December 3, 2016

The Third Time I Was Fired

I have crashed ambulances more than once. For the most part, most crashes weren’t my fault. In the case of some grinders, I may have had a small piece of culpability, mostly due to slightly suboptimal decisions on my part, at least in hindsight.

One of my first crashes occurred on a snowy night. There was an inch or two of fresh snow sticking to roads when my partner and I had to respond to an emergency call. I have to admit, I was having a good time. Non-medics may not know this, but turning the lights and sirens on during a snowstorm with big, fluffy flakes in the air makes the view out the windshield look like you’re accelerating the Millennium Falcon into hyperspace. I was roaring southbound on a three-lane road that was congested by traffic. But the far-right lane opened up and I got into it. Having no other traffic in the lane allowed me to increase my speed. Punch it, Chewie!

I was approaching 40 miles per hour or so when I realized why there was no traffic in the far-right lane. It was a turn lane. As a matter of fact, it was a right-turn only lane that ended at a triangular curb island. The island had a lightpole sticking out of it. You know what I mean, right? One point of the triangle curb separates the turn lane from the continuous traffic lane.
Like this. But not so obvious without the red line around it. And covered by snow.
(Via GoogleMaps)
I realized it was a turn lane when I hit that curb at 40 miles per hour. In my defense, the snow on the road had hidden the island. It was as deep as the height as the curb - it made the curb invisible! We may have gotten a little air, with snow and slush flying around us. I have no idea how I missed the foot-wide lightpole in the middle of the island – I guess when we got air, we rotated a little. When we landed, we skidded sideways right toward a flabbergasted driver in a crappy sedan. I was skidding sideways and had no ability to stop at all. I started flailing my arm at him as a signal for him to get out of the way. He stared at me with his mouth open. Finally, he pulled forward and the ambulance skidded and sparked to a stop right where he had been parked. I took a deep breath and tried to calm my nerves. My partner unleashed a string of profanities that were mostly aimed at me and my utterly inadequate driving skills.

I was hoping that the ambulance wasn’t damaged and we could go on our way without letting anyone else know what had happened. Chances were probably low, being that the ambulance was sitting at a tilt, there was a not insignificant amount of steam spewing from the grill, and the steering wheel was able to spin freely. When I got out and looked, I found that each wheel on the ambulance was pointing in a different direction. We notified dispatch that our response would not be completed by us and that we had been in a non-injury crash.

My partner and I sat in the ambulance waiting on a tow truck. I tried to interrupt his string of angry curses and get him to focus on our story. I was leaning toward the crash being caused by me trying to avoid a school bus full of nuns and handicapped children – the maneuvers that caused the accident were heroic, see? In the end, there were too many holes in that story, so I decided that the truth would set me free. The truth, as I recalled it, was that I was crawling along very slowly in accordance with the weather conditions when I slightly clipped a curb.

A sport utility vehicle pulled up behind us. What kind of jerk stops at a busted ambulance at the side of the road? I thought. What, does he think he can help? We don’t have a radio? Seriously, who does that?!?

The owner of the ambulance company does, that’s who.

Crap. The owner got out of his Suburban and my partner got out of the ambulance and hustled over to him. Crap. I hoped my partner would be gentle. I didn’t think he was completely clear on the “...gingerly driving very slowly due to the weather…” tale. I approached cautiously and heard part of the explanation he was giving to the boss: “…I’ve never been so frightened! It was terrifying! I’m shocked we weren’t killed…” Crap. You’ve got to be kidding me! He can’t deliver the story any more gently than that? I mean, help a brother out!

Thump thump. That was the imaginary  sound of the metaphorical bus running me over.

So that was the third time I was fired from that job. I’m pretty lucky that each time I got canned, they let me keep working and continued to pay me. I’m also lucky that my driving mistakes and errors of judgment didn’t result in worse outcomes.

November 19, 2016

Status Epistaxicus

You and your partner respond to a downtown office for an epistaxis call. You find a 35 year old male patient who has had an atraumatic nosebleed from his left nare for 10 minutes. He seems to be holding pressure on the anterior part of his nose correctly. He has a pulse of 90 beats per minute, a respiratory rate of 16, and a blood pressure of 180/100.  He is warm and dry without blood on his shirt, but he explains how severe the bleeding is, with alarming and horrifying descriptions of “gushing” blood (but no evidence of severe bleeding on him or in the area). He does not feel like he is swallowing blood. How do you proceed?

