Endotracheal Thinking

My internal dialogue, before intubating a patient:

Well, now, he doesn’t look especially good. That shade of blue isn't healthy. I need to sit him up. Why do people want to lie down when they can’t breathe? I guess I laid down after the workout at the gym yesterday, but that was different. I was seeing imaginary fireflies. Wait, the firefighter is talking to me… Uh huh, CHF history. Got it. Check his breath sounds, Bill. Oooh, nasty! Wet as can be. Rales almost all the way up. Feet? Swolled. JVD? Nope. There is never JVD. People are too fat for JVD. Need to get him moving; ask for the bed. What’s his pressure? Sweet, that is high enough. Give him some nitro. Maybe a little more. A little more. Yay, paramedic dose! At which hospital is he seen? Yeah, not going across the city to that place today. I wonder what caused this guy to overload? What else do I need to do: ECG, IV, pulse ox… Wait, pulse ox is done? Well, what does it say? Crap. Is it really that low, or is it a bad reading. Check the pleth. Crap again, that looks to be a strong wave; the sat is probably true. Is it time for more nitro yet? Nah, not yet. Has he been sick lately? Where was I? Oh yeah, to-do list. Aspirin? Neb would be dumb. Steroids? No. CPAP or intubate him? What other history does he have?

My internal dialogue, after intubating a patient:

Where is the tip of my tube? What does the capnography look like? Where is the tip of my tube? What else do I need to do? Maybe the ECG. Where is the tip of my tube? Keep an eye on dude’s sats and end-tidal reading. Where is the tip of my tube? I need to call to set the hospital up, but it will have to be quick. Where are we going, again? Where is the tip of my tube? What is to eat near that hospital; I’m hungry. Where is the tip of my tube? Why did we just make two left turns in a row? Is my partner lost? Where is the tip of my tube? Has his blood pressure changed? Where is the tip of my tube? Nitro! More nitro! Where is the tip of my tube? IV is in; I need to make sure that doesn’t get away from us. Shut that bad boy down. Where is the tip of my tube? What am I missing? Where is the tip of my tube? Seems like run-of-the-mill pulmonary edema, but what else could it be? Pneumonia? Near drowning? Where is the tip of my tube? What else makes pulmonary edema like this? Where is the tip of my tube? Remember that one fire-medic who insisted on calling both pulmonary edema and pulmonary embolism “PE”? You had to take his meaning from context. Where is the tip of my tube? I think he was usually interchanging the terms. There was no difference in his mind. Where is the tip of my tube? What was that guy's name? Where is the tip of my tube? How much longer to the hospital? Okay, almost there. Where is the tip of my tube? What is his capnography reading? Where is the tip of my tube? What else do I need to do before we get to the hospital to avoid looking stupid? Where is the tip of my tube? Am I ready to give a big room report? Where is the tip of my tube? How old is this dude, again? Born in 1948... duh... carry the one... screw it. Too much math. Where is the tip of my tube? Is the tube still good?

It is pretty distracting to intubate a patient. But I have no esophageal intubations brought into the ED in 20 years of EMS.*

No Goose Tubes!
Original source

*That I know of. When I was attending.

Syncope

Yesterday, I found myself standing at the end of a jet bridge at the airport. A group of firefighters with their fingers in their ears were standing with me, and we waited patiently as the airline staffer maneuvered the bridge to a recently-arrived aircraft. The jet bridge driver shut everything down, locked the bridge in place, and slapped the door of the airliner.  Someone inside popped it open almost immediately and a flight attendant looked around until she saw me. “Thirty-five charlie,” she told me.

Of course my patient was in 35C. Nobody ever needs help in the front of an airplane. If someone does need help at the front, the other people on the flight are apparently morally obligated to carry the ill party to the back of the plane. I smiled and boarded the aircraft. The other passengers were waiting in their seats for me to do my thing and get out of the way.  Some airlines de-board the plane, so the medics have to wait for everyone to get off before accessing the patient. This airline was being cool.

