Off

No posts for a week. I'm off.

Croup

I'm tired. Fortunately, it's been another slow day. 1 call in thirteen and a half hours. An old man with dementia feeling weak. Another hour and a half to go. Watched both World Cup games today.

If I don't work in the city tomorrow, which is unlikely, I will be off for a week as I am taking a vacation. Hooray!

Tomorrow I plan to sleep late, then do some cleaning, mowing the lawn, doing errands, maybe even going to the gymn and hitting the weights. Get to bed early, then I am off.

Get a call fifteen minutes before crew change. A five year old asthmatic, except his lungs are clear and he is satting at 100%. He has a barking cough and his throat hurts. I'm guessing its croup. I give him some humidified oxygen and he seems to be doing fine. En route to the hospital, we get diverted because our origional hospital has just gone on diversion. I end up punching out almost an hour and a half late.

Stop Grimacing

Took a nurse from a nursing home to the hospital for an infected dog bite. She was feeling a little woozy, so her boss ordered her to go to the hospital by ambulance. She had a little banadage on her arm. The bite occured two weeks ago, and she had been taking antibiotics, but the arm still seemed infected. She was embarassed to go by ambulance. My general attitude is you want to go to the hospital, I'll take you to the hospital. Fly the friendly skies. Then she pulled off the bandage and showed me the bite. It was nasty. Big punture wound, all white and red and ulcerous. She was afraid she might have gotten some nursing home germs in it. Like MRSA.

We did a routine kid choking, okay, he's not choking anymore, and when we get there, he is smiling and giggling. Nothing wrong with that.

Went to a business for a man who'd had a stent put in a week ago after a stress test revealed ST elevation on exertion. Healthy young guy, younger than me. No prior problems. He said he had a 95% blockage in his LAD becfore he got the stent. The LAD. Left Anterior Descending artery. The Widowmaker. Anyway, he hadn't been feeling well for a couple days with occasional chest tightness so the nurse at his job said they had talked to his cardiologist and he might have to be recathed so they could check the stent to see if it was working properly.

Last call was for a guy with a hernia that had popped out and he wasn't able to reduce it as he sometimes could. He said it would have to be resewn -- he knew the jargon. He was in a fair mount of pain. I thought this would be a great test case for me to call to ask for morphine, but he said he would wait until the hospital. He wasn't that bad. I felt like saying, then don't tell me you're in pain, and stop grimacing if you don't want me to help you.

I taped the World Cup today and instead of missing it while out on calls, I was able to watch both games, which were very exciting.

MORPHINE

Walked in the door and the buzzer went off. 100 year old lady tripped in the dark during the night and broker her arm. She said her pain wasn't bad as long as she wasn't moving her arm. I asked her if she wanted any morphine and she said no. She was a very proper old woman who had spent her life at an upper class country club and who had quite high social standing.

I have been doing a lot of thinking about pain relief. There are two groups of patients I would like to help tht I feel are being neglected. The group that says that are allergic to morphine and the group that on hearing the word morphine, immediately says no. The first group is broken down into those truly allergic and those who just get nauseous. The second group thinks either they are not hurt enough to have to get MORPHINE or that Morphine will turn them into skanked out junkies. I think the 100 year old lady was in this group. Proper ladies do not partake of morphine under any situation.

I am working with the head of medical advisory committee to try to get us to carry another drug -- either tramadol or possibly nubain that would enable some relief to these people. What I did do the other day with someone who said they were nauseous whenever they got morphine was to pretreat them with phenergan and that worked really well. I'd just like to be able to provide relief to everyone. I suppose I could have just told this old lady I was going to give her something for her pain and gone ahead and given her a little morphine without naming it.

Other two calls were for a woman with a fever and a chest pain and a woman who took twice the dose of a diet pill and felt her heart racing. I thought it was a bit of a BS call, but when I did a monitor, she had flipped T's in the inferior leads. How that compared with her old ECG, I don't know.

On Time

Eleven hours fifty-five minutes and no calls, and then the buzzer rings.

Fortunately, as we're pulling out, my relief is pulling in and I punch out on time.

Of Course

Old lady with Alzheimer's fell and sliced the back of her head on a door. She denied she had fallen. Her husband told her she had to go to the hospital. You're not coming with me? she asked. No, I think I'll go to a tag sale by myself, he said. What? And leave me? No, he said, of course I'm going. He smiled at me and shook his head.

