Medical Mystery

My partner and I took care of a 29-year-old man complaining of exertional dyspnea. He was frustrated that he would become winded on the walk between his bed and the comfortable chair in the living room. It wasn't like he got winded after several flights of stairs, after all, but just a walk from one room to another.

At the time I met him, he was not dyspneic. He was, though, 450 pounds. I find that medics often overestimate patients' weights, but this patient was discharged from a local hospital the week before and his weight was documented on his discharge paperwork. Four hundred fifty-two pounds, to be exact.

Working through the call, I discovered that he had a history of asthma, hypertension, congestive heart failure, gout, and type 2 diabetes. He didn't know the names of his medications, but that was okay because he had been noncompliant with all of his medications for two weeks. Neither of us knew why he wasn't taking his prescribed meds. He did say, though, that he didn't often wear his oxygen, even when he felt short of breath, because "it smelled funny."

The exertional dyspnea issue had been worsening for months, and the man was frustrated that modern medicine couldn't figure out the problem well enough to find a solution. Noncompliant with his medications, 450 pounds, off his oxygen. 

It was a genuine medical mystery.

PTSD Sucks

My partner and I were recently assigned to the report of excited delirium in the parking lot of an apartment complex on the south side of town. We arrived to find a very large, very naked man lying prone below a pickup truck shouting commands. Dude was about six foot five and two hundred fifty pounds of muscle. He was calling in airstrikes onto my position. Excited delirium is a topic for another day; let’s talk about post-traumatic stress disorder.

By: Cpl. Andrew Johnston [Public domain], via Wikimedia Commons

As an unfortunate side effect of modern times, I’ve seen plenty of PTSD. I’m sure you have too. Besides the giant naked man calling imaginary airstrikes onto the ambulance, I’ve seen memorable PTSD at fireworks events, in counselor offices, and in jails. I remember a psychiatric transport with PTSD; she had been abused extensively as a child. It is a common diagnosis.

PTSD began appearing in American consciousness as “shell shock” during the world wars of the Twentieth Century. It used to be psychologically grouped as one of the anxiety disorders, but the new DSM-5 has moved it to a trauma- and stressor-related disorder.  Something like 7% of adult Americans live with PTSD to varying degrees and about 20% of Iraq and/or Afghanistan military veterans are estimated to live with the condition.  The Anxiety and Depression Association of America says that 7.7 million American adults have PTSD.

Not all trauma is obvious.
By Journalist 1st Class Preston Keres [Public domain], via Wikimedia Commons

The symptoms of PTSD can be remembered with three words: reliving, avoiding, and arousal.  PTSD involves persistent remembering or reliving of a traumatic event. The trauma can be obvious (war) or more subtle (long-term abuse). This remembering manifests itself with flashbacks, vivid dreams, and such, when exposed to circumstances similar to those of the traumatic event.  The flashbacks and other “remembering events” are unpleasant, so patients with PTSD try hard to evade similar circumstances that would trigger the memory events (avoiding). Finally, PTSD patients either have amnesia (partial or full) to the trauma, or have persistent psychological arousal. Arousal manifests itself in insomnia, irritability, anger, concentration problems, hypervigilance, and a heightened startle response.  All of those symptoms needs to exist for at least a month and, like with most psychological diagnoses, should negatively affect a patient’s life.

Treatment for PTSD begins with psychotherapy. Talking with a counselor trained in trauma care is the foundation of PTSD treatment. Serotonic antidepressants (SSRI or SNRI) can be added, so medications like fluoxetine, paroxetine, and sertraline can be used. Prazosin (minipress) is used to reduce nightmares and aid sleep. Tricyclic antidepressants are occasionally employed, but their use is unproven. Prescribed benzodiazepines worsen or prolong PTSD.

Post-trauma stress debriefing was extremely popular at the beginning of my career. The most current science (1-5) seems to be leaning away from debriefing, especially debriefing from peers or others who do not specialize in graduate-level post-trauma therapy and counseling. The American Psychological Association says psychological debriefing has “No Research Support/Treatment is Potentially Harmful.” You certainly shouldn’t force debriefing on anyone who doesn’t want it after a potentially traumatic call.

PTSD in the prehospital setting should be managed in a common-sense manner. My treatment paradigms run from walking away to chemical and physical restraint, depending on the patient presentation, the setting of the call, and the specific details of the events. For example, a veteran who had an episode of anxiety triggered by post-game fireworks resulted in my leaving. He was with his sober wife and several friends. He was not in such distress as to be non-functional or dangerous to himself (or others). People around him obviously had a handle on things and suggested my presence was not helpful. I made sure they knew I was sympathetic, could offer a quiet space for him to recover himself, and was willing to offer whatever help (pharmacological or otherwise) modern healthcare could provide. They were appreciative, but left without my help.

