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.
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.


Wednesday, July 10, 2013


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

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.


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.


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.