The Most Important Question

Yesterday I ran on a 55-year-old male with non-specific chest pain.  His presentation wasn’t screaming “cardiac” chest pain, but rather just kind of vague, could-be-anything package of generalized malaise and precordial discomfort.  There was no recent trauma, his ECG was completely unremarkable, and his exam was generally unremarkable.

When I am on a call, I get to a point where I have a pretty good idea of what is going on.  I have the OPQRST story, SAMPLE history, or whatever mnemonic you happen to use.  A set of vital signs are taken, and any other evaluation adjuncts like 12-leads and blood sugar levels are done.  After about five questions, or so, a medic has enough of an idea of what is going on to piece together a one-sentence description of what is going on: “Fifty-five male, non-specific chest pain.”  At this point, I need to think of differentials.

Differential diagnoses answer the question, “What is going on with this patient?  What else could it be?”  So for atraumatic adult chest pain, a minimal differential list would include things like:

• Acute myocardial infarction
• Pericarditis/Myocarditis/Endocarditis
• Stable/Unstable/Prinzmetal’s angina
• Pulmonary embolism
• Pleural effusion
• Pleuritis
• Acute aortic syndromes such as thoracic aneurysm or dissection
• Costochronditis
• Intercostal muscle strain
• Occult trauma (don’t forget this one, even on atraumatic lists)
• Pneumothorax
• Pneumonia
• Hyperventilation
• Thoracic disk herniation
• Coughing-related stress fractures
• Rib fractures related to neoplasms
• Arrhythmogenic pain (such as from tachyarrhythmias)
• Aortic stenosis
• Reflux esophagitis
• GERD
• Malingering (this one should always be last of all)
• And many more.  But this is a decent start, for now.

As I am working through the call, I think of these diagnoses, consider specific presentations or information that would rule in or rule out each diagnosis, and continue to work through the call.  For example, when considering pulmonary embolism, I would ask about the nature of the pain, consider the patient’s respiratory rate and heart rate, ask about birth control (not in this patient, but you know what I mean), ask about immobility or travel, and so on.  Eventually I get to the point that I find PE to be unlikely and mark it off my list, or find that I can’t rule it out.  In the latter case, I need to treat for that condition. 

Pneumothorax is on the causes of chest pain list. (This one is on the left - viewer's right.)  Listen to breath sounds.
(By Hellerhoff (CC BY-SA 3.0) via Wikimedia Commons)

With this patient, as the call went on, I asked myself, “Self, what else could it be?”  Occult trauma came up on the list.  I asked the patient if he had experienced any “…accidents, falls, car crashes, bar fights, shark attacks, or that kind of thing…” recently.  He chuckled and denied.  I lifted his shirt and checked his chest and back.  Atraumatic.  I can essentially put a line through occult trauma on my mental list and ask the question again: “What else could be going on?”

I worked my way through the list to pericarditis.  Without asking the patient, I attempted to ease him back from a sitting position on my bed to a supine position.  The patient commenced to bitching about how that made him worse.  I asked him about recent medical or dental procedures, and he told me about having extensive oral surgery performed about a week prior.  Well, now.  It seems as though pericarditis is still a contender, huh?  Pericarditis is still on my list.  But here is the important thing – as I start treating the potential pericarditis (IV access, analgesia, and so on), I ask myself the important question: “What else could it be?”

I use the patient’s presentation to decide how I work through the list.  If I am caring for a patient who looks sick or toxic (pale, cool, diaphoretic, altered, hypotensive, and so on), I would start at the most dangerous items on my list.  My personal “most dangerous” chest pain cause list includes AMI, PE, the aortic problems, and pneumothorax.  If a patient looks just fine, with normal vitals and an unconcerned affect, I would instead begin with the more common diagnoses. 

Apparently, some medics don’t practice prehospital medicine in this manner.  They are more comfortable working off of a complaint-based list.  A “chest pain” patient causes them to mentally turn to the chest pain checklist: vitals, O2, 12-lead, IV access, aspirin, and transport.  Abdominal pain results in the abdominal pain checklist: vitals, O2, 12-lead, IV access, and transport.  In my humble opinion, this is a poor way to provide care.

