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Ambulance: Sepsis

Written by RSS Poster Medic Scribe

EMS has focused on trauma, stroke and STEMI in recent years with resulting improvements in outcomes.  Many health care systems are now turning attention to sepsis care and the considerable role EMS can play in early recognition and treatment.

Here in Connecticut we have Sepsis Alerts, which while rarely generating the full response of Trauma, Stroke and STEMI Alerts are important to help hospitals be able to quickly recognize sick people on entry and devote them more immediate attention than they might otherwise receive.

EMS can start the treatment soonest with aggressive fluid resuscitation for those who meet the indications.

Great material on sepsis is available at this web site:

Sepsis Alliance

Check out this excellent video:

Learn to recognize sepsis:

IDENTIFICATION OF POSSIBLE SEPTIC SHOCK

Suspected infection – YES

Evidence of sepsis criteria – YES (2 or more):

o Temperature < 96.8 °F or > 100.4 °F.

o Heart rate > 90 bpm.

o Respiratory rate > 20 bpm.

o Systolic blood pressure < 90 mmHg OR Mean Arterial Pressure (MAP) <65 mmHg.

o New onset altered...

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Ambulance: Goals and Globetrotters

Written by RSS Poster Medic Scribe

Saturday night saw one of the pinnacle achievements of my life.  Twelve months before, while attending a Harlem Globetrotters game with my daughter, I announced that I was going to learn how to expertly spin a basketball on my finger just like the Globetrotters do.   Ever since then, I have carried a basketball in the ambulance.  In between calls while at posting locations, I have taken the ball out and practiced.  At home I have a basketball in every room of the house.  I even found a heroin addict in Hartford who for $5 a pop would give me spinning lessons. He was an ex-basketball player, who I am pleased to say now has a handyman business and is no longer on the street. (At least that was his plan when a few months ago, he told me I wouldn’t be seeing him around anymore, and true to his word, he disappeared no longer to be seen at his regular haunts.  I can only hope he is doing well).  I practiced so much I developed tendinitis in my elbow and had to suspend all spinning for a month. The elbow is much better and I can spin again without...

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Ambulance: Common Cardiac Arrest Mistakes: Naloxone

Written by RSS Poster Medic Scribe

This is the third in a series of posts on common drug mistakes some EMS responders make during cardiac arrests.

You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

You set your monitor by the man’s head and connect the fire department’s pads to your monitor, while your paramedic student quickly places an IO in the man’s tibia. As you approach the two minute mark, you charge the monitor, and then order stop CPR. The patient is in asystole. “Continue CPR,” you say, as you harmlessly dump the charge by hitting the joule button.

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

What drug do you give?

***

Epinephrine.

According to the 2010 AHA Guidelines

There is no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.

Resuscitation...

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Ambulance: Common Cardiac Arrest Mistakes: Sodium Bicarbonate

Written by RSS Poster Medic Scribe

This is the second of three posts about common cardiac arrest drug mistakes some EMS personnel make on a routine basis.

You have been working a cardiac arrest for a 54-year-old male with no prior medical history who collapsed after grabbing his chest.  You shocked him twice for fine vfib, but now he is in a PEA. It’s been 20 minutes since you started ALS interventions and another medic suggests you try sodium bicarb.  What do you do?

Remember it 2019, not 1979, 1989, 1999 or 2009.

Unless the patient has preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressenat overdose, (which this patient clearly does not) sodium bicarb is not recommended by the AHA.  In 2010 sodium bicarb was made a Level 3 Recommendation.  Level 3 means it is not helpful and may be harmful. In 2015 that recommendation was reviewed and maintained.

While you should always follow your protocols and your local medical direction, in Connecticut, sodium bicarb in cardiac arrest is reserved for “suspected pre-existing metabolic...

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Ambulance: Cardiac Arrest Mistakes: Amiodarone

Written by RSS Poster Medic Scribe

You and another medic are on the scene of a cardiac arrest. You find the patient in ventricular fibrillation and immediately defibrillate him into a narrow complex rhythm. You have pulses back and while you take a blood pressure – 130/84, the other medic inserts an IV. The other medic then says to you, “Pass me the amiodarone.”

What do you do?

A. Pass it to him.
B. Say, “No.”
C. Say “Why?”

You go with C. The other medic says, “To give to the patient (Dummy!). He was in v-fib.”

You say, “No, it’s not indicated.”

Who’s right? You or the other medic.

It is amazing how many medics have different views on this question, and some of this depends on when they were trained and how well they have kept up on changing guidelines. It also depends on their local medical control and the protocols they operate under.

Here in Connecticut our state protocols for cardiac arrest call for amiodarone or lidocaine for patients “unresponsive to CPR, defibrillation, and vasopressor therapy.” There is no protocol that...

