Dead Neb

This is one of the posts where I remind you that I am not your medical director, boss, paycheck signer, protocol author, or decision-maker regarding your continued EMS employment. So take the opinions laid out here with a grain of salt, huh? But see if I can convince you to come over to my side.

Here’s a scenario for you. You and your partner respond to a cardiac arrest, with dispatch giving CPR instructions over the phone.  You arrive to find a 25-year-old male pulseless and apneic, and asystolic on the monitor. First responders report that their AED delivered one shock prior to your arrival.

Digging into the patient’s pre-arrest history, you discover the patient is a brittle asthmatic and had been struggling to control his breathing all day. His friend reports that he had been hitting his metered dose inhaler (with the spacer attached) much more than usual. There is no other recent illness, trauma, drug use, or significant information. The scene is safe to hang out and work the arrest.

What are your treatment priorities for this patient?

Continuing high-quality CPR in 2 minute rounds, of course. Harder! Faster! Intravenous or intraosseous access. Epinephrine every three to five minutes. Ensure ventilation, whether through an OPA initially or through a King or an ETT as needed. My plan would be to work the patient on scene until I pronounced him or got pulses back. I think asystole is confirmation of death, in most cases, so I would probably be looking at a round or two and calling it if things didn't turn around.

Here is what brought this rant up: In this case I found online, the scenario includes “…bagging in a duoneb treatment…” Click the link and read the case. Would you give the patient a duoneb treatment via in-line neb into an endotracheal tube? I mean, he is an asthmatic who was having trouble breathing before he arrested. Albuterol and atrovent could improve his breathing, right?

Nope.  I wouldn’t.  As a matter of fact, hell-no I wouldn’t give an in-line albuterol treatment to a patient in cardiac arrest.

Why waste your time, attention, and efforts delivering albuterol? Simplify your task list!

I attempted to research the use of albuterol or atrovent in the setting of cardiac arrest. I didn’t find anything pertinent. I suspect that it is too silly a question for research to have been done on it. I tried to find information on the absorption of nebulized albuterol in cardiac arrest. Nothing. I searched ACLS algorhythms and other guidelines for albuterol administration in cardiac arrest patients. Nope. Is albuterol efficacious to reverse asthmatic cardiac arrest? Dunno, but probably not. I did find that an MDI with a spacer is as effective as a nebulizer in treating an acute asthma exacerbation. So it isn’t as though your neb will be more effective than the MDI that the patient had been hitting all day. I also found that the amount of nebulized medication absorbed is related to tidal volume (duh), which is decreased when you’re bagging a patient. It is even worse when you consider the deadspacing resulting from all the extra in-line neb tubing.

Here is my thought: In a cardiac arrest, you are already pouring a β-2 agonist into the patient’s body. Epinephrine. Have you ever given intramuscular (or subcutaneous, if you’re old enough) epi to an asthmatic? It hits like a hammer and starts to open the lungs quickly. In a cardiac arrest, you aren’t giving a half-milligram into the deltoid. You are blasting a whole milligram into the venous circulation. And then repeating it after three minutes. And then potentially repeating it again and again.

Think of IV epi like the water in a swimming pool. Albuterol is like adding another drinking cup of water. Yeah, the dumping the little cup into the pool added more water, but not any amount that it significant compared to the water that is in the whole pool. 

Part 12.1 of the AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science* deals with an asthmatic arrest, specifically. “When cardiac arrest occurs in the patient with acute asthma, standard ACLS guidelines should be followed.” Standard ACLS guidelines never mention albuterol or atrovent in cardiac arrest algorhythms. Respiratory arrest is treated by opening and securing an airway. V-Fib and V-Tach get defibrillated every two minutes, get IV epi every 3-5 minutes, and may get amiodarone.  PEA or asystolic arrests get epi.  Hypoxia is treated by securing an airway and ventilating the patient. Acidosis is treated by ventilation (not bicarb). Tension pneumo is treated by a big-ass needle between the ribs. My prehospital protocols are similar. No albuterol. No atrovent.

