Uplifted

A man with his finger slashed by a lawn-mower, a nursing home aspiration pneumonia, and a young mother having a hard time dealing with stress. I'm doing a good job today of being thorough and being nice. Even though physically I'm still a little tired from trip. Mentally, I am quite uplifted.

Last call was for a woman worried she might have chest pain and feeling a little short of breath. Under stress. We took her in and made her feel better.

I'm off tomorrow.

Shock

Went to a nursing home for the unresponsive. The nurse explained the man was dying of lung cancer and was a full code and had no family. He was awake now, she said, but she had to sent him in because he was a full code. The man was fully alert and had no pain and good vitals. I think he was just sleeping.

Today was the Memorial Parade and the ambulance was supposed to be in it -- all three of our ambulances. I was glad when we got a call. I'm just not a parade kind of guy. The call was for a man's defibrillator going off.

When we arrived, it had gone off four times already. I put him on the monitor and it looked like V-tack.

Then all of a sudden, his whole body convulsed in pain and he cried out. The artifact was caused by the wires moving as his body convulsed with in pain.

It shocked him once more before I could get the line in and start giving him some 150 mg of Amiodarone over 10 minutes.

Here's the initial 12-Lead:

Shocking is incredibly painful. This guy, who even though he was diaphoretic, was joking with us, and then when the defibrillator went off, his whole body winced in pain, and he started cussing at me to hurry up and give him the medicine. I also gave him some Versed, and then hung an Amio drip at 30 mg/hr. He didn't get shocked again and felt much better.

His final rhythm was hard to determine. It was still very funky, but his rate slowed from the 150s to 100 and he was perfusing better. It was irregular. His wife said he only had 1/3 of a functioning heart.

In the hospital his rate was down in the 80's and showed his pacemaker kicking in.

He was better and thankful to his defibrillator and to us. We missed the parade and I was thankful to him.

Last call was at the same nursing home for the unresponsive diabetic with a CVA history and a blood sugar of 150 according to the home. We took her out to the ambulance and checked it. 28. Fixed that.

Back to Work

I'm at work. Tired, but here.

First two calls were for an assault on which we got canceled and a young woman with vomiting. She looked very sick -- the kind of sick where you don't feel like talking or even getting up to sit on the stretcher. Only in her twenties, renal diaylsis, hypertension, obese. I've been picking her up for years. Today she had a fever and looked like she'd put on another thirty pounds since last I saw her.

Last call was for a man who broke his leg in his driveway. He was in some serious pain. I ended up giving him 15 of morphine. At the hospital he thanked me for taking such good care of him. He was finally high by then, but at least I took some of the pain away.

Saturday - Arrival Home

We awoke at five-thirty, loaded our bags on the school bus, grabbed a quick bite to eat, and then were off on a four and a half hour bus ride. We went a different route than we came -- more highway but longer. The trip featured two types of traffic jams -- cows in the country, and standstill traffic of people and cars and scooters in downtown Santo Domingo.

A number of people on the trip were having GI problems and we had to make one unscheduled rest stop so people could run to the bathroom. I was lucky -- other than a brief episode one night, I came off fine. At the scheduled rest stop I finally got my tostones - fried green plantain -- and they were very good. The airport and customs at San Juan were all a pain, but we made it through fine. I always get stopped and searched. I think it has to do with my passport photo where I have long hair and a big mustache and look like a drug Lord. This time on my MP3 player I had Arlo Guthrie's "Coming into Los Angeles" playing. (Coming into Los Angeleez, Bringing in a couple of keys...Don't touch my bags if you please, Mr. Customs, man."

I read the Da Vinci Code on the plane. It kept me turning the pages, but I was never really engaged. When we landed home at 9:40 P.M. I still had twenty pages to go, but no real desire to finish. After picking up our bags, we said quick good-byes, and then went our seperate ways. Everyone was very tired. I crashed as soon as I got home.

Good to be home, but still, I'd love to go back soon.

Friday

We just had a half day today, doing small cases, and then packing and loading.

For the week we did sixty surgeries and almost two hundred consults.

In the afternoon a small group of us went with some of our local hosts on a boat trip through a mangrove swamp and out into the ocean, where we were taken to a spectacular beach.

The Dominican is a poor, but beautiful country. The people were so nice to us. They were so grateful. I am grateful to them. Trips like these help all of us. They remind you of what the world, of what we all should be about.

I hope to always come back.

