October 22, 2016


Years and years ago, I ran an interesting cardiac arrest. Well, I’ve run a few interesting cardiac arrests, but there is one that I would like to tell you about today. It involved a fifty-something male who had chest pain, waited too long before calling, and attempted to treat the pain with Pepto Bismol or some such ineffective remedy. So he eventually arrested and fell down, which notified his family that something bad was happening. The family was on the ball. 911 was called and his adult son began effective CPR immediately.

Besides his son slamming away with some good, rib-cracking CPR, this patient had an ambulance and a fire truck relatively nearby. So the professionals (plus me) had a quick response time. Let me tell you how this went, so you can see how long ago this happened…

The paddles were gelled and pressed against the patient’s bare chest. VFib was identified. Charge to 200 joules, clear, shock. I kept watching the monitor postshock and the patient was still in VFib. Click the thumb dial to 300, charge, clear, and shock again. Still VFib. The 360 joule shock resulted in asystole. A firefighter got back onto the patient’s chest and I intubated him. My partner started an IV and pushed a milligram each of epi and atropine.

See? Long, long time ago.*

Anyway, this arrest was like a demented ACLS megacode run by an idiot who had never seen an arrest before but had read about the rhythms once. The patient kept switching rhythms like the ACLS instructor had just bought a new rhythm simulator and was just randomly pressing buttons. The epi and atropine changed the asystole to a pulseless IVR and more epi turned that into VFib again. Shock, asystole, meds, IVR, meds, VFib, repeat. I recall there was at least some VTach mixed in and there may have been a significant run of PSVT.
Bad for the patient.
By Jer5150 (Own work), via Wikimedia Commons
In any case, I found myself chasing rhythms while transporting. (Because back then we felt like we could do effective CPR in a moving vehicle, so we gave dead people a final cruise through the city.) On the way to the hospital, I contacted my base hospital to have them set up the receiving hospital. I was transporting to Hospital A, but I called my base physician at Hospital B so s/he could call Hospital A for me. Its our system. I got a certified legend on the phone.

I explained what was going on, what I had done, my plan (keep on doing what I had been doing), and that we were 5-7 minutes away from Hospital A. He stopped me and gave me instructions: “Bill, listen to me. This is what I want you to do. I want you to deliver three shocks at 360 joules to the patient as quickly as you can. Don’t even look at the monitor, don’t do anything but charge and shock. Charge-shock-charge-shock-charge-shock as quickly as the monitor will do it. I will wait on the phone so I can hear you do it. Give him all three now.”

Okay. That algorhythm wasn’t in any ACLS class that I’ve taken.
Old-school defibrillator paddles, for those who have never seen them.
By User:Tirante (Own work), via Wikimedia Commons

So I did it. booooOOOOOOOOOOOOOOOO BLAM. The firefighter on CPR leaned forward to restart CPR and I told him to hold off. booooOOOOOOOOOOOOOOOO BLAM. Number two. “What the hell are you doing?” the firefighter asked. I grinned at him wildly with a gleam in my eye and a frantic giggle. I hit the charge button again. booooOOOOOOOOOOOOOOOO (“No, please, stop! What are you doing to him! It smells like burning and hatred!”) BLAM. The very confused firefighters looked as though the first thing they were going to do when the call was done was to make sure I was charged with assault. I checked for a carotid pulse.

Well, holy shit. The patient had a pulse. He kept that pulse all the way to the hospital and maintained a decent blood pressure.  A 12-lead in the ED showed an apical MI. I later found out the patient had a CABG or four, got to know the MICU nurses, and was eventually discharged to home. He had close to 30 minutes of prehospital CPR, total.

I’m still not totally clear on how the triple shocks worked. I think each shock lowered the resistance for the next one. Keep in mind the LifePack-10 I was working with didn’t throw biphasic shocks. One way or the other, the physician on the other end of the call saved the patient’s life from miles away. If I’d have called the receiving hospital directly, those shocks wouldn’t have been delivered.

Sometimes you contact base with one expectation and get help you didn’t even know you needed.

