2014: Year In Review

I had a great time writing blog posts this year.  In 2014, there were 52 posts put up on the blog (not counting this one).  Maybe there are some that you missed, or need to find again. 

The most popular posts:

1. Chuck Yeager Voice - this one almost doubled the page views of second place...

2. MRSA is not a river in Africa

3. Giving NTG to an Inferior MI.  People still think I’m a maniac for my point of view on this one… (The first part of that topic is a scenario.)

4. My Anti-Quick Six Rant

5. I Hate Adenosine

Speaking of stuff I hate besides adenosine, there are also articles about Peroxide, Rats, and the term “Sober and Competent” (plus Part II).

I shared a few stories about my egregious mistakes and bad habits, hopefully to stop you from doing the same dumb things.  They include vicious, wild Three-Legged Labs, the story of the guy who was Shot in the Calf, why I stopped Wearing Uniforms Home, and why I need to stop Prejudging Calls.  There are also stories of Medics Getting Hurt, evil medication Ampules, and another story of another guy who was Shot in the Groin without getting a hole in his pants.

I try to orient my posts to prehospital knowledge: skills and information that a medic needs but that a doctor or nurse wouldn’t need (as much).  Even so, there are topics that I think prehospital personnel don’t have a firm grasp of.  So I’ve written posts about why Pancreatitis should be treated better, the different kinds of Aphasias, Leadership Traits, how ECG Filters work, my opinion of How a 12-Lead Should Be Laid Out, a discussion of Rare Syncope Causes, why I think the phrase ‘Children Aren't Little Adults’ is trite and meaningless, and my thoughts on when patients are Fakers/Malingerers.  There are posts about what I think are the prehospital world’s Good Journals and Blogs, basic Ethics, Three Reasons for Noncompliance among your subordinates, and the importance of being in a career that requires Expertise.

But I really like to focus on prehospital skills.  So I talked about Establishing Good Habits, Making Decisions in Advance, with Part II, and a post about communication that could have been called Don't Tell Me Your Problems; Tell Me What You Want.  I talked about how history taking is kind of like a Tree of Knowledge, the Power of WTF, my feeling on Family Riders (TL;DR is NO), my thoughts on Field Training, and even whether it makes sense to make Left and Right Turns.  I posted about how to give Big Room Reports, Telling Family Grandpa is Dead, and the prevalence of Acting in EMS (at least on my ambulance).  Other posts include What Equipment to Bring into a call, how to handle Advance Directives (we do really bad at this), different stages of Agitation, and the first Five Actions on an MCI.  Going on, we discussed Bulletproof Vests (I’m not a fan), the reasons for Single Car Crashes, why I hate approaching Slumper Cars, and how to write Narratives.  Finally, I also gave my untested idea about Distracting Injuries, ranted about Giving Your Expert Opinion, and the fact that I can’t do anything about Bumsicles.

By the way, in the interest of balance, the least read posts of 2014 were:

     48. The Patient Who Almost Shot His Nuts Off

     49. How to Give Your Expert Opinion Without Confusing People

     50. The Different Flavors of Aphasia

     51. Expertise

     52. How to Not Screw Up Advance Directives

They aren’t bad, especially the expert opinion and advance directive posts.  You should take a minute and read them…

Have a good one, and a better 2015.  Happy New Year.

Try to keep your NYE party under control...
(By Bird33ou [Public domain], via Wikimedia Commons)

I Hate H2O2 (Sometimes)

I was working special event duty this weekend.  A lady presented to the first aid room after a minor fall onto concrete.  She abraded her knees, fairly deeply.  Some of the abrasion could even be described as lacerations.  One of the other medics jumped to it.  He busted open a bottle of 3% hydrogen peroxide, poured it over the lady’s knee wounds, dried it all with a 4x4, and bandaged it all up.

Did he do the right thing for that patient?

I need to put this here so that the next pic isn't the one that constantly shows...

Hydrogen peroxide (H2O2) was used as an antiseptic in this case.  The difference between an antiseptic and an antibiotic is that an antibiotic is usually directed at killing specific bacteria.  An antiseptic is designed to kill or impede most microorganisms – bacteria, fungi, and viruses.  Several antiseptic categories exist, but common ones are alcohols (ethanol), biguanides (chlorhexidine), bisphenols (triclosan), chlorine compounds, iodine compounds, and hydrogen peroxide.  One of the most common antiseptic soaps uses triclosan.  When you swipe an alcohol prep or iodine prep on an arm, you’re using the alcohol as an antiseptic.