I like to be welcoming, so I grinned my most friendly grin and loudly welcomed everyone to Omaha. Most people got the joke and knew they were in Denver, but I always vaguely hope I give someone a reason to briefly worry about where they wound up.

I made my way to the back row and found a late-fifties female patient who looked to be completely well. There were three or four other people around her who appeared as though they were about to burst with the anticipation of telling me their story. I held eye contact with the patient, said hello, introduced myself, and asked her how she was feeling. She told me that she was completely fine; embarrassment seemed to be her only complaint. Asking around, I discovered that the patient had enjoyed a syncopal event without fall or seizure activity, but appeared to improve with time and oxygen. One of the firefighters had pushed an aisle chair* back to row 35, so I got the patient onto it, pretended to listen to her complaints that she could walk off the aircraft, and made a dumb joke about how she had to use the chair because it would be too much paperwork if she fainted again while I was standing around looking useless. I heard a more complete story from the nurses twitching with the excitement of delivering a handoff report and then followed the patient off the plane.

We moved up to the concourse so I could perform my job more fully. The patient was 59 years old, had no medical history, took no medications, and had no current complaints. She explained that she felt hot about an hour ago during the flight, so she stood to go to the bathroom. While heading to the john, she fainted. Something like this had never happened before, she reported neither recent trauma nor illness, and didn’t hurt herself when she fainted (someone caught and lowered her). She had a blood pressure of 128/72 and a regular pulse rate of 68.

Normally I have to be careful to preserve patient privacy when I write up a case study like this. I change details and make up parts of the call. This case study, though, combines dozens of patients with the same story into one tale. This call is one that I see at least once per shift at the airport. People faint on airplanes all the time. All. The. Time.

I bet someone is fainting on that plane right now... Source

The issue is that syncope can be a big deal. Most causes of syncope are benign, and it is one of the most difficult findings to diagnose even in emergency departments – let alone on an airport concourse. Some of the causes of syncope to consider include arrhythmia, ischemia, structural cardiac abnormalities, cardiac tamponade, pacemaker malfunction, occult trauma with hemorrhage, GI bleeding, ruptured AAA, ruptured ovarian cysts, ruptured ectopic pregnancy, pulmonary embolism, subarachnoid hemorrhage, neurocardiogenic syncope, carotid sinus hypersensitivity, orthostatic syncope, medication effects, TIA, CVA, subclavian steal syndrome, psychiatric syncope, transient hypoxia or hypoglycemia, vasovagal events, and so on.  The list is long. It is difficult to pare down, especially, as I said, on an airport concourse without the machine that goes ping.

My biggest goal when evaluating and managing the in-flight syncope patient is to not alter my normal practice. Patients deserve a full work-up, even when they are in a hurry to make a connecting flight and even when I will run the same call the next day. I try to evaluate everyone for ongoing symptoms, as well as concerning findings like seated syncope, syncope without prodromal symptoms, and alterations in physical exam and vital signs.

I offer transport to an emergency department for a complete evaluation, and am almost universally turned down. I have had some hysterically bad reasons for non-transport. One patient told me that she couldn’t be in medical danger because she had never had severe medical problems before. I pointed out that the fact that because people haven’t yet died doesn’t mean that they won’t eventually die.

Anyway, the in-flight syncope refusal is so common that I have a consistent speech that I give: “Listen, before I let you go, I need you to make your decision based on the information that I have. Fainting is caused by a long and illustrious list of problems. The most common reasons for fainting are usually less dangerous, but that doesn’t help us decide whether the cause of your event was life-threatening or benign. Your event could have been caused by a dangerous problem that could come back without warning. This event may be the only warning your body will give you before you suddenly die. It is unlikely, but a possibility that you need to plan for. I can’t tell you why you fainted. The safest thing for you to do is to go to the hospital.”

No no no no. No hospital.

“Okay, that’s your decision. You’re an adult and have been making decisions for a long time. I’m not going to take over for you now. There is one thing that I need you to understand, though. An airplane in flight is a really bad place to have a medical problem. A cruising altitude of thirty thousand feet is something like six miles. Being six miles above the ground isn’t like being six miles away from a hospital, however. If you have a medical problem in flight, you won’t be able get the help you need. What I will tell you is that if you don’t feel absolutely 100% normal in every way, the airline will reschedule you for free. Make sure you are feeling perfect before you get on the plane. Is that something you can agree with?”

