EMS Kevlar is Silly

I spent the first half of my career wearing a bulletproof vest while at work.  Most paramedics in my system did, so I just kind of followed along.  Plus, I was in the Big City EMS department.  Big cities are dangerous, right?  And the vest looked cool – made me feel like a cop or something.

People in olden days were insane!  Polish inventor Jan Szczepaik invented the bulletproof vest in 1901.  Here is the first (successful) test of the invention with a shot at his (egregiously underpaid) servant done with a 7mm revolver at three paces.  (Author unknown. Public domain via Wikimedia Commons)

I never had need of it.  Wait – once I didn’t have it on when my right nipple almost got bit off while wrestling a dude on PCP.  I wish I had the vest on at that moment, but that wasn’t a vest thing.  The nipple-biting incident was the culmination of a string of bad choices on my part.  Improving my choices that night could have resulted in me not needing a vest, and not getting my nipple almost bit off.

For those of you smart enough to forego bulletproof vests, they are hot.  They cost a few hundred dollars.  They are uncomfortable in that they ride up in front and cause your shirt to come untucked.  They make you look 40 pounds fatter.  They don’t breathe at all.  The torso sweat throughout your shift goes right into the vest and never leaves – after a week a vest smells like my 8^th grade gym locker did (the year I never took my gym clothes home).  Of course, you can expend a lot of effort and expense getting defunkifying sprays and cleaners. 

I’ve been at my agency for 15 years.  In that time we’ve gone from about 70,000 calls per year to close to 100,000 calls per year.  So some back-of-the-envelope math says that I’ve been employed while my agency ran more than one million EMS calls.  Do you know how many times I’ve heard of a medic being saved by their bulletproof vest?

None.

What troubles me about the vests is that they are outward signs of inappropriate risk estimation.  When one researches EMS injuries, such as these 2011 data, one finds that EMS providers dodging gunfire at work is an exceedingly rare event.  Which is consistent with what I have seen in the last 15 years.  The 2001 data show that the most common event that results in injury is “Bodily reaction and exertion.”  That classification includes lifting heavy stuff and performing repetitive microtasks.  Second is “Harmful exposures” (not necessarily hazmat spills – this includes noisy environments and emotionally stressful events) and third is “Contact with objects and equipment” (needlesticks, rough surfaces, etc).  “Falls” comes fourth and “Transportation incidents” comes fifth.  You have to go to the sixth most common event to find “Assaults and violent acts.”  Most of the 2,100 assaults in 2011 are unchanged by wearing a vest or not.  Violent acts include animal and insect attacks, face punching, finger biting, shoves, cutting/stabbing, and other non-ballistic torso injuries.  You knew a bulletproof vest isn't knife proof, right?

So if we alter our behavior and equipment to match the risks inherent in our jobs, we should focus on lifting mechanics and moving in the back of an ambulance.  I don’t know about you, but standing in a hunched position in the back of the bus ends up hurting my low back.  I do much better if I just sit on the bench or captain’s chair.  Consider hearing protection when you have the siren on.  Watch out when you are handling needles.  Watch your step on icy or uneven ground.  Wear safety goggles.  Consider some kind of grip-enhancing overshoes on icy days.

Traffic accidents are pretty common for EMS providers.  When was the last time you put a seatbelt on yourself in the back of an ambulance?  Maybe not when you are moving around and getting equipment, but there are calls when your work is mostly done and you are typing a PCR and chatting with the patient.  Is your seatbelt on then?  Do you wear a high visibility vest or uniform when working in roadways?  Honestly, you are more likely to be run over working on the side of the road than you are to be shot in the torso.

Those are the things we would do if we were concerned about safety.  Until you are doing those simple things to improve your safety, I don’t believe you when you say you just want to be safe.  Deep down, you know the Kevlar vest is mostly a fashion statement.

