Are we Over Bagging?

When I went through EMS education, I was taught that when ventilating a patient with a BVM that it was important to deliver as much of the content of the bag as possible. We would almost wring out the bag to get as much as possible. But were we really helping our patient?

Our Patient needed oxygen and if a little was good, a lot must be better. We ventilated hard, pushing the O2 in quickly.  But without a secured advanced airway we ran into issue with abdominal distention.

When we bag, we must do so gently. If we push too hard we can push the epiglottis down and force all or part of the air into the stomach. Air in the stomach doesn’t help our patients and only creates a vomit fountain.

I was shown a great aid in teaching how to properly ventilate a patient. Using a BVM, attach an Endotrachial tube to the end immerse the end into a 3/4 full cup of water. If you bag fast the water will bubble out of the cup making a mess, but with practice you can ventilate without spilling the water. This is the proper way to ventilate a patient, gently.

Recent research has shown that Oxygen can destroy surfactant in the lungs. We need this to provide the “lubrication” to keep alveoli open. Think of washing sugar off of you counter-top, the water will always break up the sugar, but we we used a pressure sprayer it would break it up even faster. Fast bagging is the equivalent of a pressure sprayer while ventilating.

We’ve also found that we give far too much oxygen, we bag with 100% oxygen, under positive pressure, how long can we keep our patient’s lung compliance?

The last major faux pas of bagging is doing it too frequently. Our body breathes, in part, to maintain our acid/base balance. We rid ourselves of acid during the expiratory phase. If we bag too frequently, we prevent the body’s natural ability to rid acid. Ventilating once every 6-8 seconds for a non-perfusing patient and once every 5-6 for an a apnic yet perfusing patient would be sufficient.

Positive pressure ventilation can be very beneficial to our patient, but if we do it wrong can have many untoward effects. Slow down, be gentle and help our patients!

Posted in Airway, Respiratory | 4 Comments

Baby it’s Cold Outside

As the weather is becoming colder in many parts of the northern hemisphere, the time is coming that we’ll all be working hard to stay warm.

Many textbooks spend a brief time discussing hypothermia, but put much more emphasis on Frostbite. So here’s a question for the group. . . If the temperature is 34*F (1* C) and the wind is 30 mph (48 Kph) can you get frostbite? The answer is no, for frostbite to occur the water in the cells must freeze. Water will not freeze above 0*C.

Even at temperatures far above freezing the body’s core temperature can cool to dangerous levels. The body has some great mechanisms to maintain temperature. First the body will shunt blood away from the periphery to maintain heat at the central core. (consider your appendicular areas like a big heat-sync. )

As this mechanism fails to maintain temperature the body begins more active ways to rewarm. Shivering causes a rapid contraction and relaxation of the muscles to create heat through movement.

At about 93*F (34*C) the shivering ends, the body can no longer expend the energy and goes into a shutdown mode to preserve the body. The pulse will slow, the level of  consciousness will reduce, the motor control will be affected. If we do not actively rewarm the body these shutdown mechanisms will continue until we can no longer “restart” the body.

All of our intuition tells us to remove the patient from the environment and cover them up. Removal is important, but to cover them may not help. As I stated earlier, the body pulls blood away from the exterior leaving a cold body. Since blankets don’t actively provide heat they will only insulate the cold inside. We need to actively rewarm with warm packs, warm (non-caffeinated) water or drinks. We need to warm them from the core, not a warm room.

Since the body has closed down the limbs to blood flow, any remaining blood in the appendicular areas will also cool. If we rewarm from the periphery (i.e. a warm room) the cold blood will return to the core and cause and after drop.

Years ago the Boy Scouts would recommend that rewarming someone was easiest by taking the patient and another person and having them cuddle together inside of a single sleeping bag. This method works but should probably be reserved to a last resort as we maintain professionalism.

Hopefully everyone in the North is looking forward to the cold, it’s going to be a long time before we can be warmed by the sun again. For all the readers in South, try to stay cool 🙂

 

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Who’s Your One?

Every day we put ourselves out for others. We respond at all hours of the day and night to help strangers. We volunteer on our times off to help vacationers enjoy themselves. But are we really making a difference.

We proudly exclaim that we “Save Lives!” But do we really? By far the majority of our patients are not going to die, even without our intervention. A study done in New York City years ago showed better outcomes of those suffering a stroke who called a cab over an ambulance. In the first 18 years of my career I only had 3 cases of cardiac arrest that we were able to revive. . . with unknown long term outcomes.

In recent years, changes in how we do CPR, different equipment and updated training methods have allowed us to have better outcomes.

