Clinical Pearls: Syncope

I'm doing a new thing here. I'm listening to medical podcasts on the way to work, so I'm going to try and share some of the pearls of clinical wisdom I pick up. The sources are a variety of free podcasts available through iTunes.

If you're an experienced provider, you've probably (like me) forgotten a lot of the nifty bits of clinical information that you were taught in school but didn't NEED to know. The stuff that got lost when you were cramming NREMT and ACLS skill sheets in your head. The stuff that might actually be more useful now that you're out in the field.

So that's what I'll try and bring you: Short, sweet tidbits that can help the experienced (or new) provider up their game.

We see syncope a lot. A lot of it is (or seems) harmless, and many of us like to wastebasket it into the vasovagal category, and don't mind getting a refusal.

Try to be more suspicious. Don't get suckered by how good they look now. Think about the patho. If it's not a seizure or low blood sugar, it's probably not enough blood or oxygen getting to the brain. Arrythmias? Stroke? Aortic stenosis or dissection? Occult (you know, hidden) bleed? Pulmonary embolism? There are some big, scary bears that cause syncope, and you should suspect them before you call it a vagal or psychogenic.

But how do you make that judgement? What should worry you?

First, most of these folks warrant a good assessment. Get a real detailed history. Find out if they had symptoms before they syncopized. Get a good set of vitals, and a 12 lead ECG is an excellent idea. Check neuros. Ask friends and family if they are acting normal. Go LOOKING for trouble.

But who are the folks to be worried about?

• Patients with chest or back pain, new onset, before or after the syncope, should be concerning for aortic aneurysm or dissection, or PE, or cardiac causes.

• Patients who don't return to their baseline after a syncope should be concerning for intracranial pathology (CVA/TIA/bleed).

• And patients who have no prodrome, no symptoms before passing out, no dizziness or tunnel vision, those folks should have you worried about weird rhythms.

Vasovagal syncope is not uncommon -- but just like anxiety attack, it should be a (presumptive, field) diagnosis of exclusion, the one you reach after everything else has been exhausted.

Hope this is helpful to some of y'all. More coming soon!

Drugs

They say we shouldn't do it. They say that Rapid Sequence Intubation - the practice of sedating and chemically paralyzingly a patient to place a breathing tube in their trachea - is too dangerous for paramedics to perform. They say the studies show it's too risky. They say we're not good enough at intubating. They say you can support a person with basic techniques.

They say, they say. And in many cases - trauma in particular - I tend to agree.

And yet.

* * * *

Drugs got him here, and drugs will be his salvation. He wasn't breathing when the fire department EMTs arrived. Narcan helped his respirations, but nothing else. They're not sure what he took.

They've barely stopped bagging when we walk in. Not down too long, they say. History of drug abuse and suicide attempts. So we start the workup.

I start a line in his ankle, the only site I can find. My partner hooks him up to the monitor. He's breathing forty times a minute, but his oxygen saturations hover around 85%. He won't wake up and his lungs sound like a tire chain in a tumble dryer. Even with suctioning, an NPA, and more bagging, he doesn't really improve. His jaw is locked tight, and all I can do is run the Yankauer over his teeth.

The nearest hospital is 35 miles away, on windy, rain-slick country roads.

They say...

We load him in the ambulance, make a few more desultory attempts at BLS airway managment, and then make the decision.

My partner draws up the drugs. I get out my tools -- Options A, B, and C.

My eye briefly lingers on the small cardboard box of Option D. I can picture what's inside, the plastic package and scalpel and Sharpie-scrawled message some wise-ass coworker has left: "GOOD LUCK. STAY CALM."

I leave the cric kit on the shelf. Everything else, though - tube, bougie, King - I lock and load. Line them up neatly. Lights up. Suction running. All the positioning tricks I know. He predicts like a difficult airway, no matter which mnemonic or scheme I use. Nothing good about this. We can't get his sats over 90%.

My partner, holding two syringes, asks if I'm ready. The firefighter assisting us looks at me expectantly.

Well. I suppose. I'd better be, hadn't I?

He pushes the drugs, and I wait until he stops breathing. His jaw loosens, and I slide the blade into his mouth. Everyone is gathered around - the firefighter holding cric pressure, my partner pulling the patient's head into a better sniffing position - and all of a sudden I can see the cords.

"Whoa! Okay, tube, tube. Good. Okay. Through the cords. Stylette out. Balloon up. Get that capnography on. Ears? Okay, bag. Yeah? Sweet."

And then it's all over but secure the tube, clean up, sedation, NG tube, and so on -- all during the long drive in.