I have been injured many times in my career.  I have three or four needlesticks under my belt.  I have a few falls where I had enough hang time to realize that having my feet over my head in midair was not a good position.  Those hurt.  I may have missed a few days of work here and there due to back pain after ill-advised lifts.  Once I wedged myself between the floor and ceiling of the ambulance in order to use both hands to treat a patient.  My partner hit a speedbump, my neck crunched, and my arms went numb for three days (I was embarrassed, so didn’t even report that one).  There was the nipple biting incident (again, poor choices on my part) and I once got punched in the mouth by a girl wearing a big-assed diamond ring.  I donate a chunk of scalp on the infernal oxygen christmas tree almost every day.  I’ve been in a bunch of wrecks but have gotten off lucky and never been hurt in one.

Most of those were due to my own decisions.  Most of those were avoidable.  And every single one of them didn’t require a hot, sweaty, smelly, expensive Kevlar vest to save me.  What I needed to do is slow down, watch my step, duck lower in the back of the ambulance, wait for more help when dealing with angry people wearing big-assed rings, and wear my seatbelt. 

I don’t wear the vest anymore.  But I do wear goggles, the reflective vest, and put on my seatbelt in back when I can.

Seriously, old people are nuts!  Check the look on dude's face!  And what's with the friggin' bicycle? Who rode that to the scene of the experiment?  (National Photo Company (1923), Public domain, via Wikimedia Commons)

First in on an MCI

MCIs are among the most common of unusual calls.  I mean unusual in that a single ambulance can run the vast majority of EMS calls.  It is kind of unusual to need additional busses.  But not all that unusual, right?  It is something you can expect to do in your first month on the job, and continue to run for the rest of your career.

Most places define an MCI as an incident that requires more resources than can be provided at once.  In a vernacular sense, though, a paramedic referring to “an MCI” is probably talking about a multiple patient scene.  In my jurisdiction, we begin referring to incidents as MCIs when it requires a three-ambulance response to deal with the sick and injured.  So in this post, when I am talking about an MCI, I’m talking about a scene like that.  I know that a five-victim grinder with three ambulances isn’t overwhelming to an EMS system and doesn’t represent mass casualties, but the principles are the same.

Think of how easy it is to get to a three-unit response.  It is a really common situation.  Car crashes do it all the time.  A decent fight can do it.  Shootings.  Carbon monoxide.  Weddings.  Structure fires.  Hell, most special events like NFL games are really just preplanned MCIs that develop slowly.  I’ve even run MCIs caused by spilled cleaning supplies.  Every crazy situation you can think of has been run by some poor sucker paramedic somewhere.  

Let me let you in on a secret: How well you run an MCI will make or break your reputation.

Whether the MCI is run well or poorly, it will affect how your coworkers perceive you from then on.  Even your first one.  Even if it falls on your first day.  An MCI must be run well.  And the secret to a smooth MCI lies on the shoulders of the first arriving crew.

The first crew has five actions to perform.  Taking care of these actions means the call is likely to go well, from an EMS point of view.  The five actions constitute 90% of the success of the whole scene.  Not performing the five critical actions usually means that the call becomes irrecoverable – any supervisor or later crew will have a very hard time getting the call back on the tracks.

The actions are simple: 1. Identify the call as a big deal, 2. Request more help, 3. Get onto an MCI channel, 4. Start getting bed counts, and 5. Set up the scene. 

That's it.  If you do this, the call is much more likely to run smoothly.  Like 90% likely.  And these are tasks you can do on your first day on the street. 

Identify the call as a big deal: You arrive on scene to find a three-vehicle highway accident.  One of the vehicles is a fully occupied school bus that rolled.  You have a high likelihood of ending up with more patients than you can transport by yourself, right?  If there is someone who is critically injured, you can’t just ignore them until you check out everyone on the bus, right?  You need more help.  Let people know that you are on a big-deal call: “Dispatch, this is a three-vehicle accident that involves a rolled over school bus.  Show me as ‘Highway Operations.’” 

Don’t forget your Chuck Yeager voice.

One of the biggest problems can arise when you are slow to identify your call as a big deal.  Listen, I get it.  We all want to be badasses who can handle anything the EMS Gods throw our way.  Or patients trickle in one at a time until you notice that there are too many for you to handle.  Whatever.  The earlier you identify your call as a big deal with more patients than you can comfortably transport, kick into MCI mode and identify the call as a big deal.