Thursday

Since we are all done with triage, I went into the OR this morning. Going in there is like being in the Discovery Channel. Last year I scrubbed in on a gall bladder and got to stick my hands in the body to hold up the liver for the surgeons. I really wanted to do the thyroidectomy this time. I got to palpate the trachea and the crico-thyroid membrane with all the skin removed. Fascinating. The doctor told me, even with the skin all pulled back it is a difficult job to insert an airway into the membrane. There just isn't a lot of space.

Later one of the nurse anesthetists let me put in an LMA, which was very cool and very easy to insert. We may be getting them on our rigs in several months. While it doesn't secure the trachea, it takes no time at all to put in.

Post-op was slow with triage done and pre-op done for the day; there were more nurses than patients. I went back for the first lunch. I felt like I had nothing to do, but then I started looking around and while the things to do were not the big things, they were important -- getting water for patients, talking with them, making them more comfortable. I felt like a nurse. Imagine that. It wasn't bad. Say what you want about nurses, some of them here are very good and they have an eye -- not for what procedure can I do, but what can I do to make the patient feel better.

I did take care of one man in particular who I oversaw all post-op care for. An old man who all his life had a hernia, which was so big that when he walked in the day before, you could see it through his pants. The top doctor here kept saying "no more patients, but then someone in need would come in and he would say, okay, add him, add her. He is a great man. Anyway, the patient was so gracious and happy. He was a gardener for an old woman and she came and sat with him and told me how she had watched him labor all these years and how nice it was to see him without it.

A very gratifying day.

At night we were invited into town for a party thrown in our honor by the people who paid for our stay. It turns out they were the local version of the Lion's Club. They raised funds to house us at the resort and they all gave speeches and hoped we would come back every year. They had local musicians play for us and they served a big spread of roast pork and chicken and pasta and bread, and papaya for desert. The pork was fantastic. I told them I liked the skin -- cuerito -- so they gave me two huge pieces of it. So good, but so much fat.

I awoke in the middle of the night with a knife in my stomach. I was worried I had gotten some horrible GI bug, but I think it was just the pork skin and fat. A half hour later after emptying my stomach a couple times I was back to normal.

Wednesday

Another busy day in triage and post-op. I am amazed at the stamina of the two surgeons. They are doing ten cases a day, ranging from gallbladders, hernias, tubal ligations, mastectomies, to simple cyst removal. Tomorrow I will scrub in for a thyroidectomy.

Everyday I wear a baseball cap from the Dominican national team. They all talk baseball with me. They love the Red Sox, who have four Dominicans on the team, including their favorite and mine David "Big Papi" Ortiz. The Dominicans are not as crazy for Pedro Martinez anymore, although they follow his individual stats.

After work the bus went for gas. We saw a roadside bar and one of the great friends I have made, went in and bought us all Presidentes in the big 22 ounce bottles. Muy frio.

I told him.

Un hombre que me compra un Presidente es mi amigo para la vida.

A man who buys me a Presidente is my friend for life.

Tuesday

Before we started, we meet out front with the patients and sing a song called "Alabara mi Senor." It is the only official religious moment of the day.

Back to triage to start the day. The hospital was packed. I had a hallfull of people all talking a hundred miles and hour in Spanish. I got their names, dates of birth, towns they were from. I took their vitals, weighed and measured them, and got the gist of their complain, and then turned them over to a nurse who grew up in Cuba, who got their full history and did a full exam. And then those we think need surgery are told to wairt until the doctor gets out of surgery, and he comes down and examines them and they get booked. I make certain to say Buenas Dias and tell them all my name. Now whenever I walk down the hall, they all smile and call my name and have questions for me. In pre-op in the afternoon, I was talking if not in hundred mile and hour Spanish, at least going fifty-five.

I worked hard today and felt less guilty about my beer -- this time in La Mar -- the ocean.

Monday

I was going to start the day in triage, but the young college girl, who was going to interpret in Pre-op was sick, so they switched me with one of the pre-op nurses, so I did IVs and Spanish in pre-op. The IVs here are very easy as all of the Dominicans have ropes for veins. My Spanish was much improved. They bused us back to the resort for lunch, and since I went in the second wave and all my preop work was done, all of us in the second wave got to stay. Back to the swim-up bar.

Una cerveza para mi mano derecho y una otra cerveza para mi mano izquierda.

La Vida.

Sunday

This morning we set up the hospital, which is really pretty amazing. We walk into this cement building, and then with the medical equipment we all carried in one of our checked bags, and the equipment trucked in on the MMI van, in just three hours we have a functioning operating room.

