EMS

There was a case recently where a paramedic was working a code on a patient in PEA. During the code, the EtCO2 of the patient rose from 12mm to 27. The medic correctly assumed that his patient was a ROSC patient. He stated so to the ED staff when he turned the patient over to them. The doctor ignored the medic, and stated that the increased EtCO2 meant nothing, and declared the patient dead. Some time later, when the staff went in to prepare the patient’s body for delivery to the morgue, they noticed the patient trying to breathe. The code was resumed, with the result that the patient finally expired several days later. Lawsuits are pending.

The evidence is overwhelming, capnography is a reliable predictor of ROSC in an arrest patient. Here are some studies to prove my point:

Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales, RA. Society for Technology in Anesthesia 2011.
  End Tidal Carbon Dioxide Levels Predict Cardiac Arrest. Manyam H. Society for Technology in Anesthesia 2011.
End Tidal Carbon Dioxide Predicts Cardiac Arrest. Manyam H, Thiagarajah P, Patel G, French R, Chaluvadi S, Balaan M. American Heart Association  Resuscitation Science Symposium 
Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales RA, Dyott W. Prehospital Emergency Care (NAEMSP). January 2010; Volume 14, (Suppl 1), 48-49.    
  Capnography as a Survival Predictor in Cardiopulmonary Resuscitation.Farinha LF. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S57.Sleep and Pulmonary Rehab
Partial Pressure of End-tidal Carbon Dioxide – Reliable Criteria for Termination of Non-traumatic Cardiac Arrest Resuscitative Efforts in the Field. Grmec et al. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S26.
Capnography during CPR in SUMMA 112: Preliminary Study. Diez-Picazo LD, et al. Congreso Nacional SEMES 2009. June 2009.
   

You have a patient in SVT. (for more on SVT, see this post) How do you decide whether to cardiovert or use drugs? The ACLS classes recommend that you look for signs of poor perfusion, such as altered mental status or a systolic blood pressure below 90mmHg. The problem with waiting for these signs is that they are relatively late signs of cardiogenic shock.

A person with altered mental status or an SBP below 90mmHg is already decompensating, and is into the third (or possibly fourth) stage of shock. The blood pressure and mental status changes indicate that the brain and other vital organs are not being oxygenated, and as we all know, this leads to acidosis and cell death.

If only there were a way that we could determine that our patient’s SVT is reducing cardiac output due to Starling’s Law. Wish no more, here is your answer:

As cardiac output decreases, so does venous return to the lungs and heart. This lower blood flow results in less CO2 making it to the lungs to be exhaled. If your SVT patient is placed on capnography, and the CO2 is less than 37mmHg, you need to start thinking that your patient is having a bit of trouble perfusing, most likely to reduced cardiac output. This is the beginning of our patient’s journey to decompensation city. It is time to begin leaning towards cardioverting our patient before we reach the point where our patient has deteriorated so severely that he has begun to lose brain cells.

Don’t fall behind the curve. Be proactive, and you will do yourself and your patients a true service by catching problems earlier rather than later.

What is Supra Ventricular Tachycardia? I think that I did a good job explaining it here. The problem that brings this up again is yet another nurse who thinks she needs to school the dumb paramedics.

I was recently training a new paramedic, and I showed him a picture of a Sinus Rhythm at a rate of 180 beats per minute. I told him that he was, for the purpose of this discussion, working at the first aid tent of a marathon, and that this was the presenting rhythm of a marathon runner who was complaining of dizziness. I use this scenario often as a training aid, and this medic, as new medics invariably do, identified the rhythm as PSVT and stated that it should be treated with 6mg of Adenosine. I asked why, and he told me that PSVT is any rhythm that has an origin above the ventricles, and a rate of over 150 beats per minute.

I pointed out to him that while SVT is technically any tachycardia that occurs above the ventricles in a purely literal sense, it is important for clinicians to recognize that what we refer to as PSVT is a dysrhythmia, and that there is not any set heart rate that separates Sinus Tachy from PSVT. The only way to tell the difference is to do a good patient assessment.

A nearby RN overheard, and attempted to tell me why I was wrong, and that 150 bpm is the standard for defining SVT.