Probably a big deal.  I'm no expert, but it looks like more than two people may have been hurt. BA38 crash, Heathrow, London, UK.  (By Marc-Antony Payne [CC-BY-3.0], via Wikimedia Commons)

Request more help: Do this early.  I find that paramedics are more likely to try to handle the call too long by themselves.  Request what you need and do it early.  Be specific in describing what you want.  If you end up cancelling some units, that is fine.  Start getting help to your scene: “I will need five ambulances to this scene to start, and you will want to start preparing to send me more…”

Get on an MCI channel:  My jurisdiction has radio channels set up to facilitate mutual aid communication between different jurisdictions.  The police have four channels, fire departments have four channels, and there are even command channels for people to talk to one another.  If I am on an MCI, I know that the more ambulances I use, the higher chance of another agency responding to my scene.  They deserve to be communicated with, as well.  In addition, an MCI can clog up a radio channel and there are other calls going on in the system.  So switch everyone involved to a tactical channel that most agencies possess: “Switch all units assigned to this call to Green1…”

Request a bed count: This step is needed more as transport numbers increase.  Three patients being transported in three ambulances probably don’t actually need a bed count.  But as the number of transports increases, hospital systems will become more stressed.  Requesting a bed count early is important for a few reasons.  First, it tells hospitals that you have a big deal call going on.  They should get ready.  Second, it tells you that Hospital A just got slammed from a different big deal call and has no trauma ORs readily available.  Good to know.  Finally, it gives receiving facilities the chance to make whatever adjustments they need to make.  Bed counts in my system can be a simple call to medical control asking where to take five patients, or it can involve dispatchers getting onto web-based MCI resources that contact hospitals region-wide.  This is a system-dependent task, so make sure you know what needs done in your system.

Set up your scene and tell people your plan: There are a few sub-tasks with this one.  We’ve all had the MCI management lecture in school with ICS jobs like staging, triage, communications, and transport.  Each call is different in how you will set it up.  A compact scene with straightforward patients is easier to handle, for example, so you may handle all of the ICS roles yourself.  Alternatively, you may decide that you will be best served by backing off and setting up the whole enchilada.  I say it depends on your call.  But every MCI needs to have this decision be an actual conscious decision.  Make the choice of how you want to run this call.

The tasks are dependent on what kind of scene you have going on, what resources you need, and that kind of thing.  You need to tell people where to go.  This is when you set up a staging area, decide on triage and treatment areas, and that kind of thing.  On any MCI, though, it is important to set up ingress and egress routes.  Be specific as to how you want people to approach your scene – it will cut down on freelancers.  For example: “Have the first two units come to me at mile marker 123.  Have units after that stage on the northbound highway at mile marker 122.  I will want cars to enter from the south and exit northbound…”

So how does this all sound?  “Dispatch, I have multiple victims at this fire with minor burns and smoke inhalation.  I’m going to need two more units, nonemergent.  Have them approach from the Main Street side and stop at First to avoid fire trucks.  Let’s move this scene to the Green1 channel, and call Burn Center Hospital to make sure they can handle six patients with minor burns, please.  I will be Southern Operations for the duration.” 

How about a bigger deal?  “Dispatch, Ambulance Six on scene.  This looks like a gas explosion and building collapse with more than fifty casualties.  Show me as Downtown Operations.  Send me three ambulances to my location at the south parking lot to set up triage.  Stage all other ambulances at First Avenue until we call them in.  I’m going to need at least twenty ambulances before this is all done.  Switch to Green1 for this scene and start getting bed counts for me.” 

One final point – this has to be practiced all the time.   The way to get good practice is to implement a plan like this on every call where you need two more ambulances.  I despise disaster drills.  I hate tabletop MCIs.  Whatever the emergency managers, chiefs, and administrators have in mind doesn't matter because it is the first medic on scene who sets these calls up for success or failure.  Don’t wait for a school shooting to try to remember all of this.  Your whole system should have this as second nature, based on running dozens of car crashes and fights that result in multiple responses.  That way, when the big one does drop, it is run using your normal practice. 

