Fumble!

My agency’s protocols have requirements for base contact in certain situations. Some high-risk medications, a few rare and aggressive procedures, and certain types of refusals require base contact. When I was the QA Coordinator for my agency, one of my responsibilities was to ensure that those base contact demands were met. Medics would rebel against the base contact requirements. They felt like they made no sense. Especially infuriating to medics was a requirement to contact our base when transporting an emergency patient to another hospital. I would try to explain that base contact was a safety net for high-risk situations, and provided a second (or third) mind to work on the problem.

If you aren't screwing up, base contact should be no problem. 

That said, a couple of years ago, I responded to a grocery store for a fall. A woman got out of her car in the parking lot, took her infant out of the back seat, and dropped him onto the asphalt from approximately waist height. The baby cried for several minutes, but was soothed with snuggles and a pacifier before I arrived. When I got there, the baby was sleeping in Dad’s arms. The parents planned some fairly extensive travel with the kid, so they wanted me to “check him out.”

By MesserWoland [CC BY-SA 3.0], via Wikimedia Commons    

The patient was a three-month-old male without apparent injury. He was warm, pink, and dry with a heart rate of 150 and a respiratory rate of 40.  I didn’t take a blood pressure, but he had capillary refill under two seconds. The secondary exam was completely atraumatic. I explained to the worried parents that the infant was at low-risk of injury. There was no visible trauma and infants aren’t very good about “toughing it out.” If they hurt, they cry, and this baby wasn’t crying. I explained that occult injuries could exist, but that I would feel comfortable with their travel plans. If they wanted ambulance transport to an emergency department, I would facilitate that, but the baby seemed fine to me. I even told a story about my wife stumbling and tossing my two-month-old end over end about ten feet in the air. Babies are tough.

The parents seemed relieved and agreed that ambulance transport seemed excessive in this case. I filled out a refusal form for them to sign. My protocol requires base contact for all transport refusals in patients less than five years of age. So I called base and explained what I saw and what I did. My description was pretty much the first half of the previous paragraph, word for word.

The resident on the other end of the biophone asked to talk to the patient’s mother, so I handed the phone off. After a minute or two of chatting, mom handed the phone back to me. I put it to my ear. “They are agreeing to transport now,” the doctor said.

Well, that wasn’t what I was looking for. As a matter of fact, that was the exact opposite of the outcome I was looking for. But I understand several salient facts. First, I am an hourly employee. It is not a big deal to transport his kid to a pediatric emergency department. Second, transport would cost me nothing. Arguing, on the other hand, would have costs. Thus, I asked for the infant’s car seat and we got to work installing it in the ambulance.

As I took the child from his father’s arms, I noticed that the child’s head didn’t look quite right. I paused and examined the kid more closely, running my hand over his scalp.

He had a huge temporal hematoma. Huge. This kid was trying to grow a second head out of the side of his skull. How did I miss that? I palpated his head! There was no hematoma when I touched it! Did I miss it, or did the hematoma grow after my exam?

The child was hurt. I missed it on my first pass. It actually worked out that the infant had skull fractures and a small subdural hematoma. He was admitted for overnight observation and sent home the next day. And I was going to let them go without further evaluation to travel.

I felt like a total butthole. To this day, I still don’t know how I missed an injury like that. My index of suspicion was too low, I was moving too fast, and I dropped the ball. Complete fumble on my part.

Me, on that call...  Fumble! Ball! BALL!
Photo by AJ Guel (originally posted to Flickr) [CC BY 2.0], via Wikimedia Commons

The biophone physician saved me. More importantly, he probably saved the patient. I called him and thanked him for acting as a safety net. He was humble and told me it was just his job. He preferred all pre-verbal children who worry the parents enough to call 911 deserve to be seen in an ED. My threshold (then) was much lower than that. I am grateful to him for stopping me from making an error.That, ladies and gentlemen, is why biophone contact requirements exist. Medics who are screwing up don’t know that they are screwing up. Screwing the pooch feels exactly the same as rocking a call, when you are in the moment. An extra, uninvolved brain applied to the situation can save everyone a whole lot of trouble. I no longer complain about making base contact. 

I Hate Prehospital Lactate

Picture this scenario: You respond to a nursing home and discover an 88-year-old male patient with a baseline history of mild Alzheimer’s dementia. The nurse... caregiver… nursing home employee explains that the patient’s physician ordered him transported from the nursing home to St. Elsewhere’s emergency department. (She seems to believe that is an adequate reason handoff report.) After your extensive and repetitive investigation, you drag out that the patient has a temperature of 38.2°C. A urinary tract infection is suspected. The patient is a pleasant elderly male who verbalizes no complaints. He is slightly pale but warm and dry and there is nothing abnormal about his physical exam. He has a blood pressure of 104/68 with a heart rate of 96.