We went to the health center and I ran down to the library there to see if I could find a research article. I swear librarians are the nicest people in the world. You can't find a more helpful person. The health center is near my house and I think I will just drive there whenever I want to read any research articles. They have everything. If not in the stacks, then they have it online. It only costs 7 cents a page to print out. Sometimes I've paid up to $30 for an article I desperately wanted to read.

Last call was for an eight-year old girl who ran out in front of a car and got hit. She was sitting up by the side of the road when we got there. Her sister said there was no loss of conciousness, but the girl didn't remember what happened. She had road rash on her right side and looked like a broken arm. We took her in on a priority.

We had a cookout afterwork with about fifty members, including family coming. Good food. Pork tenderloin, beef tenderloin, barbecued chicken and hamburgers and hot dogs for the kids. Then the police chief talked about how they planned to fill the EMS chief for the town position. I have mixed feelings about the job. On one hand I would love to be the EMS chief for this town. I get along with everyone well. I have lots of ideas I would like to try out, it would be a big challenge. Plus there is the town pension. But it would mean less to no time on the road as a medic. And much less money, as while the salary may be more than I make in 40 hours, it would mean no overtime pay, and there have been years when I make more in overtime than I do in straight time. Everyone got in a big discussion then about pagers, and the discussion went on and on about the right kind of pagers to get and all the problems with each kind. I guess I would rather spend my time learning about capnography than pagers. I don't know. I love being a field medic.

Who Let the Dogs Out?

Began the first of what will be six days in a row in the suburbs. Started the day with the same woman from the group home I brought in on Tuesday with the abdominal pain/knee pain complaint. The people at the group home were angry tht the hospital hadn't given them a diagnosis. She was sitting in her chair, feigning unresponsiveness when we got there. On Tuesday she and I had sung "Country Roads" together, so I sat next to her and started whispering in her ear the lyrics to the song, and wouldn't you know, she starts singing: "Country roads, take me home, West Virginia!" and then she ad libbed "Who Let the dogs out!"

She stood, got on our stretcher, and we took her in. The hospital said it was the third day in a row she had been there.

Then I did a 77-year old female with increasing respiratory distress. Only respiratory history was COPD, but she sounded like she had rales. Pale diaphoretic, warm, some pedal edema. Heart rate 108. Respirations in the high 30's. Sats in the 80's. She had a nice straight up wave form. I held off on a treatment and held off on Lasix and just went with 02 by nonrebreather and nitro, and she started breathing much better. Heart rate and respiratory rate improved steadily. Sat came up to mid 90's. Did capnography change the way I practiced? No, but it gave me more confidence in not giving a treatment, which I am always leary of doing when I sense CHF. At the hospital she had a temp of 100.7. I listened to her lungs with the respiratory therapist and she said she heard crackles and decreased sounds in one of the lobes. Only a tiny expiratory wheeze when she took a really deep breath.

The City

Seven calls in 12 hours in the city.

Did a lady who fell down three stairs, severely breaking her forearm and twisting her ankle. She was crying in pain. I asked her about allergies, and whether she could take morphine. She said it always made her sick. I convinced her to let me give her some phenergan first, then then I gave some morphine very slowly. I ended up giving her 12.5 of morphine, and it helped a great deal. No nausea.

The most interesting call was for an unresponsive. Obese male in his thirties with IDDM and kidney problems who hadn't been taking his insulin was found incontinent and thrashing about on the ground. His heart rate was 140. Pressure 200/100. Pupils dilated and non-reactive. Altered breathing. Respiratory rate in the 30's. I did a finger stick and only got 375. I did again and got 377. He was feverish and the hospital later said it was 103 degrees. He was a very difficult extrication. We had to use a scoop and at several places stand him up straight. I thought at one point when we were carrying up the steep narrow basement stairs that he had coded.

In the ambulance I put him on the capnography and was surprised to see a good number of 38. With the nonrebreather he was SATTing at 98. I felt a little better about the immediate prospect of him coding. Still we took him in on a priority. The hospital got 666 for a blood sugar. They knocked him out and intubated him.

Other calls were for an MVA, a neighbor hit on the head with a cane by a fellow tenant, a guy with walking pneumonia, an uncooperative nursing home patient, and a woman who fell and scraped her legs.

