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.

Airway

In the prehospital setting, we are taught that airway comes first. A before everything else. And as paramedics, we're taught that the definitive airway, when we need to protect it, is a properly placed endotracheal tube.

But is this really the best for our patients? Certainly an ET tube is the right definitive airway for the hospital, but a plethora of recent studies suggest that paramedic intubation success rates are relatively poor. I'm not even talking about the effect on morbidity and mortality; it appears to be a fact that we're no good at getting the tube in the right hole on the first try.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.

"Nine hundred twenty-six patients had an attempted intubation. ... For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients)."

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.
Tam RK, Maloney J, Gaboury I, Verdon JM, Trickett J, Leduc SD, Poirier P.
Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):311-5.

"The study population comprised 1,029 intubated patients ... ETIs were successful for 64.6% (95% CI: 61.7, 67.5) of the first attempts; 79% of successful intubations were achieved within two attempts."

We get upset when we read these studies. What are they saying? We can intubate people! Our skills are solid! And yet, the numbers would seem to indicate this is not the case.

Many, many people have weighed in on this issue, and a few recent calls I've run have made me ponder these issues. I cannot argue that some of the data out there shows that paramedics are bad at intubating people, and there's no doubt that we're not doing our patients any favors by screwing around in the field.

The questions I want to ask are why are we bad at intubating people and how can we do better?

There are some of the local first responder agencies I work with that prefer alternative airways. The King Airway, in particular, has become popular lately. While I feel that the King is a great rescue device, I see red when I hear agencies espouse a culture of de-emphasizing ET intubation in favor of just "tossing in a King." Here's the facts in my experience: King airways allow you to ventilate and oxygenate a patient, so they're good for the purpose of a rescue device. They get the job done temporarily. They do NOT protect a patient's airway and lungs against vomit. If you bag too forcefully, you WILL end up with subcutaneous emphysema in your patient's neck. They do NOT always work, and if "Insert Tab A" is your ONLY plan, when that doesn't work you are hosed. (Yes, I'm looking at you, Mr. Non-Transporting Firefighter Paramedic.)

The three major reasons paramedics have issues intubating patients, in my opinion, are EXPERIENCE, VERIFICATION, and TOOLS AND TECHNIQUES.

Experience is the biggest factor. We don't perform enough intubations to be truly proficient. A physician will perform hundreds, if not thousands of intubations before they are even out of residency. A paramedic may perform ten, if they're lucky. Maybe more, in a good paramedic training program. This is not near enough. No wonder we're no good. If we expect to be good at intubation, we need to do a LOT more of them.

Verification is the second most important factor. I firmly believe that there is NO, zip, zero excuse for a misplaced ET tube in this day and age. If your agency isn't using continuous waveform capnography, you're behind the times. Visualization, lung sounds, tube misting, sure, but ETCO2 is the gold standard. You cannot have a misplaced tube with a good ETCO2 waveform on your monitor. If every patient you secure a tube in has that waveform, you won't misplace tubes. It's as simple as that.

Tools and techniques are the final factor in why we don't get our tubes in the right place. When's the last time you pulled out a bougie? Are you proficient using both Miller and Mac blades? Do you have a video laryngoscope? When's the last time you practiced -- let alone performed -- a NASCAR intubation, a digital intubation, or your surgical airway procedures? Do you know two-person intubation techniques to improve visualization? Do you know exactly how and when to use your rescue techniques and devices? If you answered NO to any of these questions, I don't think you should be intubating people in the field.

All of these ideas are nice, but how can we actually implement them, and do better at airway management? For the answer, I've got one more paper.

An analysis of advanced prehospital airway management.
Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ.
Department of Surgery, Harborview Medical Center, Seattle, Washington 98104, USA.
J Emerg Med. 2002 Aug;23(2):183-9.

"The results showed there were 2700 patients intubated... The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%."

Wow! Look at that! Paramedics can intubate people! So what the heck is so difference about the system in Seattle, that they have such success rates?

