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Thursday, August 22, 2013

I want your opinion

I have a question and really want to hear from all of you.

Currently, the state of Minnesota defines a health officer as:

Health officer.

"Health officer" means:
(1) a licensed physician;
(2) a licensed psychologist;
(3) a licensed social worker;
(4) a registered nurse working in an emergency room of a hospital;
(5) a psychiatric or public health nurse as defined in section 145A.02, subdivision 18;
(6) an advanced practice registered nurse (APRN) as defined in section 148.171, subdivision 3;
(7) a mental health professional providing mental health mobile crisis intervention services as described under section 256B.0624; or
(8) a formally designated member of a prepetition screening unit established by section 253B.07.

I have been of the opinion that the list should also include paramedics.
That would facilitate the medic writing a transport hold on scene and taking the patient to a hospital. There have been some concerns about the MD's agreeing over the phone, because then you need to ensure that the patient is seen by that MD. Triage and bed space in a large ED with multiple providers doesn't always make that realistic. And some MD are unsure if it is appropriate to agree to a hold over the phone without really seeing the patient.

So, would it make an impact in your job if paramedics could sign the hold form? How?
On your first day of work, would you have been able to make that decision?
Recognizing that much of the state is served by EMS providers trained to the EMT level, should they be included in the definition?
Remember, I am not governor so I am not making any campaign promises, I just want to know what you think.
Paul

Thursday, August 8, 2013

Best Practice

This is the button to avoid!!
I think we all agree the Lucas 2 is an upgrade from the previous version. I understand it is top-heavy, but the auto adjusting is nice and I have been told it is much more quiet.

One new option it gives us is the choice between continuous compressions and 30:2.

Dr. Lick and I think the patients have the best circulation when the compressions are uninterrupted, even when you are only using a basic airway. This is contradictory to the current AHA recommendations, but the science is ahead of the 2010 AHA guidelines.

So, avoid the 30:2 button, use only continuous compressions regardless of what airway you use.


Monday, August 5, 2013

Watch out, it's graphic!



A little on the gory side, but it is a good demonstration of ventilating lungs.

We were using this at a training day for a different group. In the video, you can see the lungs expand with each breath. If you watch the deflation period, it is much quicker when the PEEP valve is off. When the PEEP valve is in place, the lungs deflate to a certain point but hold some volume. Think of this as maintaining open alveoli that would normally collapse. These are then ready to accept now, oxygenated air with the next ventilation.

If you watch, you can see blebs forming on the right lung, among other places. This is because we have caused injury to the lungs by over-inflating them at times.

This is also a good exercise to watch the effects of hyperventilation on lungs and how they lungs are affected when we ventilate rapidly without giving enough time for them to deflate normally.

Tuesday, July 30, 2013

Something to think about

For the past 2 years, the Twin Cities and the surrounding communities have been leaders in cardiac arrest survival. The innovation coming from this community is setting the tone for cardiac arrest care around the world. Overall survival from cardiac arrest in Hennepin County is 14.5%. This is almost twice the national average of 7.9% survival of all victims of cardiac arrest.
There is a special segment of the data set that is pulled out and compared so that people can be sure they are comparing similar data points. This is called the Utstein data set. This only includes people who have a witnessed cardiac arrest and are found in a shockable rhythm. In Hennepin county, the survival for these patients is a nation leading 43% compared to a 31.5%  average for the rest of the country.
 
Believe it or not, there is room for improvement.
 
Where?
 
In our community, victims of cardiac arrest only get bystander CPR 28% of the time. To be clear, bystander CPR is defined as someone other than a member of the EMS response, not the firefighters and law enforcement members who provide first responder services as part of our EMS system. The national average for bystander CPR is 36%.
 
In the Cares data set for Hennepin county, if the Utstein group was limited to those with a witnessed arrest, who were found in a shockable rhythm AND had bystander CPR, their survival rate when up 4.5% to 47.5%. 
 
