I couldn’t imagine being first on scene… prays for EVERYONE involved.
My ramblings and an attempt to share what little knowledge is in my head.
I couldn’t imagine being first on scene… prays for EVERYONE involved.
This study will have two versions written about it. This version is my “cut the fat” version I am trying encapsulate in this blog. As well, with my venture in medical free lance writing, I will have a “medical education” category for those who want the juicy morsels of dense medical language.
With out further wait… here is sepsis study on a plate.
Sepsis is a hot button topic in the world of prehospital medicine. There has been alot of literature put out by hospitals that declare more than 50% of in hospital deaths are due to multiple organ death (MODs), which is the ultimate deathly out come of sepsis.
The problem with sepsis and EMS is not only figuring out what we are looking for, but also to relay to the ER what we are seeing. Granted, we are not allowed to fully “diagnose” a patient, but effect EMS education teaches differential diagnosis to create a “field diagnosis.” We want to start drawing the picture of what the patient will need for continuity of care. Depending where you work, ER nurses and docs alike appreciate a field diagnosis. Again, depending where you work. In order to have that continuity of care, the EMS provider has to be ready to give the facts and findings of your field diagnosis.
Center stage at hospital night at the Apollo. Your are taking your patient to bay 1. There are 20 people in lead vests and gowns and goggles. You begin to speak loudly (que Eminem walking to the mic) and clearly. Then you are interrupted by questions you don’t know. The whole set falls apart. The crowd begins to boo. The doctors glare. The nurses snicker. The a clown with a long curved cane scoops you up and drags you to the ambulance bay…
But never fear! Sepsis study’s for ambulances are here!
For a potential Sepsis activation, you need to first understand the steps of infection and it’s relation to the human body. I’m sure many of us have had the case of chest pain that ended up being pneumonia. Productive cough? Elevated temp? Could still be cardiac but through our deferential diagnosis we know we have a higher chance or treating pneumonia instead of angina. Breathing treatment and fluid versus aspirin/nitro.Entrance into the portal of infection evil…
There are three steps in the chain of fatal sepsis. First step is Systemic Inflammatory Response. This is the time when majority of people of who feel ill take tylenol and get rest. The body is giving basic signals that it is fighting an infection.
Next is Sepsis. This in an untreated infection. The infection is now spreading into the blood stream (septicemia) and fluids begin shunting to organs to protect the body from shutting down. A patient can be altered, have low BP, elevated heart rate, tachypnia and elevated temperature. The blood vessels dilate, in effort to protect the organs, and the patient starts to present with signs of shock.
“The situation is usually made worse by the damaging effects of the toxins on tissues combine with the increased cell activity caused by accompanying fever.”
The next phase can be the deadly end. Multiple Organ Death (MODs) is when one by one the organs begin dying off. The body begins losing the battle against the infection.
EMS’s mission in this equation is early recognition.
Criteria for sepsis activation in prehospital is still developing. IStats. Sports medicine lactate testers. Many tools have been dropped off in our jump bags.
A study performed in Albequre, New Mexico, hospitals worked along side EMS in order to start prehospital sepsis activation. The study hypothesized that, “in patients that EMS sepsis alert criteria, there is a strong relationship between prehospital ETCO2 readings and the outcome of diagnosed infection. The secondary hypothesis was that ETCO2 also predicted hospital admission, ICU admission and death.”
Yup. The same tool used to treat respiratory problems and help declare ROSC can be extremely useful in alerting the hospital if your patient is about to go into septic shock.
Alburqure created a field sepsis protocol. Hospital alerts were initiated if there was a suspicion of infection and certain criteria met with; temperature reading >38.3 or <36 c, heart rate greater than age expectation, hypotension, elevated lactate readings, elevated respiratory rate, and hypocapnia.This is NOT the EMS protocol. It is a visual to help understand what creates the criteria.
As with any form of shock, a body that is in a sepsis state compensates to save valuable life saving organs. As vessels begin to shunt, you have standard shock symptoms included with infection symptoms.A sample sepsis protocol for preshospital.
So what was the result with the study?
Out of the 351 patients that met criteria over the course of a year for Field Sepsis, all patient’s MET the criteria! It worked!! EMS was successful in diagnosing sepsis in the field. Plus, they created a form of communication and trust with their local hospital.
I know many of us are cardiology gurus. We love what we can fix in the field. Truly, it is amazing what we can do to the human heart for survival. Now infection is the next focus for saving lives.