On the other hand, naked men hiding under pickups in daylight are difficult to leave to their own devices. Talking to the patient in a calm but firm voice can be helpful. (It couldn't hurt.) Remind the patient that s/he is safe, that you are with the paramedics, and that you are there to help. In the case here, my job was difficult. The patient’s flashback lasted an especially long time, upwards of twenty minutes. The police officers on scene felt that their uniforms were causing the problem, so they left. The first responders thought it was disrespectful to physically manage a veteran, so they were disinclined to help my partner and I. We waited out the episode, talking to the patient all the time.  After an interminable amount of time, the patient calmed. He was frustrated that “it happened again.”  We took him to the hospital and learned another lesson: An ambulance feels similar to a Bradley fighting vehicle and can retrigger some veterans’ PTSD.

Like with all psychiatric patients, PTSD must be managed on a case-by-case basis. Some patients respond well to talk, while others may require physical or chemical restraint for their own safety (my safety too). The most important step in the process is understanding, balancing respect with safety. 

Paramedicing is tough. We see some heinous shit. If you have signs of PTSD, even mild signs, know that help exists for you. Get yourself to a professional. There is no shame in asking for help with your medical condition. 

1. Feldner MT, Monson CM, Friedman MJ. A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions. Behav Modif. 2007;31(1):80–116.

2. Lewis, S.J. Do one-shot preventative interventions for PTSD work? A systematic research synthesis of psychological debriefings. Aggression and Violent Behavior. 2003;8:329-343.

3. McNally, R., Bryant, R.A., Ehlers, A. Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest. 2003;4:45-79.

4. Rose S, Bisson J, Churchill R, Wessely S. Rose, Suzanna C, ed. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews (2). 2002; Art. No. CD000560.

5. Van Emmerik, A.A.P., Kamphuls, J.H., Hulsbosch, A.M., & Emmelkamp, P.M.G. Single session debriefing after psychological trauma: A meta-analysis. The Lancet. 2002;360:766-771.

Zofran

I have a touch of cognitive dissonance. Bear with me as I work through this.

I see new medics giving a ton of Zofran (ondansetron). It seems like whenever a patient mentions in passing, “I have a little nausea…” BAM Zofran. “I have a tendency to get car sick sometimes…” BAM Zofran. I’ve even seen medics give prophylactic Zofran after narcotic administration, because Fentanyl and Morphine can cause nausea. I think we give anti-emetics too generously. I have always reserved it for cases when I can’t get my job done, like a patient who can’t be immobilized without making a little vertical fountain of beer-soaked burrito (it is always alcohol-soaked Mexican food, for some reason), or when I can’t take a history due to the shouting pukes.

It caused me a little embarrassment, once. For years, the indication for anti-emetic administration was “intractable vomiting.” That may be because the only anti-emetic we used was droperidol – a medication with a more dangerous profile than Zofran. One day a trainee and I were discussing my opinions regarding her being way too generous with the Zofran. I made her pull out her protocols and read the indications out loud. I expected her to say the phrase “intractable vomiting” and I could scold her for giving Zofran to vomitless nausea. Instead, she read the indication: “Nausea and vomiting.” Wait. What? When did that change?

I hate seeing medics give Zofran at the first report of the slightest amount of nausea. Screw subjective nausea.

But on the other hand, I am pretty generous with Fentanyl when people complain of pain. If a patient is hurting, I give the good stuff. I find myself starting with higher Fentanyl doses than my peers, and I find myself giving higher total doses of narcotics than the average medic. Nausea can be just as uncomfortable and debilitating as pain. So, why the difference between being lavish with administering narcotics, but getting irritated when other medics are generous with anti-emetics?

See? Cognitive dissonance. I don’t like feeling like a hypocrite. I also don’t like not being able to rationally explain my actions. So I had to think through my feelings about anti-emetics.

I decided that the difference is the setting.  When a patient claims to be nauseated, but is distracted from my history taking efforts due to posting ambulance selfies on Facebook, I don’t think Zofran is indicated. Nor would Fentanyl be normally indicated in that setting. Show me something. Even something subtle, but show me something. The equivalent requirement before I administer analgesia would be an expression of discomfort on one’s face, a little alteration in vital signs, or otherwise acting in a manner consistent with being in pain. Another sign of pain that isn’t necessarily so subtle is to show me a broken bone. Show me a burn. Show me a little something, and I am free with the narcs.

Concerning nausea, don’t just tell me you’re nauseated; show me something. Give me one little shout for your friend Ralph. Show me the puke you sprayed everywhere before I arrived. Even a little uncomfortable-looking lip smacking or wet-sounding burps. Nystagmus. Anything. Show me something and I can be generous with Zofran, too.

Even when I am aggressively treating subjective complaints, I think there should be a minimal level of objective support for the complaint. So that is why I can find it irritating when medics give ondansetron for a reported tendency towards car sickness before we even get into the ambulance. But in fairness, I do need to slide a little bit away from my hard-ass point of view and be a bit more free with the Zofran. (But only a little bit.)

Next, I need to explain my irritation about starting an IV just to give Zofran. Intramuscular Zofran works just fine. But that is another post…

My First IO

I had been a paramedic for about a year when I had the chance to pop an IO into a kid for the first time. I was newly hired at my current job, working in the field training program with an instructor. My field instructor that day was a certified badass; she was an incredible medic. (I assume she still is.) We were assigned to a pediatric auto-ped on the edge of the city. 