Continually ask yourself the important question: “What else could it be?”  Work through another differential on your list.  Keep ruling out or ruling in items on the differential diagnosis list.

It is interesting, by the way, that trauma care is similar but with a different question that changes the mental orientation toward the call.  Stay tuned for the difference, coming next week.

Changing My Mind (And My Practice)

I had the opportunity to change my mind recently.

I give a lot of analgesics to a lot of patients. Like, a lot. Back in the day, I used to be much more stingy.  In the first agency I worked for, documenting and restocking opiates was a monumental hassle.  In addition, in the late nineties during the formative stages of my career, physicians were pretty stingy with analgesic orders.  It wasn’t uncommon at all to get an order for 2 milligrams of morphine.  Like the Rogue Medic says, “Severe pain plus two milligrams of morphine equals severe pain.” So it worked out that a patient needed to have large BSA second-degree burns for me to go through the hassle of opiate administration.

I’m not trying to make excuses for poor care; I’m just explaining how I used to do things.

Over time, that changed. First, my current agency makes it very easy to administer narcotic analgesics. There is essentially no cost to me in time or effort. In addition, over the past decade or so, protocols have relaxed to the point of being able to give reasonable doses of the medications. Fentanyl was added. Also, I realized a couple things. EMS Rule #1 says to make people better than how you found them. Concentrating on helping people as your metric of success makes your job more mentally and emotionally enjoyable. Don’t concentrate on difficult ALS calls or wild, rare procedures as your metric of success. Just concentrate on helping patients. One of the easiest ways to help a patient is to give them pain medications when they are in pain.

I believe patients when they say that they are in pain. There is no cost to me to give a “seeker” some medications.  There is no cost to me to give meds to a patient who isn’t in “real” pain. After all, who am I to say what is real pain and what isn't? I don’t care if my patient is a sissy. Who am I to decide if pain is "severe enough" to warrant Fentanyl? I don’t care if their vital signs don’t reflect numbers that I expect for a patient in pain. If a patient says they are in pain, I offer analgesia.* If they accept, I give it.  It is a simple way to chalk the call up in my win column, and I have been doing this for several years without problems.

In contrast, I rarely give antiemetics like ondansetron or droperidol. The protocols I grew up with indicated those medications for intractable vomiting. Essentially, if I couldn’t provide care over the noise of someone screaming for their friend Ralph, I would give them medications that would allow me to do my job. The protocols changed at some point, where they now indicate antiemetics for nausea. Not intractable vomiting, but just nausea.

Dammit, Becky! How many times do I have to tell you! I don't know who this Ralph guy is!
By Usien (Own work) [Public Domain], via Wikimedia Commons

A couple of weeks ago, I told a trainee to hold off of giving Zofran to a patient. The patient complained of nausea, but I wanted to see at least a little retch before treating the nausea. Come on, give me a wet-sounding burp, at least. It wasn’t like the patient was puking, or even had been puking. Their vital signs were normal and everything. Dude's stomach was just a little queasy.

On my way home, thinking about that call, I found myself experiencing cognitive dissonance. If it makes sense to give analgesics more freely, based solely on a patient's report of their subjective pain perception, why doesn’t the same logic apply to antiemetics? The answer that I came up with is an obvious one: The same logic does apply. I realized that withholding antiemetics is stupid; at least as stupid as not giving analgesia for complaints of pain. All of my reasons for administering analgesia work for administering antiemetics. The protocol allows it, there is minimal cost to me, the medications are relatively safe, and they are easy to deliver. I can give the meds via intramuscular injection – I don’t even need to start an IV! Why wouldn’t I get the easy win? Help a patient? Make them feel better?

If making someone feel better is a win, why wouldn’t a good paramedic give the medication that makes the patient feel better?

So now I am trying to offer antiemetic medications more. I still try to wave an alcohol prep under the patient’s nose and other less-invasive ways to end nausea first, but a little IM Zofran is an easy thing to do.