Study quoted: Sepsis alerts in EMS and the results of pre-hospital ETCO2; from American Journal of Emergency Medicine, 2018
From the hospital view. https://emcrit.org/pulmcrit/ssc-1-hour/
There was a time I was burnt out. Well, that’s not exactly true. There was a time that every three months I was burnt to the core. I wanted to quit. I wanted to go to nursing school. Hell, I even put in an application to Fed Ex.
Unfortunately, there was one time that my burn out led to injuring a patient.
You see, I was burning the candle from all ends. I was going through a terrible separation with a woman who had two kids I cared for and adored. I was a supervisor of a shift that was falling apart. I worked nights, went to school during the day, and had to attend meetings in the mid afternoon (peak night shift sleep hours).
I turned into the medic who would blow up about too many gloves being on the truck. Trash cans would fly across the bay floor after a mighty frustrated kick. Mop handles would shatter on the side of the ambulance like I was swinging a samurai sword. My off shift drinking was constant. My anger was out of control and would occasionally come out on a patient. My refusal numbers were rising and the end of the road was coming closer.
One morning, my partner and I were called out to a patient complaining of abdominal pain. Before the call even came in, we were in the mood that this patient was going to be a refusal. We were both exhausted from outside life and had no intention of transporting. We were a dangerous crew that had lost all interest in their job. We wanted to be anywhere except on the ambulance.
We arrived at the home of the patient and in all honesty, I barely remember the call. I am sure I talked her out of going. I probably made her feel stupid for calling 911. I probably took the anger of my personal life out on her.
The only thing I remember was waking up in the afternoon to numerous missed calls from members of our upper leadership. The patient ended up have a ruptured appendix and was rushed to surgery after another crew, an hour after we left the residence, did their job and transported the patient.
I was close to being fired. I was close to losing my license. I was having the biggest wake up call in not only my career, but my life. I hurt someone. Yes. She signed the refusal AMA form. But at what cost? And with how much encouragement?
I like to share my mistakes for others to learn from. Burn out is dangerous. Burn out hurts patients.
In the paper posted on Medium, the greatest cure for burn out is to regain the awe of your job, or life.
“If this path to burn out is, as Aldous Huxley wrote, ‘a reducing valve’ of awareness, it’s awe that helps to open us back up. Dacher Keltner, a professior of psychology at the University of California, Berkeley, has shown that awe is tied directly to feeling of expansiveness, transcendence, and connection.”
I was working too much OT and my personal life was falling apart. I had to make huge changes in my life, step down from positions, say no to projects, and budget my spending so I could say no to OT shifts. I stepped down as supervisor (surprisingly, I didn’t get demoted) and transferred myself to a county known to be strict. I wanted to remind myself why I not only got into the field, but to also get back to the basics of patient care. I was not taking care of people and most of all, I was not taking care of myself.
My love for the job came with helping people. Where did my love for care go? My personal life was spiraling out of control and I was not feeding myself creatively. My tank for the awe was ran dry.
“Awe doesn’t just shift the way we think, it changes our biology. According to a 2015 study in the journal Emotion, awe, more than any other positive feeling, is linked to lower loves of a molecule called Interleukin-6, which is associated with stress and inflammation.”
The awe for the job came back when I chose to learn again. There is something to learn every shift. You just have to look for it.
Even if I haven’t taken the chance to learn about something, I enjoy creating hilarious back stories for patient’s and their family. Everyone has a story.
“Perspective allows me to see that ‘my’ world is tiny when compared to the actual world. I feel more open and energetic, and less burnt out.”
It’s all about perspective and reminding myself why I got into the job in the first place. It’s the greatest way to help someone and it’s so damn interesting.
Check out the article; “The natural cure for burnout is profound and utter awe” by Brad Stulberg on the site Medium.
2,000 law suits and appeals have been pushed forward against Johnson and Johnson. The state of Oklahoma has started proceeding in regards to damages done to the state.
As stated in the New York Times; ” Oklahoma had said it would need $17 billion to repair the damage done by the epidemic. About 6,000 Oklahomans have died from opioid overdoses since 2000, according to officials there.”
It is about time some one has step forward and pursued dealers in this rich man drug war!
My AHA BLS quiz application was just released on Android. Check it out!
If you haven’t checked out Life in The Fast Lane, you HAVE to give it shot. This site’s ECG library helped me not only get through medic school, but also helped me learn what I was seeing on strange 12-leads my first year as a medic.
I receive their email updates to keep myself informed, but it had been awhile since I’ve visited their site. They now have a library of just about any emergency medical topic you can think of.