Throughout our career there are many times that we are unsure if we are really helping. . . Keeping a drug dealer alive to harm more lives. . . Working a case that we know is futile . . . Or responding in emergency mode at 3:00 am for someone who cut their toenails too short (yes, that was a call I’ve been on).

Today, I’d like to see if we can get some interaction. Please comment on the call that you have been on that you really made a difference. The call where you held a hospice patient’s hand as they passed away, The call were you made a very scared child calm by singing the “spongbob song” or changed someone’s outcome by talking about their family.

Mine is a call for a woman in labor a few years ago. She was very premature (22 weeks) and delivered a baby about the size of my hand. As I was about to tell her that the baby was too small to be viable, it moved. We went into full resuscitation mode and delivered the live baby to the hospital. Upon arrival many questioned why we worked on a baby that would likely not survive. When returning to the station that night, my crew and I were all considering stripping down to our boxers and work boots to quit the career. We were imagining the long term potential for this child, would it have a normal life or have some sort of long term disability? Our supervisor was able to talk us down with many very loud, passionate but inappropriate words shared by all with the idea that our job was to keep people alive, and the baby was alive.

Fast forward through the years, the child is now living a normal life. Neurologically and physically intact and a big sibling. This child is having a positive affect on their family and the people that he/she meets with a smile. This one child was nearly the reason I quit but has become the one person that I can point to and say “I made a difference!” Without me, and my crew there, this baby wouldn’t be affecting others today.

We all have similar stories and can raise others who question “Does our job really matter?”

Please add your story! YOU Make a difference!

EMS Makes a Difference

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“Gentlemen, Start Your Engines!”

A few weeks ago, I had written about our ability to only pay lip service to “Is the scene safe?” Over 4500 vehicle crashes involve and ambulance every year in the United states. Our most dangerous time in EMS in driving to or from the scene.

Many of us show wanton disregard for the safety rules of driving. We drive like our hair’s on fire to try to get to help someone, but never take into account the number of lives that we’ve endangered, including our own, on the way to the scene. Some of us even consider the ability to drive with “blinky lights” as a draw to the career.

Traffic laws, limits and intersection controls were established to provide for the safety of everyone. Anyone disregarding these, even for the right reasons, puts everyone else in danger. We’ve all seen drivers that appear startled or confused when approached by an emergency vehicle. They don’t know what to do, or are in such a hurry that they feel their preoccupations are more important than everyone on the road.

In many areas the flashing lights are not much more than a magnet, drawing in inconsiderate people that wish to tailgate to allow us to get them through traffic sooner. We see others that feel that it’s important to pass those that are properly pulling over to the right (US Laws).

When operating an emergency vehicle, it’s important that we put our own emotions in check. Very few emergencies are so time sensitive that we should put ourselves at risk to arrive quickly. Yet our departments judge us and are judged upon response times. Families are upset if the response time is too long. We need a paradigm shift in our thinking to ensure safety over arbitrary seconds that really do not change the outcome.

Years ago, while first responding I followed the ambulance to the hospital in my personal vehicle. The hospital was over 20 miles from the location and the ambulance ran hot. I followed the traffic laws in my vehicle. Upon arriving I found that the crew was still unloading the patient from the ambulance having only arrived less than one minute before me. Did all of the unsafe practices of driving in emergency mode really benefit the patient for less than a minute difference?

When we drive in Emergency mode it is very important that we stop at all intersections and clear before entering. In the US a green light does not mean “Go” it means “when the intersection is clear, you may proceed.” If we come to an intersection, it’s important that we pass all standing vehicles on the left side (this may differ based on traffic patterns in other parts of the world) as most people will turn to the right to avoid the ambulance based on the siren sound, not on necessarily seeing the vehicle. If you are in their blind spot they may turn directly into your vehicle.

Most departments have rules against emergency personnel carrying fire arms because of the perceived danger of weapons. But they don’t realize that far more people are killed by traffic crashes over firearms. In the US, 36,000 people are killed every year in vehicle crashes while only 12,000 are killed by weapons. Beyond end of life, there is someone injured in a vehicle crash every 9 seconds throughout the year. I am not advocating carrying guns in EMS. I am, however, questioning are we focusing on the wrong thing? We should be working more on creating a mindset of vehicle safety rather than gun violence.

It’s time that we begin to teach “Arrive Safe” before checking for scene safety.

Posted in Well Being | Leave a comment

Around the World in 80 Days

This last week we passed 80 days since I moved Medical Mondays to this blog format from Facebook. I want to thank each of you for being readers and I’m amazed how many countries are represented by frequent viewers.

