EMS Sticks Together

During the overnight shift, we heard another unit call for PD. The tone in the tech’s voice told us something wasn’t right, and we responded to their location. Us, and literally 3 other ambulances, 3 PD cars, and a conditions boss all pull up nearly simultaneously to the unit that called. They’re outside a club, where apparently some club-goers assaulted them. The scene was 8 EMS personnel, all wearing tactical gloves, prepared to let anyone at the club know that EMS are not to be messed with. Of course, everyone involved had fled already, much to the disappointment of my partner who remarked he “hadn’t been in a brawl for four years”. The conditions boss sent us back to our standby’s, but the message was clear, we have each other’s backs.

Intox

As anyone working in a big city in paramedicine knows, we often get sent to “unconscious” patients that end up being a drunk that decided to catch some Z’s in the middle of the street. We had one such call today, at 4pm in the afternoon.

We picked up and onto our stretcher and into the truck. After enjoying a nice sternal rub he woke up. Of course he denied drinking, and then the following exchange:

Intox: “why am I here?”
Me: “you were sleeping in the street”
Intox: “what are you talking about, I was at home” (he’s homeless, so maybe a true statement)
Me: “you can’t sleep in the street, someone called 911, and now you’re going to [insert name of a not-so-highly-respected hospital]”
Intox: “nooo!!! please don’t take me there, let me out, last time I was there they didn’t get me no foooood man, how am I supposed to get my Chinese food?”
Me: “you’re going there”
Intox: “man, you guys are the worst, why you always be picking me up?”
Me: “probably should stop getting drunk and sleeping in the street, enjoy your stay at not-so-good hospital.”

Oh, and he couldn’t tell us his social security number, but could remember his Medicaid number and tried to chide us by saying it would cover his visit, which was weird because last night a homeless guy asked for money, which I denied him, and then yelled at me that maybe he would just go to the ER and complain of chest pain and they would feed him. Thanks for contributing to society.

Sick

Within EMS, when we are dispatched to a “sick job”, it’s a BLS emergency (meaning EMT’s are sent, not paramedics) because it’s assumed to be a less serious patient. But, in medicine, if a doctor asks a colleague to come see a “sick” patient, it means he/she believes that person is seriously ill. It’s the EMS equivalent of a “legit” job.

Woodworking

The middle-aged Hispanic male that presented to the ER today after cutting his hand open with a circular saw unnecessarily reminded me that power tools are indeed sharp, and probably should not be used when your hand is in the line of fire. Yes, you may have your morphine. Ow.

Super Medics

One thing I’ve learned through working with experienced paramedics, is that some are very knowledgable beyond their training. Another thing is that unfortunately some believe certain things based on anecdotal evidence, and have a problem with confusing correlation and causation.

I had recent conversation with a fellow medic student about a cardiac arrest he was on. They did about 20 minutes of CPR, three rounds of ACLS drugs for an asystolic arrest, then got orders for bicarb and pushed D50 (supposed to be pushed early for an asystolic arrest) plus 2 amps of bicarb, and apparently got pulses back 30 seconds after the bicarb was in. He said the medics claimed the bicarb is what achieved ROSC, and they also told him next time to push D50 after the bicarb because “bicarb is more important”.

There are a couple problems with this. Number one, according to protocol, D50 is pushed immediately after vasopressin, essentially to rule out a hypoglycemic arrest. But, beyond the protocol, if we have a hypoglycemic arrest then correcting the underlying cause is the most important thing (as with any arrest), and so it is entirely illogical to say D50 should be pushed after bicarb, which is nearly always pushed towards the end of an arrest as a “last ditch” med. If it makes sense to push D50 at all, then it should be done first thing, why try to correct an underlying problem after 20 mins when you could do it immediately? In addition, there is very little evidence for giving D50 at all, and more evidence that it can cause neurological damage for an arrest that survives. It probably should only be pushed for arrests with a strong suspicion for hypoglycemia.

Moving on to bicarb, the statement by the medics that pulses returned due to the bicarb, nearly instantly after giving the dose is ridiculous to me. It’s not an instant fix to their acid-base disorder. More importantly, many studies have shown that bicarb is essentially useless in arrests, and some even demonstrate an increased mortality rate after ROSC for arrests where bicarb was given, often with patients that are now alkalotic from the bicarb. It seems the only time bicarb might be a good thing is in cases of known pre-existing metabolic acidosis that went into arrest. And, in that situation it should be given early to (again) correct the underlying disorder. Why it’s in our protocols as a telemetry option at all is confusing to me considering the evidence against it.

Anyway, an argument ensued because he felt like I was attacking the knowledge level of medics in general and he accused me of being close-minded because I don’t have the experience as a paramedic to know what is good medicine. He asked why don’t I ask “a medic I trust what they think about bicarb?” I explained that this is information I’ve previously researched, and I don’t see the point of his exercise. The medic may have had ROSC after bicarb on a few arrests, and so anecdotally believes this to be evidence that bicarb is what brought them back. Unfortunately, that doesn’t make it true. And, despite not graduating medic school yet, that doesn’t mean I don’t have the prior education (more than most medics) and the critical thinking skills to be able to read well-researched journal articles and understand them. But, I guess because I don’t have 10 years experience, I couldn’t possibly understand be right when the “senior medic” says something contradictory.

