Thursday, December 25, 2008

Prehospital Cardiology Blog

Just wanted to include a link to an awesome prehospital cardiology blog.

Comprehensive, well-written, immediately useful.

I can't ask for much more.

Just Another Day

To those of you who.......

...are far from your families in order that my family might be safe

...ate cold ham and fixings today provided by people with warm hearts in an ambulance garage or day room or nurse's station

...drove across cities and towns and back country roads to calamities great and small today under flashing lights while the rest of us watched our kids vroom Tonka ambulances and fire trucks across the living room floor

...know what it's like to deal with frequent fliers who also didn't take the day off

...get the job done day in and day out, but especially on days like today....

Merry Christmas, and THANK YOU.

Monday, December 22, 2008

...and I'll Tell You No Lies.

4 a.m., the home stretch of one of the busiest shifts I've ever done in a normally quiet suburban town we cover.
The dispatcher tells us the guy who called complaining of shortness of breath seemed anxious, and when we get there I realize anxious is an understatement.
He meets us at the door, and the moment we open it a crack he jogs into a living room down the hall and drops into a couch.
He can't or won't sit still.
"I've been having trouble breathing since midnight," he says."I had some chest pain earlier but it's gone now."
His history is textbook train wreck: mid-50s, lifelong smoker, diabetic/hypertensive with coronary artery disease and a stupendous case of the high-lows: everything that should be high is low and everything that should be low is high.
The more we talk to him the more agitated he gets.
We try putting a nonrebreather on him but he tears it off every time, maybe from hypoxia, maybe from claustrophobia. He accepts a nasal cannula, but barely.
He looks sick, and my partner and I move a step faster than normal, believing we may be headed to the cath lab.
So here's where I need to take a moment to debunk an EMS myth of my own.
The myth goes like this: any time a patient tells you they're going to die, believe them.
Well, that makes for a nice truism, but I've found that the ratio is something like 1 in 100 people who tell me they're about to die that actually go ahead and give it a shot.
Mostly, patients who tell me they're going to die are responding to a mix of anxiety and dyspnea, and almost all the time we're able to deliver them to the hospital without a problem.
But there are exceptions.
Back to the living room:
In the midst of the usual hurly-burly that goes into treating a patient like this, I was finishing up applying electrodes to the patient's chest for a 12-lead EKG when he became eerily calm and grabbed my arm.
He looked right into my eyes and said, with all the stress of placing an order for a medium regular at Dunkin' Donuts:
"I'm going to die."
I tried to be reassuring while still managing to get the EKG done.
"No, I'm going to die," he said again.
The 12-lead showed that the patient was suffering from an anteroseptal STEMI, but his vitals were good and he had a strong radial pulse at 80, matched by a similar rate on the monitor, so my partner and I figured we were in good shape to get him to the cath lab less than 5 miles away.
Then, in an instant, the patient died.
He went from 80 and normal sinus on the monitor to pulseless and asystolic in the space of about 10 seconds: do not stop, do not pass VTach or VFib, go straight to nothing.
It was like turning off a light switch.
We fought as hard as we could for the patient, but nothing we did had any effect, and he was pronounced dead not long after we got to the hospital.
There was no one to tell. The man lived alone and left no list of contacts or next-of-kin for anyone to locate.
I know the police were trying to track down rumors of a sister elsewhere in the state.
Sometimes patients will do what they say they're going to do, no matter how hard you work to fix them.
A lot of our patients lie to us, try to convince us they're not sick when they are, or that they're sick when clearly they are not.
And sometimes, there are patients who tell you no lies, and you remember them probably forever, and at the very least for a long time.

Wednesday, December 17, 2008

Questioning the Sacred Cow

Anyone who follows the writing of emergency physician and author Dr. Bryan Bledsoe knows that he's not afraid to challenge many of the things we take for granted in EMS.
Among other things, he has in the past been critical of what he sees as the overuse of air medical transports, has wondered not only about the usefulness of CISD, but also questioned whether the process actually increases the psychological trauma of high-stress incidents.
He has a really interesting article on right now outlining a series of studies that jibe with Dr. Bledsoe's distrust of the sacred cow.
His thought-provoking column is a round up of studies, some of which have been inexplicably ignored in the US for over a decade, like the one comparing neurological outcomes in trauma patients between Albequerque, where aggressive c-spine immobilization is the norm, and Malaysia, where c-spine immobilization is unheard of.
Interestingly, the study found that the neurological outcomes in Malaysia were better.
This study was published in 1998, and yet we continue to strap thousands of people a year to hard plastic boards without a second thought.
Other studies Dr. Bledsoe highlights include one that suggests IV epi is of little use in cardiac arrests and another that proposes using D10 for acute hypoglycemics versus D50.
Check out the column, I don't think you'll be disappointed.