I asked her why she felt I was incorrect in saying that the aforementioned marathon runner is probably in Sinus Tachy. This rhythm is a response to the normal metabolic demands of the runner’s body. A person taking a stress test has similar responses. (After all, the target heart rate for a stress test is usually over 150 beats per minute)

Instead of answering, the RN tried to tell me that the AHA defines SVT as all tachycardias that originate above the ventricles and have a rate over 150. Sigh. Where does the AHA say that?

Ask anyone who works in EMS, and they can tell you a hundred stories of people who abuse the EMS system. I have seen my share, and the stories have infinite variety:

The thermostat:
It was 2 o’clock in the morning when we went to this woman’s house for a complaint of “difficulty breathing.” When we got there, the “patient” didn’t want to go to the hospital, she just wanted help. Having just moved into her house, she didn’t know how to program her electronic thermostat and wanted us to show her how. It wsa 82 degrees in her house, nowhere near being a medical emergency.

Incarceritis:
People fake seizures, unconsciousness, chest pains, you name it, in the belief that they will not be arrested if they go to the hospital. The sad fact is that they are sometimes right. The officer sometimes doesn’t want to sit around the hospital for several hours, waiting for his prisoner to be discharged for minor misdemeanors. Felony arrests? Forget it, you are going to jail as soon as the hospital is done with you.

A variation of this was one morning’s call:
A man was required to be in court at 8 o’clock in the morning for a child support hearing. He walked from his home towards the courthouse 10 miles away. (Why he didn’t take the bus is a mystery.) He made it about 3 miles, and then called 911 with reported shortness of breath and chest pain at about 10 after 7. When we arrived, he wanted to go to the hospital that, coincidentally, was two blocks from the courthouse. When we arrived and asked him what was going on, his first words were, “I am trying to get to court because my wife…”

We all knew that this was a fake call intended to get him to the hospital closest to the courthouse, so that he could walk out and be in court faster. Since there is no penalty for failure to pay for the ambulance ride OR the ER bill, this is the equivalent of a free taxi. We decided that the best thing for this patient was to go to a different hospital. Why? Well, if he really was having chest pain, the patient would be less likely to walk out of that one, opting instead to use the ER bill to show the court why he had a medical reason for missing court. IF he wasn’t really having chest pains, then he didn’t need to go anyhow. Besides, to reach the hospital he wanted, we would have had to pass another, closer one, and there was no medical reason to pass a perfectly good hospital to go to the other one.

Lest anyone think that we were being mean or lazy, he still got a complete workup. His vitals were: SaO2 98% on room air, 100% on 2 lpm of O2. HR 82, RR24, BP 142/94. Monitor showed SR, and 12 lead showed nothing important. He was hot and sweaty, but that is unsurprising considering that he was about 60 pounds overweight, and it was 82 degrees with 80% humidity. He still got 325 mg of aspirin, NTG spray x2, and transport to the closest hospital (rather than the one he wanted)

People abuse the system every day. This is why universal, “free” health care will never work.

WARNING: Medical terminology to follow, but I will try and keep it to a minimum.

I was the first medic on scene to a 54 year old male, whose chief complaint was that he nearly passed out while he was lifting a heavy object from the back of his minivan. He had a History of insulin dependent diabetes, a heart bypass, high cholesterol, and high blood pressure. His vitals were as follows: HR 72, RR 20, BP 136/72. He takes lopressor, insulin, lipitor, and aspirin. His 12 lead showed nothing acute, except LVH. I was in the middle of finishing my assessment when the transport unit arrived.

The medic on that truck told the patient that the near syncope was probably due to stimulation of the vagus nerve that lifting the box caused. I pointed out to the patient that while the other medic was probably correct, due to his extensive history, it would probably be best to take him in, just to be sure. You see, diabetics frequently do not have the classic symptoms of a heart attack, and often the first sign that a diabetic has of a serious heart attack is fainting, nausea, or shortness of breath, and not chest pain. The patient agreed with me, and decided to go to the hospital.

Apparently, that angered the other medic, who had been hoping to talk the patient out of going to the hospital. After he dropped the patient off at the hospital, he decided to come talk to me about “taking over his patient.” I pointed out to him that he is a new medic (less than a year on the street) and that patient refusals are not there for his personal comfort- paramedic inconvenience is not a reason to avoid transport.

If there is any piece of advice I can give you new medics out there, it is this:

If you are ever undecided as to the proper course of action, whichever option it is that causes you the most work is usually the correct one. Don’t ever forget that we are the patient’s advocate, and all of our decisions need to be in the best interests of the patient, not ourselves.