The system in Seattle is tiered, with a small number of ALS ambulances backing up a larger system of BLS first responders and BLS ambulances. The initial training program for ALS providers in this system is extensive and stringent. While there are some unrelated issues with this system, the fact is that a SMALL number of HIGHLY TRAINED paramedics can and do intubate people effectively.

What's the implication? First off, I'm sorry, but paramedics need to get the hell off fire engines. We need to reduce the number of paramedics in almost every EMS system, and removing ALS first responders is the way to start. More and more studies are coming out which question the efficacy of ALS for critical patient (cardiac arrests and trauma patients in particular). First responders need to focus on solid BLS skills -- that's where the lives will be saved.

Second, every patient does not need an ALS ambulance. While systems need to have effective triage tools and constant, vigilant QA to make sure that the patients who need ALS get it, there's nothing wrong with BLS transport. Simple logic says that if you reduce the number of paramedics in a system, those paramedics who remain will see more critical patients and perform more procedures.

Finally, we need to change paramedic education. Three terms at a community college is ridiculous. Two years of full time college to be a paramedic. End of story. If that's too much time for you, if that's too hard, TOO BAD. We have too many medics, I said it above, and making the entrance and educational requirements tougher will only improve the quality of our providers.

We need to change our systems from paramedic-saturated over-ALS'd behemoths where each medic is maybe managing one or two airways a month, to lean, mean, highly-trained and highly-experienced systems with a small number of medics who can consistently, effectively manage airways the right way, the first time, definitively.

Tricks

I don't think I am alone among medics in that I have a small "dirty tricks" bag that I bring to work. I don't mean "dirty tricks" in the sense of pressure points or joint locks -- though those have their place -- but instead little items that are not standard issue which we have found to be useful.

I recently went through and organized my little black bag, and when I was done, here's what I had:

- O2 wrench
- Small zipties
- Needle-nose pliers
- A Code Strap
- InforMed Emergency & Critical Care Pocket Guide
- Tarascon Adult Emergency Pocketbook
- County Protocol Pocket Guide
- RSI Dosage card
- Booties
- Extra-large Tegaderm
- One each adult and pediatric single-use adhesive SpO2 sensors
- King Airway syringe
- A Zerowet Supershield

So, readers, I ask you -- what do YOU bring to work that isn't standard issue, but you've found to be useful, or want to have in case of that particular unusual situation coming up?

Protocol 36

As part of our ongoing Web Based Continuing Education series, we here at Drug-Induced Hallucinations hereby present, for the discerning medic or EMT, a list of "street" synonyms for pandemic H1N1 flu that we may encounter in the course of our duties. Collected from various¹ sources².


Hamthrax

Tuporkulosis

Porklio

The Other Yellow Fever

Sowmonella

Whooping Oink

Porktussis


1. H. Tayler.
2. My "lady friend."

Freezeframe

03:30:00 - I'm fast asleep, curled up sideways in a recliner, jacket zipped all the way up. Out hard, REM-land, dreaming.

03:30:05 - Fire dispatch drops tones for a breathing problem in our district.

03:30:12 - EMS dispatch taps us out.

03:30:15 - My partner slaps my boot. I barely heard the EMS alert.

03:30:26 - I pop the tab of a Red Bull on the way to the bay. The motor on the garage door whines softly as it opens, letting the night in.

03:30:42 - My gut reels at a depth charge of caffiene, carbonation, and chemicals. My partner is talking to fire ops, pulling up the map on the laptop, and trying to find his seatbelt, all at the same time. I put the car in gear, slap the big red button, and away we go.

Conclusions

(If you haven't already, read the previous three posts.)

* * * *

I.

We scream down into the small town, and hockey-stop in front of the fire department. A young man in a fire dept t-shirt jumps in the back, wide-eyed and freshly awoken.

"I'm just a basic," he says, and I point with a free hand to the airway seat.

"Not a problem. Sit up there." I lean forward, towards the breezeway to the cab. "Okay, let's go."

Both lines are running wide open, and before even a few hundred of fluid are in he's looking better. His heart rate slowly creeps up, and his blood pressure slowly improves. The arrival at the hospital is anticlimactic, after the adrenaline rush of before, and the dozen providers waiting in the ER slowly disperse as it becomes apparent that the patient is now relatively stable.