Those antiseptics are used externally, though.  Most aren’t designed to be poured into an open wound.  What if an antiseptic kills bacteria, but it also kills human skin cells?  Are there studies that can help us?

In lab conditions, hydrogen peroxide appears to work to kill bacteria.  It works best on Gram-positive bacteria, but when catalase is present (like in living tissue), hydrogen peroxide becomes less effective.(1, 2)  Some studies did not find that hydrogen peroxide messes with wound healing.  For example, Gruber’s group (3) found that peroxide lengthened the healing time of wounds.  This is probably because bullae formed in the wounds, suggesting that hydrogen peroxide should be avoided with new epithelium.  Lineaweaver, et al.,(4) found that wound healing was not inhibited in rats, but this study also found that microorganism load didn’t change a whole lot, either.  Two other studies did not show that hydrogen peroxide was effective as an antiseptic.(5, 6)  One final study on fetal tissue indicates that hydrogen peroxide may increase scarring (7).

So, in short, hydrogen peroxide does not appear to work well as an antiseptic.  This makes sense when you think about it – its not like surgeons pour 3% hydrogen peroxide over incisions, right?  Ever seen an ED physician pour a bottle of peroxide into a laceration before s/he sutures it up?  Nope.  They use clean water irrigation to clean wounds.

"Uh, yeah.  I'm going to need about 15 gallons of hydrogen peroxide, STAT!"
Shotgun wound by DiverDave (Own work) [CC BY-SA 3.0], via Wikimedia Commons

In addition, there seems to be some questions as to whether H2O2 affects wound healing or not.  It appears to be cytotoxic.  So if there is questionable efficacy, plus controversy regarding healing rates, why use it?

Use soap and water.  Copious irrigation with clear water.

For me, hydrogen peroxide is really good for one thing – loosening dried blood, especially on equipment and white shirts.  There are calls after which I pour a bottle of peroxide all over the pram.  The bubbles show where the blood is, plus loosens it up so I don’t have to scrub it off as extensively.  It seems to really help in tight little seams and other hard to reach places.  I also use it to loosen up blood stains on a white shirt.  I’ve not had a shirt ruined since starting to dab with peroxide.

1. Brown CD, Zitelli JA. A review of topical agents for wounds and methods of wounding. J Dermatol Surg Oncol 1993;19:732-7.

2. McDonnell G, Russell AD. Antiseptics and disinfectants: Activity, action and resistance. Clinical Microbiology Reviews 1999;12(1):147-79.

3. Gruber RP, Vistnes L, Pardoe R. The effect of commonly used antiseptics on wound healing. Plast Reconstr Surg 1975;55(4):472-6.

4. Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg 1985;120(3):267-70.

5. Leyden JJ, Bartelt NM. Comparison of topical antibiotic ointments, a wound protectant and antiseptics in the treatment of human blister wounds contaminated with Staphylococcus aureus. J Fam Pract 1987;24(6):601-4.

6. Lau WY, Wong SH. Randomised, prospective trial of topical hydrogen peroxide in appendectomy wound infection. Am J Surg 1981;142:393-7.

7. Wilgus TA, Bergdall VK, Dipietro LA, Oberyszyn TM. Hydrogen peroxide disrupts scarless fetal wound repair. Wound Repair Regen  2005;13(5): 513–9. 

Expertise

I’m kind of an amateur dinosaur nerd.  What can I say, I’ve liked paleontology since I was a kid.  Anyway, I was surfing through some paleontology blogs, as I have been known to do on a Saturday, and found a post about a paleontologist who was sorting through bones in Ottawa’s Canadian Museum of Nature.  Mental Floss had the story, also. Without getting deep into Mesozoic detail, the bones were classified as two genera similar to triceratops.  The paleontologist, Dr Nick Longrich, reanalyzed the bone fragments and decided that they were actually two different genera of Canadian dinosaurs that were previously believed to only come from the American southwest.*

There are apparently blatantly obvious differences between all of these animals...

Ceratopsidae Skulls, to Scale by Danny Cicchetti (Own work) [CC-BY-SA-3.0], via Wikimedia Commons    

It isn’t all that uncommon for something like that to happen.  Here is another post where a PhD student stumbled upon a previously undescribed sauropod (long neck big dinosaur) genus sitting in a box in London’s Natural History Museum.