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Ambulance: Service Dogs for First Responders

Written by RSS Poster Medic Scribe

A fellow paramedic here in Hartford, Greg Shovak runs a great educational program called EMS and PTSD – Learning from Combat Veterans to Understand PTSD.  I attended one of his sessions a few years ago and thought it was excellent.  I learned a lot of PTSD, and also had my first introduction to service dogs.

Here is his organization’s facebook page, which has lots of great information:

EMS and PTSD

Service dogs are not just for combat veterans, but also for first responders.  Several of the medics I work with (including Greg) have them and they often bring them to CMEs.  Their dogs are awesome and that means something coming from me (see my dog history below).  I can see how the dogs bring them great comfort.

Greg has been a true leader in helping those in EMS recognize and seek help for their PTSD.

Here are a couple articles he recently wrote on PTSD, including one that mentions his own service dogs.

https://www.emstoday.com/emerging-voices-content/2018/12/makingstrides.html


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Ambulance: PTSD

Written by RSS Poster Medic Scribe

I attended a critical incident stress debriefing (CISD) a few years ago. I thought I had been invited to an informal get-together of folks from another service who I had been on a upsetting call with the day before. Had I known it was a formal CSID debrief, I wouldn’t have gone, as I had always avoided them in the past. Not that CSIDs don’t help some people, they are just not for me.

I have been in EMS for thirty years now, and I have been on traumatic calls. This one ranked up there, but since I wasn’t the first medic in, I didn’t catch the brunt of it. For me the worst calls are not always those that make the news.  I take it hardest when my patient dies in my care, when I have to witness a sudden deterioration and  feel helpless to stop it or feel like maybe had I done things differently I could have possibly affected the outcome for the better. Other calls where the patient’s fate has already been settled before I arrive are less taxing to me than they used to be.  This was such a call.

Each of us processes trauma and stress differently. When I...

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Ambulance: Beautiful Boy: The Movie

Written by RSS Poster Medic Scribe

Beautiful Boy, a father’s story of his son’s drug addiction, is now streaming on Amazon Prime. The movie, based on the real life stories of David and Nic Sheff, a father who witnesses his son’s addiction to methamphetamine and heroin, is forced to make artistic plot choices.

I wondered how the movie director was going to handle the son’s seemingly endless relapses chronicled in the book. A typical Hollywood story has the hero slay the monster and then when everyone thinks the monster is dead, the monster comes back to life and the hero must slay it again after coming perilously close to death yet again. The problem with the real life plot of addiction is that one relapse is rare. In the book, the young man had more than I could easily count. He had so many, I felt like flipping the pages to get to the end and some resolution. Enough already! I get it!

In the movie, the director makes the artistic choice of stopping the movie after the second relapse. The father’s love for his son is apparent. The son’s helplessness in the grips...

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Ambulance: Calm

Written by RSS Poster Medic Scribe

When I first became an EMT, a friend asked me why I liked the job so much. When I come through the door, people look at me like I am an angel, I said. What is it like driving lights and sirens? Another friend asked. Awesome — I feel all powerful. I hit wail and the cars part for me like the red sea parting for Moses.

If you asked me then if there was anything wrong with what I described, I would have been seriously puzzled by the question. I didn’t quite understand the true nature of the work.

When I became a paramedic I quickly learned to be a circus ringmaster, barking orders to partners, other first responders and even bystanders. All eyes were on me as I orchestrated getting vitals signs, med lists, moving furniture, putting on oxygen, getting an IV, delivering medicine, extricating the patients, even determining who could ride with us to the hospital. Eventually I brought that same leader of the band approach to running cardiac arrest (compressions, shocks, IV access, drugs, intubation, post-ROSC 12-lead, dopamine to support blood pressure, all...

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Ambulance: Tidying Up

Written by RSS Poster Medic Scribe

Twenty years ago when I was looking to buy my first house, my realtor didn’t understand why I did not like the home she was showing me that seemed to meet all my specifications: price, location, size. She did not understand that just two months before I had worked a cardiac arrest there. I could still see and smell the man and all his bodily fluids in the cluttered living room where he collapsed. If I bought that house I would have to live with his ghost. Not for me.

Home hunting is hard when you are in EMS. You walk in thinking as I always think when I enter a home, how am I going to get the patient out of here? A stretcher will never fit in that bedroom. Spiral staircase, forget it. Even if you didn’t do a cardiac arrest in particular houses, you did arrests or memorable calls in houses with the same design. You remember the mother screaming in the bedroom. You see patients wedged between the toilet and the sink. Blood drips down the stairs.  You see all the crap that was in your way that you had to move to get the patient out to the ambulance.

I...

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