Let me pause here for a moment. Do you transport this patient emergently or routine? Flash-and-noise or just drive? I acknowledge you don’t have nearly enough data to mentally simulate a call, but imagine that everything else is unremarkable or normal. Blood sugar, you ask? Normal. Does he have a history of… No. Everything else is normal. Do you transport this patient emergently or routine?

Whatever your decision, on the way to the hospital you call in a prearrival report: “Coming to you with an… uh… how old are you, dude?… oh, yeah, eighty-eight, that’s eight-eight, male with new-onset somnolence from a nursing home. His physical exam is normal and his vitals are 104/68 with a rate of 90ish and a respiratory rate of twenty. We’ll see you in five or six minutes.”

The person receiving your phone call asks you if you have the ability to take a lactate reading. Do you? Would you have checked this patient’s lactate levels?

Lactate. By Edgar181, via Wikimedia Commons

I hate prehospital lactate. Wait. That is probably too strong a statement. I don’t understand the utility of prehospital lactate measurement. Yeah, that's better. No matter how it is explained, though, I don’t get the point of asking medics to check a lactate level. Why would I want to waste my time measuring lactate levels in the prehospital setting?

There. I’ve said it. Let me see if I can talk you into my point of view.

Lactate results from anaerobic metabolism. Most tissues form it, with muscles producing the most. In normal settings, the liver rapidly clears lactate along with some help from the kidneys. Lactate is an end product of anaerobic glycolysis. I’m not going to get into the Krebs and Cori cycles here. Look it up if you care. In the meantime, think of it this way: When you get done with a hard workout, your muscles are sore. That’s lactate. If you’re a little acidotic, it is lactic acidosis.

Hospitals commonly evaluate lactate in acutely ill patients. Elevated lactate is not completely or unanimously defined but high lactate has been stated as a lactate level greater than 4mmol/L in most articles. Most people think of lactate as related to the evaluation of shock states, but lactate can rise for a bunch of reasons. It isn’t as simple as “hypoperfusion (shock) causes lactate to rise.” Even so, lactate levels are often used to establish the severity of a patient’s illness and to guide therapy in the hospital. But lactate rises because more is being produced, less is being cleared by the liver (and kidneys), or a combination of the two.

Causes can be divided into two classes: Those states in which tissue oxygenation is impaired (Type A) and those in which oxygenation is normal (Type B). Type A lactic acidosis is caused, then, by shock; septic, cardiogenic, hypovolemic, and other shocks along with cardiac arrest, carbon monoxide exposure, and trauma. Type B lactic acidosis causes include diabetes mellitus, leukemia and other cancers, alcoholism, HIV infection, and medications or conditions that cause mitochondrial dysfunction.

Type A, Type B, who cares. The most simple way to think of elevated lactate levels is that the patient is experiencing cellular insult. If you remember one thing, remember that. Elevated lactate equals cellular insult.

Why do we care? This is where my question comes up. All of the studies I have found work out that the measurement of a patient’s lactate level is a powerful prognostic tool to stratify mortality rates in hospitalized patients. For example, Shapiro et al. stratified more than 1,200 infection patients into three lactate groups: less than 2.5 mmol/L, 2.5-3.9 mmol/L, and greater than 4.0 mmol/L. The mortality of the lowest lactate group was 4.9% while the highest lactate group had mortality rate of 28.4%. (1) Even prehospital-specific articles present similar findings. For example, a Dutch study found that prehospital patients with lactate over 4.0 mmol/L had a mortality rate of 26.7% and those with lactates under 4.0 mmol/L had a mortality rate of 1.2%. (2) Lactate measurement, then, is apparently a powerful prognostic tool that can drive care and treatment decisions.

There are a lot of studies like that. If you want to look at the research for yourself, I would suggest you start with this full-text overview article. This one from ACEP is a good summary, as well.

It still leaves the question: Why do I care, as a paramedic on a field ambulance?

Obviously, I am talking about urban or suburban American EMS agencies here. Critical care ambulances, rural or remote caregivers, and other atypical EMS agencies may find lactate monitoring helpful and important.

Sepsis alert programs are becoming more common. At least, they are becoming common enough for me to recognize that they exist. The most common criteria for a sepsis alert patient is (a) adult, (b) suspected or documented infection, (c) fever, pulse over 90, or respiratory rate over 20, and (d) SBP less than 90 or MAP less than 65 or lactate over 4 mmol/L. Take the lactate out of that mix. What changes? If you have an infectious adult patient with a fever, tachycardia, and hypotension you still have a septic patient. You shouldn’t need the lactate level to tell you that.