You will see that we have gone around the world and have at least one country from every continent represented; except for Antarctica, I think that they’re too busy trying to stay warm to read a silly blog.

As we move into the next 80 days, I’d like to ask two things of you. First, please spread the word about this weekly update on Pre-hosptial care. Each of us know others involved in public safety, ski patrol, ems or emergency care. Please help me spread the word and fill in the map. My second request is to comment on this article. Please let me know your first name, country and involvement in caring for others. I’ll Start; Jay, United States, Paramedic & Ski Patrol.

I hope that everyone is enjoying these articles and would be able to help me reach more people. The page can be viewed from www. medicalmonday.com or  medicalmondayems.wordpress.com. I’d like to fill the map more completely.

Thank you to each and every one of you for taking the time to read my articles. If there are topics that you’d like to see covered, please write me at jay (at) vanzeeland dot info.

Medical Monday reader map

Posted in Education | 2 Comments

Be Safe Out There!

When we took our initial training, Scene Safety, BSI were drilled into our heads. We entered every scenario parroting these words, but beyond lip-service do we put these into real life practice?

When we enter a scene, how often do we pause for even 1 second to think of the possible situation that we’re getting into? We load our hands with equipment and go busting into the house with little regard that there could be someone planning to do us harm. We concentrate far too much on “what is” rather than “what if.” With our hands full carrying extra equipment could we possibly defend ourselves if needed.

We were taught to never have anything between us and an exit if we needed, but become so unifocused that we seldom know who’s even in the room. As we enter is there someone waiting behind the door to do harm to us? Is there an uncaged animal that is very interested in protecting its master? Is there furniture or trip hazards that may cause us a severe injury because we are concerned with the patient that we’re carrying.

Unfortunately the average career span for EMS providers is only 5 years. If you were to ever query those that abandon this noble career early you will generally receive an answer that starts with “Well, there was this kid.” If you talk to old dogs, you will hear “my back couldn’t take it any more,””I couldn’t deal with the sleep deprivation,””Our patients are getting far too heavy.”

Each of these are indications that we never really checked for our own safety. We see some awful things and are part of the worst moment in many peoples lives. Are we paying attention to what this does to our own psychological well being? As we enter every scene we need to remember that “I’ve done nothing to cause this, I’m only here to make it better. Sometimes it can’t be made better.” or “I’ll fix those that I can and let God take care of the rest.” Because many of us place greater value on the untapped potential of children we are hurt more by their demise.

Anyone who has been involved for a long time has musculoskeletal issues that will haunt them for the remainder of their lives. All because they felt that they were young and strong enough to move someone. As we carry a patient up or down the steps there’s a lot of torsional loading that can cause injury. Even stair chairs, which are extremely underutilized, put us into a lifting position that we must lift with our backs rather then legs. GET MORE HELP! Yes there are some very tight situations, but we are further ahead to take a few extra minutes planning and obtaining more people to help. What percentage of our cases are really dependent on those extra seconds? Our rush puts the patient and ourselves at greater risk.

When working on the roadways, we often trust that police or possibly fire will secure the scene, but we are equally responsible to ensure that we will be safe from other traffic before attempting a rescue. All of the flashing lights become a distraction to anyone that’s driving and can result in them driving into the scene. As we try to pull someone from a pretzeled car, we sometimes have to put ourselves into the same pretzeled position. All of this can cause injury if we try to carry a load.

We were instilled with the need for Body Substance Isolation in class that we were almost afraid to shake somones hand without gloving up first. But as we get away we start to feel that we cannot feel through the gloves or that they are too hot. We feel that the patient’s will not feel comfortable if we are afraid to touch them. We wear gloves as much for the patient’s protection as our own. We touch people in personal places and think nothing of feeling a strangers skin for warmth, moving a breast out of the way or cutting off clothing to assess for injuries. All of these should be done with professionalism and with a barrier between our skin and theirs. Any body fluids, can cause us harm. . . Remember if its “Wet, sticky or stinky and not our’s, don’t touch it.”

Taking an extra few seconds to ensure that we are and will remain safe throughout the call, and our lifting will help provide us many additional years of helping others. We are called to places that are inherently not safe, after all someone was hurt there or is sick there. As we leave the station at the beginning of every shift, or leaving every call we should ask ourselves and our partners “Are we going to be safe out there?”

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Bigger Than a Breadbox

Years ago I noticed that every time that my mother would bring home a loaf of bread that the immediately took the heels out and threw them away. I asked her why and she replied that because her mom did it. When I asked my grandma she said the same, “Because my mom did it.” I asked great-Grandma why she did it and she replied “My breadbox was too small.”