Later, charting, I puzzle over the case, and the numbers. I look at the overall curve of the blood pressures, the heart rate, and slowly a conclusions dawns. Under the cover of my concern about a GI bleed, a relatively simple vasovagal event -- overstimulation of a nerve in the heart, causing heart rate and blood pressure to drop -- appeared to be something much more serious.

* * * *

II.

He has a head injury, probably a concussion, and repeats his questions. He wants to know everyone's names. Was he in a car accident? What's happening? Can we call someone for him?

The answers are patiently provided as he's IV'd, medicated, backboarded, and ultimately medicated. The flight nurse is standing there for the last moments of the extrication, and introduces herself to the patient as we start rolling the stretcher down the road to where the helo waits.

We roll past the other car, still on its top. A yellow blanket covers one window.

He asks where he's going, and again is told that he's to be flown to the trauma center.

And yet, when we reach the bird, and go to load him in, his eyes light up, and he reaches up to touch it.

"Whoa," he exclaims, "Is this a helicopter?"

* * * *

Moments (III)

3am. Another chest pain call.

Neither of us recognize the street name. Unfortunately, neither does the mapping program on our MDC. Or the map-book.

Finally, after turning into a dead-end, thinking we were right, and groaning at the absence of the bright red marker truck, we call them on the radio, get the lieutenant to guide us in.

He meets us at the door. "More like abdominal pain, not chest pain, guys." He shrugs, apologetically, as if this makes it a less important call.

Upstairs, on the bed, is a woman in her seventies. She is obviously uncomfortable, holding her belly, and rapidly trying to tell us everything we need to know about her symptoms and history.

At least, that's what I assume she's saying. I don't speak Cantonese, so it's hard to be sure. Her son tries to translate, with some success. Abdominal pain is her only complaint. Right here, pointing just above her belly button. One of the EMTs says he felt a lump there. My partner asks if it was pulsating. No, he says, he didn't think so.

As my partner leans over the bed to feel the woman's belly himself, he asks casually what the vitals are.

"Umm..." the EMT glances down at the monitor. "Pressure is 89/42. Heart rate is 48."

My partner does a beautiful double-take. I'm already going for the manual BP cuff, and toss it to him before pushing the button to run another automated pressure. Another firefighter asks what we need.

"Spike a bag," I say, "and check status of Podunk Hospital. And Big City Med Center."

The pressures are the same, and a 4 lead just shows a sinus bradycardia. My partner is concerned, and as soon as I have a wide-open 18 running in her arm, he starts saying, "Okay, let's go. C'mon, guys. Let's move."

We carry her downstairs on a blanket; as we do so, my partner and I share a terse conversation, like you do when things get serious.

"Thinking triple-A?"

"Mmm."

"Big City Med Center? Or one of the trauma centers?"

"Big City, I think."

"Take a friend?" Nodding at the firemen.

"Yeah, maybe."

We set her on the gurney, lift it up. I lay her back and pop her legs into Trendelenburg.

"Want help with anything?"

"12 lead, I guess. See about her rate."

I nod, and we hop in the back. He bustles with oxygen and getting a second bag of fluids together while I put the 12 lead on, pondering differentials for hypotension and bradycardia in abdominal pain.

Triple A? Definitely the front-runner.
Bad GI bleed? Could be, but no history for it.
Electrolyte imbalance maybe? T waves looked okay on the 4 lead strip. Hmm.

I reach around to stick V6 on. Out of the corner of my eye I see my partner pull pacer pads out.

"Okay. How old was she? Right. Uh, hold still, ma'am."

Click.

ACQUIRING 12 LEAD

Did we ever check hospitals? I snatch the radio off my belt.

"Firecom, Medic 601, status of Big City Med Center please."

ANALYZING 12 LEAD

"Medic 601, Big City shows green."

The Lifepak prints the short strip, calm and dispassionate.

*** ACUTE MI SUSPECTED ***