Archive for March, 2012

EMS shortages, cut more medics is obviously the answer.

So there is a shortages of medics and instead of figuring out ways to recruit and keep more medics it seems the trend is just to reduce the amount of paramedics. I found this article on an EMS blog and think it is a breath of fresh air.

“I think this from a clinical standpoint, this is the right next move for the community,” he said. “I think it’ll make a real big difference in our ability to provide quality care to that next level in our community.

So now instead of having two medics on an ambulance in Austin they will reduce it to one medic per als unit. The idea being that since medics will be performing more of their skills on their own they will become better at it. I don’t necessarily think having only one medic per ambulance is a bad thing. What I do have a problem with is the spin that is put on things when cutting EMS staff.

We are just as important as other public safety sectors but too often we are first on the chopping block when it comes to budget cuts.

To paraphrase Chief Justice Roberts in the Ricci case, “The best way to deal with a shortage of ambulances is to provide more ambulances.” The answer to a shortage of ambulances is not to provide more fire trucks just as the answer to a shortage of electricians is not to send plumbers.

Check out the article in the following link:

Too Old to Work

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Right sided 12 lead diagram

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On right ventricular MI

(As a general disclaimer, you should never go outside of your protocol or medical direction. Depending on what state you live in you could be decertified, brought into legal complications if possible actions cause patient harm, and you could harm a patient. The following discussion is being introduced as informative, and if you agree with it should be presented to your administration for their consideration, only after you yourself have vetted all information.) Also I meant this to be a small post, sorry it ran long.

I hear it too often, chest pain of possible cardiac origin, use nitroglycerin. On the whole it seems like a reasonable assumption. We reduce preload with nitroglycerin, we reduce the workload that the heart has and thus we reduce the oxygen consumption that is necessary from the myocardium. If it’s angina we may completely eliminate the problem, if it is not angina we will know it because the pain will not be relieved and we will also provide the heart with a slightly better possible outcome since we have done all of these beneficial things for the heart. If it is not angina we will still have reduced preload, reduced the myocardium workload, and reduced the hearts oxygen consumption.

There are a few contraindications to nitroglycerin use. The big ones we all know are not to use it with a patient that has taken Viagra or other ED medications within 24 hours. We know not to use nitro with a patient that is hypotensive because of possible further lowering of the blood pressure. Obviously if the patient is allergic to nitro we can’t use it on them. There is another small but very important precaution for it’s use and that is that it should not be used with patients that have a right ventricular MI.

The reason we should not use nitroglycerin with a patient that is having a right sided ventricular MI is that according to William E. Gandy at EMSWORLD:

The right ventricle is not designed to provide systemic circulation. Its purpose is to pump blood through the lungs and pulmonary circuit. Thus, the pressures it is required to produce are less, and it has a thinner wall than the left ventricle, which must pump blood throughout the body.

Its functional abilities are dependent upon preload, or the volume of venous return to the heart, principally during diastole, since veins do not have muscular walls to keep blood moving as do the arteries. The right atria and ventricle have relatively little “suction” from contractions to pull blood into them.

So a reduction in venous return will result in diminished pumping pressure by the right ventricle, diminished pulmonary circulation, diminished left ventricular filling, diminished cardiac output, diminished systemic blood pressure and, if not corrected, possible dysrhythmias, shock and death.

All of this because we followed our protocol and administered nitroglycerin to a patient with chest pain.

So first how can we ever determine if the MI is right ventricular in nature?

The first classic sign is hypotension. Consider most patients that complain of extreme chest pain, many times the pain alone can cause the elevation in blood pressure. If that elevation is absent or actually becoming hypotensive and we don’t see the patient taking medications that may lower it, such as beta blockers, we may be able to begin to see signs of a right sided ventricular MI.

12 lead ECG monitoring has steadily been receiving more and more importance in early detection. It is true that on a standard ECG we can’t see right ventricular MIs. What we can do is figure out when to “suspect” them.

Quick note on 12 leads: if you have the ability to do 12 leads do them on all patients that require them. Do them and do them often. It is not only a skill reading them, it is also a skill obtaining them. I have seen doctors and nurses fumble on obtaining them. I have also seen techs get such a clear and quick 12 lead it would surprise you. I’m not saying one person is smarter or better than the other. I am saying practicing this skill can dramatically decrease your time in obtaining a 12 lead. Also it doesn’t take long to obtain the 12 lead. It does take long if you don’t know which pocket on the monitor you have the 12 lead cables, once you find the cables they don’t have the electrodes attached, and now you can’t find the electrodes. With practice you can finish a 12 lead in about the amount of time it takes your partner to prep an IV bag.

If we see ST elevation indicating an inferior MI, which would be ST elevation in leads 2, 3, and avf we should consider a right side MI and do a right sided 12 lead.

A 12-lead tracing that shows ST segment elevation in any of the inferior leads (II, III or aVF), or relative ST segment depression in V2 or V3 compared with lead V1, should immediately trigger acquisition of a right-sided 12-lead (Gandy)
In a standard 12 lead we would place the limb leads on the limbs, V1 would go on the 4th intercostal space just right of the sternum, V2 on the 4th intercostal space just left of the sternum, V3 between V2 and V4, V4 on the 5th intercostal space midclavicular line, V5 level with V4 anterior axillary, V6 midaxillary level with V5.