Could Be Old, Could Be New

Back at work. Slow day. A woman at a group home claiming first abdominal pain, and then knee pain. A nursing home call for an old fall with a questionable xray. Could be an old fracture of the shoulder, could be a new one. Patient not in much distress. Then a motor vehicle with no injuries.

I’m not complaining.

New Report on EMS

The Institute of Medicine has just released a series of reports about the nation's EMS system, including one prehospital care. I am still away, and have only glanced at it, but plan on reading it in detail. Here's a summary:

"Emergency Medical Services (EMS) is a critical component of our nation s emergency and trauma care system, providing response and medical transport to millions of sick and injured Americans each year. At its best, EMS is a crucial link to survival in the chain of care, but within the last several years, complex problems facing the emergency care system have emerged. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air medical crashes. This heightened public awareness of problems that have been building over time has underscored the need for a review of the U.S. emergency care system. Emergency Medical Services provides the first comprehensive study on this topic. This new book examines the operational structure of EMS by presenting an in-depth analysis of the current organization, delivery, and financing of these types of services and systems. By addressing its strengths, limitations, and future challenges this book draws upon a range of concerns:

The evolving role of EMS as an integral component of the overall health care system.
EMS system planning, preparedness, and coordination at the federal, state, and local levels.
EMS funding and infrastructure investments.
EMS workforce trends and professional education.
EMS research priorities and funding.
Emergency Medical Services is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems. "

Here's the link to read it on-line:

Emergency Medical Services:
At the Crossroads

Away

I am away for a few days. I will be back posting on Tuesday.

Clearance

Eight hours. Four calls.

Started off with a man in his thirties with sciatica. His pain was so bad that he couldn't move. He was allergic to sulfa drugs so I couldn't medicate him. I have run into a number of morphine or sulfa allergies lately and it has me wondering about investigating alternative drugs for us to carry so these people won't be denied pain relief prehospitally.

We were called for an unresponsive and found a man cold and clammy out cold leaning against a fence. I was think ETOH, but when I checked his sugar I found it was LO -- less than 20, so I gave him some D50 and he woke up. He was fasting and on his way to see his doctor to have his blood work drawn.

We did a long distance VA transfer and then an MVA. The woman was cspined when we got there. There were two victims -- each going to different hospitals. On assessement, her pain was just in her shoulder and across the seat belt harness. I went through the clearance with her and was able to take her off the board en route. That made her much more comfortable. She had been carsick, nauseous and anxious.

I really want to push the BLS spinal clearance. It is an easy protocol to follow. The other day I saw a woman c-spined in triage and she was crying because she had to pee and they wouldn't let her off the board, and she didn't really even have an injury -- she'd been in a low speed MVA, and her she was all in her business suit and she had to pee and the truage line was long and they were yelling at her to quit moving around.

In a Row

Worked 12 hours in the city. Six calls. Six emergencies.

A chest pain at a medical facility. They gave the poor guy three nitro, 2 of morphine and he says 10 baby aspirin. The nurse said three, but he said other nurses gave him more. So they were on their toes about the need to give ASA for chest pain. The problem was his pain was in his back and it was clearly reproducable. he flinched when you touched a certain spot. been going on for two days. Good 12 lead. The drugs they gave him dropped his pressure to 80, but then it came back up to 100. He was a COPDer on a cannuala at 2. The nurse said he couldn't get more than two. She said when she put him up to three, his SAT dropped from 91 to 86. I asked how that was possible. She said it was because he was a COPDer. But his SAt still will go up if you increase his oxygen. he's a COPDer, she said. I just looked at her. Since he was a little short of breath, I bumped it up to 3 in the ambulance, his SAT went up to 95 and he said he felt better.

We did a nursing home hemoturia, a 31 year old with abd pain, a 34 year old with a sore throat, a 60 year old obese woman with an arthritic hip, and an unresponsive diabetic.

The lady with the arthritic hip was the great grandmother. She weighed about 350, the grandmother was three hundred, the mother was 250, and the daughter who was maybe five was a little fatty at maybe 100. I wanted to line them all up and take a photo.

Working eight tomorrow.