Occult sepsis, without hypotension, but with documented/suspected infection, exists. Picture that patient: Adult patient with an infectious process, a little elevated heart rate, maybe with a little tachypnea and fever. Would a lactate reading be the sole deciding factor in that transport decision? Because that is the scenario patient we started this blog post with. And I would transport him nonemergency. If you tested his lactate and found it to be elevated, say at 4.5 mmol/L, would that patient become an emergency transport? Isn’t that treating the monitor and not the patient? Would the minutes I save matter to the patient’s outcome?

If we take the scenario in a different direction, to a sicker patient, I still don’t see the efficacy of prehospital lactate testing. If the patient were altered, pale, diaphoretic, and hypotensive, he would represent a challenging prehospital patient. I would have a lot of work to do. I have a potentially septic or shocky patient and those patients are already labor-intensive. Adding lactate complicates things. Simplify!

Point-of-care lactate monitors and the test strips they use are crazy expensive. My agency would have to buy about 40 monitors and the strips. What benefit would they give? A hospital could buy one, keep it in the ED, use it liberally, and get the lactate data minutes after EMS would have provided it.

Would finding an elevated lactate reading cause me to initiate a treatment that I wouldn’t have otherwise given? Would you give a medication for a high lactate patient that you wouldn’t have otherwise given? Nope. Not that I can think of.

I just don’t see how it would affect my care on an ambulance, and I also can't see how it would save a significant amount of time or work for the emergency department. I’m open-minded. Can you explain it to me?

1. Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Annals of emergency medicine. 2005 May;45(5):524–528.

2. van Beest P, Mulder P, Oetmo S, et al. Measurement of lactate in a prehospital setting is related to outcome. Eur J Emerg Med. 2009;16(6):318–322.

The Case of the Creole Urethra

A year or two ago, I was working a special event and was called to the men’s restroom at the venue. I was vaguely irritated. I will let you in on a secret, one that you probably already know: No “good” call ever began in a public bathroom. Nothing good starts in any bathroom, generally. Public restrooms offer even lower odds. I’ve run cardiac arrests and shootings in public bathrooms; they were not good calls. So my initial mindset was not the most… productive.

As expected, I found nobody in the restroom who was obviously in need of my help. It is not a good spot to be in, walking into the can and asking the fifteen or twenty guys with handfuls of themselves whether they needed some assistance. It is a set up for amateur comedians to really shine. But because I am a consummate professional, with very little pride remaining, I loudly announced my presence and asked if anyone had called for the paramedics. A well-appearing man walking out of one of the stalls told me that I was there to help him, and that he was almost done. He beat me to the suggestion that he wash his hands and meet me outside. Working outside of the bathroom sounded like a good idea to me.

We went outside and the man began our relationship by demanding an ambulance: “I need an ambulance to take me to the hospital.” It was seriously the first thing he said to me. No introduction. No exchange of names or handshakes. Just a statement of needing an ambulance. I shrugged, smiled, and called for a transport unit to start heading my way.

While waiting I decided I should attempt to do some paramedic-type stuff. I introduced myself, asked what was going on, took a set of vital signs, and performed a quick exam. This is what I found:

The patient was a 48-year-old male who was complaining of severe inferior abdominal/groin pain associated with urinary retention. His last normal urination was approximately 18 hours previous, and he felt a strong need to urinate. Any attempt only produced a few pathetic drops of non-bloody urine. He had no flank pain, and wasn't presenting in a way consistent with renal colic. At this point, the patient was in distress and apparently knew that I didn’t have a way to cath him. His vital signs were normal, his exam was as expected, and his appearance was consistent with a man in pain due to a bladder fit to burst.

The patient had a theory of why he was unable to urinate. He hadn’t urinated in about 18 hours, right? Well, about 18½ hours ago, he was eating Creole food. Either the Creole food or the spices in said Creole food had apparently caused a reaction in his urethra that had swelled it shut.

I had never heard of such a thing. I was excited to learn something new. I asked if he had experienced similar reactions to Creole food in the past. Nope. Were there other signs of allergic reaction, such as itching? Nope. Was he allergic to shellfish or a specific spice in Creole cooking? Not that he knew of. Did he know of anyone else who had had Creole problems like this? Nope.

Why did he think it was the Creole food? It was the only thing it could be.

None of this was making sense to me, but I needed to get ready to handoff the patient to the transport unit. I collected and wrote down the patient’s name, birthday, medical history (none), allergies (none), and vital signs. I asked about the patient’s medications.

“I’m prescribed Flomax, but I haven’t needed it. So I quit taking it five days ago.”

I laughed out loud.

For those who don’t know off the top of their heads, Flomax (tamsulosin) is an Alpha-1 blocker used for benign prostatic hypertrophy and bladder outlet obstruction, among other things. This guy quit taking the med that helped him pee!