*I still remember the VFib jingle I learned in my first-ever ACLS class in paramedic school: Shock shock shock, everybody shock. Little shock, big shock, mama shock, papa shock… For the youngun’s among my readers, that results in a stack of three shocks – 200, 300, and 360 joules. Everybody = epi. Little = lidocaine. Big = bretylium tosylate. Mama = magnesium sulfate. Papa = procainamide. You gave a 360-joule shock and an epi between each of the other meds. That’s how it went…

October 1, 2016

Weightlifting, 2-Man Coverage, and EMS

A couple of years ago, I took up weightlifting. I am lucky to work out in a gym that provides trainers and coaches who work to improve my form. They also watch out for my safety. I wouldn’t have thought it, but picking a weight up from the ground and lifting it over your head is complicated as hell. Details matter. How far apart are my feet? Are my feet parallel or toed out? Ankle position. Knee and hip relationship. Hamstring tension. What is the position of my femur relative to my pelvis in three dimensions? It goes on and on. Even my thumb position relative to the rest of my hand matters.

It isn’t a matter of “…try not to curve your lower back.” Picking up something heavy from the ground is something cavemen did, but it is extremely complicated to do well.
Not me...
By Sasan-sj [Public domain], via Wikimedia Commons

Recently I ran across an article that explained one of many football defensive coverage schemes: 2-man coverage. Check it out – the detail is incredible. And this is a basic look at what football players deal with dozens of times per game. This barely gets into the physical aspect of football defense – a cornerback’s hip position, whether a linebacker’s break uses his left or right foot. This just explains some of the intellectual concepts that go into the coverage scheme. An example quote (because I don’t really expect you to read the article):
As you can see, both safeties will gain depth at the snap to play from a deep-half alignment. This allows the free and strong safety to drive downhill (top-down) versus the deep dig (square-in), 7 route (corner), post, etc. while also having the ability to get over the top of the 9 (fade) route or overlap the inside seam.

Huh? Can you go over that again, slowly? I knew football was more complicated than John Madden let on during a game (“The best way to gain more yards is advance the ball down the field from the line of scrimmage”), but aren’t football players supposed to be dumb? A person with the ability to understand play concepts like that isn’t dumb.

How about fly fishing? Want to hear about the details of thumb and wrist position during a backhand cast versus a roll cast? How about different flies, or how barometric pressure affects fish, or which caddis fly is hatching, or different ways to read a stream? There are anglers who work on the details of elbow position for months, to make their cast slightly better.

It is easy to spend time focusing on the details of hobbies we choose to do. When you love something it is fun to work on improvement. All it takes is finding a coach or mentor with knowledge, the willingness to share that knowledge, and hours upon hours of hard work.

Do you spend as much time or burn as many synapses improving the tiny important details of your EMS game? Or did your knowledge base peak on the day you got out of class? How aggressively are you challenging yourself to improve?

September 17, 2016

My Call! I'm In Charge!

One night, long long ago, I was attending when my bus was assigned to an auto-ped. We were a little bit away from it, so it took us five or seven minutes to get there. On the way, about halfway through our response, dispatch advised that an ambulance from a private EMS service was on the scene. Let’s call the private company “XYZ” for the sake of storytelling.

Good, I thought. I won’t have to work. Let them handle it and I can go back to eating.

My partner and I got on scene and strolled over to see how things were going for the private crew. Three important things need to be mentioned here. First, I am fully down with someone else doing a good job on a call. Knock your bad selves out. I don’t need to steal good calls. Second, I like to help if I can help. Sometimes you need an additional pair of hands.  Finally, it is my city. My agency is responsible for EMS in the jurisdiction. I have a responsibility to make sure care is being performed reasonably well, at a standard consistent with the expectations we have in the city. So I walked up and asked how things were going.

“This is my call! I’m in charge!” The XYZ medic wanted to make sure I knew who was in the leadership position.

“Great. Need a hand?” I offered.

“I’m running this call!” He shouted. He would have done better to give me a task.

One great piece of advice I received in paramedic school was that if you feel the need to announce that you’re in charge, you’re not. Someone in charge should be directing the scene, making decisions, delegating tasks, and otherwise generally being in charge without feeling an overwhelming need to loudly declare the fact.