Bystander CPR is very important and makes a big difference. It is something that can add to our success if we can improve our community participation.
I urge you, as the experts in cardiac arrest care, to encourage others to get invovled, learn CPR and perform it when an arrest happens.
There are CPR classes happening all over the community. It is simple to learn and poses minimal risk to the patient with the potential for great benefit.
 
 

Tuesday, July 16, 2013

A Cardiac case

Great reminder of the importance of suspicion.

When taking care of patients with emergency symptoms, whether it is in the ED or in the field, we all start to recognize situations that give you a sense of impending doom. in the ED, the nurse's movements in and out of a room may catch my attention while I am working at my desk, and something tells me I should step into that room sooner rather than later. In pre-hospital cases, sometimes you just know that you are about to have a patient that is going to require your expertise in order to survive. It may be the tone of the dispatcher's voice, or there may be nothing other than your own gut feeling. We have all looked at someone, not knowing their vitals, history or current symptoms and instantly worried that they might die in the next few moments.

The case I had the other day was one of 3-5 patients per shift I see with chest pain. I heard the nurse bring the patient into the room behind me, and I did my work waiting for the ECG to be placed on my desk.I am not sure what caught my attention, but I distinctly remember them getting him into the bed. Then,  there was a delay in getting the EKG in my hands. For some reason, my gut said I needed to see his EKG before I started on another patient.

 Here it is:


He has no chest pain:




Not much to see, is there. So I thought, " Huh, my gut feeling was wrong this time"


When I went in to see him 10 minutes later, he looked uncomfortable and the QRS shape on the monitor looked very concerning.
He said that he was having chest pain again, like what had brought him in from work today. My "spidey sense" sense had told me to pay attention to this patient, and now my suspicions were confirmed.


Here is the EKG when he was having pain:

At this point he was sent to the cardiac cath lab and had a stent put in his right coronary artery.



A few things I will stress related to this case. 

Develop your gut feeling or " Spidey sense". It has really come in handy in the years I have been doing this job. If you listen to your gut, and find out it was inaccurate, learn from it and keep going. My gut feeling is something I have learned to rely on and not ignore it just because it is wrong on occasion.

Gut feelings have saved many a life in EMS. Just recently I was passed a note from an ED MD in town who says an Allina crew saved a patient's life. They had the gut feeling something bad was happening with the patient and insisted she be triaged to a critical room. There were no bad vitals and no significant exam finding. The providers just had a bad feeling. This turned out to be exactly where she needed to be when she nearly bleed to death from an ectopic pregnancy

Next, it is OK to do as many EKGs as you want. Keep trying to get a picture of the STEMI that you think is evolving.

Paul

Wednesday, July 10, 2013

Kudos

I got this email today and it was clear I needed to get this out to the people who are doing the good work.

Paul,
I just completed my review of 125 more EMS charts for the compression injuries study and I had to send you a note.
 
Allina paramedics (and EMTs) do an absolutely outstanding job of documenting their CA care. After looking at the quality of EMS runs sheets that are completed by other ambulance services, Allina is so superior in this regard that it deserves mention. There are so many useful details that the others just don't bother recording, and ImageTrend was a great choice compared to other tools I see. I am lucky to be trying to do this CA work here, rather than with another service. Whatever you are doing in terms of education around documentation, keep it up.
 
I recognize this sounds like more of a homer comment than something Bert Blyleven would say in a Twins game, but the recognition is important. This person looks at charts from many services in the area, so she has informed viewpoint.

Thank you for the good work you do.

Paul



Tuesday, July 9, 2013

Heart Block




This was a great case I helped with recently. This is a classic presentation of syncope in an older patient with no medical problems. He just kept passing out when he stood up.
First Point: ALWAYS do a 12 lead when the problem is syncope, and always leave them on the monitor. You never know what you are going to see.

So the EMS crew found him in the above rhythm and correctly identified 3rd degree heart block. He had no symptoms of chest pain. i often think of this happening with an inferior MI, but he did not have the clinical picture.
Point #2: The QRS was wide so they correctly did not try to interpret it for a STEMI.

