Fixing Problems

Sometimes being a paramedic wears thin, and I develop the urge to tell people what I think of them. By people, I mean dispatchers, firefighters, partners, coworkers, supervisors, nurses, physicians, other drivers, bystanders, random neighborhood dogs, patients, 911 callers, people in charge of making the roads generally smooth, people in charge of road signs, people in charge of radio song selection, family members, restaurant employees… The list of people who should loudly and proudly be told what I think of them is long and illustrious. These situations come up most often when I am hungry, tired, or have been working too much overtime.* Don’t worry, I have a plan for the speak-my-mind urge. I have a note page on my phone with a whole bunch of reminders for me to read when I have a bad day. It is a dorky thing to do, I know, but I sometimes need to remind myself that “EMS is not a hard job. Roofing is a hard job. Don’t volunteer to go back to roofing.” Another one reminds me that my daughter thinks being a paramedic is heroic and reminds me to act like she is watching me when I am on a call. I have ten or fifteen affirmations like that. I just read through them when I feel the nearly-bottomless well of patience that I have for my fellow man start to run out. The reminders have saved me from showing my ass more than once.

One says: “You can’t fix anything. Don’t try.” I think it is my favorite affirmation reminder, which is weird because it is pretty negative and apathetic. It feels like failure and submission. But I know what I meant when I wrote that note.

I know that I meant that system-wide, EMS related things that irritate me can’t be fixed. At least, the solutions don’t come from my partner and me in the front of an ambulance. Every conversation about how things would be different if I were in charge may as well be whispered into the wind. Nobody cares about my personal opinion of post locations, response times, EMD, and protocols. Nobody cares what I think about the overall skill level of EMS as a whole, or of my system itself. Certainly nobody in other agencies cares what I think of their systems, policies, customs, and employees. I was a captain in my agency and nobody cared then, either. They certainly don’t want my opinion now that I am a paramedic. I don’t think people really care what the Chief thinks, when you get right down to it.

That’s because an EMS system, especially a large one, is like an oil tanker. Steering inputs take a long time to take effect. Deciding to turn the wheel or advance the throttles can have huge consequences that extend outside of the ship itself. Systemic changes, then, are the results of discussion among groups of stakeholders over long periods of time. I can be involved in that, but it is unlikely that I can either personally initiate that process or have a measurable impact in it.  

Source

There are things that I can fix, though. I do try to fix those. That is where the importance of the reminder note lies.

Fear. Pain. Worry. Grief. Loneliness. Cold. Discomfort. Those are things that I can fix. I can concentrate on fixing those on every call, for each patient, on an individual level. Lessening pain and fear are easy for me to do for a patient. Setting a patient at ease, smiling, giving them a blanket, and administering analgesia costs me almost nothing. It is what I am paid to do. And I can ameliorate those problems that my patient is having without going to several city council meetings first.

By attacking the problems that I can solve, I am actually helping to “steer the EMS oil tanker.” My actions help to set the expectations among my patients, peers, and other stakeholders in regard to how my EMS system performs. Concentrating on the core EMS functions result in the systemic problems taking care of themselves, through cultural improvements over time. I can also help “steer the tanker” by giving newer paramedics and EMTs all the help and support I can give them – like someone gave to me once. We can talk about ECGs, pathophysiology, EMS hacks that make the job easier, how to start difficult IVs, the best route to the next call, and those kinds of things. It is like gently pulling on the oil tanker’s steering wheel. (If oil tankers don’t have big wooden wheels with knobs on the end like a pirate ship, I will be sad.) I get more out of talking to my partners about what was going on with the last patient  than I do talking about why supervisor so-and-so shouldn’t have ever been promoted.

If modern supertankers don't have steering wheels that look like this one, I will be thoroughly disappointed.
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I decided to not worry about the EMS system until my work is done, fixing the patient-related things that need my immediate attention. Chiefs and medical directors are paid extra to worry about stuff like hiring practices, response times, and financial stability. Let them worry about that crap. I will focus on the next patient I see.