The AHA Guidelines continue: “Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with hypercarbia and acidemia, hypotension due to decreased venous return, and depressed mental status, but the most common cause of death is asphyxia.” Albuterol doesn’t reverse asphyxia; ventilation does. Ventilation also helps reverse hypercarbia and academia.

But giving it doesn’t hurt…

Yes it does. It is one more task you have to perform. It requires endotracheal intubation, or at least a supraglottic airway. You can’t deliver albuterol via BVM and mask. When you have an intubated patient, most of your time should be spent thinking about whether or not the distal tip of the tube is where you intend it to be.  You don’t need to be distracted by an in-line neb.

This is the Rube Goldberg puzzle you want to assemble during a cardiac arrest, huh?

In-line nebs are a hassle to assemble. They are like friggin’ puzzles.  An in-line neb interferes with monitoring an intubated patient’s end-tidal CO2 level – the best way to monitor the distal end of your tube.

The list of actions you should perform during a cardiac arrest is long. I wouldn’t make the mistake of prioritizing a nebulizer treatment higher than CPR, IV access, IV epinephrine, airway management, intubation confirmation… The list of more-important tasks is long and illustrious.

Managing a cardiac arrest in the field is a difficult task to do well. Why would you complicate a difficult task for marginal or theoretical (if any) benefit? Don’t waste your time with the neb.

Highway Parking

Imagine you are dispatched to a possible unconscious party in a running vehicle on the left side of a busy roadway. (As a reminder, I hate slumpers in a car. They are terrible, terrible calls and they rarely generate a medical patient. See this link for my rant about stumpers after you read this post. Man, do I hate those calls.)

Anyway, as you approach the scene, you do indeed see a sedan parked at the left side of the road, against the median.  How do you park the ambulance when your call is on a roadway?

Ambulance parking is what I want to write about today. I see a bunch of variations on parking an ambulance on a highway or a major road.* A related point is how people enjoy getting where they are going when they are driving. The same holds true for me, when I am not at work. Off duty, I am the guy likely to be loudly ranting about how somebody messed up rush hour for no good reason. (“Jurisdiction X always screws up traffic! I’d have already cleared this scene! How long does it take to run a five-car crash on a highway?!? Don’t they know what they’re doing to traffic?!?”)

On duty, though, I park the ambulance diagonally and spread out. Yes, I ambulanspread. There are three main reasons. It gives me more room to work behind the “shield” provided by the parked ambulance, it helps other drivers to recognize the ambulance is stopped, and it will tend to push the ambulance away from my scene if it is hit hard from behind.

First, an emergency vehicle should be at the back of the scene. Whether it is a fire truck, police car, or ambulance depends on who gets there first. Whatever vehicle is parked at the back of the scene is acting like a line of cones, making traffic merge away from the scene. 

Second, other drivers need to realize the emergency vehicle is stopped. To help illustrate this, look at this picture:

The ambulance here is parallel to the flow of traffic. How fast is it going? This is the same view that other drivers have of an ambulance when it is driving along at 80mph the speed limit. There is one side of the ambulance visible to drivers approaching from behind. An oncoming driver has to see and understand the ambulance is getting closer and closer… oh, the ambulance is stopped. At night, at highway speeds, when intoxicated, when distracted, when blinded by flashing lights, sometimes recognizing that an ambulance is stopped occurs after driving into the back of said ambulance.

Look at the alternative:

Parking diagonally to the flow of traffic presents two sides of the ambulance. It is a view that hardly ever occurs when the vehicle in question is driving. It is more intuitively obvious the ambulance is stopped. 

Finally, consider the two pictures again. If a heavyweight vehicle traveling at highway speed hits the ambulance in the top photo, where is it going? Right, directly ahead into the scene where we are working. If the ambulance in the second photo is hit, where is it more likely to go? The wheels will pull it at least partially to the right, in the direction it is pointing and away from your workspace. 