By ACLS standards, the man is unstable, I guess. He is passing out, he is groggy and has a low BP, but he is not having pain or real dyspnea. This is the first challenge, should you pace him? Pacing means pain, and that means sedation and their goes your ability to use mental status and brain perfusion as a sign of cardiac output. These can get real tricky.
He got atropine, then external pacing and then versed because the mini-taser 80 times a minute gets a little uncomfortable.

So he presents groggy, twitching every .75 seconds and yet his pulse was 24. So the pacing was not effective at the time.
Please send me a note if you have ever felt like you successfully managed a patient with an external pacer. My experience is that you have to crank the energy way up just to capture the heart. And I define capture as feeling a pulse with each twitch, not just a change in appearance on the monitor. In order to get the energy that high, you HAVE to sedate them and I really think you have just complicated the whole picture.

My choice of management was to intubate him immediately so we could remove the patches from his hairy back.
Seriously, I chose not to pace him, watched his HR of 24 and asked him 300 times if he was still with us while waiting for the cath lab to be ready to put in a pacemaker.

And he did fine. My point is this. The decision making around pacing for bradycardia can be very challenging. I do not think that pacing is a great, successful therapy for bradycardia. It has it's own problems. Like the need for sedation and trying to determine if the pacing is really helping. So, follow your protocol, but be willing to critically think about your decision to pace and if you are really helping the patient.

Paul


Monday, July 1, 2013

Back to Blogging

Sorry about the lapse in recent posts. Sometimes I can't decide if I should post something just to post something or if I should hold out for riveting subject matter.
 
Prepare for riveting subject matter...
 
Our care goal for the year is going really well. All of the Allina Health EMS staff have changed their documentation patterns and I am very pleased to say that things are looking good.
 
The priority is good patient care, recognizing those patients that truly are at risk of having something bad happen to them and being as careful with them as you can.
 
When we launched this, we all talked about the increase in calls to MDs for medical control clearance. Well, for the month of May the care goal generated 31 calls to an MD for medical direction. If Lisa looks at calls that were made unrelated to care goal data, there were 14 that month. I am glad to say this care goal is not generating an overwhelming number of calls for medical control. I have not had any negative feedback from hospitals regarding this at all.
 
Now, we are seeing a number of cases where there should have been a call. So there is room for improvement. Interestingly, these are very often because the patient has persistently abnormal vital signs. Remember that there is a number range for HR and RR that the patient must fall into to be signed without a call to the MD. There is only one call related to alcohol where an MD call was not made and should have been.
 
You are doing a good job, thanks.
Paul

Thursday, May 9, 2013

Documentation Request

I am going to use this communication medium as an opportunity to convey a request.

Nearly every call we go on involves a first responder of some sort. Some of those agencies have committed to providing an advanced level of care for the patients in their community. They are initiating care before we arrive, commonly administering medications under the medical direction of AH-EMS. We support those EMR services that want to do more, like the medications, with some stipulations around education and training.

For the most part, the only medications that the EMR services are doing are the ones outlined in the Minnesota state rule regarding "variances". The rule is for BLS ambulances services and allows them to provide glucagon, epinephrine via auto-injector, sub-lingual nitroglycerin and albuterol via nebulizer. The rule does not mention EMR services, but we use follow the letter of the rule for consistency when initiating the plans with the EMR services.

For clarification, there are no variances relating to procedures. I commonly hear people refer to an IV variance or a King airway variance. There is no rule in the legislature about those procedures. It comes down to whether or not the EMS medical director wants the group to do it. Of course, the responsible medical director would ensure proper training and review of cases.

This brings me to my main point. Two years ago, AH-EMS received a grant to study the effects of the care provided by our EMR groups. We specifically chose to evaluate the care provided by two of our groups doing advanced cares. Allina Health has a very talented group in the research consulting unit who was able to tie together the AH-EMS patient report with that of the EMR services we chose to study. They were able to link about 80% of the calls in the time period chosen. That equals about 10,000 calls where we have both the EMR report and the AH-EMS report for the same person. From a data perspective, this is great. the 20% gets lost in things like misspelled names, cancels of either party, etc.