No Quorum

We didn't have a quorum at the Regional meetings today, but we still talked about the agenda items. There was some contention about my proposals for spinal clearance for basics and morphine for undifferentiated abdominal pain, but more support than opposition.

I went into work afterwards, but the only call so far has been for an abd pain with fever.

2-0

Two calls -- an MVA for neck pain and a nursing home fall with no apparent injury. I've been watching World Cup Soccer and was hoping to be able to see the USA-Check game. The Checks were up 2-0 and in full control when we were called out, so that was okay. They lost 3-0.

Tomorrow I have my monthly EMS Regional meetings and then I am going in to work a four hour shift.

Insisted

Checked another prisoner. Took a kid with some scrapes from falling off his bike to the hospital. Mom insisted on the ambulance.

Got lots of work done on my capnography site today. I'm leading a journal club discussion in another week or so on some capnography articles. Very interesting. One article points out that supplemental oxygen can obscure impedending ventilatory crisis unless you have capnography. Pulse oximetry is only good without supplemental 02.

Here's the article conclusions:

Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial.

Pediatrics. 2006 Jun;117(6):e1170-8.

CONCLUSIONS: The results of this controlled effectiveness trial support routine use of microstream capnography to detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children. In addition, capnography allowed early detection of arterial oxygen desaturation because of alveolar hypoventilation in the presence of supplemental oxygen. The current standard of care for monitoring all patients receiving sedation relies overtly on pulse oximetry, which does not measure ventilation. Most medical societies and regulatory organizations consider moderate sedation to be safe but also acknowledge serious associated risks, including suboptimal ventilation, airway obstruction, apnea, hypoxemia, hypoxia, and cardiopulmonary arrest. The results of this controlled trial suggest that microstream capnography improves the current standard of care for monitoring sedated children by allowing early detection of respiratory compromise, prompting intervention to minimize hypoxemia. Integrating capnography into patient monitoring protocols may ultimately improve the safety of nonintubated patients receiving moderate sedation.

Bottom Line for EMS:

Capnography provides early warning of respiratory compromise.

Supplemental oxygen impairs detection of hypoventilation by pulse oximetry.

Chest. 2004 Nov;126(5):1552-8.

CONCLUSION: Hypoventilation can be detected reliably by pulse oximetry only when patients breathe room air. In patients with spontaneous ventilation, supplemental oxygen often masked the ability to detect abnormalities in respiratory function in the PACU. Without the need for capnography and arterial blood gas analysis, pulse oximetry is a useful tool to assess ventilatory abnormalities, but only in the absence of supplemental inspired oxygen.

Bottom Line for EMS:

Without capnography, supplemental 02 can obscure impending respiratory problems.

Concordance between capnography and arterial blood gas measurements of carbon dioxide in acute asthma.

Ann Emerg Med. 2005 Oct;46(4):323-7.

CONCLUSION: In adult asthmatic patients with acute exacerbations, concordance between PetCO2 measured by capnography and PaCO2 measured by arterial blood gas was high. These findings must be validated before capnography replacement of arterial blood gas as an accurate means of assessing alveolar ventilation in acute asthma is recommended.

Bottom Line for EMS:

Capnography may provide a reading as accurate as ABGs.

Cold Pizza

I worked a 16 in the suburb. A 16 can be great on a Saturday, but today we were busy at least early on. Started off with an MVA where we took a mother and a daughter to the hospital with neck and back pain. They were struck from behind at a low speed and did not appear to be too injured.

Then we did back to back nursing home pneumonias – both pretty severe. One patient had COPD. She was SATTING at 88% on a cannula at 2 lpm. Her temp was 103. Her respiratory rate was 60. I put her on the capnography and she was rebreathing, meaning she was breathing in before she was done exhaling. Her capnometer was 20, which is low. I put her on a nonrebreather at 15 lpm. Her SAT went up to 99%. Her respiratory rate went down to 36. Her wave form leveled off, and her capnometer went up to 32, close to normal. Then after about ten minutes, I tried to put her back down on a cannula –same thing happened – she went back into a higher respiratory rate with rebreathing, declining SAT, and declining capnometer. At the hospital the nurse said she was getting too much 02. I told her how I had tried to wean her down, showed her the capnography waves and numbers and made a remark about the hypoxic drive being more theory than clinical experience. She said maybe she would try her on a vented mask. Worth a try, I said. When I came back two hours later, she was still on a mask.