*Not true, of course, if contraindications like allergies, concomitant CNS depressant use, altered mental status, and such exist.

My Lucky Depression

I have major depressive disorder.

Depression is one of those conditions that comes with baggage. It is misunderstood. Before I understood what I struggled with, I thought that people took too many medications to manage imaginary or overwrought problems. ‘If your life sucks, don’t take meds to ignore it; fix your life!’ Or, ‘I think 90% of Americans are on antidepressants, next it will be in the water like fluoride, hahaha.’ You see the stigma in the worst question a person struggling with depression hears: "What do you have to be depressed about?" So I want to take a minute to explain how it feels to me and how I manage my condition. I do this in the hopes that it loses some of its stigma for everyone.

To me, depression is all in my head but it isn’t imaginary. It is a medical problem that exists within and is caused by my brain. This is true as much as with asthma or cancer. It isn’t my choice and it isn’t a sign of weakness, any more than asthma or cancer is.

Depression feels like a roller coaster, with highs and lows. The highs for me are normalcy, but the lows are the depressive periods. Whenever I am doing well, it is the roller coaster ascending or staying level. Sometimes, though, I can feel the apex of my mood coaster. There is a crest on the hill, that when I pass it, nothing can stop the descent. Once I pass that crest, there is no easy return. I have to go all the way down. I don’t know how deep this valley will be, or how long it will last. I could be a short dip or it could be a massive crash. I don’t know; I’m not the guy that built the coaster. The anticipation knowing that the crest is ahead is unbearable. There is usually no specific event that causes it. It feels random: "Oh, shit. I feel the crest coming up. The descent is ahead. Shitshitshitshit..." It is a horrible feeling to know that I am passing the summit just before the stomach-churning downhill rush. Thinking about it - ruminating on avoiding it - doesn't help. It makes it worse.

The depressive lows feel like a massive burden. I am not a good enough writer to explain how uncomfortable a depressive state is. It is mentally, emotionally, and physically unbearable all at once. It is like weights are pressing down on me, but also squeezing me. Everything is heavier. Lights seem dimmer. Insomnia is a big problem. When in the pit of depression, I can get an hour or two of sleep per night for a week straight. Nothing feels good on an emotional level, even when I know that intellectually good things are happening. It is a struggle to do anything – it is a chore to get out of bed, but it is a chore to go to bed. It isn’t quite like sadness for me. It is more complex than that, which makes it hard to describe. I am sad, but I am also apathetic, tired, lazy, angry, ashamed, and frightened, all jumbled up into one steaming pile of negativity with a false smile on my face.

Outwardly, I don’t think that I show the struggle. People that know me especially well may be able to tell. I get irritable. Angry. I am short-tempered with my family and co-workers. I hate my bosses and I hate my peers. My decisions get reckless. My temper is on a hair trigger. I get impulsive and make hasty bad decisions.

I think depression has affected my job and my family. I don’t see how it couldn’t have. I waited too long to get help and manage my condition. I am sure that depression has slowed the progression of my career. I hope it hasn’t affected my family too much. 

The first time I asked for help was three years ago. I made an appointment to see my doctor. Thankfully, he could see me in only about a day or two. My doctor knows me as a tough guy. (I walked around with a hot appendix for two weeks claiming it was just gas. When I finally went to see him for that, he gave me some barium to drink before going to CT two hours later. I asked to go back to my office so I could finish up two hours of work before getting the scan. With what turned out to be appendicitis. So that is the kind of patient that my doctor knows me as.) Anyway, I was waiting in his office when he walked in. He asked what was going on, with a smile. I told him that I needed help, that I thought I had depression, and then I commenced to bawl for 15 minutes about nothing. It was one of the most embarrassing things I have ever done. But it shouldn't have been embarrassing. I just needed help.

