Chargeshockchargeshockchargeshock

Years and years ago, I ran an interesting cardiac arrest. Well, I’ve run a few interesting cardiac arrests, but there is one that I would like to tell you about today. It involved a fifty-something male who had chest pain, waited too long before calling, and attempted to treat the pain with Pepto Bismol or some such ineffective remedy. So he eventually arrested and fell down, which notified his family that something bad was happening. The family was on the ball. 911 was called and his adult son began effective CPR immediately.

Besides his son slamming away with some good, rib-cracking CPR, this patient had an ambulance and a fire truck relatively nearby. So the professionals (plus me) had a quick response time. Let me tell you how this went, so you can see how long ago this happened…

The paddles were gelled and pressed against the patient’s bare chest. VFib was identified. Charge to 200 joules, clear, shock. I kept watching the monitor postshock and the patient was still in VFib. Click the thumb dial to 300, charge, clear, and shock again. Still VFib. The 360 joule shock resulted in asystole. A firefighter got back onto the patient’s chest and I intubated him. My partner started an IV and pushed a milligram each of epi and atropine.

See? Long, long time ago.*

Anyway, this arrest was like a demented ACLS megacode run by an idiot who had never seen an arrest before but had read about the rhythms once. The patient kept switching rhythms like the ACLS instructor had just bought a new rhythm simulator and was just randomly pressing buttons. The epi and atropine changed the asystole to a pulseless IVR and more epi turned that into VFib again. Shock, asystole, meds, IVR, meds, VFib, repeat. I recall there was at least some VTach mixed in and there may have been a significant run of PSVT.

Bad for the patient.
By Jer5150 (Own work), via Wikimedia Commons

In any case, I found myself chasing rhythms while transporting. (Because back then we felt like we could do effective CPR in a moving vehicle, so we gave dead people a final cruise through the city.) On the way to the hospital, I contacted my base hospital to have them set up the receiving hospital. I was transporting to Hospital A, but I called my base physician at Hospital B so s/he could call Hospital A for me. Its our system. I got a certified legend on the phone.

I explained what was going on, what I had done, my plan (keep on doing what I had been doing), and that we were 5-7 minutes away from Hospital A. He stopped me and gave me instructions: “Bill, listen to me. This is what I want you to do. I want you to deliver three shocks at 360 joules to the patient as quickly as you can. Don’t even look at the monitor, don’t do anything but charge and shock. Charge-shock-charge-shock-charge-shock as quickly as the monitor will do it. I will wait on the phone so I can hear you do it. Give him all three now.”

Okay. That algorhythm wasn’t in any ACLS class that I’ve taken.

Old-school defibrillator paddles, for those who have never seen them.
By User:Tirante (Own work), via Wikimedia Commons

So I did it. booooOOOOOOOOOOOOOOOO BLAM. The firefighter on CPR leaned forward to restart CPR and I told him to hold off. booooOOOOOOOOOOOOOOOO BLAM. Number two. “What the hell are you doing?” the firefighter asked. I grinned at him wildly with a gleam in my eye and a frantic giggle. I hit the charge button again. booooOOOOOOOOOOOOOOOO (“No, please, stop! What are you doing to him! It smells like burning and hatred!”) BLAM. The very confused firefighters looked as though the first thing they were going to do when the call was done was to make sure I was charged with assault. I checked for a carotid pulse.

Well, holy shit. The patient had a pulse. He kept that pulse all the way to the hospital and maintained a decent blood pressure.  A 12-lead in the ED showed an apical MI. I later found out the patient had a CABG or four, got to know the MICU nurses, and was eventually discharged to home. He had close to 30 minutes of prehospital CPR, total.

I’m still not totally clear on how the triple shocks worked. I think each shock lowered the resistance for the next one. Keep in mind the LifePack-10 I was working with didn’t throw biphasic shocks. One way or the other, the physician on the other end of the call saved the patient’s life from miles away. If I’d have called the receiving hospital directly, those shocks wouldn’t have been delivered.

Sometimes you contact base with one expectation and get help you didn’t even know you needed.

*I still remember the VFib jingle I learned in my first-ever ACLS class in paramedic school: Shock shock shock, everybody shock. Little shock, big shock, mama shock, papa shock… For the youngun’s among my readers, that results in a stack of three shocks – 200, 300, and 360 joules. Everybody = epi. Little = lidocaine. Big = bretylium tosylate. Mama = magnesium sulfate. Papa = procainamide. You gave a 360-joule shock and an epi between each of the other meds. That’s how it went…

Weightlifting, 2-Man Coverage, and EMS

A couple of years ago, I took up weightlifting. I am lucky to work out in a gym that provides trainers and coaches who work to improve my form. They also watch out for my safety. I wouldn’t have thought it, but picking a weight up from the ground and lifting it over your head is complicated as hell. Details matter. How far apart are my feet? Are my feet parallel or toed out? Ankle position. Knee and hip relationship. Hamstring tension. What is the position of my femur relative to my pelvis in three dimensions? It goes on and on. Even my thumb position relative to the rest of my hand matters.

It isn’t a matter of “…try not to curve your lower back.” Picking up something heavy from the ground is something cavemen did, but it is extremely complicated to do well.

Not me...
By Sasan-sj [Public domain], via Wikimedia Commons

Recently I ran across an article that explained one of many football defensive coverage schemes: 2-man coverage. Check it out – the detail is incredible. And this is a basic look at what football players deal with dozens of times per game. This barely gets into the physical aspect of football defense – a cornerback’s hip position, whether a linebacker’s break uses his left or right foot. This just explains some of the intellectual concepts that go into the coverage scheme. An example quote (because I don’t really expect you to read the article):

As you can see, both safeties will gain depth at the snap to play from a deep-half alignment. This allows the free and strong safety to drive downhill (top-down) versus the deep dig (square-in), 7 route (corner), post, etc. while also having the ability to get over the top of the 9 (fade) route or overlap the inside seam.

Huh? Can you go over that again, slowly? I knew football was more complicated than John Madden let on during a game (“The best way to gain more yards is advance the ball down the field from the line of scrimmage”), but aren’t football players supposed to be dumb? A person with the ability to understand play concepts like that isn’t dumb.

How about fly fishing? Want to hear about the details of thumb and wrist position during a backhand cast versus a roll cast? How about different flies, or how barometric pressure affects fish, or which caddis fly is hatching, or different ways to read a stream? There are anglers who work on the details of elbow position for months, to make their cast slightly better.

It is easy to spend time focusing on the details of hobbies we choose to do. When you love something it is fun to work on improvement. All it takes is finding a coach or mentor with knowledge, the willingness to share that knowledge, and hours upon hours of hard work.

Do you spend as much time or burn as many synapses improving the tiny important details of your EMS game? Or did your knowledge base peak on the day you got out of class? How aggressively are you challenging yourself to improve?