He's hard to sedate and fights us some on the way in -- maybe a speedball? -- but his sats slowly come up.

By the time we leave the hospital he's at 100%, sleeping peacefully with the aid of a versed drip. The doc shrugs her shoulders.

"Don't exactly know what's up. We'll have to wait for labs and imaging. Could be a few different things. Sounds like it was a tough one out there. Good job, guys."

* * * *

They say, they say, and sometimes I think they are right, and sometimes I think they are wrong.

Faker

We've run on him fifty times. I've written a dozen charts personally in the last year, and I'm one of twelve ambulance medics in our district. Everyone knows him. Everyone knows the address. We groan when the dispatchers name the apartment complex, and snarkily ask our partner if they need help getting mapped in.

Chest pain, always chest pain. He has the history -- a zipper scar, a boxful of pills, a 12 lead with Q waves. He looks scary -- pale, clutching his chest, always telling you it's real bad this time, it's never been this bad. The first time, and the second, and the third, you get worried, you work him up hardcore, pushing the nitro and fentanyl and repeating 12 leads and bypassing the community hospital to go to a cath lab facility, just in case. Just in case.

But the fourth, and the fifth time, your concern start to wane. Despite everything, he's stable. He doesn't decompensate or throw PVCs. He doesn't get cathed. And then the doc at the recieving facility starts to tell you about all his visits. How he requests narcotics by name. The mysterious morphine allergy. And the picture starts to come together in your head.

* * *

We were out of district when the call came down for a domestic at his address. We sent the cover unit an MDC message. Just so you know, if the guy claims chest pain, he's usually not as bad as he looks. Work him up, but he's got a history of seeking. Just so you know.

A while later they write us back. Wasn't him. He beat up his brother. He went to jail.

Huh. Isn't that something.

* * *

But an hour after that, we're toned to the police station. Law enforcement request for medical. I bet my partner a dollar it's him, that he's developed chest pain in the cell.

We walk in. I turn to my partner. "You owe me." He laughs. The firemen are standing around, getting vitals. No one seems rushed. I ask the cops about what happened. Is he still in custody. Yes? Okay. Which hospital? The one by the county lockup? Sure, we can do that. No problem.

I walk back to the cell. Vitals okay? Right. And when did he say the chest pain started? How does the 12 lead look?

"Well," says the fire medic, "actually tonight it's this weakness. And he's acting like he can't talk."

I blink rapidly, and look at the patient. He's not moving anything on his right side. The corner of his mouth droops. A fireman asks him about allergies, and his answer sounds like Animal from the Muppets.

Are you kidding me?

I do the neuro exams. He's definitely a "good" stroke, by the numbers. He's got the risk factors. The fire paramedic rolls her eyes. "He's pulled this before, too. Haven't you seen it?"

No. No, I have not. We can't treat it like he's faking. We have to work it up like it's real. It looks real to me.

"Absolutely," she agrees, and she is in fact a decent paramedic, one of the better ones to ride an engine. "All I'm saying is, don't get too excited."

We load and go. Code 3 to the closest hospital, call the stroke alert, large bore lines in both ACs for CT scans, 12 lead just in case, the whole Happy Meal deal, with toy included.

At the hospital, the ED doc thinks it's genuine. He passes the Hand Drop Test, smacking himself in the face. His reflexes are absent on the affected side. He doesn't have a bleed, on the scans. We tell the doc about the history of seeking and faking, and he nods, but says it's no reason this couldn't be the big, bad, ischemic stroke it appears to be. I agree readily. Absolutely, doc. Just want to make sure you have all the facts in hand.

"Appreciate it," he says. "We'll see. Neurology is coming in -- and pharmacy is sending the tPA up."

Six hours later, dropping off another patient, they tell us he got the 'lytics, and went to the ICU with some improvement showing.

Huh, we say. He finally had the real thing happen. Poor guy.

* * *

A month later, I run into the doc again.

Hey, you remember that stroke? The one who had the history of faking, but turned out to be having the real one? How'd he do?

The doc just shakes his head. "They did CTs and MRIs and all the tests you could imagine. Never found any evidence that he'd actually stroked."

What? Seriously?

The doc sighs and rubs his head. "Oh yeah. Yeah."

"Wow," I say. "What happened? I mean -- he got the tPA. How'd that work out?"

A shrug. "Who knows."

Another doc pipes up. "Bled out, probably. Poor bastard."

Throat

It's a huge apartment complex. We find the building we want, and park nearby. We shoulder the airway kit and Lifepak and medbox. We walk up the path around to to the front of the building, and then up two flights of stairs.

