t imagine why. Those can go in a different bag, and I can take them back into the hospital room.

Wipe everything down with the antiseptic spray and a towel. Coil the cables just so. Sweep the floor. Clean the metal thing. Interesting. When you shut it, the light goes off. Big red trash bag goes into the red dumpster next to the ambulance. Walk through the door, carrying my now dead patient’s belongings. The door says ‘Emergency Personnel Only’ and I feel important for a brief moment.

Whew. No longer do I feel like I am about to vomit.

Swap the bag for my stretcher. Some more antiseptic spray and a new sheet make the stretcher ready for the next patient. It looks good put back in the ambulance. I feel a strong hand on my shoulder, and a mild sense of fear begins to creep over me.

It’s Tony. The man who hired me for some reason unbeknownst to me.

“You did a good job, kid. Me and Billy are proud of you. You are going to make a good EMT. We are glad to have you here with us.”

Maybe one day. But never as good as you.

 

 

ACLS megacode fail

Recently, during a private ACLS class for a few members of a local ambulance service, I ran into a scenario which I had never seen before.

I’ve been teaching ACLS for about 4 years now, give or take a few months. I am in the (admittedly bad) habit of using the same scenario for my mega-code. It is the same scenario which my paramedic instructor used the first time I took ACLS.

A husband (or wife, or daughter, or boy/girl friend) was driving his/her wife (husband, father, mother, lover, landlord) to the hospital because he/she was complaining of chest pain. They find your ambulance/fire truck at an intersection/fire station, doughnut shop, and pull up to you. The driver states the patient suddenly became unconscious while enroute to St. Elsewhere. “Go!”

The first few students went through the scenario, and miraculously saved the patient’s life. Well done, ambulance technician, well done. The last two were remarkably different. Once “go” had been uttered, it got strange.

“Okay, lets get him out of the car, and on to the ground. I have my gloves on. Is the patient breathing?”

“No, he is not breathing.”

“Okay, lets put in an oral airway and begin bagging him with 100% O2 at a rate of 14. Call for backup”

“Ventilations are being delivered. Additional help is on the way.”

“Does he have a pulse?”

“He does not have a pulse.”

“Okay, let’s start chest compressions at a rate of no less than 100, 2 inches deep.”

“Compressions are being done, and a pulse is palpable at the carotids with each compression.”

“Let’s put the AED on the patient and press ‘analyze’.”

“The AED is on the patient, and after analyzing, it says “Shock advised.”

“Deliver the shock, and re-check the pulse.”

“The shock is delivered, the AED says ‘no shock advised’ now, and the patient does not have a pulse.”

“Okay, I’m going to have my partner attempt an IV or establish IO access to the anterior tibial tuberosity.”

“IO access is obtained without difficulty, and with good flow noted.”

“Okay, how far away is my backup?”

“Your backup is 4 minutes away.”

“Okay, let’s continue BLS until they get here.”

 

At this point, I am literally speechless. This is a person with a paramedic license, mind you. I have delivered this scenario literally a hundred different times. Had this scenario been run the way it virtually always is, they would have seen pulseless ventricular tachycardia on the monitor, defibrillated, seen asystole, given epinephrine 1:10,000, then seen ventricular fibrillation, defibrillated unsuccessfully, pushed 300mg amiodarone, defibrillated, then seen a sinus rhythm with a pulse at a rate of 70, then they would have hung an amiodarone infusion, and the patient would have awakened on the way to the hospital. But, alas, that was not done. And the hypothetical patient had a hypothetical bad outcome.

 

“I’m sorry, could you show me in the ACLS textbook where they advocate continuing BLS until firefighters arrive?”

“Oh, it probably doesn’t say that in the book, but that’s how we do it where we work.”

“Interesting. Unfortunately, I cannot pass you, and suggest that you read the textbook again, and obtain your ACLS card elsewhere.”

I am interested to know where, or if, this student actually passed ACLS, and am also interested to know what the student’s supervisor/training director would have thought had they been there to witness this horrible ACLS failure.