We checked out a prisoner with a bruised arm and took a man bleeding from his dialysis shunt to the hospital, even though the bleeding had stopped.

Doesn’t sound like a lot of calls, but all back to back, particularly when you had an uneaten large pepperoni, sausage and onion pizza in the front during two of them, it seemed like a lot.

The night ended quiet.

Report

1:30 in the morning, the buzzer goes off. Call for a person at a nursing home who the nurse says is faking it and just wants to go to the hospital, but is complaining of chest pain. Great. I sleep walk out to the ambulance. We drive there without lights and sirens simply because we will get there in the same amount of time either way because no one else is on the road. The nurse meets us at the door. We wheel the stretcher in and ask which way. "Out of the way," she says, "I need to lock the door." Okay.

She leads us to the room. She seems very annoyed. On the way, she says, "I shouldn't be telling you this, but he is faking, There is nothing wrong with him, but I had to call the doctor and he said send him in."

The patient is familiar to me. I've taken him in in the past. He is a COPDer. The nurse is back with the paperwork, which she is giving to my partner. "I need that," I say. She looks at me, but then back at my partner, still trying to hand him the paperwork and talk to him. "No, you need to talk to me," I say.

"Don't talk to me like that," she says.

What? "Excuse me, you need to give me the report. What exactly is going on with the patient?"

"I'm not talking to you. He's an EMt, I can tell him."

"I'm the one who's going to be taking care of the patient, you need to give me the report."

"Well, how would I know that?"

"That's why I'm telling you, you need to talk to me."

"I'm not giving you the report."

I feel like I am in a dream. I haven't raised my voice, I haven't done anything and this nurse is yelling at me at two in the morning.

"Look, you dialed 911. You have to give a report."

The police officer has come over to intervene now.

"Let's think about the patient," he says to her. "You need to cooperate with us."

"He can read it, but I'm not talking to him."

"I can't read it," I say.

The light in the hallway is dim and the writing is not the clearest.

I finally get some semblance of a report. She says he was belligerent and threatened to kill himself because she wouldn't call an ambulance. And that he is all the time faking illness. I ask if he has psychiatric problems. He does, she says. Wht meds is he on? It should be on there, she says. I hand her the paperwork back. She looks at it. It lists nothing. She has to go get the med list for me. I talk to the patient. He refers to the nurse as a B----. He says he has chest pain, the runs and hurts all over. He says he just got out of the hospital following a three day stay for pneumonia. None of that is on the W-10. We load him on the stretcher and go.

I call for times and the dispatcher asks what did we do to the nurse. She called to complain about me in particular. I tell the dispatcher I'll write an incident report.

I do. I write about how she said the patient was faking and how he had to threaten to kill himself to get her to call for an ambulance.

She'll have to give another report to someone else.

Hoping

Working a sixteen hour overnight. I taught skill sessions this morning, and then came to work. Did one call -- a woman with a possible infection. I get off at six in the morning, I don't like overnights so I am hoping it will be quit. Being up all night can wreck the rest of my week. Its so always a gamble. getting paid to sleep or getting paid to be sleep-deprived.

Expert

I could be an expert in a lot of things I suppose. I could be like this super hedge fund guy -- a guru who knows the ins and outs of the market. I could be a lawyer specializing in the intracacies of the tax code or maybe a wilderness guide who knows the forest like a feral animal. Instead, like many of my peers in this profession we call EMS, I am an expert in picking people up off the floor. Today we used one of my favorite moves to get a huge person up. Lay them on a board, strap them in, then with a person on each side and me at the head, I lift the board up to a standing position while they balance the patient, and a family member gets the walker or wheel chair, then we unclip the patient, they thank us, we get a refusal, and put our board and clips away. Another job well done.

Two lift assists today and an old man with pneumonia.

No Where

In the suburban town where I work several days a week there are four full-time medics, three ambulances and two sets of ALS bags, one LifePack 12. Each medic is assigned an ambulance. I share an ambulance with the other day medic, as well as the same set of ALS gear. I come in in the morning, check my gear, and then don't have to worry about it for the rest of my week as I am the only medic using it. What I do do each morning is switch the narcatics into my ambulance along with the Life Pac 12, the pedibox and the spare drug box. This week, the mechanics came early in the morning, woke us up and said they needed to take one of the ambulances. I took the gear out of the ambulance, but by mistake I left the other medic's ALS bag in the ambulance they took down to the garage so when he came in that night, he had to use my bag. This morning they brought the other ambulance back. I switched the narcs, the Life pack 12, the pedi box and the spare drug kit.