Are we still doing things in medicine because that’s the way it’s always been done? Yes. We longboard our patients despite the fact that there’s never been a study showing them to be effective. I recently read an article by Dr. Brian Bledsoe in which he reminisced that when he started as a paramedic that we were very selective about which patients needed to be “immobilized.” When the DOT came out with the 1984 standards, in an effort to make pre-hospital medicine easier to learn, LSB’s became common place as a means to prevent being sued, rather than used for specific situations.

How many of us have been to a campground with a water pump? What happens during the first few pumps? Nothing. We have to prime the pump before it becomes effective. Our heart is the same way, we must prime it first. What happens when you stopped? You had to start over again. Our current standards for resuscitation have us doing 5 sets of 30 compressions interrupted by breathing. Over 2 minutes we do 150 compressions, but 50 of those are simply re-priming the pump. We end with a net of 100 compressions that circulate blood. 50 per minute wouldn’t be enough to sustain most of our lives, but that’s what we’re using to try to restart the heart. Have you ever tried to clutch start a car? Do we do it slow or fast?

Newer methods allow for the first 6 minutes of compressions only and have had results of approximately 600% greater recovery (8% to 47%). Yet we still stick with 30:2.

We should never rely on the old methods, simply because that’s the way it’s always been done. We must always strive for better. Until we can find a way to save people, prevent illness and prevent trauma 100% of the time, we should never be content with the way it’s always been done.

Perhaps it’s time that we start to look for a larger “Breadbox” of tricks rather than continuing to throw out great ideas.

Posted in Cardiac, Education, Patient Care | Leave a comment

Allow me some indulgence

Please allow me a few minutes to brag.

As many know, this blog was started to educate the members of the National Ski Patrol. Recently the patrol that I belong, Pine Mountain Ski Patrol, was awarded the Central Division & North Central Region 2014+2015 Outstanding Small Alpine Patrol awards as well as a National Unit Citation.

This small group of dedicated volunteers works very hard to ensure that every guest of our resort has a safe and enjoyable vacation.

All of us dedicate ourselves to helping others in our own way, please help me congratulate this group of volunteers who help others.

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We have a 24 y/o GSW PNB, CPR In progress, EPI x 2, Shock x 3, Now PEA, Coming in 10-33, ETA 8 min.

This headline may make a lot of sense to anyone experienced in pre-hospital medicine, but to the rest of the world, it is a bunch of gibberish. When we begin in medicine, we are taken aback by the amount of technical language and terms used by the industry. We start to wonder how that could ever make sense to a patient. As we progress, we want to fit in and learn the medical jargon to fit into the industry. Somewhere along the journey, medical jargon becomes a way that we can deflect the emotions and remain separated from our patient. Nevertheless, this crutch becomes a barrier.

Imagine being a patient hearing that you need a PCI. Would this have made sense to you 3 months before you started your medical training? It likely would mean nothing to this patient as well. If you were to tell them that they needed a procedure that would open the blood vessels of the heart to return blood flow to the cells they would have a much better understanding of upcoming events.

When we talk with patients, we sometimes mask our explanations with incomprehensible jargon, either make ourselves look smarter or to reduce the impact of some bad news. The patient deserves to really know and understand to be able to provide truly informed consent.

How do we get back to using plain English? We should first return to our roots. We began our involvement in medicine for many personal reasons; among them was likely the altruistic idea that we could help others. The new language was, at first confusing, but we learned it by relating it to our experiences or simple understandings. Simple understanding can make for better explanations. “In order for the heart to pump it has to get oxygen from blood; just as you get tired if you can’t get enough air when running, your heart feels the same way. Because the vessels are blocked, not enough blood can get through. We need to open the vessels.” Now we’re explaining things in ways that our patients can understand.

How would you explain a concept to a child? You would get down to their level, not laude over them. You would with compassion, explain what was happening in simple terms. We can use this same simplicity to talk with any patient. I’m not suggesting that we condescend, but that we use the same innocent approach to better help our patients.

An area that we often have a difficult time discussing is telling family members that one of their loved ones has died. We use phrased like, “Gone,” “Lost him,” “pass on” or “couldn’t help.” All of these can be reasons for the family member to rationalize that their family isn’t dead. Grieving must begin for anyone to heal. By giving them an exact moment in time to start the grieving process, by telling them that their loved one has died, you are actually doing them a great service. You’ve given them a time to start healing. You are helping them by telling them the truth in simple terms.

