I Just Need to Shut Up on the Way to Calls

This kind of thing happens way too often.

There I was, sitting in an ambulance with my partner, minding my own business, when a call came in:

“Ambulance Four, 321 Main Street, Code 10.”

Code 10 means emergency, with lights and sirens.  I repeat back the address to which I am responding: “321 Main, ten.”

“Twenty-five female, full term labor.”

"Kay," I replied.

The rant was kicked off.

“Dammit, I hate OB calls! Especially full term labor calls! It isn’t an emergency! Millions and millions of women have been having babies without my help since the human species evolved! There is nothing that has changed in the last 20 years that now requires an ambulance! This woman had nine months to save up cab fare and failed! And she is apparently so unpleasant that there isn’t a single person with a running vehicle in her life that likes her enough to give her a ride to the hospital! What about normal, full-term birthin' is an emergency?!?”

My partner rolled his eyes and didn't answer the rhetorical question.

“She probably isn’t even close to delivering! [Switching to a poor female imitation voice] ‘Ooh, I feel a cramp… I need to call 911’  [Back to my voice, shouted] She is probably twelve hours away from delivery! We’re running ten in order to give her more time pacing the L&D hallways! Childbirth isn’t an emergency!”

My partner, I’m sure, tried to block out the rant coming from his right. He had probably heard it before, after all.

Me, while enroute to EMS calls.

By Visitor7 (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

We arrived on scene of a nice little cottage to find a nice lady on the floor in a frighteningly large puddle of blood. Like, way more blood than you see in a run of the mill childbirth. Disconcertingly large expanding puddle of blood. There was one tiny little infant foot protruding from her vagina. Just one, though. Where's the other foot?!? 

The firefighters on scene looked like they wanted to run away. I am positive that I felt the same way as I tried to look unperturbed and in-control.

Shit. It is. Indeed. An emergency. Shitshitshitshit.

I am glad my patients don’t see me on the way to calls.

I Hate the Term "Sober and Competent"

You respond to a call at the request of the police department to check out a “sick case.”  You arrive to find an 18-year old male without complaints.  The police tell you that they need you to check him out – he is acting weird.  During your exam, you find the patient to be calm and cooperative.  He knows what day of the week it is, what city he is in, and tells you his name.  There are no signs of alcohol consumption.  He stopped taking his medication a few days ago, but he can’t remember what it is that he was supposed to be taking.  Medication names are hard to remember sometimes.  He stopped the medication by choice, not due to running out or anything.  He prefers how he feels when he isn’t on it.  He explains to you that there is no problem and seems to be a nice guy, but his eyes are not meeting yours.  When you ask him what he is looking at, he explains that his cat is asking him to stay home.  You do not see a cat.

Oh, there he is, the evil bastard...
By Mrmiscellanious, via Wikimedia Commons (Public Domain)

You, being a smart medic, know that this patient should probably go to the hospital.  When you suggest that course of action to the patient, he declines.  You work to try to convince him to go to the hospital, but he won’t agree to voluntary transport. 

What do you do?  He is oriented to person, place, and time.  He is sober.  Is he allowed to refuse? 

This is an example of why I hate the term “soberandcompetent.”  That’s how I am going to spell it from now on, because that is how it is said.  Soberandcompetent.  I hate the term because “sober” has grey areas.  “Competent” is a legal term that is decided in court, and also has grey areas.  Awake, alert, and oriented times three (or four) is unhelpful.  Decision making capacity is what we are trying to assess – is the patient capable of making his or her own decisions? 

Let me walk through each of those sentences and see if I can convince you too.

Sober is a term that is loaded with grey areas.  Listen, most of us have been in various stages of alcohol intoxication.  I’ve found myself completely sober, buzzed, too drunk to drive, falling down drunk, and woke up in dried vomit and not known where I was drunk.  Which level do we care about?  Can buzzed people refuse?  Drunk people?  Certainly not falling down drunk, right? 

Can someone "hold my hair drunk" refuse?
By Landii [CC-BY-SA-2.0], via Wikimedia Commons

The problem that I have is that there are grey areas in assessing people for clinical signs of intoxication.  Speech clarity is subjective, except at the completely clear and completely unintelligible ends of the scale.  The same goes for gait – is a little stumble a sign of ataxia or a sign that the patient didn’t see the uneven sidewalk?  Supposedly objective findings like blood alcohol levels don’t necessarily have anything to do with how well a person walks and talks (or drives).  Most signs don’t work well in assessing drug intoxication.  I mean, many people can suck down a whole joint and not slur their speech.  So the term “sober” is pretty subjective.  What we actually care about is whether a patient has the capacity to make decisions for themselves.

Here’s what Dr Steven Pantilat says about competence: “Physicians [along with paramedics and other clinicians] commonly confuse competence and decision-making capacity. Competence and incompetence are legal designations determined by courts and judges. Decision-making capacity is clinically determined by assessment.”¹  Incompetence is a legal determination made in a court of law.  Quit using the term competence, please.  We don’t care about competence; we care about whether a patient has the capacity to make decisions for themselves.

Orientation (AAOx3) is only the beginning of determining decision-making capacity.  You’re right that a person who can’t tell you who, where, and when they are is probably not capable of decisions.  But, once again, grey areas.  What if a person knows that it is August and that their 10^th wedding anniversary was last week, but they don’t know what day of the week it is?  We don’t care about orientation to three questions; we care about whether a patient has the capacity to make decisions for themselves.