Our first call was for a minor motor vehicle that was going to be a refusal until at the last moment the man balked at signing the refusal and said, hell, he might as well go to the hospital. My partner, who is new because my regular partner is away this week, set up the stretcher, and then we took a nice ride in. Later in the day, we were sent for dsypnea at a cardiologist's office. After we pulled in, I glanced in back to see if all the gear was on the stretcher. Guess what? Where's the ALS bag? No where.

I threw the spare house bag and the spare drug kit on the stretcher and prayed that the patient would not need to be intubated. It turned out all right. He just needed a treatment and I was able to get a nebulizer off the shelf along with atrovent and albuterol from the spare drug kit. Still. A close one.

It wasn't the first time I have forgotten something. See : The Stretcher

We drove back to the base, got the ALS kit, only to discover we had the patient's cane. We took the cane back to the hospital and realized we had left our 02 tank at the hospital when we saw it sitting orphaned in the hallway. Then I went back to the ambulance and found my wallet had fallen into the doorway, and was half-in/half-out of the rig. What a day.

Last call was for a woman at a charity benefit with abdominal pain. It was right lower quadrant pain, dull and crampy, sudden onset. Did not increase with movement. I thought it might be kidney stones. The pain came and went. She was related to someone because two doctors met her at triage and started examining her there, much to the annoyance of the triage nurse. She didn't know the older doctor who was spouting possible diagnoses. The other doctor, an ER resident, looked apologetic and mouthed she was asked to examine the patient.

Dumdum

Just two calls today -- a three year old who swallowed a dumdum lollypop and then told his mom his throat hurt and a 77 year old man with a TIA that resolved as we were arriving.

Note/SuperImposed

We were sent to a group home for a fall only to find an apparently uninjured 50 year old woman with Down's laying on the floor, saying her back hurt and to call her mother with the bad news. The aide was on the phone telling her supervisor they had called the ambulance to cover themselves. The physical survey was unremarkable. The aide told me the woman had hit her while they were arguing over a napkin, then the woman had pulled at the napkin, then let go, hit against the wall, then fallen slowly to the floor.

I have been a really good paramedic since I came back from the Dominican. I just really have been at the top of my game both medically and as importantly with the bedside manner. I have been battling some bad news about the health of a friend and it was starting to break me today, and I snapped at the driver on the way to the call for going to slow looking for a turn when clearly there were no turns visible. Anyway, I have been to this home many times before often for similar calls, so I just ask which hospital, put the patient on the stretcher and take them in. It is easy than getting upset, and it isn't even my place to get upset.

So we're riding in and I am reading through the big blue book with all the patient's history, and here is the gist of the patient's story. Born to older parents, she lived with them at home for many years. Her mother is a nurse, and she often went in to work with her and volunteered helping the elderly patients. She was beloved. Her father died, and then, her mother aged now and in a wheelchair, was having a harder time taking care of her Down's daughter, who getting older herself started having some mental problems, and one day, attacked the mother. The mother scared of her daughter could no longer care for her and the daughter had to be removed and was placed in this home a few years ago.

Here is what the nurse wrote in the notes introducing the patient to the staff:

"This is a very difficult and confusing time for Y. She was born with disabilities and her family embraced her and cared for her throughout her life. Her parents aged. Her father died and her mother is increasingly frail. This is frightening to her and she has no idea how to manage in the future.

As a result of her Down Syndrome, she is more likely than we are to have problems with dementia. That means that her memory is failing her and that she has to come up with an explaination in her own mind for the things that no longer make sense because her memory is failing her. She has created a host of "friends" who are part of her everyday life, as well as the notion that she is pregnant and will soon have another child. What a wonderful way to surround yourself with the family that you see is dying off!

The false ideas that her mind creates serve to provide comfort and safety against fears of aloneness and isolation that she cannot imagine she could endure. We have to learn how to live with these things and to help her to feel more secure.