What did we find?
That is the point of the research and it is not done yet, so you'll have to wait.

BUT, we did find out that everyone documents in a different way. Some people put EMR procedures under the activities tab, and then put "done by FR" in the comments, or just leave it under their own name with no comments. This makes it look like AH-EMS did the King,  for example, when it was the EMR who did it. This means that our data has a giant conflict because 2 groups are claiming the procedure and we can't be sure who did it.


So, here is the solution.

I ask that all of you document any EMR medications or procedures in the Prior Aid slider in the At Scene tab. That is what it is for, and we can search it with reports and know exactly who did what. We cannot search comment fields for things like " done by Bloomington PD".

So, I encourage you to change how you document EMR interventions. I know that there may be cases where it is not perfect for telling the story. But, look at what we have now. We have people using numerous ways to document the EMR care and if we are going to keep track of their work, review the cases and research it, it needs to be done in a uniform way. So let's use the Prior Aid slider in the At Scene tab.

In the name of research, I thank you.









Saturday, April 20, 2013

How good is Allina Health EMS?

Hello,
I've been thinking about how we can make things easier on our staff at the airport, this may be a start.

I have just returned from a trip where I got a chance to learn about the EMS system in Great Britain. Interestingly, I found that they have many of the same challenges that we do. They are trying to improve their outcomes of cardiac arrest and are looking at the best way to do that. They are trying to develop processes to reduce the number of non-emergent ambulance responses and alternatives to taking everyone to the hospital. They have standard national protocols that are the minimum standard for all ambulance services. That means that they have a uniform set of medications and equipment.

There are national clinical performance goals that they take very seriously. At the end of the year, if it looks like they are going to miss the required marks, they cancel all meetings and send everyone into the field to work on the goals.  The medical directors are directly responsible for these goals and have to answer for them.

Their goals include response times, care of stroke victims and of patients with STEMI.

Their goals also include survival of cardiac arrest.
For reference, the Allina Health EMS  survival to hospital discharge rate is 14.4%. This is better than the average of Hennepin County, Minnesota or the US.

In Great Britain, the number is 7.5%.

You should be very proud of what you do.


Ultimately, I learned we have a very good EMS system. While we can lean from others about how to tackle some of the challenges in front of us, we do things very well.

Tuesday, April 9, 2013

Interesting Case





One of the reasons I went into Emergency Medicine is that on every shift, there is the potential for an interesting case. I suspect there are many people in Emergency Medicine and Emergency Medical Services who are of the same opinion. We all tolerate the mundane cases, the repetition of influenza cases in January and the long nights with no patients. You do all of this knowing there that there is still part of this job that gets your attention when you see something that you didn't expect, or haven't seen very often.

Look at the image above as I give you the details of this case.

This is a young person who came in saying he fell on the steps in the past few days and has vomiting and abdominal pain. Part of the reason he fell was that he was drinking, but he and his partner assure me that he had not overdone it and that his symptoms were not from a hangover.
He has normal vitals, but was very uncomfortable. I did a bedside ultrasound and saw no free fluid i.e blood, so I started into by speech about pain and muscle contusions and how unlikely it is that there is anything wrong internally.
Blunt trauma to the abdomen can cause damage to wither the spleen or liver, most commonly. The term used is spleen laceration or liver laceration, but they are more like fractures or bruises. With blunt trauma, that is the injury you worry about, unless the mechanism is atypical, like a handlebar to the abdomen or if someone throws a shoe at you. But "Who throws a shoe? Honestly."

When you have a focal impact to your abdomen, you can bruise your bowel which will cause pain. Then, once the bowel swells, you will stop passing food and you start to vomit. That process can take up to 48 hours and that did not fit really well in the case I am presenting here.

I kept looking at the patient and decided he was in to much pain to send home without formal imaging, hence the CT scan image you see above. What is outlined in green is the patient's pancreas and it is broken in half. This is rare, painful and has the potential for many long term complications. The treatment is placing a stent in the pancreatic duct using upper endoscopy. You do this because you don't want the pancreatic enzymes that normally digest food leaking into your abdomen and wreaking havoc on your abdominal organs.