Why would I volunteer to worry for free when other people are being paid to worry? Instead, my note reminds me to concentrate on the problems that I have the responsibility and authority to manage on my own. That’s why "You can’t fix anything. Don’t try” is one of my favorite notes.

*It's funny: Call volume, call type, and such things that we think make a good/bad call have little effect on my attitude.  My attitude revolves around how full my belly is, how sleepy I am, and how much overtime I have worked in the last month.  A call that enrages me when I am hungry (hangry) is a funny call when my belly is full.  That leads me to believe that call volume is less important than having enough time between calls to eat...

Sooty Boogers Are Bad News

A while ago, I responded to a structure fire. We arrived to find a real, actual fire like you imagined when you were a kid, or see on TV shows about firefighters, but never really actually see in real life. My partner and I staged and watched the proceedings. After a few minutes, there seemed to be a flurry of activity. One of the firefighters helped walk a patient out of the house, pointed to the ambulance as though to direct her to my partner and me, then went back into the burning bungalow. When there is hot stuff that needs wet stuff, EMS can take a back seat. My partner and I went to the patient.

Like, house ON FIRE on fire... Source

Out patient was a 50-something year old lady who had been in the burning house. She was coughing and complaining of a sore throat and slight shortness of breath, but seemed to be okay otherwise and speaking in full sentences. She had soot on her face and sooty streams of black boogers running to either side of her nose. Her eyebrows were even singed. When I asked her to open her mouth, I saw that she had a soot-covered tongue, as well. 

My partner got the pram over to us and we loaded the patient up. This was a good medic that I had for a partner, so she knew where I was going – she restrained the patient’s wrists to the pram siderails with some Velcro restraints that we carry. I grabbed a prep kit and squirted a bunch of Neosynephrine into the patient’s nares, while telling the patient that we would help her breathing get better. The patient’s dyspnea was worsening and her voice was becoming noticeably more hoarse. I knew time was short.

I asked my partner to grab a set of vital signs and I lay an unrolled sheet behind the patient’s head. I find that any mess that I make is easy to wipe up with a sheet, then toss. Looking cool is EMS Rule #2, after all. I took a 7.0mm endotracheal tube out of its packet, aligned the notches on the adaptor cap with the end of the tube, and smashed the cap hard onto the tube. (From hard-won and embarrassing experience, I know that having the cap pop off is a pain in the ass.) I squirted a healthy glob of viscous lidocaine onto the end of the tube, and added some to the patient’s nares as well, for good measure. 

The patient was altered by this point, appearing much more dyspneic, somnolent, and more difficult to communicate with. Every time I see it, I am re-surprised at how fast a patient’s mentation can change and how quickly their respiratory status can decompensate after airway burns. I tried to keep talking to her while I was setting everything up, letting her know that everything would be okay and that I was going to take good care of her. My partner was grabbing other equipment like a BVM and an endotracheal end-tidal capnography detector. When everything was ready to go, I made sure the patient’s head was straight on three planes.

See, I knew it is important to start in an anatomically correct position. The patient needs to be straight in the nodding (chin up-and-down), shaking (chin side-to-side), and tilting (ears to shoulders) planes of motion. If the anatomy isn't straight, nothing will line up. It has to line up for me to slide a tube into lungs without being able to see what I am doing. Once her head was straight in comparison to her torso, I advanced the endotracheal tube into her nose. She was pretty much unconscious by this point. A few centimeters into her right nare, the tube needed more pressure to push through. I have attempted to intubate patients with crazy nasal and sinus anatomy and that feels completely different - like a bony wall. This was more like popping past structures, rather than breaking through them. Most people have what feels like little obstructions a few centimeters into their noses and you have to push past or around them. It doesn’t really crunch, but it does feel more like you have to mash the tube around the obstacles. 

And, unsurprisingly, it wakes patients right-the-hell up. That is why my partner tied this patient’s hands as the first step. Her eyes popped open and she gave a hoarse, gasping groan. I kept her head in position and advanced the tube a bit more, listening the whole time to air passing in and out of the endotracheal tube. I can tell where the tip of the tube is, in most cases, by how the airway anatomy feels and by the volume of air passing through the tube. I wanted to get the tip of the ETT right above the patient’s cords, where the air was loudest. 