The memory loss that comes with Alzheimer's Type Dementia can be hard to deal with. And it can be seen as a wonderful protection against the many things that memory would serve to present as unbearable. Imagine being more than 50 years old and having nothing but the security of your parents love. So, as memory fails, and fears of being left alone in the world increase, you develop ideas about any number of people who will be here to share your life.

As we care for Y and come to learn her strengths and limitations, we must also understand that her life has been very different from ours and from the lives of people whom we are accustomed to serving. Until today, she has been protected by the love of family that many we serve have never known. And it was her behavior that brought that to a halt.

While we have many thoughts about how wonderful it is to serve people who would, without the care we give, be in institutions, we must understand that Y has known a lifetime of family and safety. We are not rescuing her from something awful, we are supporting her in a time of tremendous loss and separation."

You find poetry in most unexpected places.

***

Only other call was for an old obese woman diabetic, short of breath with a high blood sugar.

***

I was supposed to work in the city tonight starting at six. Ten minutes to six a call came in for a motor vehicle and we responded to find a Saab wrapped around a telephone pole. The patient was pinned in the driver's seat, the door against her hip, the airbag deployed, the steering colum broken, and the patient was screaming about how bad her head hurt. It was split open in back. I didn't think we were going to be able to get her out of the car with out the fire department. Two of the cops were banging away against the passenger door. I was talking to the patient through the window. I made sure to tell him my name and say I would stay with him. I kept looking up at the wires on the telephone pole. They weren't loose or anything, but I was standing right under them. the car was rocking. It was on an incline. Glass was flying. I got an 02 mask on him and a collar, and amazingly the cops got the door open. I still didn't think we were going to get him out. The door was halfway across the front seat. I went in through the now open passenger door and was able to link and pull her him out onto a board. He was very pale. His hip was killing him now. We got going to the hospital right away. His heart rate was up 160. He was screaming for me to give him something for his pain, but he wasn't stable enough for me to give it to him. The night medic had met me on scene so he rode in with me which was great. We got the trauma room and he was headed for surgery when we left. The x-ray of his pelvis looked like two people superimposed. The left side was almost on the right.

I was in the EMS room writing my report when I saw the other five people reach for their pagers. Then all said at once to me, they're looking for you, you're supposed to be in the city. You're on the schedule. I called in and told the supervisor I had arranged with another supervisor a couple days ago for them to come get me in an ambulance at the suburban post at six and then drop me off there at midnight, and he said it was all set. The message didn't get through. I told the supervisor I was still at the hospital. They didn't have anyone to work with me anyway, and since I was beat, they said I could just go home, so tonight instead of eating in the ambulance in the rain, I've had a steak and a beer and some fried green plantain, and am soon for bed.

TPA

35 year old male sudden onset of difficulty speaking and extreme right-sided weakness -- unable to move right arm, facial droop. 3 out of 3 on the Cincinnati Stroke Scale. No prior history of CVA. Mother calls 911. We are there within ten minutes of onset. Quick stair-chair down to the ambulance. We do everything en route -- Vitals, 02 by cannula, IV, Blood sugar check, 12 lead ECG -- notify the hospital of a stroke alert. We are at the hospital within 25 minutes of onset. We are talking to the doctor within 30 minutes. The patient is whisked right off to CAT scan. He comes back with a clean head CT -- no bleeding. The doctor tells the nurse to get the TPA ready. When we come back two hours later, the patient can move his right arm, shake my hand, and while his speech isn't perfect, he can now say his name.

So many times you get called, and the symptoms are hours old or no one can pinpoint the start time or if they can, and its within the window, there is an exclusionary factor. It was great to have a case where it all worked the way it was supposed too.

Did three other calls -- a woman who took a coworker's pepcid and felt quesey, an old man who'd been on the floor since 4:30 the other's day's afternoon and who had horrible cellulitis with weeping sores, and an old woman with dehydration who I had taken in two weeks before for the same problem.

Morphine Proposals

Two days off. I did some EMS project work. I put together three proposed protocol changes along with the backing science. One involves asthma -- making SoluMedrol a standing order and adding Magnesium for severe asthma, also on standing order. The other two both involved Morphine, and are an excellent example of how research is changing the way we practice (although I am not certain the committee will go along with my suggestion). I am proposing to make morphine for undifferentiated abdominal pain a standing order at a "judicious" dose of .05mg/kg before having to call medical control. The dose for fractures and burns is .1/mg/kg. I am also proposing that morphine for chest pain be taken off standing order and returned to a medical control option because of recent research suggesting that not only may morphine may not help patients with Acute Coronary Syndrome, it may contribute to their deaths.