An unusual case that is worth bringing up because it is easy to let your guard down when you hear a mechanism that so often leads to no significant injury. I even make jokes about how I see people who fall on the stairs everyday, yet I still brave the steps in my house.

Extra credit: Send me note and tell me what is represented by the dark area I have identified with an orange circle.

Paul 


Thursday, April 4, 2013

Narcan for Cardiac Arrest

Jeff,  A long time listener from Eagle Valley wrote in with the following question:

"We are seeing more arrests from heroin overdoses, should we be using narcan early in those cases, or following our cardiac arrest protocol?"

Jeff, great question.

It seems logical that since the arrest is caused by the heroin overdose, we should use the antidote early to correct the problem. I have seen the same approach in cases of hypoglycemia causing cardiac arrest; people give D50 to correct the  initial problem, hoping it will improve the cardiac arrest condition.

The quick answer for this, we should be following the cardiac arrest protocol.

Here is the AHA text from the section of the 2010 guidelines for CPR and Cardiac Arrest.

Naloxone has no role in the management of cardiac arrest.

Here is the rationale that I use when asked "Why not use glucose or narcan when you know exactly what caused the cardiac arrest."

Hypoglycemia and heroin are indirect causes of cardiac arrest. They have little if any direct effect on the heart. Therefor, reversing them does not counteract some direct effect that is causing the cardiovascular problem. They cause respiratory arrest, which leads to hypoxia and then cardiac arrest. So, if the person is in respiratory arrest, it makes sense to reverse the problem ( give D50 or Narcan). Once they are in cardiac arrest, you are dealing with problems that are not going to respond to reversing the hypoglycemia or heroin.

Said another way, giving narcan in a cardiac arrest may increase their respiratory rate, but you still have no cardiac activity to work with,  so you should be treating per cardiac arrest protocol.

There are some conditions that have a direct effect on the heart. Those we should be treating if we are suspicious they caused the cardiac arrest. These are commonly referred to as the "H's and T's". If the high potassium caused the cardiac arrest, we should treat the high potassium since it has a direct effect on the heart.

References:
I found only 3 articles about narcan in cardiac arrest. One was a case report of a person who arrested from a pain medication overdose. She got ROSC after narcan but did not live. The other is a retrospective look at care provided over a long time. They found 36 cases where the patient got Narcan because of suspicion of overdose. 15 had a change in their EKG, but there is no comment about if the people lived or even got ROSC.

So for now, follow protocol and look for the "H's and T's", of which heroin and hypoglycemia are "H"s".





Thanks to Vikki Peckman, Doug Thompson and Kyle Strege. All knew that in a newborn, the right arm is the most accurate assessment of the oxygen state of the child since the left arm ( and legs) carries blood from the ductus as well as the aorta so the oxygenation is mixed and lower than the blood going to the head and right arm.


Saturday, March 30, 2013

Newborn Class

I had the opportunity to take the Neonatal Resuscitation Program class last week. This is standardized class put together by the American Academy of Pediatrics and jointly sponsored by the American Heart Association. I was clued into it by a few of our providers that have taken it and thought it was time well spent. I figured that I should take that class and learn from it so I can speak the language of the others at Allina Health EMS who are taking care of newborns.

Key points:

There was a lot of information, but a few key things really stuck out and I would like to share them with those of you who have not taken that class.