After setting up, I work in the triage area, intervewing patients. Since it is Sunday and a day of rest around here, not too many come in. We target five for surgery to begin tomorrow morning. We expect a bigger line to be out the door.

I am having some trouble with my Spanish as many of the older Dommincans mumble and their dialect takes a little getting used to.

We got off ealy and I spent a couple hours at the swimup bar, drinking cervezas. Ah, the missionary life.

The food here is great. It doesn't look that good -- lots of potato, rice, chicken and pork dishes, but it is excellent. I had oxtails for lunch that were terrific. The cheese is also fantastic and I am not a cheese eater. It is just so fresh nd quite unlike what I have had before.

Tonight we meet as a group on the beach under the stars to go over the day ahead. I am assigned to triage to start the day, and then post-op in the afternoon. I am always anxious about what I will get to do, particuarly this time when there are so few surgeons (just a surgeon and a resident) and they have added a number of helpers and two college student translators who were not origionally on the list)and while my preference would be to be in pre-op where I can talk Spanish and start all the patient's IVs, in triage I will get to speak lots of Spanish (hopefully better than today), meet the patients for the first time, and then later in post-op, take care of them when they come out of surgery. I don't feel this trip that they are unaware of what I can do. I feel like I am being treated on par with the nurses, which
is all I ask.

Saturday

We had a long trip yesterday. I had to get up at three in the morning to get to the airport on time. Our flight from San Juan to Santo Domingo was delayed a couple hours. Once we arrived in the the Domonican capitol city, we then had to take a four plus hour bus ride over the mountains to arrive at this beach side village after dark. After staying under mosquito netting last year with often no electricity or running water, I am embarassed to say, we are all housed at a four star all-inclusive resort. It seems when the mission people were trying to find housing for us, some wealthy Dommincans overheard and were so impressed with what we were doing for people of the town -- free surgeries -- they offered to pay for us all to stay for the week at the resort in town.

Gas

Day started off with a man with gas who wanted a ride to the VA hospital. The only other call was an old woman at a doctor's office who hadn't eaten for three days and had been vomiting and was fairly short of breath. I ended up having to put a non-rebreather on her. I couldn't get a great history as she didn't feel up to talking. She had a pacemaker that was actively pacing so I couldn't get much from the ECG. No pain. Clear lungs. I gave some fluid. Aside from being dehydrated, I would love to know what else was wrong with her.

Off

Could have, but didn't work today. Spent the day moving furniture, working on the lawn and getting ready for my trip. Cut the grass low so it won't be too wild when I come back after all the rain we are getting.

Neck Pain

Went to the gym at 4:00 A.M. again this morning. Good time.

Three calls in eight hours. A woman with neck pain who had surgery on her neck fusing C4-5-6 two days ago. She was laying in bed and said her neck hurt whenever she moved. What was causing the pain? I don't know, but we c-spined her where she lay.

We did a lady with MS who's left side was spasming, and she was completely flipped out by it. We called and got permission to give her some ativan, which shut down both the spasms and the anxiety.

The last call was an intercept for chest pain for a patient from the I want to get out of work warehouse, and she walked out of the hospital before we were done with our paperwork.

Off

Spent the day doing errands and cleaning up around the house. Poured rain again. I was glad I wasn't working. It was some serious prolonged downpour. I'm working the next three days, then its off to the Dominican for eight.

Excited

I was just really excited to go to work this morning. I love my job. I awoke up thinking what interesting calls am I going to have today.

Well, I've had three and they were all pretty boring -- two MVAs and an I want to get out of work abdominal pain from the warehouse where we always go for i want to get out of work calls. Still, I've had a good day. I've been working on the computer, getting lots of good work done, particuarly gthering reasearch on the new protocol changes I want to propose, including steroids on standing order and magnesium for asthma, and morphine for undifferentiated abdominal pain. While at one hospital I went into their bookstore and bought a book about pain management and it had a great couple pages about how in age of advanced diagnostic tools and tests denying morphine to patients with severe abd pain is archaic and inhumane and how all the research shows it helps rather than harms diagnosis. I looked at another book, which said pretty much the same thing, including what to say to the surgeon if he is angry at the ER doc for giving morphine. The doc should suggest the surgeon give the patient narcan after first explaining to the patient that he needs to put him back in extreme pain in order to help see what is wrong with him.

I'm only working till four again today as I have to go to a meeting for my trip to the Domminican on Saturday. I'm off tomorrow, but back on Wednesday.