There you have three reasons explaining why it is important to park diagonally at calls on highways or major roads. What do you think? How do you park your vehicle when you are working on a highway?

*Parking an ambulance on a neighborhood street in front of a response address is completely different, as well as much simpler. In short, park on the wrong side of the fire apparatus. As a matter of fact, you don't even need to try. Life and karma will do it for you. Whether you park behind the fire engine or in front of it, you will be on the far side from the scene.

The Porpoise

There was an assisted living facility around the corner from my first EMS job. A man lived there with a bunch of fascinating memorabilia in his room. The man had medals on display showing he was apparently a hero in the Second World War. There were black and white pictures of him in an Army uniform. I’m told the medal collection hung on his wall was impressive, including some of the big-assed crazy medals you get from foreign countries. There were photos of him with presidents, and there were framed personal letters on his wall from presidents and celebrities. I specifically remember a photo of the man with President Eisenhower’s arm around him in a friendly way. There were pictures of him and Kennedy in his Army uniform, standing tall. But by the time I knew him, he was living in this assisted living place with Alzheimer’s or some other form of dementia.

I remember this man well, because he would fall down on a regular basis. The staff (I’m hesitant to assign titles like “nurse” or “caregivers” to them) supposedly wasn’t allowed to assist uninjured residents back to their feet. Apparently the “assisted” in assisted living only goes so far. Anyway, it was common for us to go to the place and pick someone up. This man was an especially common lift assist.

The condition in which we found him was generally consistent. He was never hurt, but you had to get him upright again. He would be naked at the bottom of a bathtub. Wet from head to toe. Soapy. Angry. Combative. Ever try to grab hold of a combative octogenarian when they are wet, soapy, and naked? Probably, if you’re in EMS. So you know that naked, wet, soapy elderly people present few handholds. 

Oh, yeah, and he had a sword hidden his cane. For god’s sake, you had to get the cane away from him before he ran you through.

We called him The Porpoise.

CC0 Public Domain Source

“What was that last call? Why are you guys back so soon?”

“Picked up The Porpoise.”

“Oh. You two okay?”

I’m of two minds, thinking back on The Porpoise. On one hand, it is sad that age and disease eroded this hero into the state in which I knew him. Aging sucks. I hope he had a big family who missed hearing his stories. I hope they still visited him often, especially when he had clothes on and wasn’t slippery as a greased pig. (A rageful, cane-stabby greased pig.) 

On the other hand, it is awesome that he was still a badass. I can’t wait until I am old enough to live in a nursing home and terrorize new EMTs to the point that I get a nickname. You people are gonna hate to run on me…

More Cops More Cops Get More Cops

A couple of years ago, my partner and I were assigned to a shooting. When we turned onto the address’ block, we found plenty of law but we had beat the fire department to the scene. A cruiser blocking the street pulled aside to let us pass. We parked in front of the response house and I grabbed the jump kit. 

We approached the front door and a police officer stopped us. “I only need one of you for a pronouncement,” he told us. More people in a homicide scene complicates the investigation, so police will occasionally ask us to just put one medic into the crime scene in cases of obvious death.

I turned to my partner with a smile. “Hold my kit, son.” I handed him the jump kit. My smile broadened – that jibe got to him. I essentially told him that I was the important one and he was like my assistant. It is probably something that you wouldn’t get if you hadn’t been there, but it still makes me chuckle. Especially the irritated look on his face. Hold my kit, son…

I stepped off the front porch into the living room of the house. It looked like a slaughterhouse. There was blood everywhere. I don’t think I had ever seen this much blood in one room, let alone splashed on the ceiling, all four walls, and the floor. The house was trashed, as well. Apparently the victim put up a fight for a long while before being shot several times with a shotgun. 