Perfect. My tube was in position and I paused for the patient to take a deep breath. Her respiratory effort was too low for this to be easy. Sometimes it helps to gently tap the tube against the cords to generate a cough, so I tried that. Knock knock, open up. The patient coughed and I waited for the cough to end and the patient to take the deep breath. She took a huge gasping inhalation and I advanced the tube. The inhaled air seemed to pull the tip of the tube through the cords and into her lungs.

The sound of a successful nasal intubation is pretty clear, in many cases. I have heard it described as the “Who’s Your Daddy Cough.” When you hear it, you will know why it is called that: The patient’s glottis is no longer closed, holding air in the lungs. So air escapes with a gasping cough noise. Then the patient begins to breathe in and out through the tube. That is exactly what happened with this patient. If advancing the tube didn’t work pretty easily, it was probably because the curve of the endotracheal tube didn’t match up with her airway – her trachea could have been more anterior or whatever. When that happens, I adjust the patient’s head position to make the volume of air passing through the tube louder as it sits just above the vocal cords. I could move the head foreward, chin down, chin up, etc., in order to find a good position with the loudest volume of air being breathed through the tube. I didn’t need to do all of that in this case, though. She pretty much sucked the tube right into her lungs.

So at that point, I believed that I had successfully intubated that patient. My whole concern was where the tip of my tube was located. I had to make sure it was in the patient’s lungs and would stay there. I listened to breath sounds to confirm the  tube’s placement, but I also knew that auscultation was a crappy way to confirm the tube’s location. I had my partner listen, too, because she was a good medic and her opinion mattered to me. The best way (the only way that matters at all, really) to confirm tube placement was to use continuous waveform capnography. Continuous confirmation of the location of the end of the tube is critical. It is an ongoing struggle, to know if your tube is still good. It became almost all I could think about. This patient had a good waveform with an end-tidal carbon dioxide reading of 45 mmHg. I used umbilical tape to tie the tube into position and began to assist the patient’s ventilations. There was a little bit of a nosebleed, so I used the sheet I had placed behind her head to wipe her up a little.

A firefighter arrived to take over the BVM on the ride to the hospital, so I could start an IV and give the patient some Versed. A few milligrams of benzo-love after the tube is in place and confirmed goes a long way to making a patient like this more comfortable (plus the amnesiac effects of midazolam is a nice bonus, too). 

Airway burns are a serious thing. Even adult airways don’t have much of an interior diameter. It is pretty easy for swelling associated with the inhalation of hot gasses to swell an airway shut. I was lucky with this patient that she didn’t close down completely before I could get her intubated. If you see a patient with airway soot, especially in the mouth, with singed facial or nasal hair, get on the tube quick-like.

And so, those are the steps of a blind naso-tracheal intubation. Maybe this post is a swan song of the procedure, for historical interest only. You can look back on this post in the future and laugh at how barbaric EMS used to be. "Tell me about when you used intracardiac epi and nasally intubated patients, grandpa! Did you ever use MAST pants and drive around in a white hearse?" Nasal tubes are a procedure that are on the march toward extinction (probably for the best). In my experience, RSI stands for “Really Slow Intubation” and I can nasally intubate a patient much faster. But oral intubation after rapid sequence induction doesn't bash through and break nasal structures, causing airway concerns to be complicated by epistaxis. Blind nasal tubes are procedures in which success is heavily influenced by experience. You need between six and ten per year to get really good and maintain your competence. There just isn’t enough reason to get enough practice to get good at the skill, nowadays. 

Show Me the Head Mirror

Once upon a time, a very long time ago, I responded in a solo capacity to the report of a “down party” in a public area. At the beginning of my response I was unconcerned – down parties are a common call that usually entail waiting for the detox van. My concern increased slightly when dispatch let me know that the nearest AED to the call location had been pulled. My concern rose to a fairly significant level when dispatch told me that the HALO camera* showed CPR in progress. It sounded like there was work to be done.