Hacuna Matata

Rainy Sunday. Only worked ten hours because I am soon off to see The Lion King.

Did a diabetic with a blood sugar of 36, and then was called for a stroke. Found a man in bed with a flaccid right side and difficulty speaking. His family found him this morning unable to get out of bed. He had a blood sugar of 56, but that was because he couldn't get out of bed to eat. I gave him an amp of D50 and it caused no improvement. The last call was for a "blown aneurysm in the arm." It was a pass from the commercial service, sending us lights and sirens. Our patient, at a nursing home, met us by walking down the hall. The nurse said there was just some yellow discharge from the site of the "anerysm." He was very stable.

My relief who I asked to come in two hours early for me, came in two hours and twenty minutes early, which was great.

Hacuna Matata.

Rain

Back from Boston. My friend and I decided to just go to his house and drink beer and eat barbeque rather than brave the rains at the ballpark. It turned out to be the right decision as even though they played the game -- it was called after five innings of downpour with the Red Sox losing 6-0. I ate some killer barbeque, but passed out on the couch well before ten with only a few beers in me. At least I woke up refreshed this morning. I have been behind on my sleep lately. I'm home now and am getting ready to go teach the new AHA to a paramedic refresher class.

Bledsoe Column

It's pouring rain. I'm supposed to go to Fenway Park tonight. Not looking good.

I just read the latest Bryan Bledsoe column at jems.com. Here's the link:

All Things in Moderation

Here's some excerpts:

"...during an average EMS career, a provider will reach a point when they suffer a significant amount of disillusionment. It’s not uncommon. We all encounter it. The causes are usually varied, but a common feature is the realization that the majority of EMS calls are non-emergencies. That means that all of the skills and technology we were trained to use are rarely required. This is the dirty truth of EMS."

"...some people in EMS will respond to this inevitable disillusionment in a different way. They determine, often subconsciously, that they’ll continue to use their skills and practices even if the patient does not stand to benefit. As this evolves, they’ll find ways to rationalize their behavior. Before they know it, they will have violated medicine’s most sacrosanct dictum — primum non nocere (first, do no harm)."

"Today, it seems the sign of a good paramedic is one who puts the most needles into bones, frequently calls the helicopter, intubates a child when a BVM will work, immobilizes somebody on a backboard even though most have a less than a 1% chance of a spinal injury, and runs “precautionary Code 3” just for jollies. I’ve been in nearly every state in this great union and often heard war stories from people proud of the number of crichs they’ve done, the number of IOs they’ve done, or the numbers if chests they’ve needled. I always want to ask (but never do) if the patient got better."

"An old internal medicine professor at Texas Tech once told me two things that I follow to this day:
1. Being a good clinician is more about knowing when not to do something as opposed to knowing when to do something; and
2. Never be the first to use a new drug or procedure nor the last to give up an old one."

Here's my favorite line:

"We’re not happy simply taking somebody to the hospital."

Something to think about.

Science Teacher

Worked 12 hours. Did three dialysis transfers. I don't think they were boning me, I just think we were in the wrong place when the calls came in.

I did a syncope at a college where a guy gave me a report prefacing it by saying, he didn't think the guy needed to go to the hospital. I did as I always do. I looked him in the eyes listened to his report and thanked him. He said he was a science teacher and he dropped the name of a guy I know and respect who he said he has taught with. The teacher started to leave, then he turned around and said, "Do you have a heart monitor? You might want to put him on the heart monitor?"

"We have one," I said.

"And the pulse ox, you should put him on the pulse ox."

"We have it under control," I said.

I told the patient who didn't remember passing out, he needed to go.

"But the EMT said I didn't have too."

"He was a science teacher," the guy's friend said. "This is the paramedic."

We took him in. When we stood him up to do orthostatics, he got very dizzy.

Later we sat for three hours, then did a woman with abdominal pain and then an MVA. We just missed a shooting that came in near where we were posted right after we were sent to the abd pain. It got very busy in the city. A rainy night. I was tired.

I'm off to Fenway Park tomorrow. I can use the break.

Preparation

Spent the day working on some projects and cleaning the house and trying to fix my computer which has been connecting to the internet at extremely low speeds. It turns out I had a bad phone line. I ended up ordering DSL, starting in June. I have a full calendar coming up. I'm teaching an AHA update class, going to Fenway Park, helping my father clear his furniture out of storage, going to the Lion King, and in little over a week, I'm going back to the Dominican Republic for another medical mission. I am starting to worry that I haven't worked as hard on my Spanish as I should. I think next week I will be in around the clock Spanish mode -- only Spanish TV, spanish newspapers, and as much Spanish conversation as I can drum up around the hospital.