A young woman, visibly upset, opens the apartment door when we are halfway up the last flight of stairs. Here, she says, in here, leading us to the living room.

He sits on the perfectly normal couch in the perfectly normal apartment, and there is no blood or gore, no gunshot wounds or impaled objects. And yet his eyes are full of fear. His right hand is white-knuckled around his own throat, and he doesn't say a word.

He is barely two months younger than me, and if he lets go of his throat, he cannot breathe.

* * * *

His girlfriend, or wife, tells us the story as she knows it. How he crawled into their room and woke her up. How between a few words he gasped out and his pantomimed gestures she gathered that he tripped over the cat, and struck his throat on the edge of the table. How she called 911 while he sat, trying to stay calm, stenting his own airway open.

He's able to answer questions by nodding. He's healthy. He didn't pass out. Nothing else hurts. We try to look at his throat, but as soon as he lets go his sats drop and he moves no air. We quickly abandon our exam and let him resume his careful hold on his trachea.

Can you walk? we ask. Nod, nod. Good. Let's get some shoes. And we pop a nonrebreather on and walk him down to the ambulance, simple as that, supporting him and taking a break when we need to.

At the car, my partner throws a quick line in while I call the trauma center on the radio. The fire engine has showed up, and I load a couple of friends for the quick trip up to the Level I center. The fire guys sit on the bench seat, doing vitals and reassuring him.

I sit in the airway seat, behind him, out of sight, the cric kit out and open, prepping an ET tube, RSI drugs handy, hoping fervently I won't have to use any of it.

I don't.

* * * *

At the trauma center, at least twenty people have gathered. Trauma surgeons, emergency docs, anesthesia, respiratory ... they crowd the room. Trach trays are opened, sterile gloves donned. Game faces on.

He finally gets really, really worried when he sees everyone gathered for him, and I can see tears well up in his eyes. I'm standing at the foot of the bed -- I have no intention of leaving before I see how this ends. The social worker makes sure she has his girlfriend's information, and steps out of the room to call her.

They prep to attempt a tube with a Glidescope, ready to go into his neck if that doesn't work; anesthesiologists at his head, surgeons at his side. An anesthesiologist has taken over holding his throat. The room is full of quiet, professional chatter; let's go with a six-oh tube and etomidate and sux is fine and are you all ready? A nurse steps up with the syringes full of medicine.

I meet his gaze, and realize that in all the bustle and confusion, there's very little attention being paid to him as a person. And it strikes me how much more frightening that would be.

And so I reach out my hand, and he grabs it, tightly, and I hold his hand until the drugs take hold.

Laundry

This is what happens when you do laundry in a dual-medic household.

Yes, it's true, She Who Must Be Obeyed works in The Business too.

Accessories

The scene: A house, at night. A fire engine and ambulance idle softly in the cool air. A patient has been loaded up, and now Yours Truly and a fire lieutenant wait for his wife to lock up the house. Yours Truly notes the fireman is holding some of the lady's belongings.

Me: "... That's a very nice purse you have."

Lt: "Do you like it? It's from my spring collection."

Me: "It matches the color of your eyes."

Lt: *blush*

Overtime

Eleven hours in to a shift in the city, my phone rings. I glance at the face. "SUPERVISOR JIM." Hmmm. They've been paging for a night shift, more and more frantically. I thumb the green key.

"No."

"Hear me out!"

"No. I'm not working a twenty-four."

"Dammit, just ... listen, okay? It's a sweet deal."

"... okay."

"There are two medics on the car already. The problem is, neither of them is a lead medic. But they're both checked off. And one is in the lead training program. You just need to be THERE, to keep an eye on things. They'll do all the work."

"... no charts?"

"You can sleep in back all night, and just wake up for calls! Come on, man."

I take a deep breath.

"Let me check to make sure the wife doesn't mind."

"You da MAN!"

"And I want movie tickets."

"Done."

* * * *

Three in the morning. I'm horizontal on the bench seat, strapped down against the bumps and turns of post moves. The radio is clipped to the stretcher next to me. I've just, finally dozed off when the tones blare. Damn Motorola. I swear, every time they go off, a year drops off my life.

I try and sit up. Too bad I'm still strapped in. Coughing, I pop the belts and make my way to the jumpseat. We're already moving.

I rub my eyes and address the cab of the ambulance as a whole. "What tomfoolery are we off to now?"

"A stabbing."

"... what?"

"See?" The MDC is turned to face me.

ENTRY: STARTING MED, SAYS SUBJ HERE IS STABBED IN BACK, REFUSING TO ANSWER OTHER QUESTIONS. POLICE ENRT. MED TO STG.