Sign here.

*They make extra-narrow wheelchairs that fit down the center aisle of a modern airliner.

Sucker!

A couple of weeks ago I went to a shelter first thing in the morning. My shifts start at 0630 and we picked up this call at 0640 or so. We arrived to find a 30-something male with intractible vomiting. There was no gastrointestinal bleeding, but he couldn't stop shouting for his friend Ralph. It was hard to even communicate with him about his basic history and his situation. Being that I am trying to be more liberal with Zofran, and being that he looked sincerely pathetic and uncomfortable, I gave him 4 milligrams intramuscularly.

We were closest to a nearby community hospital, but the patient was adamant about going to the city trauma center. He said he had been followed there for a long time. It wasn't significantly farther to go there, so I was okay with that. On the way to the hospital, the retching and vomiting eased and I could chat with the patient and complete an exam.

He sat on the bench as we drove. He was pale and diaphoretic, but appeared feverish with goosebumps and chills. He was tachycardic (HR 130) but normotensive. He was a little tachypneic, as well, but I attributed that to the recent grandiose emesis. He said he hadn't been feeling well when he went to bed the night before, and woke about two hours ago with the nausea and vomiting. He claimed no medical history (at which point a little voice tried unsuccessfully to tell me how it was odd that he was followed at the city trauma center without any medical problems). There was no diarrhea, but he did have some abdominal cramping so maybe he was saving that for later. 

I got out my laptop and started filling in his demographics. I collected his name, birthdate, and such, and asked if he takes medications. "Methadone," he told me.

Methadone. 

"When was the last time you had some?"

"Two days ago," he answered.

"When are your appointments at the clinic?"

"Everyday at seven A.M." he replied.

I looked at my watch. It was about seven o'clock. The whole picture clicked into place. 

We got to the hospital, the patient crossed the threshold into the ED entrance, and loudly proclaimed that he was respectfully refusing further care. He said it as though it was rehearsed; like he had to say this certain thing at a specific time. He turned around, left through the ambulance entrance, and turned right to head to the methadone clinic next door.

And that, ladies and gentlemen, is how I transported a patient to his methadone appointment. Oh, yeah, I gave him Zofran too. You win some and you lose some...

The Nosebleed

This is not my story, but it made me laugh so I had to share.

An airport medic I work with was assigned to the report of an epistaxis at one of the airline gates. For those of you who aren’t from Colorado, nosebleeds are pretty common due to dry air and an apparent propensity for Coloradans towards forceful and insistent nosepicking. So epistaxises (espistaxi?) are common and not usually a big deal, outside of hypertension, blood thinners, or trauma. We get called because people don’t know how to stop them. Rather than applying pressure by squeezing the nares against the septum, most people go with the dab and check approach. But there are other ways that people try to stop nosebleeds.

This is a lithograph from the 1830s showing a maid attempting to stop a man's nosebleed by putting a key down his shirt. Source

The medic arrived to find a young girl with a little blood on her upper lip, from a minor right nare nosebleed. She was about 10-years old, so blood thinners and hypertension were not a problem. There was no trauma reported. This call looked to be no big deal, except for the whiskey-tango-foxtrot dynamic.

See, she was lying on the filthy airport floor with her arms extended over her head and one shoe and sock off. An airline representative was intently slapping the sole of her bare foot.

Whiskey. Tango. Foxtrot. What in the unnatural f*** is going on here? our hero thought to himself.

The patient’s mother immediately told our medic that his help was not wanted. Mom seemed to be unimpressed with the nosebleed, and didn’t want any more of a scene to be made. The medic is like me in that he wasn’t looking for excuses to inflict unwanted care upon a patient who didn’t need it. But he also knew he couldn’t leave things like this, either. So he vocalized his bewilderment to the footslapping airline worker: “Excuse me. What are you doing to her?”

