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.

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.

SIDS

An interesting and depressing subject came up in medic school recently. We were going through various scenarios where we have a patient that is either found in cardiac arrest (he has no pulse) or goes into arrest while in your care. The main point was to review legal/ethical issues for patients with a DNR order (do-not-resuscitate) or for those that don’t have one, yet express a desire to not be resuscitated. In short, if in any doubt, do CPR. Oh, and for the guy that says “just let me die!”, well, he might die, but then we’re doing CPR — sorry buddy.

Anyway, we eventually exhausted most scenarios, until we arrived at the situation where we find a SIDS baby (sudden infant death syndrome). We are asked what we would do if we arrived on scene and find a baby that is cold to the touch, pale, and has obviously been dead for a while. The parents are hysterical and pleading with you to do CPR. You and your partner know there is absolutely no chance the baby can be brought back. So, what do you do?

We are told that generally the safe thing to do is to start CPR and transport the baby to the hospital in order to make the parents feel that everything was done. The instructor says no harm will be done by doing CPR even if you know it won’t be successful. I disagree.

One, CPR is a brutal thing we do to patients, but we do it because it may save their life. In the case presented to us, it is not medically necessary. Two, the receiving hospital has to have a team ready to accept the baby and do it’s own (futile) interventions. Granted, they probably won’t make a whole-hearted attempt once they hear the full story, but will likely go through the motions anyway. As a result, they won’t be able to care for other potentially critical patients that may have a real chance at life. Finally, by starting CPR we give the family false hope, and they will have to essentially see their baby die a second time when the doctors inevitably stop resuscitation.

I’m not sure what I would do in that situation, and I’m sure the right thing is not cut and dry. A baby that been dead for an hour has no chance, just like an adult, but because it’s a baby we treat the situation differently. I think possibly either response, CPR or no CPR, may be equally right, but it’s a tough call for sure, and one I hope I do not have to make.

New Medics

I started paramedic school last week. It’s a class of about 25-30 people, all EMT’s in New York City or nearby. The course is pretty expensive relative to average EMT income, but still less than you’d spend at a California university for a year. Either way, it’s a big commitment, consuming something on the order of 1300 hours of training in 11 months. About 30% don’t make it to the end, and 15% of those that do make it will fail the NYC “MAC” test, supposedly the hardest paramedic test in the country.

That said, I’m already concerned for a few of my classmates. We finally finished all the orientation/legal/ethical shenanigans, along with a healthy dose of “this is a very tough course, it’s a big commitment, your girlfriend will leave you, your friends will think you’re dead, etc., etc.,” and then began some EMT skills. We broke off into small groups of 5 with instructors, whom presented a theoretical patient encounter.

We started with the general impression (after BSI/scene safety, of course!), which was a 52 y/o male found sitting on the couch in his apartment complaining of chest and epigastric pain for the past few hours. Great. We move through the ABC’s: airway is patent (he’s awake and yelling at his wife), breathing appears normal, so let’s check out circulation.

The instructor asks a student across from me to evaluate circulation for our chest pain patient. He says, “well, the first thing I would do is check his voids for any major bleeding.”

*smacks head*

For those not in the medical field, the assessment he mentioned (checking the voids) is recommended for trauma patients in order to check for bleeding we may not catch otherwise. Due to the fact that our patient was MEDICAL, I don’t think he would appreciate us checking under his arm pits, and between his legs just in case he fell out of his window, walked back upstairs, cleaned up all his wounds, and then forgot to mention the incident to us. Right. We’ll see if this guy is part of the 30 percent.