I don’t actually know a lot about classifying fossils.  It seems incredible to me that an expert can look at the curve of a bone, or the shape of an opening on a bone fragment, and know that they are holding a new genus of dinosaur.  Think about the time one has to spend, the investment in knowledge, and the experience level needed to be able to do that.  That is an incredible amount of deep, deep expertise needed for that job.  You also hear about this kind of expertise in relation to art appraisal, where an expert can look at details and name the artist – based on friggin’ brush stroke patterns.  Pilots can feel something wrong with their aircraft, based on how it is handling at that moment, in those conditions. 

I wish I had a job like that where expertise is necessary.

Oh, wait.  I do.

I can tell sick-not-sick in a glance from a dozen feet away from a patient.  I can tell, with reasonable accuracy, what kind of call I am going on based on the address and time of day.  I know what particular streets offer for traffic patterns at different times.  I know the interiors of a hundred different buildings, and the best place to access each.  I know how to bring the calm to the chaos.  I know how to intubate a person at floor level in a dark, dirty, cramped room.  I can tell the difference between sinus and AFib at a glance.  I can look at a pile of medications, know what they were prescribed for, and know which the patient hasn’t been taking.  I know my way around the intestinal underground tunnels of stadiums, airports, and other big buildings.  I know if that family member right there is going to be a problem.  I can listen to breath sounds, watch a patient breathe, and feel a pulse to generally know if the patient will need their breathing to be assisted on the way to the hospital.  I know whether it is worthwhile to start an IV in the car, or wait til after extrication.  I have a sense of who needs restrained before anything even happens.  I know the right way to cut a down coat (get it wet first, so the down doesn't explode everywhere).  I know when a house is dangerous.  I know how to calm a frightened child.  I know how to calm a frightened adult.  I know how to give a biophone report so as to get what I want.  I know how to communicate with a team of providers and other personnel to manage emergencies.  I know how to manage an MCI. 

What things do you know?

*A link to find the published paper is here.

Noncompliance

When I was an angry, angry captain responsible for quality assurance, working in a basement dungeon and rarely being allowed out in public, I found out that there were three main reasons for not complying with a directive.

Dunno, can’t, and won’t.

Dunno encompasses all of the times that an employee “don’t know” something.  When an employee doesn’t know that something is required.  When an employee doesn’t know how to do something.  When an employee doesn’t know how to use a piece of equipment.  When an employee doesn’t know how to document that s/he did what was required.  Some people are just a wee tad hypocognitive and need to be reminded more than once. 

Most of the dunnos are corrected in paramedic school – a medic learns to run an arrest, intubate, start an IV, and that kind of crap.  Then they are hired into a job and an HR person goes over the other requirements, so they know how to wear the uniform, how to clock in, and how to call in sick.  Finally, a field training program of some sort covers a whole bunch of the other dunnos (and correct some of the stuff learned in school).

After all of that, though, there are still requirements that change, new procedures, and new equipment that have to be learned.  Anytime something changes, drops, or is adopted there is someone who is slow to get the proverbial memo.  Hell, I still occasionally think of Bretylium, bicarb in arrest, and MCL1 from time to time.  It took me a year or so to remember to use aspirin when we first got it.

I am optimistic that there is a bright and happy future where I
am embarrassed at being so old as to even think of this.  Credit

The “can’t comply” form of noncompliance occurs when an employee knows about a directive, but systemic factors are standing in the way.  For example, you can have a standing order that says an employee must complete the PCR before leaving the ED, but if there is another call for them that dispatch is nagging about, the run sheet is probably not going to be left. 

Another good example of this was back when we adopted waveform capnography.  End-tidal CO2 must be documented for all intubated patients.  All employees were told about the new requirement.  But even after allowing time for adoption, re-explaining the requirement, and pulling my hair out, there was still embarrassingly low compliance.  Then one day a medic explained it to me, like I should have known about it all along.  See, the EtCO2 equipment was hidden away.  Thus, it was a pain in the ass to get out and use when you had a patient sick enough to require a tube.  I don’t know why the capnography adapters were so hard to find, but all it took was moving the equipment to the airway cabinet for compliance to shoot up.  The medics wanted to comply, but there were problems standing in their way. 

If an employee knows that something is required, knows how to do it, and there is nothing standing in their way, then all you are left with is that they “won’t comply.”  Employees that truly won’t do what is asked of them shouldn’t be employees for long.  But most employees aren't actually willfully disobedient, so this is rare, and a topic for another time.