I looked around and absorbed the scene. The patient was an adult male with a visible open tib-fib fracture on the right leg. He looked to be awake, but upset and hurting. Dude looked a little pale to me, but that may have been due to a pain response resulting from his leg. He was fully clothed, except for his right pant leg being cut from the cuff to knee level.  He wore a cervical collar. There was an XYZ EMT at the patient’s feet, putting a SAM splint on the busted leg. A backboard was on the ground next to the patient. (What with the backboard and C-collar, you can tell this was a long time ago…)

Considering the patient’s pallor and the fact he was hit by a car, I wondered about his vital signs. I was hoping he wasn’t hypotensive. I asked about the blood pressure and was informed they hadn’t checked it yet. Okay, maybe they were prioritizing packaging and scene departure. I asked about the patient’s heart rate. They told me they hadn’t checked that yet, either. I asked about verbalized complaints. Hadn’t asked. I inquired about the rest of the secondary exam. Nope. They hadn’t gotten around to it yet.

I silently wondered what they had accomplished and lifted the patient’s shirt. There I found a tire track across dude’s belly.

The XYZ crew was splinting the leg and hadn’t found the tire track yet.

At that point, I announced that I was taking the call over and getting the hell out of there. I asked my partner to pull our wheels and “set me up.” He would know that I was looking for two blood pumps to be hung and for a couple of 14s to be tossed onto the bench seat. I directed the firefighters to logroll the patient onto the backboard, and then onto the bed. I told the police we would be leaving the scene in two minutes and they should go to the trauma center for a victim statement. Everyone looked relieved that decisions were being made.

Everyone but the XYZ medic, that is. He plum lost his mind. He literally jumped up and down. Spit flew when he screamed about it being his call. His hands were balled into fists and he was quivering with rage. I asked him to step back. He loudly declined by issuing a string of profanities, so I asked a nearby police officer to help him step back. The police officer smiled and took the apoplectic medic by the arm and led him over to the sidewalk, away from the scene, yelling the whole time about the arrogance of the city medics. The XYZ EMT helped roll the patient onto the backboard and then stepped back, too.

Transporting to the hospital, the call was fairly straightforward. The patient was maintaining his own airway, tachy but normotensive, and complaining of pain in his abdomen, pelvis, and lower leg. I got him naked, finished the physical exam, popped a couple of IVs into him, and set up the hospital.* We arrived and I gave the big room report.

The ED attending doctor was one that I throughly respected (and kinda feared, if I am being honest). He was a phenomenal doctor who was very perceptive and had high expectations for the performance of everyone around him. He was definitely not afraid to call out a bad job, even a little bit. It made him intimidating to me, especially as a new medic. “Who put that splint on?” he asked me irritably, glaring at me and pointing to the SAM splint on the patient’s ankle.

“XYZ” I gave him the private ambulance company’s name. I didn't put the splint on, but I still felt guilty. That was the affect this attending had on me.

“XYZ?” he confirmed with one eyebrow raised.

“XYZ,” I repeated with my hands palm-forward in front of my chest. “I wouldn’t have wasted time with it.” At best, I would have splinted the leg using the other leg, the backboard, towels, and some tape. But only after everything else was done. It is certainly possible to die from abdominal tire tracks, but not as often from broken lower legs.

“Look at this,” he directed with a disgusted tone in his voice. He showed me the patient’s lower leg. The splint ended about four inches below the fracture. It wasn’t even high enough to immobilize the break, let alone the joints above and below.

I have never been so glad to not be the one to put on a splint.

*This was back when we were stingier with pain meds. I would give him some opiate analgesia nowadays.

September 3, 2016

I Hate Transporting (Some) Narcan Patients

I am not your boss, supervisor, manager, or medical director. I have nothing to do with your protocols, policies, QA reviews, or your ability to continue to receive a regular paycheck. I also do not fill an official role in Denver Health, so the thoughts below are my own opinions. You know about opinions, right? Adopt the concepts below at your own risk.