Tomorrow I work 12 hours in the city.

Meetings

I went to my monthly regional educational and medical advisory meetings today. I was able to get the committee to agree to issue protocols immediately to permit paramedics to start utlilzing some of the changes recommended by the new AHA guidleines, while waiting until January to implement others.

The immediate changes:

CPR

Place emphasis on continuous quality CPR, with compressions at a rate of 100 per minute, 1 1/2" to 2" deep, allowing full chest recoil. Try to keep compression interruptions to less than 10 seconds. Compress while charging. Compress while intubating if possible. Non-intubated patients should receive CPR at a rate of 30:2, intubated patients should receive continuous compressions.

Ventilations for patients in cardiac arrest should be no more than 8-10 per minutes with each ventilation lasting no more than 1 second and containing only enough tidal volume to make the chest rise. Intubated patients not in cardiac arrest should be ventilated at 10-12 per minute. Do not hyperventilate.

Defibrillation

Instead of three stacked shocks, use 1 shock at maximum setting. After shocking, immediately do 2 minutes of CPR before checking for rhythm.

Patients in ventricular fibrillation who have suffered an unwitnessed arrest or for whom response time is greater than 4 minutes should have 2 minutes of CPR prior to defibrillation.

Intubation

Patients in ventricular fibrillation may have intubation delayed.

A Combi-tube and an LMA are considered 1st line airways along with ET.

Traumatic arrests should be intubated en route to the hospital if at all.

Drugs may only be given down the ET tube if IV access or IO access is unavailable.

IO

Adults may receive IO provided the device used has FDA approval. IO access should only be obtained on patients in extremis.

Asystole/PEA

Pacing is no longer recommended in cardiac arrest.

Additional changes to regional protocols, as a result of the new AHA guidelines will be implanted with regular protocol updates scheduled for January 1, 2007.

***

The new guidelines were produced by the International Liaison Committee for Resuscitation, after comprehensive review of scientific evidence from published studies.

Research shows the CPR currently being performed results in excessive ventilations (which decreases cardiac output), frequent interruptions of compressions and chest compressions too shallow and slow to produce results.

Hyperventilation increases intrathoracic pressure, which inhibits venous return. Since venous return determines cardiac output, hyperventilation reduces cardiac output, causing reduced oxygenation.

The new guidelines are about maintaining blood flow. Push hard, push deep, allow the chest to fully recoil. Minimize interruptions. When compressions stop, blood flow stops. Do not hyperventilate. When a patient is hyperventilated blood flow is compromised.

The question of shocking or doing CPR first is related to the patient’s physiological state. In the first 4 minutes of ventricular fibrillation, the patient is in the “electrical phase” of arrest, during which time the body has adequate oxygen and energy stores, a normal PH, and is unlikely to have suffered heart damage. The science shows this phase responds best to electricity. Intubation is not the priority during the electrical phase.

During the next six minutes, the body is in the” circulatory phase.” The v-fib is now fine or absent. There is inadequate oxygen in the heart, inadequate energy, acidosis, and heart ischemia. Effective circulation is needed to deliver oxygen to the hypoxic tissues to improve chances of successful defibrillation. Evidence suggests defibrillation before CPR in this phase may be detrimental.

Know the phase of arrest your patient is in.

The Committee also passed a lights and sirens document I put together for them without more than a minute of discussion. I was amazed. Sometimes documents takes years to get passed.

LIGHTS AND SIREN USE

GUIDELINES

Ambulances should use emergency lights or sirens only when transporting or responding to a call involving a patient believed to need immediate medical intervention.

Patient Response

Ambulances should respond lights and sirens only when directed by their dispatch center based on EMD criteria. Should additional information suggesting that the call no longer merits a lights and sirens response be received by the dispatch center while the ambulance is enroute to the scene, the ambulance should be downgraded to nonlights and sirens mode.

Patient Transport:

The crew member responsible for patient care during transportation will advise the driver of the appropriate mode of transportation based upon the medical condition of the patient.

When transporting the patient, the need for immediate medical intervention should be beyond the capabilities of the ambulance crew using available supplies and equipment.

Such conditions include, but are not limited to:

1. Unstable airway or severe respiratory distress

2. Shock

3. Patient with anatomic or physiologic criteria for Level One Trauma Center

4. Acute Stroke within the last three hours

5. Status Epilepticus

6. ST Elevation MI

7. Cardiac arrest with persistent ventricular fibrillation, hypothermia, overdose/ or poisoning

When in doubt, contact medical control.