One of my biggest flaws as a manager (and, I freely admit, there were many) was that I was habitually too quick to assume “won’t” when “dunno” or “can’t” actually explained what was going on.  If you find yourself in a management position, please make sure to always look for the can’t and the dunno first.  One of the major roles of managers and supervisors is to get rid of the can’ts and dunnos in your organization and allow good employees to be good employees.

Bumsicles

Two weeks ago was the first real cold snap of the season.  It got butt-ass cold.  Cold like a well digger’s brass bra cold.  You know the cold that is so cold when you inhale through your nose and can feel the boogers freeze?  Or when you climb in your car and it creaks and crunches like an arthritic old man?  Cold like that.  The second day of the cold had a high of 7°F, but that was the high for the day.  When my shift started at 6 AM, it was much, much colder. 

Ever been in cow-freezing cold? I have - goose hunting in Wyoming...
Public domain, NOAA, via Wikimedia Commons

The city is generally good to the homeless on nights like that.  At night, most of the shelters toss out the rules and throw their doors open.  Most shelters normally don’t accept intoxicated people, but when it gets so dangerously cold outside they drop that rule.  "Come on in drunk, if you need to.  If you are a needle drug user, please try to keep it to that corner over there."  But not everyone gets into a shelter, and many shelters close first thing in the morning.  Everybody gets kicked out for the day.

My first call was right out of the garage.  A homeless man was forced to leave a shelter when it closed.  He had immediately developed chest pain.  I am not going to make any statement about his chest pain or the fortuitous timing of the pain.  The second call was for a different urban outdoorsman in a wheelchair inside a convenience store.  He had been hanging out inside the store and when he was asked to leave, dude had a seizure.  He only had socks on his feet – the hospital socks with the plastic tread on them.  I am not going to make a statement about the nature of his fortuitously timed seizure.  The third call was for a undomiciled lady who began to cause a scene in a coffee shop when she was asked to leave after hanging out for an hour or so.  There was really nothing wrong with her, except for being loudly and profoundly upset about having to be out in the cold.  She complained that she moved here for the legal weed, but didn't realize how cold it could get.

It was, all in all, a frustrating morning.  It was a waste of EMS resources.  It is not what I imagined when I began my EMS career.  (In my imagination, my job involves crawling through the broken window of an upside-down sorority bus with a laryngoscope and an ET tube during a nocturnal thunderstorm.  Lightning flashing, thunder roaring, that kind of hero thing.  My job is pretty badass inside my head.)  It is also a waste of hospital resources.  I pretty much guarantee that taking care of a cold bum with “chest pain” isn’t why the doctor got into med school.

You know the most frustrating part?  There is no answer to the problem.  I would have chest pain too, if I had to spend my day outdoors with a high of 7°.  Hell, I would jump in front of a bus if I had to, in order to get indoors.  What’s the answer?

I decided that it is okay that I don’t have the answer.  It is not my job to solve this problem.  My job is to make each patient’s day a little bit better.  When it is cow-freezing cold out, I can do that with a ride to the hospital.  I get paid hourly.  I don't get a bonus based on how many people I transport are actual, imminent emergency patients.  All I have to do is give someone a ride to the hospital, their situation is better than when I found them, and my job is done. 

Listen, schizophrenics stop taking their meds.  Women go back to physically abusive boyfriends.  Alcoholics continue to drink.  Homeless people are homeless.  These are complex problems that are multifactorial and difficult to solve.  It doesn’t help for me to get frustrated or angry about the situation.  I didn’t cause it and I can’t fix it.

I have to give credit – I usually hate it when my patient goes to the waiting room when we arrive at an emergency department.  But on this day there were hospitals sending me to the waiting room.  Once there, the triage nurse would ask whether the patient wanted to get checked in with a problem, or if the patient just wanted to sit in the waiting room until they were ready to leave.  The hospital had no problem if they sat in the waiting room quietly.  Several patients took advantage, without getting checked into a room for a full evaluation.  There is a balance there: You don’t want to turn the waiting room (where my family would wait) to turn into a shelter, but kicking people out will probably result in higher evaluation costs and uncollectible future toe removals.

Toes, twelve days post frostbite injury.
By Dr. S. Falz (CC-BY-SA-3.0), via Wikimedia Commons, with permission

The ED staff didn’t have answers for the problem either, so they just concentrated on helping people.  Focus on making the day of the person in front of you a little bit better.  Isn't that one of the main reasons you're in EMS?