We pulled up to find a little kid, about four years old or so, lying in the median being attended by a private ambulance crew. I was a new medic, but not so new that I couldn’t see that things were going pear-shaped. The private crew had emptied their ambulance of all the equipment. All of it. It looked like they were trying to build a fort out of EMS equipment around the kid. There was a knee-high semi-circle of monitors, kits, a bed, several backboards and scoops, and other miscellaneous BS. That wasn’t a good sign of the skill level of those medics. It wasn’t going to fly.

If you run up on a call in my city and are doing a good job when I arrive, knock your bad self out. Continue. I don’t want the call. I probably want either a nap or a meal. Sometimes both. But my agency is responsible for the EMS care in the city. If a reasonably good job isn’t being performed, then I have to take over. Which is what we did on this call.

I went to the little patient and got a brief report from the medic who was building the Great Wall of Jumpkits. He didn’t have an excess of pertinent information to give me. My partner shoved the pram in our direction, and the firefighters (who were pretty relieved to see us) rolled the kid onto a backboard and onto our bed.  We moved to the ambulance and got to work.

I don’t actually remember a lot of specifics about the patient. He was unresponsive, but had a tachy pulse, as I recall, with a scary level of pallor. I was at the head of the bed to work on an oral intubation. My partner roped off an arm to start an IV. She threw a bunch of IV catheters at one of the firefighters. That was unusual, to say the least. Firefighters aren’t usually IV starters in my system. But I was busy with a pediatric oral tube and the fireman seemed to be making the competent-appearing hand motions, so I didn’t say anything. As soon as I got the tube, my partner helped confirm the placement and exited the back of the bus. She hadn’t any luck starting an IV (which didn’t bode well for my efforts). Our total scene time was under seven minutes.

All of this makes me sound like a bit of a badass. Took over from another crew, fast scene time, quick oral tube on a pediatric patient… I am coming off sounding fairly hardcore. I’m sure this is my memory playing tricks on me. I was under a year out of medic school. I think my memory of this call is rather rosy. It couldn’t have been that smooth. I remember competence being like a lucky lightning strike. As evidence that I wasn’t as cool as this story is making me out to be, let’s turn our attention to the IO.

Like every paramedic, I was taught to place an intraosseous line in p-school. In 1998, when I went to paramedic school, IO lines were only used on pediatric patients; we didn’t place adult IOs.  We also didn’t have battery-powered drills like we have now. Back then, we used a Jamshidi needle and pushed it into a kid’s tibia while twisting back and forth. We practiced placing IOs into chicken drumsticks. My instructor explained that an IO line worked just like an IV line. Anything that went into an IV line could be run through an IO line. Cool.

A Jamshidi disposable intraosseous needle that we used to carry.
By Tirante (Own work) [CC BY-SA 3.0], via Wikimedia Commons

My partner and the firefighter had gone oh-for-four on IVs. This kid was dying and his little veins weren’t cooperating. Little dude didn’t even have EJs. So I got into the pediatric kit and pulled out a Jamshidi. I used iodine to clean the skin of his proximal tibia and started to twist the IO into his leg. It resisted and popped through the cortex exactly like the chicken drumstick in p-school. Exactly like that. Once in, it was solid. It didn’t wiggle or drift. Well, that may be a first, I thought to myself. That went exactly as advertised. I hooked the dripset up to the IO port and turned on the flow.

Nothing happened.

It didn’t flow. I used the bulb in the line to pump fluids in. Fluids flowed in when I pumped. Maybe the needle was clogged with a chunk of marrow or something. But again, there was no flow without manually pumping it in. The site wasn’t swelling or anything. His leg looked normal. But the IO wasn’t flowing. Shitshitshitshit. I was told that an IO works like an IV. This wasn’t flowing. When an IV doesn’t flow, it is bad. Thus, this IO was bad. Shitshitshitshit. It didn’t makes sense for me to pull it, but I didn’t want to leave a bad IO, either. I pulled the dripset off of it and replaced the stylet into the IO needle. Like a plug. Someone at the hospital could pull it, I figured.

I got back to work on IV attempts. Just as we were arriving at the hospital, I got a dinky 24-gauge cath into this kid’s foot that ran. I turned the patient over to the trauma center and that’s about all I recall about the call.

Apparently, intraosseous lines never flow. They always need pressure. Nobody told me that. Weird. You think that would be a specific point of discussion in paramedic school. Who knew?

Let me tell you who knew. The firefighter in the back of the ambulance with me knew. He was a paramedic and field trainer at my agency before moving over to the fire department. That is why my partner felt comfortable tossing him a handful of IV catheters.

Lesson learned. Now I make sure to hook all my IOs into a blood pump-style dripset so I can pump it. Plus I add an inflated BP cuff around the saline bag so there is even more pressure in the system. With all that, IOs flow.

So for new medics: IO lines don’t flow, but you can push fluids and meds into the bone “just like an IV.” They just have to be forced into the bone space. Here is a video of a Jamshidi being inserted into a pediatric mannequin.