He then went on to attempt to convince me that most senior medics would be able to walk into an ER, put on a white coat, and do a better job than the “stupid ER doctors”. Right. Just like most doctors without EMS experience could go out on a bus, walk into the projects, and treat the shooting victim with his “holmies” standing around him, PD and a conditions boss over your shoulder, etc., just as well as a good medic. Right. We all have our roles.

Free time

Wow, haven’t written anything in nearly two months. That’s more of a reflection of how crazy things have been lately (70-80 hours/week crazy) rather than an absence of “blogworthy” events.

Two days ago I had a cardiac arrest that went very smoothly. BLS crew was doing the right things, I got the line while my partner got the tube, both went in quickly. Initially the patient was asystolic (no electrical activity in the heart, no pulse), started fluids, vasopressin, epinephrine, atropine, as usual. Three rounds of epi/atropine went in, and we were nearly ready to pronounce when I noticed a brief wide complex come across the monitor… hmmm. I popped another dose of epi in, made sure good compressions were still being given, and complexes were coming across close to 30 a minute. Telemetry ordered 2 amps of bicarb, two more rounds of epi, and calcium chloride if we got pulses back. In the end, we transported, and got pulses back by the time we were at the hospital. Not sure if the patient made it through the night, but a good feeling nonetheless.

I guess NYC didn’t want me to feel good for long, because before going to work, I found my car was broken into… perfect. Of course, the only thing stolen was my EMT bag, idiots. I can’t imagine the look on their faces when they opened it up to find a BVM, oxygen masks, and trauma dressings. Worthless. Ugh.

What else…

Officially applied to medical school a few weeks ago, and got my MCAT score back (did as well as I needed to, cool). In the process of filling out the supplemental applications for the schools now. Most of it is either repeating what I already said in the primary application, or answering the “what is special about OUR school?” question. “Well… I think I might be able to get into your school… that’s why.” I believe the majority of the application process is simply demonstrating that you are willing and able to do the tedious work of jumping through hoops. Hop hop…

Paramedic school is going well. An anonymous student is vying for valedictorian. I have an inkling of who it is now though, because I got stuck 3 times by the suspect when testing out for IV skills, and I hate getting stuck. Ow.

Speaking of medic school, I’m on a 12 hour rotation now at a hospital in the city. It’s amazing how different it feels to work 911 in a middle/upper class area compared to my usual rotations in a more rough part of Queens. Had a chemo PT with shortness of breath and a straightforward asthmatic so far.

With that, time to sleep on the bench until the next call.

Goodnight.

Nervous System Overview

I’m going to try a new type of post here, probably not very interesting to most, but it will be helpful for me and other paramedic students out there.

Inspired by: http://www.rhmedicclass.com, another medic student in NYC, although I’m not sure which school he/she attends, it isn’t mine.

The Nervous System Organization

The nervous system (NS) is our quick-acting/short-lasting system to maintain homeostasis (the endocrine being slower-acting/long-lasting system). It contains the central nervous system (CNS), brain and spinal cord, which is our processing, storage, and command center. It also has the peripheral nervous system (PNS), which is what actually makes us “do stuff” (like makes muscles move) and “sense stuff” (touch, pain, etc).

The CNS and PNS are connected by afferent or efferent nerves. Afferent sends signals away from the PNS and to the CNS, while efferent nerves enter the PNS and receive signals from the CNS.

The PNS has two divisions: somatic and autonomic. Somatic controls our muscles, and does what we tell it to. Autonomic is… automatic… it controls processes that don’t require thought and can’t typically be voluntarily controlled, even if we wanted to (smooth/cardiac muscle, glands, fat tissue). Of course, the autonomic is further divided: sympathetic and parasympathetic. Sympathetic is the proverbial “fight-or-flight” side. If we need to fight, it will affect homeostasis to favor that (i.e. increase heart rate and contractility, respirations, blood flow to muscles, dialate the pupils). Parasympathetic is our lazy side (decrease heart rate, respirations, blood flow to muscles, increase blood flow to kidneys, gut, constrict pupils).

Neural Tissue

Alright, before going into more detail, gotta cover the various types of neural tissues and their functions.

Neurons are cells that communicate with each other and other cells, and are the basic unit of the nervous system. They have spindly dendrites (receive information), a cell body (nucleus, no centrioles so they can’t regenerate), an axon (long extension which carries the transmission), and a synaptic terminal (where the transmission ends and is passed onto the next neuron or other target cell).