You are assigned to the report of an unconscious party in a nearby apartment and arrive to find a patient as advertised. The patient is a mid-twenties male with pale skin and miosis. He has a heart rate of 100 beats per minute and his respiratory rate is so slow that you get bored counting it and estimate it to be about four per minute. A heroin rig is on the end table next to him. You administer 0.5mg intranasal Narcan and add a few breaths via a bag-valve mask while you are waiting for him to wake up. After a few minutes, the patient wakes and begins to breathe normally. There is no indication of co-ingestion, alcohol use, or other medical concerns. The patient’s heart rate slows to 70 beats per minute and his oxygen saturation is 99% on room air.
The patient seems to be a pretty nice dude. He is rather ashamed you had to wake him up. He explains that he had been clean for about nine months, but had just experienced personal stress and fell off the wagon. “I guess I don’t have the tolerance I used to. I guess I took too much,” he tells you.

He also tells you that he doesn’t want to go to the hospital.

So here is the thing. He is completely awake now. He is answering all questions appropriately. He can tell you how many quarters are in a buck-fifty and who is president. Hell, he can even tell you who governor and mayor are. You explain to him that the smack he overdosed on may have a longer action than the Narcan you reversed it with. His overdose could return. He absorbs that information and still doesn’t want to go to the hospital.

Is he allowed to refuse transport to the hospital?

Some paramedics take all patients who received naloxone to the hospital. Some EMS protocols even require it.

Should he be allowed to refuse transport? I’m asking about what should be done, not what is mandated, or what your common habit is. What should the answer be? To me, the answer depends on patient safety and patient autonomy. Is it safe for him to refuse transport? Does he have the required decision making capacity to refuse transport?

What does published research say about the safety of non-transport after prehospital naloxone administration?
  • Sporer’s group published an article in 1996 that looked at the rate of patient admission after Narcan administration (1). They report admission is rare – only 2.7% of patients transported after naloxone were admitted to the hospital. The most common reason for admission was noncardiogenic pulmonary edema, which they described as “clinically obvious.” Other causes included pneumonia, infections, and persistent respiratory and mental status depression.
  • Vilke, et al., compared records from the San Diego medical examiner’s office with positive opioid test results to prehospital records (2). None of the 117 opioid-involving deaths in the ME’s records and the 317 prehospital refusal after naloxone matched within a 12-hour window. Another San Diego study (3) four years later looked at almost one thousand patients who received prehospital naloxone and refused transport. None appeared in ME records within 12 hours.
  • A study from Helsinki, Finland, headed by Boyd (4) attempted to describe the incidence of recurrent toxicity and the time interval in which it occurs. One hundred forty-five uncomplicated heroin overdose patients were included. Eighty-four refused transport. Seventy-one had no life-threatening events in a 12-hour follow-up period; the others were lost to follow up. Of the sixty-one who were transported, 12 (19.6%) needed more naloxone, but all occurred within an hour. The authors specifically state: “Allowing presumed heroin overdose patients to sign out after prehospital care with naloxone is safe.”
  • Wampler, et al., published a study (5) from San Antonio that was similar in design to the Vilke studies discussed above. They compared refusals after Narcan to the county medical examiner’s database within 48 hours of the refusal. Of 552 patients, none presented to the medical examiner within 2 days. A 30-day comparison of records found 9 patients who received Narcan and died, but the shortest interval was 4 days post event.
  • A huge study from Rudolph’s group (6) included 4,762 cases of acute opioid overdose over a ten-year period. Only 14 patients who were released on-scene after having been treated with naloxone died within 48 hours. Only three presented with possible rebound opioid toxicity as the reported cause of death (0.13% of the patients released on scene).
  • Finally, a recent study published by Levine, Sanko, and Eckstein (7) presented a multi-year retrospective review of LAFD’s records. Two hundred five refusal-post-Narcan patients were identified. One subject died within 24 hours of refusing care due to “coronary artery disease and heroin use.” Two others died within 30 days. A fourth subject died 16 months after refusing transport. “The practice of receiving prehospital naloxone by paramedics and subsequently refusing care is associated with an extremely low short- and intermediate-term mortality.”

As a final example of the safety of non-transport after naloxone administration, I give you the fact that people can buy Narcan in a grocery store pharmacy, administer it to their friends or family, and not go to the hospital. They can do all of that without involving the EMS system at all. In the imaginary case that began this post, if the patient’s girlfriend had given Narcan he could have avoided a hospital bill pretty easily.