How does one assess decision-making capacity?  Capacity entails:

• The ability to make and communicate a medical choice
• They don’t have to be able to speak, but a patient has to be able to communicate a choice regarding their care.  Uncooperative silence is not communication regarding a choice.
• The ability to appreciate diagnosis, prognosis, suggested care, alternatives, and risks/benefits of all the choices
• Can they repeat back to you, in their own words, what you said is going on?  Did they "get" what you told them?  They don’t need to be able to teach a med school class on the subject, but can they understand their options in layman’s terms?
• The ability to make decisions without delusions or coercion
• No hallucinating.  No abusive husbands standing behind you smacking their palm with a fist…
• The ability to use logical reasoning²
• Can they link two ideas together in a simple way? For example: Heart attacks are dangerous, and if I am having a heart attack that would be bad.  Is their plan a vaguely logical one, even if not something you would do?

In short, people need to be able to take medical information that you give them, synthesize it into information that is meaningful to them, and make a decision based on that.  Simply, does the patient understand and appreciate what is going on and communicate their choice?

Soberandcompetent is not what you should be looking for.  Decision making capacity is the threshold you should cross before a patient can refuse, or be involved in deciding about other aspects of their care.  

In Part 2, I will explain some of the ways you can form an opinion as to whether the patient has decision making capacity.  Stay tuned…

1. Jones RC, Holden T. A guide to assessing decision-making capacity. Cleveland Clin J Med 2004;71(12):971-975.

http://www.ccjm.org/content/71/12/971.full.pdf

2. Pantilat S. Ethics Fast Fact: Decision-making Capacity. UCSF School of Medicine Fast Facts. 2008. http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_competence.htm Assessed August 22, 2014.

12-Lead Layout

I start with axis when I want to rant about the layout of 12-leads.  Which probably seems weird.  Bear with me.

One of the components of 12-lead interpretation is to determine the frontal plane axis.  Axis is the heart’s mean (average) direction of depolarization.  It is similar to stadium lighting: In a bank of stadium lights, there is an individual light that points at the 20-yard line, another points at the 35-yard sideline, another points at the endzone.  But where is the bank of lights pointing?  At the field.  The mean direction of the lights is toward the field.  Ventricular depolarization is similar.  There are waves of depolarization moving in multiple directions – left to right across the septum, along the left anterior fascicle of the left bundle branch out to the left lateral wall, along papillary muscles in the right ventricle, everywhere.  But where is the mean (average) direction of depolarization?  What direction do all of those individual waves average out to?

Cardiac axis is described by a circle.  Zero degrees lies horizontally to the patient’s left.  Ninety degrees is straight down and negative 90 degrees is straight up.  Horizontally to the patient’s right is 180°.  Each ECG lead lies along a bearing.  Lead I is at 0°, Lead aVF is at +90°, and so on.  It is normal for people to have a QRS axis that lies somewhere between -30° and +120°. 

Look at the axis wheel, showing where each ECG lead lies along the circle. 

(By Bron766, via Wikimedia Commons)

Lead aVL is at -30°, Lead I is at 0°, and Leads II, aVF, and III are at 60°, 90°, and 120° respectively.  Lead aVR is at 210° on this wheel, but is also at -150° in other layouts (210° and -150° are the same - it just depends on what you want to call it).

The quickest way to figure an ECG's axis is to use Leads I and aVF.  If Lead I is upright, the axis lies on the patient's left.  If Lead I is negative, the axis is on the patient's right.  The axis is in the inferior hemisphere if aVF is upright and in the superior hemisphere if aVF is downward.  When you combine the two, the axis is normal, left, right, or right shoulder.

Onto 12-lead layouts. 

The layout of a 12-lead is pretty well set.  It came about because the first ECG, created by Willem Einthoven, showed what would become Leads I, II, and III.  Later the augmented leads were added.  So a 12-lead layout commonly looks something like this*:

The bipolar frontal leads (I, II, and III) are in a column, and the augmented leads are in the next column.  The leads jump all around.  The first column has leads at 0°, 60°, and 120°.  Next come leads at -150°, -30°, and 90°.  It jumps all over the axis wheel.  If we did the same thing on the precordial leads, it would go V2, V4, and V6 followed by V3, V1, and V5.  Think about how hard that would be to read in an intuitive way.  I think it should look like this:

I suck at Photoshop.  I'm a paramedic, not a Photoshopper.  So you get this crappy, taped-together version.  But you get the point I'm trying to make, right?

Do you see what changed?  I think the layout should follow the axis wheel, with the addition of negative aVR.  (The monitor’s computer can print the opposite of each aVR deflection as easily as it can print aVR.)  So the first column shows aVL, I, and -aVR.  The next column has II, aVF, and III. 

There would be several advantages to this.  The three inferior leads are all together in a single column.  The two high lateral leads (aVL and I) are grouped together.  Leads I and aVF (which are used to quickly calculate the axis quadrant) are side by side in the middle.  Reversing all waveforms on Lead aVR means the lead becomes less useless and actually fits into the gap between I and II.  You can quickly glance at the 12-lead, see which leads are biggest, and know where the axis is. 

Why isn’t the 12-lead laid out like this?  Tradition, it seems.  Nobody has ever told me a good reason.

*This is my 12-lead.  This is the first one that has had a 1° AV Block. It's odd - being able to run an ECG on yourself means that you can kind of track your ECG changes as you move through life.  When I was 25, I had a bunch of ST elevation from benign early repolarization and a pretty wild sinus arrhythmia.  Now that I'm 40, the BER has gone away and I have a 1° AV Block.  Sucks getting old.  At least there are no pathologic Qs, bundle branch blocks, or hypertrophies.  I can still pull a resting heart rate in the 60s, too...