“Taking care of her nosebleed,” the representative answered without looking up, as though it was obvious. Smacksmacksmack, she continued her work on the bottom of the girl’s foot.

“I am swallowing the blood,” said the supine patient.

The medic definitely couldn’t let that statement pass, so he had the young girl sit up. He cleaned her face up and put a plastic clamp on her nose.

“You’re doing that wrong,” the airline agent told him, crossing her arms irritably. “A paramedic taught me to take care of nosebleeds and that is not the right way.”

By this point, the medic in question was not only confused but also rather frustrated. He asked the airline employee what she was talking about. I can only assume that he asked in a sarcastic manner with barely veiled hostility.

“The paramedic taught me to lie the patient down, put their arms over their head, remove their shoes and socks, and hit each of their feet very hard three times. That way the blood in their body thinks they are standing up and it goes to their feet. If there is blood in their feet, it won’t come out of their nose. But she is only a little girl, so I didn’t want to hit her hard. That is why her nose is still bleeding.”

That's why her nose is still bleeding. Of course.

The point of this story is that one of my paramedic peers told the gate agent that ridiculous and convoluted process to stop nosebleeds. Apparently they told the agent in a serious way, with a straight face.

She. Believed. It.

If you are the one who told the airline rep the hysterically “proper” way to manage a nosebleed: You, sir or madam, are sincerely and deeply awesome. You are my hero. I wish I could buy you a beer for that one…

Just Another Nursing Home Transfer

My partner and I went to visit an elderly gent in a nursing home. According to his nurse,* he has baseline type 2 diabetes and dementia, along with some other elderly-related medical problems. He is normally confused, but is slightly more confused over the last few days. The nurse couldn’t really explain how he was more confused than normal; he wasn't her normal patient and she had just began her shift. I asked more specific questions to suss out his baseline mentation. I found out he would normally know his name, but not where he was or any time-related facts. He was not able to perform self-care like bathing or tooth brushing, couldn’t really follow television shows, and he slept a lot. I didn't understand how his mentation had changed, but I wasn't getting closer to finding out.

The patient was recently reported to have some UTI-type symptoms with a little diarrhea over the last week or so. That, along with a possible mental status decline over the last four or five days, resulted in an order for labs to be drawn. His doctor, upon seeing the lab results, asked that the patient be seen at an ED.

I found the patient to be elderly, friendly, and alert to name only. He looked a little dehydrated to me, in that his tongue was dry and he looked like his skin was chapped and flaky. He was a little sleepy, but he woke to voice and interacted in a gentle, confused way.  The patient was neurologically intact, other than his mental status (which I still didn’t understand how it was different than his demented baseline). There were no odors such as ketones on his breath. His blood pressure was 100/50 with a heart rate of 90, but he was a skinny old guy so I found those vitals to be abnormal but not especially concerning. The man certainly wasn’t toxic looking, if that makes sense.  What I mean is that I wasn’t worried about him dying on the way to the hospital or anything. He wasn’t diaphoretic, tachypneic, or comatose. It was a fairly routine transfer from a nursing home to a hospital.

The pertinent parts of his labs, helpfully labeled with L for low and H for high were: 

• Glucose 964 mg/dL     H (60-110)
• Potassium 3.2 mEq/L     L (3.5-5.0)
• Bicarbonate 18.1 mEq/L     L (22-28)
• Total serum osmolality 382 mOsmol/Kg     H (275-295)
• Anion gap 11mEq/L       (8-16)
• β-hydroxybutyrate (serum ketones) normal      (<0.4 mmol/L)

Do you know what is going on? What is your treatment plan?

I think a gummy bear might have less sugar than 964 mg/dL...
Source

The patient is obviously hyperglycemic. But serum ketones are normal, so it isn’t diabetic ketoacidosis.  This is something else – called hyperosmolar hyperglycemic state (HHS). DKA usually affects type 1 diabetics, and HHS is a complication more associated with type 2 diabetes. There are a bunch of other names for it, like hyperosmolar hyperglycemic non-ketotic coma (HHNC) and hyperosmolar non-ketotic coma (HONK – which sounds like a GI issue, not a sugar issue). I like HHS because it is easier to type and remember.