I was extremely impressed with their trauma library!
Please stop by and check them out!
Please stop by and check out my new ACLS Quiz App. It is full of challenging questions and gives you a score at the end. The app is free to download and is only on Android. This is a step into my new venture of adding more online accessible free medical education. I have a PALS Quiz App in the works currently. Give me honest reviews! Send me messages of how I can make it better! This is my first app and I only want to make our trade even better in the education realm.
My new PALS study app just went live today!
If you are an android and getting ready to take PALS, check it out!
True story behind the title…
I am a huge advocate for prehospital intubation. Though, I do strongly believe in good equipment, drugs, lots of practice (more than just simulators) and fail-safe options (iGel, etc). Every service has a different type of patient population. Every service has access to different equipment/protocols. Each patient has a different airway.
Grants have helped many services obtain video laryngoscopes. Granted, less ambulances, the greater chance you will have to cool toys in your airway bag. Much like the cardiac monitor was a luxury in the past, I see these devices becoming first line airway in the future.
To adapt and overcome. That’s how we survive in EMS.
I don’t know how it is in other service areas, but my service is unable to obtain ANY dopamine… what-so-ever! I’m not sure if it is a manufacture problem (think back to 2010 when a huge company of our ACLS drugs changed to erectile dysfunction pills over night). Or maybe our hospitals are having an ordering issue. The real situation is, I LOVE DOPAMINE!
As a new medic, I was terrified of it. The confusing dosage. The simple down and dirty math equation that escaped me in the opportune moment of a ROSC patient. Even it’s shiny aluminum bag made it more intimidating than other meds. Why aluminum? What was in there? Is it looking at me? Radioactive goop? A demon? A dopamine demon? A dopa-demon?
Years later another medic and I were obtaining ROSC with early administration of dopamine. It was something we began testing when running a code in a rural area. Dopamine improves function of the heart (one day I will write some science-y thing on cardiac drugs)? Why not give the heart a helping hand when we are having trouble keeping a pulse?
Witchcraft!! I already hear the torches lighting and the medical villagers chanting.
But it worked. Every time we would lose pulses, we would hang dopamine and get ROSC.
*DISCLAIMER: I am not a doctor. I am street medicine. I do not substitute the decisions or protocols of you medical director. Our protocols differ from national registry and the rest of the country. Do what you will with what I print here. Just food for thought. Shop talk.*
Then… Then the forces that be, the EMS Gods that give you a late call, took my favorite med away. The poachers at the ICU took the last dopamine bird from me. They burned all the dopamine trees.
So what do we have now as a pressor? Witchcraft!!! I mean… push dose epi!!
Push dose epi (PDE) is the newest talk on the pharmaceutical cat walk. Flashing its extra zeros in a 1:100,000 vial… Like it owns this hemodynamic fashion show. Rawr.
Apparently PDE was used by anesthesiologist for years in the OR. It’s a temporary reaction for hypotension, which is perfect in the OR. OR is stabilization of the patient during the surgery. Long term stabilization happens in PACU and ICU. Places where pressor drips are ran so the nurse can get a damn cup of coffee before her other patient crashes.
My trusty dope drip would keep that patient stable while I tripped over cables as we pulled the cot out of the ambulance. Bringing a code into the ambulance bay at the ER is never a smooth task. It’s like that dreaded day in March, when your wife has had enough and forces you to take down the Christmas lights. Cables and cords EVERYWHERE.
PDE has been gaining good scores in the transport world. A study was performed on a 100 pushes during critical care transports (study info at bottom). The goal of the study was to “characterize the hemodynamic effects and adverse events that occur following PDE administration by critical care transport providers to correct documented hypotension.”
*yawn* Please, go on…
The result, 58.5% (55 of 94 pushes) resolved hypotension. Granted, this is a new procedure and EMS is slow to change, and there are no variables discussed in the paper. I can visualize the back of that ambulance, sweating, cracking the tiny vial of tiny epi hoping to keep ROSC. Then an alarm on the monitor goes off. Mind you, this drug is not premixed. While pushing 1 ml out of the flush you notice the patient’s ETCO2 dropping because the rookie firefighter riding in with you is pumping that bag like an excited monkey. Crap. Did I check glucose yet? Five minutes from the hospital now. Push the epi. What’s this guys name? Give report.
The language also states they were looking for a resolution for the hypotension. Tiny epi will create changes for a tiny while. So use it accordingly and continuous. Just know that its effective is limited. 58% of the time, it worked every time.