I have a wild theory as to the cause of your pee issues...

“Well, there’s your problem,” I told him. “Not taking the Flomax is allowing your prostate to impede things.”

The patient did not appreciate my laughter. (Most patients don’t enjoy laughter, especially when you throw your head back and point. Not that I did here. I'm just saying.) He disagreed with my diagnosis. Truth be told, he was mad at my insane diagnostic skills. He explained how it couldn’t be the absence of Flomax that was causing urinary retention. See, he stopped taking it five days ago. The peeing problem started yesterday night. If it was the Flomax, the peeing stuff would have been a problem four or five days ago. I was bring a jerk for even questioning that. Logic.

For my part, I was worried that I was on a hidden camera show. But it wasn’t worth fighting about. I was actually sympathetic for the guy – not being able to piss has to suck when your bladder is full. I remember when I was an EMT, we were roughhousing around the ambulance bay and a medic’s leg was broken. Between the near-overdose of narcotics we generously poured into him and the anesthesia he got during surgery, the medic woke the next day unable to pee. He was begging for a Foley. Begging. With tears in his eyes. The nurse said she didn’t have orders for urinary catheterization, so would have to call his physician. I’m still frightened of any process that would cause an adult male to loudly threaten violence upon a nurse if she didn’t hurry the hell up and shove a tube up into his junk. That has to be urinary urgency beyond anything I have ever felt. And I’ve had to pee pretty bad in my life. So I was sympathetic to this guy and his bladder pain.

The transport bus showed up. I helped the patient into the care compartment and onto the bench-X. I stepped away from the side door with the attending transport medic and began my report like a comedian begins a joke: “Get this…” After explaining the situation in a subtle and quiet way out of earshot (I thought), I heard the patient’s irritated voice from inside the ambulance.

“It’s not the damn Flomax! It is that Creole food!”

I smiled a knowing smile at the transporting medic and returned to service. I still think it was dude’s noncompliance with the Flomax that caused his problem. But I’m no doctor. So I have been avoiding Creole food since that call, just in case.

Comfortable Refusals

“Base, mumble…” (When one calls the biophone, it is usually answered with 'base' and the physician's name. Base, Jones. Base, Smith. Base, Pons. That kind of thing. In this case, I missed the name.)

“I’m sorry, which doctor is this?” I asked.

“Mumble.”

I get embarrassed to ask more than once, so I decided ‘Other base physician’ would end up in the doctor’s name spot of my patient care report. “Morning, doctor,” I say and introduce myself. “I’m calling to staff an AMA refusal, can you hear me okay?”

“I can; go ahead,” is the reply.

“I’m on-scene with a fifty-six, five six, female complaining of sharp, left-sided chest pain that radiates through to her left back. The pain is worsened with deep respiration, but it's not otherwise related to breathing. She has had this on and off for three days, occasionally associated with dizzy spells but no syncopal events. She denies similar previous episodes, shortness of breath, nausea, and any other complaints. No recent trauma or other illness. I find her awake and oriented, with intact decision making capacity. Her skin is warm, pink, and dry, and the secondary exam is unremarkable. Breath sounds are clear without apparent respiratory distress. Blood pressure 180 over 100 with a pulse of ninety and a respiratory rate of eighteen. Sinus on the monitor without ST changes or ectopy. She has a history of non-insulin dependent diabetes and is compliant with her metformin.

“I’ve given her aspirin and offered her transport to the hospital, but she is declining that plan. I explained that there is no sure way for me to know what is causing her pain and dizziness, but it certainly could be something life threatening. I told her whatever is going on could result in her death without any further warning. She says she would prefer calling her daughter and getting her to drive to the hospital. I think an ambulance is better, so we can keep an eye on her on the way, but she doesn't want that. I’ve told her I think this is a bad decision, but she is firm. Like I said, she has decision-making capacity, so… uh… that's where we stand.”

“Yeah, I agree. It is important for her to take the ambulance to the hospital.” The doctor sighed while he thought about what I told him. “Are you comfortable with this refusal?”

What? What kind of question is that? I think to myself.

“I am comfortable that the patient is a sober adult decision maker who understands both the potential benefits of ambulance transport as well as the life-threatening risks of refusal.”

“But are you comfortable with the refusal?”

“I’m comfortable that I gave the patient the information for her to decide and I am comfortable that I made a solid effort to convince her to come with me to the hospital. But she is an adult with the capability to weigh her options and decide for herself, even if I disagree. What are you looking for?”

“Nothing. That’s fine. She can refuse.” This was said in a friendly and collegial manner, which made me feel better about the conversation.

“Thanks. Have a good day.” 

Weird. I wonder what that was about.

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