On a right sided 12 lead we would place V1 where V2 normally goes, V2 where V1 normally goes and the rest of the leads using the same landmarks you would use only on the right side of the chest. Thus V4 would go 5th intercostal space Right midclavicular. V3 between V2 and V4. V5 level with V4 anterior axillary, V6 Right midaxillary level with V5.

(I will attach a picture of what I described above but I do not own the rights to it so I may have to remove it.)

Once we have obtained the right sided 12 lead we can look for ST elevation in V4. If we see ST elevation in V4 a right sided MI can be diagnosed. At the very minimum we should contact medical control and advise them of possible right sided MI and request specific orders. Hypotension should be combated both with fluid resuscitation as well as dobutamine or dopamine if dobutamine is not available. Of course fluid resuscitation should be done with careful monitoring of lung sounds as pulmonary edema should be avoided.

I hope I have helped shed some light on right sided MIs and I will be posting link below to a great online article on the subject. AMLS also has some great information on the subject and that is where I got the picture I posted above as well as some of the information in this article. It was in an AMLS class I first completely understood right sided MIs. I highly encourage medics to take that class.

Any questions or comments feel free to drop me a line as a comment or email me.

EMS World. Recognition and treatment of right sided MI

KISS

Here’s a story:

 

We get dispatched to a patient’s residence for an unresponsive female. Upon our arrival an elderly female was found in her bed responsive only to deep painful stimuli, breathing at 32 per minute with white liquid oozing from her mouth, her lung sounds are congested with equal chest rise and fall, pulse at 115, oxygen saturation at 93% on room air, glucose at 180 via fingerstick, sinus tachycardia on the monitor, no ectopy noted, 12 lead revealed sinus tach, no ectopy or ST elevation noted. Blood pressure is normal at 122/78. Eyes are equal and reactive. Patient is cool and diaphoretic. No family is at location, no other information is known. We suction the patient and place her on high flow oxygen. IV is established. Some medication bottles are found but they are empty and they are from Mexico. 

 

I would like to attempt CPAP but I know that with the patient vomiting I can’t risk it, there is too much risk of aspiration. In the ambulance I consider RSI (Rapid sequence intubation or induction). I could establish the ET tube and then protect that airway from any chance of aspiration. The hospital is only 10 minutes away and when I try to open the airway and use an oral airway the patient gags, she’s coughing when she vomits, she’s still guarding her airway. I suction some more and with oxygen her saturation level goes up to 98, her pulse lowers to normal sinus rhythm. 

 

In the back of my head I still think about RSI, the dosages are not hard and the patient doesn’t appear to be anatomically complicated. 

 

I arrive and the doctor begins to work the patient up. I leave as the patient is being taken to CT. A few days later we arrive and talk to the nurse and while she doesn’t know the outcome or diagnosis she does say that approximately 8 hours after we left her she was sedated and they intubated her. Also it was difficult and a few people attempted before she was successfully intubated. 

 

Let me begin with I am not afraid of RSI when it is necessary. I have had to RSI someone that was shot in the face with a rifle and I knew without a doubt that was the only treatment that would save that man’s life. His transport time was also over 20 minutes. He had been shot in the face and the shock was making him attack us. He lived after air medics transported him to the nearest trauma center sedated and intubated. 

 The reason I am brining this first story up is sometimes we want to do more than is necessary. We may be thinking of the patient’s best interest, but we may not remember that our first rule should always be not to do any further harm. We have a lot of equipment on some of our rigs. I recently remembered this while reading a blog post on The EMS patient Perspective: http://emspatientperspective.com/2012/03/22/its-the-basics-stupid/ . I remembered that sometimes we can do more by sticking to the basics. I could have gone further with the RSI, but I was able to maintain oxygenation and protect the airway with basic oxygen administration and suctioning. The patient still had adequate chest rise and fall. 

How many of us have heard of situations where medics go above and beyond not because they had to for the sake of the patient, but because they could go above and beyond. How many times are BLS interventions minimized but in reality, how many times do they save patient’s lives? Keep it simple stupid. KISS. But how many of us truly remember this?

 

Any thoughts? What do you all think? Do too many paramedics jump to advanced skills before all the basic bases are covered? Let me know. 

Gossip is bad?

JEMS recently ran a story making the statement that gossiping in a company is bad and even said,

come to view the practice of gossiping as a safety hazard in organizations.

The link below will take you to the article. In it JEMS makes the statement that the best way to combat it is by simply abstaining from gossiping. It seems that could have a positive effect but is that enough? Should we do more to keep gossiping to a minimum? Is gossiping really that bad? Let me know your thoughts.

Here’s the link:
JEMS article

Dalai Lama

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Should epi be used in cardiac arrests?

In a new article by JAMA the effects of epinephrine in cardiac arrests is actually to a patient’s overall survivability. Very interesting article and am looking forward to the follow ups.

Here’s the link:
rogue medic