I am not dissing push dose epi. It’s what I have to use right now and I would rather have it than no vasopressor. This is my review of a new drug in my tool box. I always enjoy feed back! What has your experience been like?
My man crush, EmCrit, made a great .pdf you can keep in your truck: pressor .pdf
MDEdge has something to say on the minimal effects of push dose pressors. minimal at best
I’m sorry this has happened to you today. I am sorry you feel this way. I am sorry that you were born unlucky and suffer from this illness. I am sorry that they did this to you. I am sorry your bad day had become a turning point in my career.
As the compassionate face expresses concern and empathy, the same person sweating over you will be receiving a high five in the ambulance bay. Sometimes your bad day will turn around the attitude for a burned out medic. It is what makes us good at our jobs and keeps our skills sharp and passion fresh. Our passion to help people.
It’s the need to be wanted, to feel valued, and to feel important that the medic prides them self on. There are some awful groups that are far too self appreciating and have yet to save a life. I like to call them the “arm chair quarterback” of the EMS trade. They have yet to feel important so they make their opinions important.
I’m sorry you missed that tube but in my opinion (even though I wasn’t there and have no idea about the circumstances you were under) you should have done this… I can’t believe you didn’t already know this…
These attitudes wear down the pride of importance a medic thrives on. Especially our new para-pups. The medic feels like crap. They feel like they let down not only the patient but also their crew.
I’m sorry about your child’s respiratory issues. But today, when I was able to help them, they helped me out just as much. The fact that I was able to turn around their acute asthma helped me regain the confidence to continue on another shift. It helped me resettle my feelings about applying to another service. It helped me regain my passion to help the next person after you.
Your bad day helped me. I’m sorry.
Health care workers have the highest incident of being assaulted. It’s an average of 52%. That is just what is being reported. There is still just a part of our culture that doesn’t report because it’s “just part of the job.”
It’s not. Support the laws of attacking a health care worker is equivalent of attacking a police officer. Stand up for yourself. We are not society’s punching bag.
In my ten years with fire and ems, I have worked in a variety of settings; city fire, hospital ems, ICU medic, education, leadership, etc…
Recently, my wife and I moved our family to a rural community. We live in the county seat with is a population of 6,000 citizens. The county is large and has a variety of rural population and industry. The two of us (she is an RN) where recruited from a large metro city to come down here. It was tough to move from a city we loved, but we felt unsettled with our jobs, and were given a contract we couldn’t refuse. We weren’t accepting positions in our dream jobs, but it was a decision that was best for our family. We decided to live rural close to some family and commute thirty minutes to our jobs.
As part of the rural setting, I decided to join the volunteer department and was quickly picked up as a firefighter paramedic. Most career fire and ems employees have a very convoluted view of the volunteer. They view them as untrained an inexperienced. Volunteer has been the hardest position I have picked up. Being a paid firefighter, when you are done with the shift, you are done! As a volunteer, when I am done with my shift on the ambulance, I turn on another radio when I get in the car. Plus our department has on call shift for paramedics…
So, there I was, intubating my neighbor on his kitchen floor. It was a difficult intubation. Despite the insane amount of vomit, I managed to the get the tube. After some good compression’s mixed and delivery of oxygen, we managed to get pulses back. He survived long enough for his family to say good bye. Including a daughter who lived out of the country.
The life volunteering is something to adjust to. I try to make contact with hospitals and keep track of what happened to a patient; if my interventions or field diagnosis helped. But in the rural community, everyone ends up learning that YOU are the one who helped work his code. It feels weird having so many eyes on me. Some medics find it honorable. But as some one who likes to fly under the radar, I may need to adjust my attitude!
Everything has a beginning. An inception of an idea where someone had the ambition to create it. Sometimes by accident. Like so many people in existence today, they were pure mistakes by their parents who had to many glasses of jim beam and there was a lack of entertainment on television. Now two asshole created another asshole who is going to create more assholes because creating assholes feels good.
Even though the statement is slightly jaded, I still feel justified to say it. But then again, in my trade, we don’t always interact with the best of characters. So, the writer in me always creates a story as to how we arrived. A quick hypothesis to turn a shitty call into something we can laugh about.