I think there is some evidence to indicate that non-transport after opioid overdose reversal is a generally safe practice. The published research has holes, as does research on most topics, but seems to lean toward a feeling of safety. So we can consider the second point: Does the patient have decision-making capacity?

I have published my thoughts on decision-making capacity previously. In short, I don’t necessarily care if the patient is sober (although you could make the argument that I have used pharmacology to make him so) or competent. I care that the patient, at that moment,
  • can make and communicate a medical choice [check],
  • can appreciate the concepts of diagnosis, prognosis, suggested care, alternatives, and risks/benefits [check],
  • can make decisions without delusions or coercion [check], and
  • can use logical reasoning [check].

Seems to me that the patient described here has decision-making capacity.

So why must he go to the hospital? Well, I don’t think he does.

This is an example with a simple, uncomplicated heroin overdose that doesn’t present additional complications. There are no other ingestions. He isn’t rolling on an eight ball, or alcohol, or anything else. His overdose wasn’t related to a suicide attempt. He actually has the obvious ability to make decisions, and there isn’t residual confusion or mental slowness. All of those points wouldn’t exist in every case of Narcan administration. It is the subtleties of each case that make disposition decisions a giant grey area.

I am not saying the patient’s decision doesn’t constitute an Against Medical Advice refusal. My medical advice is that he be transported. People refuse against my advice all the time. We are taught that people are allowed to make decisions that we disagree with. Sometimes we disagree strongly. But the principle of informed patient autonomy is a bedrock, foundational principle of medical care.
This doesn't override your rights to self-determination. Source
But I disagree with the black and white outlook that requires transporting a patient who possesses intact decision-making capacity. People with decision-making capacity are allowed to decline transport in my world. In an ideal world, I would even add another milligram or two of Narcan IM to help make sure the overdose is less likely to return. But transport? This guy? Nah…

1. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996;3(7):660-667.
2. Vilke GM, Buchanan J, Dunford JV, Chan TC. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone? Prehosp Emerg Care 1999;3(3):__.
3. Vilke GM, Sloane C, Smith AM, Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med 2003;10(8):893-896.
4. Boyd JJ, Kuisma MJ, Alaspää AO, Vuori E, Repo JV, Randell TT. Recurrent opioid toxicity after prehospital care of presumed heroin overdose patients. Acta Anaesthesiologica Scandinavica 2006;50(10):1266-1270.
5. Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care 2011;15(3):320-324.
6. Rudolph SS, Jehu G, Louman Nielsen S, Nielsen K, Siersma V, Rasmussen LS. Prehospital treatment of opioid overdose in Copenhagen – Is it safe to discharge on scene? Resuscitation 2011;82(11):1414-1418.

7. Levine M, Sanko S, Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. Prehosp Emerg Care 2016;20(5):__.

August 28, 2016

Random Thoughts on Reindeer Games

There are a few ways that medics screw with each other. Some pranks or tricks are pretty universal. Defib gel on a windshield wiper, so it smears when the wipers are turned on. Turning everything on in the ambulance, so when it is started the lights, siren, and radio start blasting.  Putting an extra bag of saline in a jump kit, to make it slightly heavier.
This reindeer looks like he is fed up with your games... Source

I knew a medic who took his partner’s favorite, lucky shirt. He spent days putting it on "urban outdoorsmen" (the filthier the better) and taking a picture with a disposable camera. He then froze the shirt in a five-gallon bucket of water and gave it back, along with the camera.

One of the agencies I worked at planned pranks like an evil combination of Wiley E Coyote and a demented engineer. We would put flour into an inflated glove and hang it over a doorway, with a needle taped to the doorjamb. When the door swung open, the glove would hit the needle and pop, spilling flour onto the unsuspecting rube who just wanted to walk into a room. Evil geniuses took it further, starting with a glove full of saline, to make their mark wet. Then a glove of powdered sugar was hung at the bathroom door, where they would go to clean up. Then the mark would be angry and would be expected to stomp upstairs to clean up. So another glove of something sticky at their bedroom door. Evil, I tell you.

It got to the point that you had to enter rooms at a sprint, with a leaping shoulder roll.