Only about 60% of the population will experience an epistaxis in their lifetime, and 6% will need medical care to stop the nosebleed. Most cases occur for children between two and ten years of age and older adults between 50 and 80. (Those stats surprised me. I’m 42 and get nosebleeds weekly. Who are these 40% of people who don’t get nosebleeds?!?) Causes of epistaxis include epistaxis digitorm*, dry air, chronic sinusitis, foreign bodies, intranasal neoplasms, irritant vapors, rhinitis, trauma, hemophilia, hypertension (maybe; see below), leukemia, liver disease, anticoagulant use, and thrombocytopenia. The list of causes is even longer than that. Like with most things, the more benign causes such as epistaxis digitorum (awesome term!) and dry air are more common. Unfortunately, that doesn’t help us stratify each specific patient’s relative risk. About 90% of nosebleeds come from the anterior nasal septum – an area called Kiesselbach’s plexus. The other 10% are posterior bleeds that require emergency department treatment to stop.
The location of Kiesselbach's plexus in in the anterior septum. This is your target when you're pinching. It involves the soft part of the nose, rather than the nasal bones. Photo source.

I deal with epistaxis by starting with the concept of status. Status epilepticus is defined as a seizure lasting for more than five minutes, or multiple seizures without fully regaining consciousness in between. But a seizure can be also regarded as “status” if the patient is still seizing when I arrive on scene. A similar concept occurs with status asthmaticus – a severe asthma attack that doesn’t respond to standard treatment. I look at epistaxis the same way. If I arrive on scene and the patient has been making a reasonable attempt at stopping the bleeding,  I feel like I can regard the nosebleed as having achieved “status” level: status epistaxicus. I mean, the nosebleed was bad enough that 911 had to be called, right? It didn’t respond to normal treatment and it is still going on when I arrive. Status.

I begin with any needed adjustments to the nose-squeezing procedure, followed by some quick information collection. I want to know duration, frequency, estimated blood loss, inciting factors, past medical history, and so on. To treat the nosebleed, I first get the patient to blow their nose. Often, ineffective treatment prior to my arrival has created clots that are difficult to compress and aren’t aiding in hemostasis. So those clots have to be blown out. Be ready for the bleeding to increase, and have somewhere for some occasionally giant clots to go.  Next, I spray topical phenylephrine into the nares. A lot of medics reserve this step for severe, intractable bleeding but I feel like it is appropriate for any “status epistaxicus” that I come in contact with. Next I pinch the patient’s nose with my fingers to find the best pressure spot to stop the bleeding, and then I replace my fingers with a plastic nasal clamp. The timer starts at that point – fifteen minutes without peeking or loosening the pressure.

The concept of status epistaxicus is reserved for treatment decisions, not for transport decisions. Status seizures and status asthma will generally result in transport. That isn’t true with nosebleeds, of course. If I can get it stopped and there aren’t other concerns, I usually hope to leave the patient on scene. Transport is initiated for posterior bleeding (minimal anterior bleeding, but blood going down the throat, choking on blood, and so on), large objective blood loss, when the patient is on blood thinners, hypertension that isn’t decreasing, and if the treatment above fails to stop the nosebleed.

High blood pressure usually isn’t the cause of epistaxis. Chronic hypertension without effective treatment may cause blood vessels in the nose to become more fragile, but most experts believe that any hypertension is the result of the nosebleed rather than the other way around. See, people get anxious at the sight of blood, especially blood that was recently inside of them. That anxiety can increase the patient’s blood pressure. Studies rarely find a cause-effect relationship from hypertension to epistaxis. For example, this study found that there was “no definite association between epistaxis and hypertension.” But studies do find a correlation, like here. In the end, hypertension probably doesn’t cause nosebleed but may prolong it.

Here and here are short videos about Kiesselbach’s plexus and nasal anatomy, including internal views. Enjoy.

* Epistaxis digitorum is a phenomenal way to describe a very common cause of nosebleed – nose picking. Awesome terminology!

November 12, 2016

The Craftsman Clinician

Below is a guest post from Garrett Chism, MBA, EMT-P. Garrett has been in EMS for 25 years. He currently works as a Paramedic for Denver Health and Adjunct Faculty for Metropolitan State University of Denver. I hope you enjoy his thoughts as much as I did. 

Things I love: Hearing Garrison Keilor tell a story; the pianist carefully choosing the perfect note; the movement of a brush on canvas; the sound a perfectly sharpened hand plane makes on hardwood… And the moment a new clinician runs their perfect call and knows it. The smile and confidence they have at that moment is worth it all.

In my older age I have become slightly obsessed with craftsmanship. I spend a fair amount of time reading, watching, and listening to different forms of craftsmanship. Recently, I sat in the front of the ambulance and thought about what makes a craftsman? Do I, as a clinician, act as a craftsman?

Merriam-Webster defines craftsman as “a worker who practices a trade or handicraft; one who creates or performs with skill or dexterity especially in the manual arts.”

I find that definition to be inadequate. The difference between a craftsman and a dilettante amateur is the pursuit of perfection. As I ponder this I am preparing to teach a new employee. I have taught for most of my career. I used to think I was fairly decent at it; however, age has given me a clear lens to the mistakes of my male, egotistical youth. So as I prepare to teach again, I began to think, “What would a craftsman clinician do differently?” I ask myself how to pass on the experience of my chosen craft… not the drama, not the ego, not the inflated stories, but the really important lessons that others wiser than me have taught me. Here is my list of what makes the first cut. I hope you find this helpful, add on to it, and pass it on.