The victim’s body was on the far side of the living room, next to the kitchen and at the entrance of the hallway that led to the bedrooms. The cop pointed out the path he wanted me to follow to access the body and explained how he knew he only required one medic for a pronouncement: “Should be a simple pronouncement. I’ve been watching him closely and I’m sure he’s dead. He hasn’t taken a breath in at least ten or fifteen seconds.”

Are you shitting me? I turned and looked at my partner, slack-jawed with disbelief. Did he hear that too? He grinned and handed me my kit back. “You may need this.” I just stood there and stared at him for a second. “I’ll get the wheels and set the bus up,” he told me.

I made my way to the patient and reached down to feel for a carotid pulse. I felt a weak, tachycardiac carotid pulse, because of course this guy had a pulse. He was in rough shape. Without getting into specifics, a person can sustain quite a bit of trauma from a few shotgun blasts and a long fistfight. Dude was a mess. He had agonal breathing and had a mess of blood and teeth in his oropharynx. His trachea didn’t look quite right, either. 

I quickly checked and mentally cataloged his injuries and dug into my kit for the intubation equipment. I squatted at his head and threw down a flat gunslinger tube. It may still be the fastest intubation I have ever performed, to this day. Laryngoscope into his mouth, take a look, place the tube; bam, bam, bam. Three and a half seconds. Gunslinger.

I hooked the BVM to the tube and gave him a few breaths. I listened to the patient’s breath sounds and the tube was good. Boom shakalaka. I felt like I was at a spot where I could wait for more help. Firefighters should be on scene any time now to give me a hand with extrication.

It was at about this time that I noticed a door at the entrance to the hallway. It looked like it would lead into the basement. I can definitively say I noticed it at this point because the door handle on the basement door jiggled and turned a little bit.

The police officer lost all the color in his face. He turned white as a sheet, looked at me, and said one of the scariest things I’ve heard: “Oh. Shit. This house isn’t cleared yet.”

Wait. What?!? This horror movie scene isn’t cleared yet?!?

The officer drew his pistol, brandished it, and began screaming commands at the still-closed door. “Come out of the basement! Come out slowly! Show me your hands! Get out of there!” His voice was hitting higher and higher pitches.  This officer was freaked out. I was pretty sure he was going to put four or five blind shots through the door in a line from bottom to top. “Come out of the basement slowly!”

I stupidly sat there, bagging the patient with my mouth hanging open, and watching the officer scream commands at a door. I didn’t even think of moving to a safer place. Because I am dumb and, to be honest, I was scared. I just bagged the patient, dumbfounded.

Right then, the first of the firefighters walked through the front door. The following “conversation” occurred:

Me: “Cops! I need a lot of cops!”

Firefighter: “What?”

Me (shouting, with my voice cracking a little): “More cops!  More cops!  Get more cops!”

Firefighter (looking confused): “What do you mean?”

Me (shrieking, probably at the top of my lungs): “Badges! Guns! Get cops! Get more cops in here!”

Firefighter (muttering, shaking his head, and walking out the door): “These paramedics are assholes…”

The firefighters apparently thought I only wanted cops in the house, because they left. They got into their fire truck and went back to their station. They returned to service without telling anyone else that they had just saw a police officer screaming commands at a closed door with his gun out and a panicking paramedic was screaming the word COP.

Eventually, the scene got itself all figured out. In the end, it worked out that the door that jiggled wasn’t a basement door. It was outside door. Another cop was in the back yard checking it was locked. He never even knew that he caused so much drama inside the house. I'm glad the indoor officer didn't pop some blind shots through the door before he opened it. I bet he is too.

My partner returned and we extricated the patient with help from the police. The cops sent two officers in the ambulance to the hospital, so when the patient lost pulses I put them to work on CPR and bagging. For my part, I missed six IV attempts and handed off the patient at the hospital. (This was pre-IO and mid-ETTeveryone.) Definitely not my best work, especially communication-wise. 

Except for the tube. Man, that was an awesome tube. Friggin' gunslinger.