HHS is usually initiated by physiologic stress such as an MI, stroke, or infection. The stressor results in a relative insulin insufficiency, which allows the patient’s blood sugar to rise. The higher blood sugar results in higher serum osmolarity. Osmolarity is the measurement of stuff (solute) dissolved in a liquid (solution); in this case, the amount of salts, sugars, and such dissolved in blood plasma. In short, the ratio of dissolved solutes in the solution tips towards the solute side, rather than the solution (water/plasma) side. The body tries to correct this situation by urinating out the excess sugars.  The increased urination leads to profound dehydration and volume depletion. In contrast to DKA, ketones don’t form because there is some insulin present in the case of HHS patients.

HHS has been reported to occur in about 1 of 500 diabetic patients, so it is much less common than DKA. It is more common in elderly patients, and nursing home patients are at higher risk. HHS is a big deal: mortality is reported at 10-20% of patients, but the risk of death has been reported as higher than that in some studies. 

Treatment is concentrated on three main problems: dehydration, hyperglycemia, and underlying disease treatment.  Dehydration can be profound in HHS patients. Like, nine liters worth of dehydration, profound. When a person is 9 liters down, I can only assume their blood looks like red motor oil. These patients need fluid resuscitation to help correct the dehydration, as well as the hyperosmolarity that is adding to their problems.  

Maybe honey is a better mental picture than motor oil.
Source

The correction of hyperglycemia is through the use of insulin. Before getting aggressive with insulin, however, the patient’s potassium levels must be assessed. Insulin drives potassium into intracellular spaces, resulting in hypokalemia if the initial level of serum potassium is too low. Finally, it is important to remember that HHS is usually caused by a physiologic insult. In the case here, the patient’s infection probably initiated the hyperglycemic event, but other factors like silent MIs, pulmonary embolism, and CVA should be ruled out or treated. 

In the prehospital setting, treatment for HHS is limited to volume replacement. Most systems don’t carry insulin, and if you do make sure to check the potassium first. Keep in mind, though, that “aggressive” volume expansion means something different for other health care providers compared to field medics. I can get a couple of liters into a patient in about fifteen or twenty minutes, if I am really trying.  Aggressive in this case means more along the lines of a liter per hour. Adding your run of normal saline to deranged blood levels of electrolytes and sugars is probably a complicating factor in the absence of hypotension. So consider some fluids, but maybe take it easy.

So why did I bring all this up? I wanted to point out that I don’t recall ever hearing the term HHS, HONK, or HHNC in paramedic school. My endocrine lecture was probably four hours long, and covered a lot more than just DKA and HHS. I am sure we discussed hyperosmolar hyperglycemia, but it was lost in the fire hose of knowledge from which I was trying to drink. The paramedic text I have on my bookshelf behind me has a paragraph on HHS. It says I should treat it with ABCs, oxygenation, ventilatory support, and fluid resuscitation. Duh.

In your career, you will find that your classroom instruction and paramedic texts are inadequate to your knowledge needs. You should discover that. Take the time to look up conditions, medications, treatments, and other medical information as you come across them. The Google-machine or other search engines are incredible tools. UpToDate is a great program and website, but it requires subscription for most services. Medscape is good too, though. Friggin’ Wikipedia can be pretty helpful. Ask physicians at handoff about their thought process and differential diagnoses (after their initial exam, so you don’t interrupt their work) then look up what you don’t know about. Seek out patient follow-up and research the findings that you don’t understand.

What you learned in p-school is not enough. The case here was just a boring nursing home transfer for altered labs and a possible increase in confusion. We run those jobs all the time, and I work for a 911-only service. But look where it took us. Push yourself and your knowledge base farther.

*I use the term “nurse” in its most generic, loosest sense. I never really have any idea if I am dealing with a nurse practitioner, RN, LPN, CNA, or a random member of the public who wandered in off the streets and likes to wear scrubs.