  • Organization- like all other high stress events we have,  I encourage you to plan ahead. Work with your partner before you arrive and assign tasks. Who is going to place the oxygen?, who is going to ventilate and check the airway? who is going to check the cord and ensure it's clamped?. Being deliberate will help you a ton.
  •  Oxygen- against everything we want to do, we have got to stop reflexively putting oxygen on these newborns. Because of how their circulation transition from fetal to , it is normal for their oxygen saturations to start at 60% and rise to 90% over the next 5-10 minutes. The child is in no danger with those numbers for that period of time. In fact, they are suggesting that there may be problems if we artificially push the oxygen up to 100% immediately.
    • Important- the recommendation is to put the O2 sat monitor on their Right wrist.
Email me if you know why the right side is preferred!
  • Ventilation - it is all about ventilation. When challenged with a decision about intubating or placing an IV/IO, I wanted to place the IO to give epi for a slow heart rate. Then answer was always, put an ET tube in and see if that increases the heart rate. Wait on the IV.
    • So ventiltion is the priority.
Thanks all,




Thursday, March 21, 2013

Conspicuity Podcast

Link to a Podcast

https://www.dropbox.com/l/wm7Lz1fPA7EUX9WaP5gYJ9

A while ago, when we kicked off our safety initiative at Allina Health EMS, I interviewed my neighbor because he has some unique knowledge about safety. He worked for some time at 3M as a product engineer in their division that develops reflective and fluorescent materials.
If you listen to this, remember he has no EMS background. He is a funny guy.

Wednesday, March 20, 2013

Should a family watch a resuscitation?

Ask anyone in medicine if they think a family member should watch the care of a cardiac arrest, and I think the majority of providers would say "no".
I suspect we as providers are afraid of many things that "might" occur during the event.

What if we mess it up? 
What if I look foolish by missing something obvious?
What if the family gets out of control and tries to interfere with the care?
What if they record it and try to show I am incompetent?



N Engl J Med 2013; 368:1008-1018March 14, 2013

These French researchers showed  a measurable improvement in the family member's well being if they witnessed the resuscitation. The family members had fewer symptoms of anxiety, depression and PTSD if they were present during the event. This is one aspect I had not really put a priority on, but I realize it is a very important thing. In a time like that, we should all strive to do the best we can for the family. 

Other findings from the research?  no increase in medico-legal claims, no added emotional stress to the providers and no change in the characteristics of the care.



I have thought about these things, recently, to my chagrin. I was involved in a case where we were trying to resuscitate a patient who arrested during what was supposed to be a routine transfer. We did our job and the patient did not survive. But during the event, a family member started recording things with her phone.

 I was immediately nervous. What was I thinking?, well .. (see above)

Those are all questions you have when you are not confident in what you are doing. If you know you are doing your best, and you are following community standard, or written protocol, then a recording should not be a concern.

Unless of course, conversation or behaviors are not as professional as they should be.
Remember 

Integrity: What you do when no one is watching.





Tuesday, March 19, 2013

Transition to EMS Physician on Blogspot

All,
I have transitioned from the EMSMDBlog site for technical reasons. Turns out I am running into technical problems with the transition.
Bare with me and I will get the video running and a new post up soon.
Paul

VividTrac

video

I attended the EMS Today meeting in Washington DC last week. After a rough time getting out there, the conference and expo went pretty well. There was the usual exhibitors and I had already made up my mind about video intubating devices.
But then I was steered towards the Vividtrac 100 by Vivid Medical.

The device is simple, disposable and inexpensive. The thing that really caught my attention is that it does not use a 2 or three inch screen for visualizing the airway. This ingenious device plugs into an existing screen via a USB device. That means you can use the toughbook you need to drag in anyway.

I went home and immediately set it up on a network computer. Our business firewall gave me no problems, and I do not have administrator access.  I took me all of 60 seconds to get the program off their site and onto the computer. After that, I plugged in the device and was ready to go. Just like they told me, their software makes the video screen the priority window and it goes away when you unplug the device.
This is important to me because there will not be any "minimizing" of programs as you try to switch from patient record to video device.

I made a short video, unfortunately this mannequin is sub-optimal.

I think the are on to something with this device. It is low cost, durable and minimizes the need for more equipment.

Kudos to Mina and Shane at Vivid Medical.

Allina Health EMS Video

I am very proud of the people I work with in EMS. This is a good showcase of the people doing the work in our community.

http://www.youtube.com/watch?v=vD7cclQcVNo&feature=youtu.be