Syncopal Home Runs

Last week we talked about reasons that the Quick Six ECG view sucks.  The Quick Six view only involves the frontal leads – I, II, III, aVR, aVL, and aVF.  It leaves off half of the ECG, and the ignored half has a lot of important information.  One of the scenarios last week concerned syncope.  There are three pathologies to specifically rule out when you are taking a syncope ECG.  Remember the Two Rules of EMS.  Rule Two is “Look Cool.”  Finding one of these three pathologies is an incredible way to look cool.  It is the EMS equivalent of Babe Ruth pointing to the right field bleachers and then smashing a ball there.

By Charles M Conlon, Public Domain, via Wikimedia Commons

Consider something like last week’s scenario: It is a hot summer day when you respond to a city park for a 22-year-old male soccer player who fainted.  He is in good shape, feels fine now, and doesn’t really want to make a federal case out of things.  He asks that he just rest in the shade with plenty of water.  His vital signs include a blood pressure of 116/72, heart rate of 96, and a respiratory rate of 18.  What do you need to look for and rule out on an ECG? 

First, there are the obvious points, specifically acute ischemia and arrhythmias.  Finding new-onset atrial fibrillation can easily explain syncope, as can ventricular tachycardia, supraventricular tachycardias, and bradyarrhythmias.  Ischemia and infarction should be our bread and butter and should be found when present.  Finally, anything unusual should be noted.  “Unusual” includes big-assed T waves from hyperkalemia, new bundle branch blocks in patients that shouldn’t have bundle branch blocks, and those kinds of findings.  But this post is about three ECG findings that require the precordial leads to find and diagnose.

Brugada Pattern or Brugada syndrome is the finding that I mentioned in passing last week.  It is a genetic disease that has an increased risk of ventricular tachyarrhythmias and sudden cardiac death.  I’m not going to get into all of the genetic information – if you care about that kind of thing, you’re probably the kind of person who can look up the information without my help.  The specific pathogenesis hasn’t been well-established, either.  It seems to be related to right ventricular abnormalities and/or sodium channel weirdness.

I remember that the disease is much more prevalent in men compared to women, and is more common in people of Asian descent.  I even remember being told that southeast Asian males from traditional cultures would go to bed wearing dresses so that the evil spirits that kill men in the night wouldn’t find them – but I can’t find a citation on that information.  It is probably not true, but makes things easier to remember.  The only times I have seen it in reality the dudes involved weren’t visibly Asian. 

Brugada pattern ECGs are pretty simple – right bundle branch block or incomplete RBBB patterns in the septal leads with ST elevation.  So let’s work through that.  Septal leads are V1 and V2, but this can continue into V3.  The RBBB pattern is usually RSR’ with a wide QRS, right?  An incomplete RBBB pattern is that RSR’ shape, but barely narrow – like 0.09 or 0.10 seconds.  Anytime a QRS complex is wide (or tall or deep), the ST segment tends to be pushed in the opposite direction from the terminal QRS wave.  So a wide RSR’ pattern should have ST depression; the ST segment should be pushed down, opposite from the upright R’ wave.  But the Brugada pattern doesn’t do that.  It doesn’t do what is expected.  There is an upright R’ wave with ST elevation.  That is what makes it weird, and that is what makes it noticeable.

ST elevation with terminal R waves.

There is a difference between Brugada pattern and Brugada syndrome, by the way.  The Brugada pattern is the ECG findings.  Brugada syndrome is a person with the ECG pattern that suffered a tachyarrhythmia or sudden cardiac death.  The prevalence of Brugada syndrome in patients with the Brugada pattern is not well-established (because it is rare), but a meta-analysis demonstrated a 10% rate of complication at 2.5 years.¹  That means that for every two and a half years that passes, a person has a 10% chance of kicking it.  It is not good.  