Mode of transport for interfacility transfers should be based upon the directions of the referring physician or medical control physician who provides the orders for patient care during the transport. Generally, interfacility transport patients have been stabilized to a point where the minimal time saved by L&S transport is not of importance to patient outcome.

Lights and sirens use should be documented and justified on the patient care report (e.g., “flail chest”, “systolic BP<90”,>

Notes: In most cases (up to 95% of EMS incidents), EMS personnel can stabilize the patient’s condition to a point where the small amount of time gained by L&S transport will not affect the patient’s medical condition or outcome. In previous studies and in most situations, L&S transport generally only decreases transport time by a couple of minutes or less.

The American Heart Association gives a class III recommendation to L&S transport of patients in cardiac arrest. A Class III indication is not helpful and is potentially harmful. Providing CPR during L&S transport may increase the risk for injury to EMS personnel.

Exceptions to these policies can be made under extraordinary circumstances (e.g., disaster conditions or a back log of high priority calls where the demand for EMS ambulances exceeds available resources). These exceptions should be documented.

(The above document was adapted from Pennsylvania Guidelines.)

I have a lot on my plate for next month's meeting. We are going to start discussion of protocol changes. I am also giving presentations on the case for letting basics utilize the selective spinal immobilization protocol and a presentation on the ResQpod device.

ResQpod

Death of The Hypoxic Drive Theory

Three calls so far:

An old man with weakness in one of his legs times three days. He was a bit testy and didn't like answering questions. At the hospital, he told them he had gout.

We took an 80 year old lady with shortness of breath in. She had a COPD history, but wasn't wheezing. She'd just come out of the hospital following a five day stay in the critical care wing for heart, lung and kidney problems. She was short of breath even on a cannula, so I put her on a mask. The nurse said she had been belching, which can be a sign of an inferior MI. Her twelve lead had no significant ST changes, but she had all the conditions for a silent MI -- female, elderly, diabetic, ex-smoker, high cholestrol, cardiac history. I'll be interested to follow up on her.

Both the nurse on scene and the nurse at the hospital were concerned about having the patient on 02 by mask given her COPD history. I didn't go into it with them, but in addition to the EMS tenet that no one who needs it shall be deprived of oxygen, I came across an interesting article by a respiratory therapist named Jeff Whitnack called:

The Death of The Hypoxic Drive Theroy

Very interesting reading. Here's an excerpt:

In the May 98 issue of Clinical Pulmonary Medicine is an article titled Acute Respiratory Failure in Chronic Obstructive Pulmonary Disease” by Schiavi. In it the author concludes that…… “....The traditional idea that oxygen induces hypoventilation by suppressing hypoxic ventilatory drive at the level of peripheral chemoreceptors is no longer tenable.”

Here's the guy's home page, which includes a link to his powerpoint presentation.

Jeff Whitnack's RT Page

Last call was for decreased mental status in an elderly DNR patient with a COPD history. He was breathing in a strange way. He wouldn't open his mouth, so his exhalation would puff up his cheek's like a frog, then the air would go up out his nose. It produced a capnography wave similar to a bronchospasm. When I made him open his mouth to breath, his wave form straightened up.

Last call was for a middle aged man with chest pain and heart palpitations. He was very diaphoretic and looked uncomfortable. I put him on the monitor -- saw a rate in the 180's, and followed it with a 12-Lead.

It looked regular to me at the time, so I tried 6 mg of Adenosine, which briefly slowed it to reveal an irregular underlying rythmn, then he was back up in the 180's.

I gave him 25 mg of Cardizem. He was a big man and I was thinking maybe I should even give him a little more. His weight could have taken 30 mg in a first dose. The 25 worked.

My partner took a sharp turn and I dumped the contents of my med kit on the floor. I was a little late preparing a Cardizem drip. I got it hung as we pulled in to the hospital and was running it at 5 mg hour, then as we were wheeling him down the hall, he went back up into a rapid afib. I opened up the drip and tried squeezing it in, but he stayed up. I had about 15 mg in, when I turned over care. I came back from writing my report and he was finally back down in the 70's without any more meds than the drip.

Here's the heart rate trend summary, a feature I am just getting used to using:

Always

Started with a COPD/?respiratory infection. Gave her a combivent and she was much improved. I used the capnography. She only had a slight shark fin to start, but it did level off.