"Huh."

My partner scrolls down.

UPDATE: SOMEONE IN BACKGROUND YELLING, "THE COPS ARE COMING, HIDE THE WEED, HIDE THE WEED!" H/U ON ME. NO ANS ON CALLBACK.

I lean back against the airway seat. "Okay. This is probably BS. Don't stage too close."

We find a spot about ten blocks away and nose up to a curb, shutting the lights off. I close my eyes, and instantly start to drift aw--

*shwzooom!*

The whole ambulance rocks.

"What th' f-"

*shwmm!*
       *fwmmm!*
             *zmmmm!*

This time I can see the lights, as three more cops rocket past us, in full afterburner, doing somewhere upwards of Mach 2. I look out the back windows as five or six more police cruisers blow past, stacked up in a line, lit up like Christmas trees, and apparently headed for hyperspace.

"Hmmm. Guess they think it's real."

A few minutes later the tac channel crackles. "Per police onscene, medical is cleared to come in."

We zip around the corner, down the street, thread our way through shoals of white police cars, and pull up in front of a house surrounded by uniforms. A man is laying on the porch. I blink and rub my eyes again.

"Okay," I tell the front of the ambulance. "I'm just gonna walk up. If he's truly stabbed, we'll just put him on the gurney and bounce."

As I approach the porch, four cops enter the house with guns drawn. "Police!" they shout. Definitely a secure scene. The man is sprawled on the porch, moaning and holding his side.

"Well?" I ask one of the cops. "Stabbed?"

He nods. "In the back."

I fish my flashlight out, and roll the man slightly to his side. Sho' nuff, there's a neat 4cm puncture wound in his mid-back, thankfully well away from his spine.

I'm already stepping off the porch as my partners and the fire crew approach. "Put him on the gurney," I tell my crew. "No c-spine. I'll be in the bus."

As I climb back in the rig, I spin the dial on my radio all the way to the end, from FIRE DISPATCH, past TAC A and B and C, through EMS OPS, to TRAUMA.

I try to suppress a yawn and key the mike. "Trauma, Medic Six with a system entry..."

* * * *

At the hospital, as the trauma team pokes and prods and ultrasounds and ponders, I chat with a cop and a surgical resident.

"So," the doc asks, "any idea who did this?"

The cop shrugs. "Maybe a domestic. It's not really clear."

Chuckling, the resident suggests, "Was he Standing On A Corner, Minding His Own Business? Was it Sumdood? Or Those Three Guys?" Clearly he's not new to taking care of the Knife & Gun Club.

The cop snickers. "Yeah, probably Sumdood. That guy is always causing trouble."

I wave at the cop. "Well, what are you doing here? Get the f*ck out of here! Go catch him!"

* * * *

Later, in the ambulance, I compose a text message to my supervisor.

Stabbing interrupted my nap. Actually had to work. Damn you!

Parking

"Well," said the fire captain, "how are you going to get out? Do you want me to back you, or ... ?"

I looked up and down the four-lane highway. Between an engine, a rescue, our ambulance, and two cop cars, we'd completely blocked two lanes. I'd nosed the ambulance up close to a State Police car when we arrived. The trooper was still taking statements from witnesses.

I shrugged at the captain.

"I think I'll just push the state trooper's car into traffic, and then once it's been smashed out of the way by oncoming traffic I should have plenty of room."

"Hey!"

I turned. Oh yeah. The trooper was still taking statements -- five feet away.

"Oh, crap!" I grinned at the fireman. "They have ears!"

The trooper just looked at me and fired up his standard-issue Fifty Megawatt State Trooper Glare. I tried not to wilt.

"Well ... gotta go! You guys take care!"

"Soooo..." The captain was smirking. "I'll back you, then?"

Crosses

In this part of the country -- maybe everywhere -- when someone is killed in a car wreck, more often than not family or friends will put a cross up by the roadside where it happened. Sometimes there's a name, sometimes flowers, occasionally a photo. If you keep your eyes open, you'll see these little memorials here and there, scattered around, slowly fading and weathering.

I always, my whole life, drove by crosses on the roadside and wondered what happened. Was someone drunk? Just tired, or unlucky? Were they young or old? Just idle thoughts as I drive down highways and back roads.

The other day, as I was driving to work, I passed a roadside memorial I hasn't seem before. For some reason I pulled over to glance at it. The name sounded familiar, though I didn't recognize the photo tacked to the scarred tree.