I arrived to find two bystanders performing CPR on a very fat man. The obese patient did have the appearance of being quite dead, with the mottled, bluish skin color of pulselessness. One bystander was doing CPR and the other was performing mouth-to-mouth ventilations. Now, let me pause here a moment to point out that while this call was a long, long time ago, it wasn’t so long ago that mouth-to-mouth was a common thing. As a matter of fact, it may have been the first time I had actually witnessed stranger-on-stranger mouth-to-mouth.

Anyway, I started some additional help in my direction (solo arrests are not especially fun calls), confirmed pulselessness, restarted the bystander on CPR (he was doing a decent job of things, considering the patient was about waist high while supine), gave the mouth-to-mouth bystander some gum, and asked what happened. Apparently, the gentleman did the television-style chest grip before gasping and falling over. The AED had shocked the gent once.  Oh, and I didn’t really offer gum to the bystander. I wish I had. That would’ve been cool.

I attached my monitor and found the patient in VFib. I blasted him once at 360 joules and started a bystander on CPR again. Being that it was a long time ago, as I have said, my next step was to secure the patient’s airway with an endotracheal tube. Nowadays I would pop in a OPA and leave the patient on a non-rebreather mask, but not back then.

I got into my kits and pulled out a laryngoscope and a 7.0mm ETT. I grabbed a smallish tube because the patient looked like he was going to be a terrible bitch to intubate. He was big as hell, with no neck. His submental space looked short and his tongue filled his mouth. It looked like a giraffe’s tongue in a human mouth. He had something going on with his neck, because I couldn’t extend his head backwards. (I later found out he had a C1-L1 fusion, or something. It probably wasn’t that extensive, but there was a lot of neck fusing going on in his past.) His neck was so fused and he was so obese that his occiput wasn't able to touch the ground when he was supine. Add the fact that the patient was flat on the ground, not at waist height, or even a couple of inches off the floor like on the pram. It all added up to look as though an unpleasant tube was in my future.

Seriously, everyone knows that giraffes have big tongues. Photo courtesy Pixabay

I heard an insistent voice from my right: “I’m a doctor. Hand me your blade and tube.” This statement and demand came from the bystander who had been performing the mouth-to-mouth. 

My standard reply seemed like it would work here: “Doctor, huh?  Nice. Stand back, please.” 

The bystander was insistent. “I’m an anesthesiologist. Give me your blade and tube.”

“Not happening. But thanks for your help, sir.” Whenever you add the “sir,” it is polite. Right? In actuality I may have said something significantly ruder than this, but it was a long time ago. One’s memory fades with time. I’m quite sure I would have ended the sentence with “sir” though.

I bent down and started working through this mess of an intubation. The whole time I listened to Dr Anesthesiologist hiss, gasp, and tell me what I was doing wrong. “No, you’re… Wait, you should pull…  Hang on. We need to…” But there wasn’t anything especially helpful coming from him. When a police officer showed up, I asked him to chat with the doctor. Anywhere away from me.  

Long story short, I couldn’t get the tube. Another medic showed up and I passed off the airway responsibility to her. She got the tube, eventually, after quite a bit of struggle. In my defense, it was hard for her too. I started an IV, shocked the patient into asystole, gave a round of drugs, and handed the patient off to a transport bus. 

After the call, I found out that the anesthesiologist wasn’t an anesthesiologist. Or a doctor. He was thinking about going to nurse anesthetist school, though. Shock of shocks.

Not even a doctor. That is why I need to see the shiny forehead disk on a headband, called a head mirror, preferably associated with a white lab coat and shoulder-mounted stethoscope, before I will believe a bystander is a physician.

The head mirror and stethoscope combo is pathognomonic. Image courtesy Pixabay

I usually don’t want a physician’s help on scene anyway. Even in the case of a real anesthesiologist on an arrest, it would be unusual for that physician to intubate a patient at floor level, without good light, and without extensive equipment and available help. It would not be a normal tube for him or her. But it is a fairly common procedure for me. 