Next call was a refusal for an old man who fell due to poor balance.

Then we did an unresponsive diabetic. I've been there many times before. Old 93 year old man just doesn't eat much anymore. He has the tiniest little wife who is always glad to see me. He is always in bed. He is a hard stick, but I always get it on my second or third try. Today I got a 24 in the hand. He wakes up slow. I always ask him if he recognizes the pretty lady standing next to me. He always says "That's my wife." She always says, "he's back to himself again." Today when he told my partner he was 93, my partner says he is shocked he is so old. Today I say, "93? Then how did you get such a young wife?" She is likely in her 80's. "Now I remember why I like you," the wife says. "Cradle robber!" I say. "Me?" he says.
As we leave the wife says as she always says, "Well I hope to see you again, but not under these circumstances." I agree with her that I hope so too. But likely, I will see her again under the same circumstances, and the call will go the same as it always goes.

Back to Back X 7

8 transports, including 7 back to back, which is a lot for a suburban town where the transports are longer than the city. Making matters worse for me today -- I had little sleep, the pollen is killing me. I can't stop rubbing my eyes -- the night medic gave me some benadryl to take. Anything to stop the itching. So now here my eyes are swelling shut from the pollen, they are closing because of the benadryl, plus I am natuarly squinting because of the bright sun -- all the awhile the calls are nonstop.I will post about the day soon, but right now I need to take a little nap. I have never had allergies this bad. The news said Hartford is the worst pollen in the nation right now. All the cars are yellow. The wind is blowing and you see all these mini Tasmanian Devil twisters of pollen swirling everywhere.

The day started off okay -- no calls for the first two hours, but instead of sleeping, I am working on mt Capnography project.

See:

Ten Things Every Paramedic Should Know About Capnography

Then at eight no relief comes in for the night EMT, so she agrees to stay until we can get someone. Then the tones sound and we're off:

1. 83 year old with dsypnea and chest pain
2. 68 year old fell and broke wrist
3. 86 year old with pnemonia and dehydration

We are just about back to the base when we are sent for

4. 16 year old eight months pregant with side pain

We swing by the base on the way, drop off the night EMT and pick up my preceptee. We contact the medical EMD dispatch and they tell us, "Immentent delievery, baby is halfway out." I am flying down the road, my preceptee is saying he can't find the OB kit, I am trying to tell him where it it. I go flying past the turn, not because I didn't know where it was but because I am going to fast. Then we get there. No immenent delivery, just a 16 year old with a pain in her side.

5. 82 year old with a question of slurred speech for a day
6. 85 year old with soreness from prior day fall.

On scene the PD is very upset because this is the third "Code Three" we have gone to that has been passed to us from the commerical service that has turned out to be a routine transfer. (See 3 and 5, although 3 actually was pretty sick).

7. 50 year old with dizziness

Then we finally, finally get back to our base.

Last call is for:

8. 62 year old with syncope and a question of a couple cocktails and anxiety.

I drive home, have two cold beers, wish I could have four more, but have to be up at 5 in the morning to do it all over again, so I go right to bed.

The end.

Two of Ten

Had the day off, spent the morning working on a document called "Ten Things Every Paramedic Should Know about Capnography," which I hope to post soon.

Here's the first 2 Things:

***

1. Definitions

Capnography – the measurement of carbon dioxide (C02) in exhaled breath.

Capnometer – the numeric measurement of C02.

Capnograph – the wave form.

“End Tidal CO2 reading without a waveform is like a heart rate without an ECG recording.” – Bob Page “Riding the Waves”


2. Oxygenation versus Ventilation

Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled through the lungs and transported through the blood. Pulse oximetry measures oxygenation.

At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste product of this process (The Krebs cycle), diffuses into the blood.

Ventilation is how we get rid of carbon dioxide. Carbon dioxide is carried back through the blood and exhaled by the lungs. Capnography measures ventilation.

Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed. Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a high saturation for a couple minutes or more.

“Pulse oximetry may provide a false sense of security, even as C02 levels rise to dangerous levels.”

-Baruch Krauss, M.D.
Capnography in EMS
JEMS, January 2003

Stretcher

I worked ten hours in the city with my preceptee. Normally he rides as a third, but it was just the two of us. We were cranking all day, but didn't do one ALS call. We did a psych, a fall at the new convention center, an old woman who cut her finger, a severe abdominal pain from the clinic across the street from the hospital, who was a direct admit, a nursing home abdominal pain, a transfer and we were on our way to another call when the transmission started slipping, so we had to be cancelled off that call. We did another call, but I can't remember what it was.