1. Be the patient’s advocate. This takes many forms, I am sure you've heard them before, be their advocate… many times you are the only one who is. The craftsman clinician makes all decisions based on this golden rule.
2. Communicate like a human being. Listen, don’t hear. Clinicians who are craftsman aren’t rapid firing questions at patients to get the quickest answer possible, only to be forgotten not ten seconds later. A craftsman clinician listens, with the intent to learn and understand. Talk to patients like they’re a friend or family member… because they are someone’s. 
3. Stop making assumptions. When I moved into a position in the hospital, I was amazed on how little I knew, how often EMS is wrong, and how much larger the patient experience is beyond the walls of the Emergency Department. I often say that even the best clinician can never be as good as the one that has been a patient before. Craftsman clinicians don’t pretend to know everything. Rather, they actively educate themselves on different areas of medicine with an open mind of what EMS can do to make the total patient experience better.
4. Focus only on the things that matter and spend lots of time perfecting them. Practice perfecting every detail of your craft. Hone a complete patient assessment, the perfectly executed treatment plan, the clear transition to the next clinician. 
5. Care. Beyond caring about your patient, care about the work you do. Care about your peers and students, as well. It’s great to practice medicine, but practice with the intent of improving every single time. Craftsman clinicians care so much about perfecting their craft that the end result is the best possible experience for a patient.

Craftsmanship takes time. It takes generations to develop. It takes constant pursuit of perfection in the tools, the education, the mentors… especially the mentors. Craftsmen dedicate their lives to their craft, love their craft, perfect their craft, and want nothing more than to pass that love on to the next generation.

Garrett Chism

November 5, 2016

Square Breathing

Last winter I ran a lady who slipped on some ice, landing on her outstretched hand. The fall hyperextended her right elbow and she felt pain in that joint. There were no other injuries, including her head and neck. She passed my amateur distracting injury test. I examined her right elbow and found pain and tenderness both in her distal biceps and proximal brachioradialis muscles. The elbow joint itself was stable, as was her humerus, radius, and ulna – as far as I could tell. The biceps muscle had a lump in the distal end that gave a step-off appearance and it was already starting to bruise.
From Gray's Anatomy (1918) via Wikimedia Commons
I felt like she tore her biceps, at least. I mean, you could pretty much see it.  The brachioradialis may have been torn, as well. I was also suspicious of an elbow sprain and kept the possibility of fractures in mind. My plan was to start an IV, dose her up with some fentanyl, splint the arm, and then take her to the hospital. She was in a significant amount of pain, however, and it would take me a couple of minutes to start the IV. I needed to distract her.

“Listen, Sally,” I told her. “I know your arm is hurting really badly right now, so I am going to give you some pain medications that will make you more comfortable. While I do that, I need you to slow your breathing.”

She nodded and did what almost everyone does – she slowed her breathing by taking very deep breaths.

“That’s good, Sally. Believe it or not, slowing your breathing will help your arm hurt less. But I have a great technique I want you to try. It helps a lot. Are you willing to try it out?”

She nodded, with tears in her eyes.

“Cool. The technique is called square breathing. Have you heard of it?” She shook her head no. “That’s alright. It works really well. As a matter of fact, snipers use the technique to control their nervous systems. It is really simple. Are you ready?”

Sally nodded, paying attention.

“It is based on the count of three. We are going to breathe based on a three-count. Inhale for three, hold it for three, exhale slowly for a three count, and then hold your breath empty for three. Got it? I will count.”

I began a slow count: “Inhale, two three. Hold it, two, three. Exhale, two, three. Hold it out, hold it out, hold it out. That was great, Sally. Here we go again.”

I began the counting pattern again, while I started the IV.

The technique works as a distraction. The need to count and maintain a pattern focuses the patient’s attention on counting and breathing, rather than on what’s hurting. Instead of focusing on the anxiety of an injury, the pain it is causing, and the fear of what is going to happen, I can often get a patient to focus on breathing through a three count. My goal is to stretch the three-count to fours. Fives would be great, too. The pattern is easy enough for me to quickly explain. I can count out the pattern while my attention is on starting the IV, or drawing up analgesia, without distracting myself too much.

It probably doesn’t work as well as I think it does, but it is better than doing nothing and watching a patient hyperventilate. At least, it is a good second-line action. The best thing for a patient like this is opioid analgesics, of course.

As for Sally, I maxed out her first dose of fentanyl as soon as I started the IV. I like to start with two mikes per kilo IV as the initial dose, except in the case of elderly people. Sally handled the analgesia well, relaxed a bit, and continued the square breathing pattern while I splinted her arm.

*Edit: The incorrect dose units in the last paragraph has been changed...