One time, before I was even allowed to be an EMT on an ambulance, I was dispatching for pay and riding for experience. On one call, the ALS firefighters had missed several IVs on a lady with chest pain and shortness of breath. The paramedic I was riding with missed a line or two, as well. I got one on my first attempt. Jerk that I was am, I started doing a little dance and chanting about how genetically predisposed I was to be the world’s greatest medic. When we arrived back to the base, I was given bad news: “Who started the IV on that patient? They found a big chunk of IV catheter in her lung. Catheter shear killed her.”

I was crushed. I had killed a young patient. I was despondent. I didn’t know what to do, except to start writing a combination incident report/letter of resignation. The medics let me wallow in despair, quietly trying to hide my tears, for several hours before telling me they were screwing with me. I didn’t think it was funny then, but now I can see some humor there.

One of the best, low-grade pranks is to introduce a new caregiver to the deep end of the EMS pool. Let me give you an example.

Years ago, I was working with a new EMT. He was new to his EMT cert, as well as being new to the agency. But he was a good guy, wanted to learn, asked great questions, and paid attention. I liked to work with him – still do. One day, we got assigned to a nonemergency call in an alley. I think the nature was a foot injury, or something similar. We arrived to find our likely patient, standing in the alley with a single crutch. (As an aside, I love the single crutch. It screams patriotism, with the addition of needing to keep one hand free to hold a drink.) As we approached, I became convinced there was a second call nearby.

The smell of “dead guy” was strong in that alley. I told my partner to start taking care of the patient with the sore foot while I checked the nearby dumpsters for what I was convinced was a poorly disposed of murder victim.  After searching for a few minutes, I came to a horrible realization.

It was Mr One Crutch’s bandaged foot that I smelled.

I was glad I had an EMT partner to handle this call. We put the patient into the bus, on the bed, and took a set of vital signs and a history. The guy had cut his foot “a while ago” and had been trying to keep it bandaged since. That day was the day he had had enough and decided to get it checked out. It didn't hurt, his vitals were normal, and it had been like this for several days.

We were only a block or two from the hospital. If it were me, I would have added additional layers of blankets to the patient’s foot so that I could cut down on the cheesy offgassing. But I wasn’t attending; I was driving. As additional pertinent background information, I need to explain that I have an angel and a devil on my shoulders, each whispering ideas into my ears. My problem is that I don’t know which is which. They switch sides randomly, and I can’t see them. In this case, though, one voice whispered, “Make him unwrap the bandage, tee hee…” The other voice said: “Yeah! Make him unwrap and examine that foot! He he he!”

Who am I to argue with my shoulder voices, especially when they are in agreement? Certainly not me! I looked my novice partner in his eyes and gave him my serious face. “Hey, brah, you know a complete exam means that you gotta unwrap that foot and take a close look, right?”

My partner gave me a look that seemed to say he knew I was joking and wouldn’t fall for that. “I’m very serious. We’re professionals here. Man up,” I told him, maintaining my serious face.

I took a few steps back in case things were splashy while my partner began unwinding dirty bandages. It was horrifying. The guy’s foot looked like an anatomical drawing of a foot, with the skin layer removed. It was muscle, tendon, and bone. But wet. Juicy. Greenish. And rotten-smelling. My partner began to retch and heave.

I told him I would see him at the hospital and slammed the back doors.

I had to drive to the hospital with all the windows down, my head out the driver’s window, and occasional gagging of my own. But it was worth it. I still smile, thinking of that partner.

What makes a good prank? First, a prank or trick needs to not hurt, break, or injure anything or anyone. That includes psychological scarring, sorry. Second, it needs to not interfere with the job. This is why I’ve never done the defib gel thing – it could possibly take an ambulance out of service. Could you imagine running with lights and siren, turning on your wipers, and having everything suddenly smeared? Not cool. Third, a prank needs to be played on people in a position to return the favor. They need to be able and willing to play back. It isn’t fun to trick someone who is frightened of returning a prank, or if they are struggling in their job. In those cases, it is the equivalent of a professional boxer grabbing an elderly nun off the street as a sparring partner. Pick yourself a sparring partner that can punch back.