Types:

1. Multipolar (dendrites > axons,  found in CNS and motor neurons)
2. Unipolar (“cell body on stick” or “lollipop neuron”, found mostly in sensory PNS neurons)
3. Bipolar (cell body in-between dendrites/axon, found in some sense organs such as sight/smell/hearing)

Functional types:

1. Sensory: self-explanatory. Includes external somatic sensory (sight, smell, hearing, touch), proprioceptors (position/movement of muscle/joints), and visceral or internal (monitor GI, respiratory, cardio, urinary, reproductive, taste, and deep pain/pressure).
2. Motor: somatic motor (skeletal muscle), and visceral motor (i.e. cardiac/smooth muscle, glands, adipose tissue)
3. Interneurons: Coordination of sensory/motor activity. They interconnect with other neurons.

Neuroglia are cells that help out the neurons.

Four types in CNS:

1. Astrocytes: Most numerous. Maintain the triple B (blood-brain-barrier), provide structure, repair damaged neural tissue.
2. Oligodendrocytes: create myelin (insulatory matter, which speeds conduction and reduces signal loss allowing signals to travel further)! This is “white matter” (cell bodies are “gray matter”). Gaps of myelin (which wraps around an axon) are called nodes of Ranvier.
3. Microglia: small/rare. Phagocytes derived from WBC’s.
4. Ependymal: line central canal of the spinal cord (CSF is here!) and ventricles of brain (CSF is here in brain! along with subarachnoid layer). Within brain can produce CSF or circulate it.

Two types in PNS:

1. Satellite cells: surround/support neuron cell bodies (analogous to astrocytes in CNS).
2. Schwann cells: In addition to being a fun word to say, it is the myelin of the PNS.

Anatomical CNS vs. PNS:

CNS:

1. Centers: neurons with common function
2. Neural cortex: gray matter covering the brain
3. Higher centers: most complex
4. Tracts: axons with common destination/function
5. Columns: groups of tracts in spinal cord
6. Pathways: link brain with rest of body

PNS:

1. Ganglia: gray matter (cell bodies)
2. Nerves: white matter (myelinated axons), either cranial (12 pairs) or spinal (31 pairs).

Next post I’ll do neuron functions, including membrane potential and propogation of an action potential.

BLS Skills

We went through BLS skills the other day in medic class. These include bandaging, splinting, spinal immobilization, simple airway management, etc. We were going over splinting and an instructor chose one of us to demonstrate splinting of a tib/fib closed fracture. This person works in a service where this type of fracture should be a relatively common encounter, yet when it came to putting on the splint… he forgot the splint. Maybe he doesn’t work well under pressure? Either way, he’s no longer in the class.

I actually wrote this post a while ago, but since then we have had 45% of the class re-test on splinting. Of those people, 30% failed a second time. Suffice it to say, the lead instructor was not happy. We practice intubation next week.. I have a feeling some people will be embarassed.

Patient Quote of the Day

Everyone in EMS has patients that say or ask “the darndest things”. Maybe I’ll make this a series, we’ll see.

PT: “me dan dos dólares para el autobús” (give me $2 for the bus)
Me: “No.”
PT: “No?”
Me: “No. No tengo dinero.” (I have no money)
PT: “Me dan pesos!” (give me pesos)
Me: *blank stare* “estamos en el hospital ahora” (we’re at the hospital now)
PT: “Muy malo…” (very bad)
Me: “Get out of my ambulance” (get out before I request ALS to sedate you)
PT: “Que?” (what?)

Ok, maybe I made up the last part…

Shift Change

I worked the overnight shift recently and had a call that got me thinking about an interesting pattern I’ve observed.

Around 0030 we were assigned a call to one of our local nursing homes known for “legit” calls at night. Why they are known for this will become evident. It came over as “labored breathing”. We take it on an easy lights/sirens run, unfortunately dealing with significant traffic due to it being the weekend. Riding the elevator upstairs I propose to my partner to guess what the answer will be to the obligate “how long have they been like this” question. She guesses 6 hours, my guess was 3 hours; I guess she is more cynical than me. But something made me tell her as the doors opened that my guess was actually “since the shift change”.

We find a nurse who points us in the direction of the room (I can hear the breathing already, not a good sign), and actually accompanies us to the room rather than conveniently disappear. The patient has two pulse oximeters on her fingers, and by my confused look the nurse then explains the first pulse ox showed 40%, so he got the second one to make sure it wasn’t broken. Nice. She’s satting in the 80’s now. He had put her on a non-rebreather mask at high flow, which is impressive considering many times I’ve arrived to find patients like this on a nasal cannula. She is barely alert, breathing is very distressed with sternal retractions and other accessory muscle use, has wheezing in all fields and is febrile. Ok, so, “how long has she been like this?” His answer: “since I came onto my shift around 11:30pm.” Nice. It’s now 0045, I didn’t bother asking why he waited to call us.

Our next call was a little comical. Another nursing home, it came over as “bradycardia”. Turns out the patient was in 3rd-degree heart block, had an altered mental status, along with cool extremeties. Not sure why, but I find heart blocks pretty interesting. The patient didn’t have a pacemaker. The funny part? The patient’s daughter wanted us to take her 30 miles away, when the closest hospital was about 1 mile away, and there are literally over 15 hospitals closer than the one she wanted. Yeah, she ended up at the nearest ER.