But then I realized -- if I replaced the lazy afternoon sunlight with 3am mist and strobing LED lights, if I swapped the soft sounds of the breeze and quiet birds for the grumbling mutter of diesels and Hurst tools, if I put fifteen people on the roadway and one wrapped between the car and the tree -- then I knew the place well, because it was my call, and my patient, and we knew even as we struggled to tube her and cut her free that she would never live.

Rules

I recently got my yearly performance review. While it was generally positive, there was a small attached list of behaviors which are now forbidden to your truly. I thought I would share a few.

* * * *

Per dispatch center request, please do not respond to dispatch directions with "delightful," "by your command," or "pip, pip, righto, guv!" Additionally, please refrain from speaking on the radio in any foreign language.

* * * *

Per fire agency request, please do not provide an exterior building size-up on medical calls, request "the first-in engine company bring up my gurney on arrival," add your ambulance to box alarms, or assume Command on a chest pain.

* * * *

Per chart review committee request, please do not use the phrases "poor life choices," "pharmacologically assisted gravity attack," or "terminal deceleration syndrome" in your documentation. Additionally, we wish to remind you that "Funny Lookin' Beats" is not an acceptable description of ECG ectopy.

* * * *

Per fleet maintenance request, please refrain from turning in a vehicle failure report with reason listed as "PONTOONS DO NOT INFLATE FULLY WHEN ENTERING WATER." Additionally, please refrain from submitting requests for nitrous systems, afterburners, in-seat DVD players, or "bitchen' rims."

* * * *

Finally, per management request, please refrain from operating a lemonade stand, massage parlour, off-track betting establishment, or payday check loan business out of your station.

Moments (IV)

We drive east, in the darkness and rain, bluegrass and crackling radio traffic in our ears.

Thirty minutes ago, we were giving report to nurses and a doctor, swapping the O2 over, 1-2-3 lift, there we go, no allergies, had three neb treatments, what else can we tell you?

Forty minutes ago, I watch my partner rip out a BVM, in the rear view mirror, and my fingers are resting lightly on the EMERG MASTER switch before he even gives me the nod. Yeah. Blinkies and woo-woos now.

An hour ago, we load a little old lady in the back of the car. She doesn't look great, but her sats perked up nicely on the neb, and she doesn't look awful or anything.

Eighty minutes ago, a firefighter is telling my partner what he knows, as I try to tease information out of an anxious son, carefully as any detective handling a skittish murder witness, firm but kind.

One hundred minutes ago, I was on the phone with my wife. Wait a sec, I said, as tones started whistling on county dispatch. Whoops. That's us. Gotta go. See you in the morning.

Love you.


Twenty minutes ago, through the hospital curtain, I heard a son, talking to a mother who might not have even been able to hear him. I'm here. We're here. Be strong.

Love you.

Spine

In a quiet, unassuming way, the call is terrifying. In two ways, actually.

She's laying at the bottom of a half-staircase, surrounded by a fire crew. Nothing appears unremarkable. She's awake and talking. She's pink, warm, and dry. She isn't covered in blood. No bones project from her skin.

She isn't moving anything below her waist.

The fire paramedic looks up at me, and gives me a short report. It's all fine until he closes with, "We called medical control to ask about solumedrol -- they said no."

It's all I can do not to gape and shake my head. We move on with the call. Backboard, trauma entry, code 3 to the big hospital. She has true neuro and motor deficits below the level of her bellybutton.

I try to comfort her, reassure her, but she knows exactly what's going on and how ominous it is. I try so hard not to lie to my patients. It's a struggle not to tell her everything will be alright. I don't know that it will be. She's an avid cyclist. She talks about riding hundred-mile races.

After we leave her in the capable care of the trauma team, I ponder the fire medic's seemingly-innocuous words. Did he know anything about the solumedrol he'd asked for, or had he just heard somewhere that it could be used for spinal injury? Did he know about the plethora of studies that question it's effectiveness, or even the dose? I'm sure he didn't realize it would have taken 11 or 12 of the 125mg vials we carry to reach the 30mg/kg dose in this comparatively small patient.

I am forced by these circumstances to come back to my previous point, which is that we should all stick to our areas of expertise. I don't know step one about fighting a house fire. I know just enough about vehicle extrication to be dangerous. I know enough about HazMat to run the hell away. I leave those things to the fire department -- it's their expertise.

But I do know about prehospital medicine. I know the protocols, and the science and medicine behind the protocols, and when medication X or procedure Y is really necessary. I have an idea of when you can step outside the protocols, call medical control for permission to do something unusual.

I know enough to know that asking a doctor if you can give a patient steroids for a spinal injury, in the city, without knowing the dose, only makes you look a fool. That's my area of expertise.