One of the coolest stories I have heard concerned two newish paramedics.  They responded to visit with a dude complaining of chronic low back pain.  Picking at the issue, they found that the man’s back hurt due to falling down a lot.  Picking at the falling down thing, they figured out that homeboy kept fainting.  That resulted in an ECG, and that resulted in them recognizing the Brugada pattern.  They took “chronic low back pain guy” to the hospital and called the Brugada.  The nurse blew them off; she even accused them of making up words.  The physician took their ECG, looked at it, slapped the medics high-five, and called cardiology.  It is flat bad-ass to call your shot like that.

The second precordial finding is hypertrophic cardiomyopathy (HCM).  Hypertrophy is thickening.  Cardio- is heart.  Myo- is muscle. And –pathy is bad.  All that means Thick Heart Muscle Badness.  HCM is how it is usually abbreviated.  It is different from more common hypertrophy like left ventricular hypertrophy (LVH) because it doesn't have an obvious cause.  It is the leading cause of sudden cardiac arrest in young athletes.²  The prevalence is 0.2-0.5% of the general population.

The ECG findings concern left ventricular hypertrophy with dagger-like lateral Q waves.  Breaking it down again, LVH involves the number 35.  Find the deepest wave in V1 or V2 and count how deep it is.  Then count the highest R wave in V5 or V6.  Add them together.  If the result is greater than 35mm (in a patient older than 35 years), be suspicious of LVH.  In a patient younger than 35, swap the height numbers to 53mm.  Lateral strain, and an R wave in aVL taller than 12mm helps to confirm LVH.  So find the LVH.  With LVH, look for narrow, sharp, needle-ish Q waves in the lateral leads (I, aVL, V4, V5, and V6).  That’s it.  If you find the LVH and the lateral Qs, speak up about your suspicions regarding hypertrophic cardiomyopathy.

Note the depth of V2 plus the height of V5 is suspicious for LVH.  In addition, the narrow/sharp/dagger-like lateral Q waves increase the suspicion of HCM.

The last syncopal finding to specifically rule out is long QT syndrome (LQTS).  LQTS is a genetic disease found in a patient with a QTc greater than 500ms in the absence of other (correctible) causes*.  There are a few ways to find the QTc.  First, measure the QT from the onset of the QRS complex to the tangent of the T wave.  Apply the Bazett formula (QT in milliseconds divided by the square root of the R-R interval in milliseconds)… Who am I kidding - square roots means there is too much math for EMS professionals in the middle of a call.  We’re busy with a patient and math is dumb.  So forget about that one.  The second method of finding the QTc is to estimate the QTc.  In heart rates under 100 per minute, the QT interval should be less than half the R-R interval.  Does the T wave end before the halfway point of the R-R? 

The final way to find the QTc is to have the computer in the monitor calculate it for you.  It calculates and prints it at the top of every 12-lead.  How’s that for handy?  In order to do that, however, it needs the precordial leads.  The monitor will not calculate intervals without all leads working.  So put the V-leads on the patient.  Normal QTc intervals are under 470ms in males and 480ms in females.  But 500ms is an easier number for me to remember.  If the number at the top of the ECG is bigger than 500, especially in the absence of other obvious causes of long QTc intervals, worry about LQTS.  Simple.  Place the V-leads and read what the monitor prints out. 

Prolonged QT intervals can be caused by a bunch of things.  The four main causes are drugs, electrolytes, CNS pathologies, and ischemia.  In the absence of those causes, congenital LQTS should be on your mind. 

Each one of these three findings needs to be specifically looked for in syncope patients.  The three pathologies are rare, but being able to find one of them would result in potentially saving the patient’s life.  Plus, it makes you look cool.  EMS Rule 2, baby.  But each of these require the precordial leads to be placed.  Do you use them?  Would you have placed the V-leads on the 22-year-old soccer player who fainted on a hot day?  If not, what findings are you missing?  How many opportunities for calling your home run shot have you missed?

1. Gehi AK, Duong TD, Metz LD, Gomes JA, Mehta D. Risk stratification of individuals with the Brugada electrocardiogram; a meta-analysis. J Cardiovasc Electrophysiol. 2006 Jun;17(6):577-583.

2. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. Circulation 1996 Aug;94(4):850–856.