Here's an excerpt from my proposal:

Proposed Protocol Change # 1:
Morphine for Undifferentiated Abdominal Pain

The Change:

In the Pain algorithm under Other Pain, change the heading to “Abdominal Pain (possible kidney stone, sickle cell anemia or undifferentiated pain)” and include the following:

If patient is hemodynamically stable: Administer .05 mg/kg Morphine Sulfate (MS) SIVP to a max of 5mg.

Establish Medical Control

Possible Physican Orders:

Additional MS

Also, add the following footnote:

“This change is due to recent research that shows morphine does not hinder abdominal pain assessment, and may in fact improve diagnoisis. Thus paramedics may give “a judicious dose” of morphine (.05 mg/kg) on standing order to patients with non-traumatic abdominal pain. Additional needed morphine may be requested upon contact with medical control.”

Background:

Withholding morphine for abdominal pain in the belief that it might mask pain, delay diagnosis and contribute to mortality has been a long-standing practice in medicine despite the lack of any research supporting such a practice. As medicine has turned to evidence-based practice and with a concern toward alieviateing patient pain, as well as the presence of increased laboratory and imaging tools, there has been a paradigm shift on this issue.

“The judicious use of analgesics in the setting of acute abdominal pain is appropriate.”
-Cope’s Early Diagnosis of the Acute Abdomen
2000 Edition

“Administration of narcotics to patients with abdominal pain to facilitate the diagnostic evaluation is safe, humane, and in some cases, improves diagnostic accuracy. Incremental doses of an intraneneous narcotic agent can eliminate pain but not palpation tenderness. Analgesics decrease patient anxiety and cause relaxation of their abdominal muscles, thus potentially improving the information obtained from the physical examination. There is evidence that pain treatment does not obscure abdominal findings, or cause increased morbidity or mortality.”
-Clinical Policy: Critical Issues for the Initial Evaluation and Management of Patients Presenting With the Chief Complaint of NonTraumatic Acute Abdominal Pain
American College of Emergency Physicians, 2000

“It should be recognized that no study establishing negative outcomes (of giving MS to patients prior to surgical exam) of any sort has been published. Humane treatment of suffering should therefore be the only argument required to treat abdominal pain.”
-Pain Management and Sedation: Emergency Department Management
McGraw Hill, 2006

Studies- (Full Abstracts and Additional Related Studies attached in Science Document)

1. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg. 2003 Jan;196(1):18-31, Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.

CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons

2. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996 Dec;3(12):1086-92. Pace S, Burke TF.

CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

3. Intravenous Morphine in Emergency Department Patients with Acute Abdominal Pain Does Not Alter Disposition Decision, Acad Emerg Med Volume 12, Number 5_suppl_1 18-19, David Esses, Polly Bijur, Conroy Lee, Michael Lahn and E. John Gallagher

Conclusions: The decisions to admit or discharge patients with acute abdominal pain were comparable, regardless of the administration of morphine.


Proposed Protocol Change #3: Make Morphine Medical Control Option in ACS

While Morphine as been a tradition of ACS care (evidence MONA), recent research suggests it may increase mortality. While not removing it entirely from the protocol, I suggest it now require a medical control option.

Am Heart J. 2005 Jun;149(6):1043-9.

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM, Peacock WF, Pollack CV Jr, Gibler WB, Peterson ED; CRUSADE Investigators.

BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

As I said, we'll see if the committee goes along with me. I expect that in five years what I am proposing will be standard everywhere. But the reaction now may be. We don't want to ruffle the surgeon's feathers, even if most of them agree with giving pain meds prior to their exam, and since MONA is still in the 2005 ECG Guidelines, who are we to change it. My arguements will be EMS doesn't always have to be the tail. We can be the dog. And as far as surgeons who are concerned that morphine may take away their ability to conduct an exam, as I read in a book in the medical store bookstore(Having already bought one $60 pain management book) one word to them NARCAN. Let them explain to the patient that they need to put them back in excruciating pain in order to try to figue out what is wrong with them.