Also, it makes people human again in my eyes. I have always lived by the statement that humans are bottomless pits of wants and needs. I mainly use it to help me reflect and analyze my ambitions and actions. But, in the healthcare world, this is true. So, at times, when we are rushed taking care of the critical in the back of the truck, or the nurse with four patient’s running frantically to take care of orders, we will lose the humanity behind the patient. Sometimes the patient doesn’t help with this mindset. Like the small lipoma removal who is feeling the sting from the five sutures wondering how he will ever walk again because of the slight pain. Or the fall in the icy parking lot who has a bruise, normal pulse rate and blood pressure, wondering why you are not going to load them up with pain meds.
We all lose the humanity behind the human. In health care, it becomes Burger King medicine, “have it your way!” Or as in JCHO terms, “how’s your pain today?” We become the bottomless pits of wants, needs, desires, and we will not demand for less. We are entitled to how we want things and in the timely manner we expected it. Just like our gossip behind the news story. Just like the lazy boy behind the counter who has no idea how much of a rush I am in. Or the impatience we deliver on our children when they don’t perform exactly how we want that minute.
We lose our humanity quickly. We forget everyone’s story.
Sometimes our interactions where too quick and too brutal that I HAVE to build a story behind you. Draw some color into your character to wash out that ugly action I watched you do or say.
These are my quick five minute fantasies to keep me from getting burned out, again. Its my quick check to brush off the nasty person I just dealt with so I don’t carry the negativity onto the next patient who may need my empathy. There is nothing more frustrating than seeing that EMS provider not giving compassion to the person that needs it because they have been starved of any humanity. They are cold and calculated. They will save your life in minutes but cannot deliver a hug.
Everyone has a story that lead them to me. I become the next chapter when they made that turn with out looking, took the wrong medication, fell off that ladder, or tragically ended their life. I want everyone to continue being human to me instead of the bottomless pits of wants and needs I know they are.
You’re not just an asshole. You’re an asshole with a story. Most of these entries are the stories behind the asshole I met.
Currently, I work full-time with an EMT partner. When it comes to airway, I am a believer in prehospital intubation. Though, when a call is out of control, and airway is immediate, I love my back up airways and an aggressive EMT.
Now, with that said, I do not believe that iGel needs to be the first line of airway protection on an ALS truck. If we lose intubation, we lose an amazing tool as paramedics. There are several districts across the United States that are taking intubation away from their medics and handing them the iGel. Their explanation for the decision is simply a lack of education and mistrust from their medical director.
I can understand a medical directors apprehension… While a physician is still paying off their student loans, they have medics out practicing their skills under a license you technically don’t own yet!! So, when you find out that their have been esophageal placements it make them apprehensive to continue granting this skill. But, when I think of a paramedics bread and butter skill, I think of ACLS and advanced airways. If that is our pride in skill, then why our we losing it??
My answer is in three parts; education, practice, and time constraints.
Our short staffing of paramedics nation wide and an ever-growing increase in call volume is currently making us stagnant. As some one who holds an associate degree and expected to make physician like decisions, I want to be as fresh on my skills as possible. Fortunately, I work frequently in education, so I am able to maintain a lot of time in the lab and reading articles. I am extremely grateful for this opportunity. As an educator, I try to get as many crews involved as possible in training and education. If you don’t use the skill you will lose it. Our own apathy is what will destroy our services.
How can we fix this? This a system approach. My system is extremely short-staffed and struggling on paying over time keeping cars on the street, none the less paying over time to keep people in the class room. Granted, we maintain quarterly training and education with acts of miracles.
Managers how a complex role. They have to juggle so many aspects just to keep the base doors open. Though, keeping an understanding of not only keeping employees up to date on their basic skills, but giving them the challenge of advancing their skills and understanding will push our trade even further.
I have read this in past for my first degree in Literature (unemployment). As future leaders in emergency services, it makes me happy to see this added to the curriculum. In a constantly developing trade, it is important to practice critical thinking in an academic sense.
Plato is using this metaphor to describe how people are educated. Everyone is taught to think in a special respect based on their upbringing. As described by the shadows on the wall being played by the marionettes or instructors, this is a metaphor on what people are taught to be true.
“I think I see a horse,” when in reality, the person is seeing a shadow of a horse. When the prisoner is released and views a real horse, he will have to test what he knows to be true.
How does this relate to the fire service? Emergency service is a growing trade that is continuing to evolve. It is a trade that is going from the technician level to the professional and clinician level. The ways we have progressed is creating professional studies that show the world what we do is back by proven sciences.
On the flip, we are a trade that has deep rooted traditions. With traditions also come attitudes that are reluctant to change. As future leaders in emergency service, we need to continue support positive change that continues to help us grow as a profession.