*A QT interval is the flat measurement between the onset of the QRS complex and the end of the T wave.  The problem is that as heart rates increase, the QT interval should shorten – that makes sense because the heart has to repolarize and be ready for the next beat.  That has to be done faster at higher heart rates.  So the QTc is the corrected QT interval – corrected to what it would be if the heart rate was 60 beats per minute. 

Deep Six Quick Six

You respond* to an office building to find a 35-year-old male complaining of flu-like symptoms.  He is embarrassed that his coworkers called 911, and states he became nauseated shortly after lunch.  He feels weak and generally punked out, and had one episode of weird unexplained sweating that has now resolved.  His vitals are great and he just wants to go home.  He says he doesn’t need an ED just because he ate some questionable food and got a stomach bug. 

Your partner runs a quick-6 ECG.  For those that don’t know, a quick six is accomplished by putting on the four limb electrodes, resulting in the six frontal ECG lead views.  This is what it shows:

No big deal, there.  Nothing concerning, and nothing that would make you want to look at the V-leads, right?  Sinus at 75, normal axis, no ST or T wave changes.

This is an EMS blog.  You’re not going to fall for that trap, are you?  You ask your partner for the V-leads:

Should the patient go to the hospital now, maybe to get the anterio-lateral MI fixed up? 

Let’s try another one.  It is a hot day when you respond to the park for a 22-year-old male soccer player who fainted.  He is in good shape, feels fine now, and doesn’t really want to make a federal case out of things.  He asks that he just rest in the shade with plenty of water.  You are about to agree, but your partner is new and she runs a quick-6 ECG:

Weird – there is a pathologic left axis.  But otherwise there is no dysrhythmia, no ST changes, and nothing land-jarring to get worked up about.  Don’t overthink things – this is a young, athletic soccer player on a hot day who fainted in the sun.

Oh, what the hell.  It is an EMS blog:

Click to zoom

Brugada syndrome.  Think he needs to go to the hospital now?

I see quick-6 ECGs used often.  I completely don’t understand why.  I have even heard rumors of paramedics teaching this to students and new-hire trainees!  Why would you only seek half of the information?  Do you only do secondary exams on the front of people’s bodies?  Or just from the waist up?  Do you palpate blood pressures often?  Do you start IVs and then blow off taping them down?

If you do, let me be clear: You are a poor paramedic.  I don’t want to work with you.  You are bringing down our profession.

It isn’t 1998 anymore, when we had LifePack10s and couldn’t look at the precordial leads.  Wait – even then we would set up MCL leads.  Medicine and medical technology has advanced.  Keep up – you are getting left behind.  In 2014, twelve leads is the current standard.  Leeching the bad humors, MAST pants, and frontal lead prehospital ECGs are no longer the expected practice.

I timed myself a few times.  I can put on the V-leads in about 45 seconds.

So I have been thinking about this and can only think of three reasons to check only the frontal plane leads.  The first is that CPR is going on.  There is no need to get a 12-lead of VFib or asystole.  It is pretty important to get a 12-lead as soon as possible after return of spontaneous circulation, though.  The second reason to not immediately get a 12-lead ECG is for privacy concerns.  There are patients in an airport concourse, or in the stands of a packed stadium, places like that, for whom lifting their shirt (and maybe hoisting up a left breast) is probably not cool right at that moment.  The obvious answer is to move them to a more private setting, but that isn’t always immediately feasible.  The third reason to not place V-leads is that you are plum lazy.

Do you not care about bundle branch blocks, ventricular hypertrophy, Brugada syndrome, hypertrophic cardiomyopathy, anterior ischemia, septal ischemia, low lateral ischemia, posterior infarcts, Wellen’s waves, and the rest of the long list of findings that the V-leads give you?  Are you really content with being able to name the dog (name the rhythm), measure the intervals, and state the frontal plane axis?  Those three things are why you ran an ECG?!?

Can you think of other reasons to not look at the precordial leads?  I am literally asking – I can accept that there may be reasons that I haven’t thought of.

If it is important enough for a quick-6, it is important enough for a 12-lead.  You’re a paramedic.  Act like it.

*With lights and sirens because 'Uh, no, I guess not' was the answer to "Is his breathing completely normal?"