I was never suicidal, but that can go along with depression. I think that suicide can be one of those impulsive decisions, and I fear that I have been lucky to not accidentally crash through the wall of hopelessness and get that impulse. If the impulse can be delayed, the urge passes. Even when suicide is attempted, only about 15% of survivors reattempt. I’ve read stories of people who survived jumping off the Golden Gate Bridge who were regretting the decision on the way down. Just slowing the impulse can end it – that is why simple, easy to climb barriers on bridges work to lower suicide rates. Winston Churchill was a depressive – he described it as a black dog that followed him. He understood the impulsivity of suicide. He said: “I don’t like standing near the edge of a platform when the express train is passing through… A second’s action would end everything. A few drips of desperation.” I’m very glad I haven’t had a few drips of the suicidal impulse.

In 2005, this fence was added to Tromsø Bridge in Tromsø, Norway, because at the time the bridge was commonly used as a suicide location. It is not hard to climb if motivated to do so, but barriers like this are highly successful at lowering suicide rates. (By Kagee [Public domain], via Wikimedia Commons)

My depression is just related to ions and neurotransmitting chemicals inside my brain. It is just the way that I am. It isn’t related to PTSD, or abuse, or my upbringing. I rarely think of calls after I run them. I’m not carrying along a memory full of faces, or anything like that. I had a happy childhood. I wasn’t mistreated or molested. My family loves me and I have plenty of friends. In that I am lucky, as well.

Finally, I am lucky that my condition has been treatable, for the most part. What works for me is medication – 10 milligrams of citalopram, daily. The Celexa helps level out the roller coaster. It doesn't stop the valleys from existing, but it makes them much more shallow. If I miss a few doses, I can feel the roller coaster start to crest the hill. Along with the medication, I need to exercise out the angry thoughts. So I need to exercise almost daily. I find that the exhaustion of CrossFit helps me the most. Missing sleep causes valleys to grow on my roller coaster track, so I try to get plenty of sleep. (It is ironic that depression causes me insomnia.) When I can feel an emotional valley ahead, I need to back off the booze and I need to avoid current events. I have to make an effort to find happy thoughts. I strive for contentment.

Studies show that antidepressants are more successful when combined with talk therapy of some sort. I haven’t found therapy to be helpful. I attempted therapy twice. Therapy ended twice, and not at my choice. Therapists tell me that I am a minor case of mental illness and I am taking up appointment space that could be used for people with more severe illness. I’m okay with that, because I wasn’t getting a lot out of talking. There are also a lot of Christian therapists, but I am not a Christian. So that doesn’t help. The medication seems to help even without talking to a professional, so maybe I just don’t need therapy.

One of the other things that has helped is to understand that sometimes you just have to go in the valley of the roller coaster. But now I know the screaming descent isn't real. The valley is in my head. My brain is lying to me that I am rushing downhill. I only feel that way. So there is a limit to the valley. Knowing that makes it easier. For me.

All of the stuff above is how depression feels to me. Your experience, or the experience of a loved one, may be different. One way or the other, depression is not something that needs to be hidden. It needs to be managed. Hiding my struggles made it harder to manage the condition because I was too embarrassed to get help. There is only a stigma associated with the condition if we allow the stigma to exist. There is no shame to depression. Don’t be afraid to talk about it.

Defend Your Patient

When a paramedic student learns to use a transcutaneous pacer, they are taught the indications of pacemaker use, premedicating the patient, attaching and activating the pacer, confirming electrical and mechanical capture, and so on. They aren’t taught the last step, which is just as important.

Defend your patient from the attack of the ED staff.

Please allow me to explain. At the beginning of my career, I responded to an elderly female who had a syncopal event in the shower. I didn’t think she hurt herself, but the exam was hindered by her mental status. You see, she had advanced Alzheimer’s disease and hadn’t really expressed a rational thought in several years. Her husband was her primary caretaker, had witnessed the event, and assisted her off of the little stool that people with Alzheimer’s sit on while they shower. So that is why I was pretty sure she hadn’t injured herself. But it did leave the syncope for me to figure out.