I almost left the stretcher at the hospital one time. I'm not used to being the person who takes care of the stretcher. I left it in the hallway outside the room while I talked to somebody, then went and got something to eat. I was standing outside the ER when the guy who normally uses the ambulance we were in (he was there working for another service,) opened the back of the ambulance, presumably to see if we were keeping it clean for him(he had sealed all of the cabinets with the brakeoff ties), when I noticed there was no stretcher in the back, so I quickly went and got it. That would have been embarrasing.

I drove halfway to one call with the sirens on, but no lights. Once we'd switched ambulances, the controls to turn the lights on are different. The first ambulance, you just hit the emergency master, the second, you had to hit the mastwer and thenb the individual light buttons, and since they don't light up on the inside, you can't tell if they are on. I only noticed I didn't have the lights on beacuse cars were looking confused and not reacting properly to us.

The day wore me down all the driving and carting the stretcher around, plus the pollen continues to be terrible.

No chance to use capnography today.

I'm off tomorrow.

Excited

I used to hate difficulty breathing calls. I get them often in the suburban town. usually first thing in the morning at one of the nursing homes. A bad COPD or pnemonia. But now I like them because I get the chance to use capnography -- the chance to learn something new.

Started off with a nonverbal former stroke patient DNR/DNI with a fever of 103.4 in respiratory distress. He had a good capnography wave form with a number in the high twenties. Not that exciting, but it just adds another frame of reference for me.

The other call was for a young woman who rolled her car. She was just banged up, but we still c-spined her and took her in for evaluation.

I was tired. I went to the gym again at 4 A.M. I'm getting excited about it again. I have a tendency to get really excited about things and then just really get into them. That's how I became a paramedic, how I became a writer, how I got into poker, for awhile I was a gym rat and hope to be again, and now how I am getting into capnography. I'm just really excited about it.

Check it:

Capnography for Paramedics

The Picture of Health

Did my second CHF is just a couple days. When I first started in EMS, CHF was an extremely common call, but it has been increasingly rare over the years. Someone said it was because of Ace inhibitors. I don't know. I just don't do as many as I used to. This gentleman was on dialysis when he started having a hard time. Nitro and Lasix fixed him. I had my preceptee with me today so it was good for him to do a CHF.

The other three calls today were for a woman with abdominal pain, a young woman feeling light headed and an eighteen year old who fell from ground level and was "in and out of conciousness." The call was at a local distribution warehouse with hundred of young employees where we have been often in the past for similar calls. The guy said he fell because he was dizzy. He had no injuries or marks on his body. His skin was warm and dry and his vitals were the picture of health. They had a house EMT on scene who seemed horrified that we didn't c-spine the kid. He was fully alert, but told me he was too weak to wiggle his toes, but when I pressed against his feet, he had plenty of strength. When we went to pick him up, he sat bolt upright. The call came in at crew change so the night medic met me on scene. He said later the patient talked on his cellphone all the way to the hospital. At the hospital, they put him in the waiting room.

The other notable thing from the day is the nurse at the business where the woman had abdominal pain refused to let the first responders have access to the patient or to share medical information with him. I talked to her about it and told her it was their job and their legal responsibility. She said it had never happened to her in any of her clinics that first responders got to interview one of her patients. She was new.

I spent a good part of the day working on collecting information about capnography for a project I am working on.

? Posterior MI

Went to the gym at four this morning. All right for me.

Four calls today.

1. A woman vomiting for a couple days, who insisted on going to a hospital out of our range, so we had to call the commercial ambulance to take her. She was very stable and ambulatory. I was glad we didn't have to take her because the next call in ...

2. At a doctor's office, a man with a BP of 70, dizzy, not feeling well for two days. I got 68/34. He was pale and gray and did not look well. His capnography number was in the low to mid twenties, showing poor perfusion. I did a twelve lead and leads V2-V3 caught my attention.

The shape is often indicative of a posterior MI. I put a lead on his back and this is what it looked like.

I would have liked to have gotten a better tracing, but we were going on a priority. I tossed him some aspirin. The hospital looked up his old twelve lead from a month ago and it looked nothing like that. Then he started having chest pain and nausea in the ED. They were getting him ready for the cath lab when I left.

3. We had a nursing home patient with lethargy and a fever.

4. A man with vertigo.

The last three calls were back to back and the last call had a triage wait of 40 minutes, so I was late getting off. I admit to being on the tired side tonight.