We are all human, we care for people; an emotion. When passing on bad new, it is okay and appropriate for you to show emotions as well, so long as they don’t get in the way of the survivor’s grief. A crack in your voice or a tear in your eye is fine, inconsolable crying is not. Some of us were taught that emotional attachments with our patients are bad. If we don’t, that loss of caring will reduce our ability to help the people rather than the malady.

In 1935, Dr. Erwin Schrödinger, an Austrian physicist came upon a thought experiment in quantum supposition.  A cat, a flask of poison, and a radioactive source were placed in a sealed box. If an internal monitor detected radioactive decay, the poison would be broken and kill the cat. Known as Schrödinger’s Cat, the thought experiment demonstrates that while the cat was sealed from view we can consider it as equally alive and dead.  It wasn’t until we observed the cat upon opening the box that we would know for certain. Today’s ambulances have become the new Schrödinger’s cat. . . While their loved one is in our care, family members are not sure if they are dead or alive. Keeping this in mind, will the departing words to your next family be different? (Dr. Schrödinger harmed no cats, we will always do our best not to hurt humans either.)

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Hlp m I cnt tlk rght, wh dnt y hlp m?

Communication is a very important part of all good medical care. If we are unable to effectively communicate with our patients; regardless if it is their inability to communicate, or our dedication to medical language that they wouldn’t understand, we cannot effectively get to the underlying cause of the issue and provide treatment.

Many maladies or preexisting conditions may cause a huge barrier to communication. The first is not a malady, yet a major problem if your patient’s experience is different from yours. Since the Tower of Babble (likely before) there have been many languages in the world. Some of these languages stem from common roots to our own, while others are incomprehensibly foreign. How do we as medical professionals learn from the patient their history or even the reason for our encounter? The easiest way is to find a family member, or hopefully the patient himself or herself, at least have a rudimentary understanding of a common language with you. I met a young lady from Japan that didn’t understand English, and my Japanese was far worse. We found a common language, albeit rudimentary, in Spanish.

If there are family members available, many times they are children who experience your language in school, they may have a better understanding of both languages and be able to translate for us until an official interpreter can be secured. Many apps that may be used on your phone allow for spoken communication and translation. Be careful! The same Japanese lady was mortified when I tried the electronic translator and it came back with something inappropriate.

New services are emerging that allow the use of your phone or internet that can connect you with a translator located far from your location. The patient will speak their information to the translator, who will then translate. Some of these services are completely voice based, while others incorporate video calls to allow for understanding of facial features along with the words. This technology has revolutionized our communication, particularly with the deaf.

Beyond language, there are occurrences that may affect the words that our patients use, even with a common language. A stroke, traumatic brain injury or even cerebral infection can lead to aphasia. Aphasia can range from the complete inability to form sounds through speaking well-formed words in a completely disjointed order or relation to the subject discussed. Frustrating as it may sound, the patient is generally aware of the problem and may exhibit extreme frustration. Because the speech and hearing centers are separate in the brain, the patient may be able to hear and understand you correctly but still not able to get out the words.

Congenital issues may also leave the patient with a reduced language or understanding. In these instances, trying to use simple concepts seems to work best. Some have caregivers, or friends that have learned to understand their utterances, while others can use pointer boards or computers speech synthesizers (Steven Hawking) to be able to communicate. Be aware that these systems also have limitations; there are over 1 million words in the English language, generally, there’s not enough space on a pointer board to store that many words. Regardless of the situation, communication through this method will be slow.

Sensory issues may also affect how we communicate with our patients. While people who sense the world differently than we have normal lives, the cross between the two may be difficult. Imagine trying to communicate with a deaf patient. We have learned that we don’t have to be in direct sight, or even in the same room to communicate, but the Deaf /Hard of Hearing community must use their eyes to understand what we are saying. Looking directly at the patient will help them dramatically to read lips. Learning a few words of their language can also be beneficial. Facial hair can make lips harder to see as well as speaking very fast or slow. Speak at a normal rate and in a normal voice; yelling at a deaf guy doesn’t work.

Over the years I’ve learned to speak every language in the world but Greek. . . Unfortunately many of my patients are speaking “Greek to me.”

We can never learn while talking. Learning is a process of inputting information to your brain, while talking, only output information that you already know. If we ever want to learn from our patient, we must take the time to listen to what they are telling us, regardless of how difficult.

Next week, I’d like to cover the opposite side of this communication. . . Our own inability to communicate within the patient’s understanding.

This program offered by Dr. Bill Vicers (deaf himself) is an excellent free resource and can be used to increase your medical ASL vocabulary.

This video is a sample of a for sale version that will mix sign, English and Spanish

Posted in Altered Mental Status, Geriatrics, Patient Care | Leave a comment