She was tachycardic and irregular, but appeared to have a sinus rhythm when things slowed down a little. Maybe AFib or atrial flutter. There seemed to be a little bit of everything. Whatever was going on, her blood pressure was normal and she had no apparent breathing problems. I loaded her into the ambulance and began to transport her to the hospital. While enroute, the lady’s heart rate became very unstable, with a run of extreme tachycardia, periods of bradycardia, sinus pauses, another pop of narrow complex tach, and so on. I was new and didn’t really know how to describe all of the different arrhythmias that flashed across the screen in about a minute and a half. Now I know it was probably sick sinus syndrome. 

Courtesy CardioNetworks (CC BY-SA 3.0), via Wikimedia Commons

Her heart rate and rhythm finally stabilized. Unfortunately, it stabilized on sinus bradycardia with a rate of 30. No distal pacemaker escaped. The patient became unresponsive and her blood pressure fell to 70 palpated. The bradycardia remained throughout the rest of the call. A milligram of atropine had no effect and I got on the horn to medical control. (Back then, we had to call for pacing and for benzodiazepines.  I think.  I may have been being an overly cautious new medic, but I think the phone call was required.) The resident who answered the phone approved the pacing plan, but denied Valium. His concern was that her pressure was too low and the benzo would drop it further. My efforts at pointing out that the pacer was about to fix the hypotension problem had no effect. Okay, so this lady was about to get paced without sedation.

I turned on the pacer and the lady, this nice woman with a husband that loved her enough to care for her at home, who raised a family and probably never missed church and volunteering at school functions, she began to twitch at each the pacer impulses. He mentation improved over the course of 10 or 15 beats, as well. I knew that she woke up because she began to bellow profanities, louder and louder at each twitch. Bellowed. At the top of her lungs. That’s right, eighty times a minute this sweet Alzheimer’s patient hollered the most vile curses at me that I have ever heard.  And they made sense, like in an insulting sort of way. Not Alzheimery cursing, but oaths and threats that had an underlying theme, cadence, characters, drama, and background story.

I rolled her into the emergency department as quickly as I could – I really wanted to get her some sedation. We got to the assigned room and I started to give my report. I wanted to give it quickly so that some meds could get into her. The ED staff did what they normally do. That is, they looked amazingly like a herd of lions feeding on a zebra – just someone’s legs sticking out of the pride of nurses. They moved her from my pram to the hospital bed, confirmed the IV’s patency, and disconnected my monitor.

Usually nurses don't get their faces this bloody, but you get the general point.
Courtesy H.E. Holecamp (CC BY-SA 3.0), via Wikimedia Commons

The patient went abruptly silent. Which was a relief, after the obscenities she was tossing out with wild abandon. Oh, wait. No it wasn’t. It was a bad thing that she fell unconscious again.

The ED’s pacer wasn’t ready. It’s not clear it was even in the room.

This happens every time I bring a paced patient to the ED. I think what happens is that ED staffers are used to disconnecting our monitors. We bring a lot of patients to them with 12-leads across their chest and the staff’s priority is to get that off so they can get theirs on. They are trying to help and firing on all cylinders. But they aren’t used to pacemakers going. So sometimes they get pulled a bit prematurely.

Defend your patient from the ED.

Every hospital does it. No matter how good or bad my biophone report is, it happens. Every single time.* Make sure nothing gets disconnected until everyone is ready to reconnect. That may even mean physically stopping techs and nurses from touching the patient and your monitor. Defend your patient. Give the ED staff time to prepare their equipment, check the IV lines, and get whatever medication they may need. Show the physician that our monitors have a pause button that temporarily stops the pacer so the underlying rhythm is visible. Let him or her see that rhythm.  There is a difference between hurrying and rushing. Defend your patient. Once everything is reported, understood, planned, prepped, and ready, then transfer the patient and disconnect your pacer.

I am embarrassed to say that this disconnect-the-pacer-too-soon story happened to be two or three times before I noticed the pattern. But now I’m ready for them…

*Admittedly, it probably isn’t every single time.  I admit there is probably some confirmation bias in my memories.  But it happens a lot.