The most helpful physicians would be emergency doctors. But the best EM physicians know that a big part of their job is based on lab results, radiology, ultrasounds, and so on. Take all that hospital stuff away, and what do they offer that I can’t? Not a lot, if I am doing my job well. It doesn’t take physician-level education to know if someone needs to be transported to a hospital. Or to work an arrest. 

*High Activity Location Observation camera; street cameras that the city uses to monitor areas downtown and such.

The Most Important Question - Trauma Edition

Last week I posted about the most important question to continually ask yourself while working through a call: “What else is going on with this patient? What else could it be?” Repeatedly working through other possibilities on your differential diagnosis list helps you to figure out what is actually going on with this specific patient. Use your history taking skills, along with physical exam to exclude possibilities (as much as we can). If you can’t eliminate a diagnosis, you need to strongly consider treating for it. But that was for a medical call.

When on a medical call, it is important for a medic to think through a list of diagnoses that could potentially result in the patient's complaints and overall presentation. A trauma call is slightly different. The main question to repeatedly ask yourself changes from searching for other causes of the presentation to “What else could be damaged?” In addition, where a medical call is run around the history in conjunction with the physical exam, the physical exam becomes much more important in a trauma call. 

Not an injury pattern often seen nowadays: Sword trauma to a skull. I'm sure there was a laceration, too.
What else could be damaged? (Apparently dude got his teeth knocked out too...)

Public domain citation

Picture yourself arriving to a shooting scene. To simplify our scenario, let’s say you’re the second bus on a multiple-victim scene. Your patient is all packaged and ready. He is a 22-year-old male presenting with a gunshot wound to the midline superior abdomen. 

What could be damaged?

A short list includes liver, diaphragm, stomach, small intestine, large intestine, spleen, kidney, gall bladder, pancreas, bladder, lungs, heart, great vessels, spine, and pelvis. Essentially anything in dude’s torso could be damaged as the result of a bullet passing through, right? You don’t know the path of the round, and you certainly don’t know its internal path. This is an easy scenario, with penetrating trauma to the torso. Blunt trauma can result in a much more complex list. Unknown-mechanism trauma and trauma that involves the neurologic system are even worse.

How does one check whether the pancreas was damaged by the bullet? The heart? Great vessels? Liver?

In the case study above, let’s start with the liver, because it is pretty probable to be injured in an epigastric GSW. What are the main results we would expect if the liver had a chunk of high-speed lead pass through it at about 1,000 feet per second? Pain and bleeding, for the most part. Check abdominal tenderness. Is there radiated tenderness away from the gunshot wound? Are there signs of internal bleeding, like Cullen’s sign or Grey-Turner’s sign? What’s the patient’s pressure and heart rate?

How about the lungs? How are the patient’s breath sounds? What is his respiratory rate? Is he dyspneic? Does he feel like he is getting enough air? Is there chest pain away from the wound?

Asking yourself “What else could be damaged?” is what allows you to find the lumbar compression fractures in a patient who fell and landed feet first. Asking that question allows you to find other wounds besides the obvious ones. Searching out other injury patterns takes you past the "distracting injury" to other injuries that are harder to find.* Asking that question is what allows you to broadly use the trauma mechanism to guide your patient care. It is what makes it harder for a change in status to surprise you.

I bet you already correlate mechanism of injury to physical exam - think about how you focus your exam when you find a starred windshield. You already do this - you see the windshield and essentially think to yourself: "What else could be hurt?"

Realize that we don’t have ultrasounds, CT scanners, or x-ray capabilities. All we have is our hands, ears, and eyes. (Tongues and noses too, but let’s not go there…) That is what makes the physical exam so crucial to prehospital success. Use your hands, ears, and eyes to search out anything else that could be hurt.

Medical calls are a search through possible differential diagnoses. Trauma calls are a search through possible organ system injuries. It is slightly different, but the same general idea. In both cases, a great paramedic goes beyond the page in his or her protocol manual titled "Penetrating Trauma" or "Chest Pain" to actually think through the pathology of the specific call.



*Understanding, of course, that the concept of distracting injuries is a questionable one. See, for example, Konstantinidis et al. or Rose et al. for studies that find no distracting injuries in the face of cervical injury.