Jayson McConnell


IMG_0300Jayson McConnell started his EMS career as an emergency critical care technician at Parkview North Hospital in Fort Wayne, IN.  As he continued to strive for education and experience Jayson continued up the ranks as an EMT-A with New Haven/Adams Township EMS.  Determined not to slow down, Jayson enrolled in and completed the accelerated paramedic program in Adams County.  Jayson currently serves as a Paramedic in Adams County, Allen County, and most recently as a paramedic on the mobile intensive care unit.  Jayson is also in the process of applying for a Primary Instructor license at the start of 2017 to increase his EMS education opportunities.

August 2016 Trauma Case Study

This case study was donated by a friend of the show that works in a large metropolitan area. Let us know what you think!

HPI

You and your partner work for an urban EMS system and are dispatched to a reported “jumper” from a bridge nearby. As you enter the scene, you and the responding fire crew are guided to the back of an industrial park with no obvious hazards noted. A few bystanders that are present inform you that the patient, an approximate 20yom, jumped off of a nearby bridge into a ditch. The bridge was estimated to be fifty feet high. You and your partner set up your stretcher at the nearest access point. After hiking down into the ditch with a few members of the fire crew, you note that the patient is lying supine on the ground and is only responsive to painful stimuli, occasionally opening his left eye and groaning. You rapidly immobilize the patient with a c-collar and extricate him out of the ditch on a scoop stretcher. Transferring him to the pram, you note the patient has an approximate baseball-sized indentation in the posterior region of the head, bilaterally deformity to the ankles, left-sided deformity to the lower leg, and right-sided depression to the chest with clear and equal lung sounds that are maintained throughout care. There is notable dilation in the left pupil and the right is constricted. Blood and clear fluid are noted from the left ear canal.

INITIAL ASSESSMENT

  • Patient remains only responsive to painful stimuli and is given a GCS of 9
  • Skin is profoundly pale, diaphoretic, and cool
  • Respirations appear shallow and irregular ranging from 10-28
  • Strong, regular radial pulses in the 70s

VITAL SIGNS

  • BP: 152/86
  • HR: 76
  • SpO2: 91% on room air
  • RR: Irregular; ranging from 10-28
  • EtCO2: 39mmHg
  • BGL: 157mg/dl

TRANSPORT AND TREATMENT

Patient transported to a local Level I trauma center that is approximately 15 minutes away from the scene. En route, patient mentation decreases to a GCS of 8 with markedly reduced respiratory rate at 6bpm. Nasal airway placed and BVM ventilation commenced with improved SpO2% to 98 and an EtCO2 maintaining between 36-39mmHg. Crew considered advanced airway placement, but withheld due to lack of paralytics and significant trismus noted. Two large bore IV lines established. Patient maintains clear and equal bilateral breath sounds. Pelvis is splinted prophylactically. Left lower leg, left ankle, and right ankle splinted.

VITAL SIGNS AT TRANSFER OF CARE

  • BP: 164/92
  • HR: 64
  • SpO2: 98% with BVM Ventilation
  • RR: Pt is now apneic and being ventilated at 20bpm
  • EtCO2: 38mmHg

FOLLOW UP

Patient is diagnosed with a subarachnoid hemorrhage, basilar skull fracture, three broken ribs on the right side and two on the left, bilateral ankle fractures, a left-sided tibia/fibula fracture, and an L4-L5 fracture. Patient rapidly transferred to the surgical department where he arrested and was later pronounced.

DISCUSSION

  • What would be your first priority for this patient?
  • How would your care change if you were a rural provider as opposed to an urban medic?
  • If you had access to paralytics or induction agents, would you have attempted to chemically facilitated intubation?
  • What would you have done differently?
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The Mute Medic Volume III

Stereotype -/ˈsterēəˌtīp/- a widely held but fixed and oversimplified image or idea of a particular type of person or thing

My eyelids felt like sandbags as I embraced the vibration of the high idle on the truck murmuring like grasshoppers on a summer evening. We had parked in an abandoned lot away from the streetlights, hoping that the unforgiving night would grant us some reprieve. Three hours left of our twelve hour night, and this was the first time we had made it to a post. After  a swig of lukewarm coffee, I folded my hands in my lap and attempted to drift away anywhere other than where I really was. The sibilating noises from the passenger seat unnerved me. Lucky bastard. I’ve done 90% of the work and he’s the one napping.  After several minutes of squirming and attempting to adjust the position of my incommodious seat, I decided that it was a lost cause and retreated to the patient compartment to stretch out. Throwing a blanket down over the bench seat, I was overwhelmed by the stench of booze, vomit, and coagulated blood from the last road scholar we had just transported. Fumbling around in the dark through my cargo pocket, I produced a jar of Vick’s. Finally, I could breathe again. With the exhaust fan humming in the background, I was able to pass into a light sleep that lasted for roughly ten tantalizing minutes. Static came over the radio, followed immediately by an unwelcome transmission.

“Ambulance 41.”

Ugh. Are we the only ones working tonight? “Go ahead,” I grumbled, making my annoyance apparent.

“Ambulance 41, assist police and fire on a shooting at a nightclub.”

“Cleeaaaaarrrr.”

To this day, I am still amazed at how fast utter exhaustion can lift after hearing those words. Swearing under my breath, I quickly tossed the blanket out of the back of the ambulance, launching myself into the driver’s seat. My somnolent counterpart didn’t stir. In a moment of testosterone overload, I punched him in the shoulder as hard as I could.

“Wake up, dude! We just got a shooting!”

“Are you serious?!” With the energy of a sloth on Ambien, he struggled to sit his seat upright, while wiping drool from the corner of his mouth. “Was I snoring?”

“Sounded like a freakin’ artillery barrage.”

As we neared the scene, the chaos was palpable. Teenagers running in every direction, and only three officers attempting to keep at least thirty unsettled bystanders back. Despite the excitement from the crowd there some optimistic statements from onlookers saying, “She’s gonna make it”.. There was a crater in the left side of her head with obvious brain matter and a pool of blood under her. Fighting the bounding of my own pulse, I reached under her jawline only to confirm that she did not have one. My partner went back to the ambulance to grab a sheet, when I began to hear murmurs from the crowd, inferring that our pronouncement was based on her ethnicity and that if she were Caucasian, then we would no doubt be working to try to save her. As the grumblings spread, drunken belligerence became the overall attitude. In the span of twenty seconds, we went from saviors to oppressors. My partner and I need not say anything to each other; our decision had been made for us. As he rapidly exchanged the sheet for the wheels, I ducked as a beer bottle grenade went soaring over my head and landed on the ground with a ferocious explosion. As did another. And another. A simple pronouncement had just became a public relations mission to avoid a riot. With stretcher now present, firefighters assisted my partner and I in hoisting the hefty young woman onto the pram as we darted for the ambulance. Gunfire erupted down the street as well more screaming and shouting. We locked ourselves inside and took off for the hospital, hearing projectiles ricocheting off of the bus.

“Ambulance 41 en route emergently to Memorial with one patient, condition Charlie minus.” My voice cracked and wavered. I tried to hide the excitement in my voice, but anybody that knows me knows that I speak a million miles a minute when I’m stressed. Immediately I called the receiving trauma center that we were about twenty minutes away from and explained the circumstances of why we were transporting a traumatic arrest to begin with. I knew that this was against our policy, but frankly I couldn’t care less at the time. As we progressed closer to the hospital, I could see the half-assed nature of work the other crew members were doing. Lazy, sporadic CPR with long intermissions between crew members as well lackluster ventilations.

“We all know what the outcome is going to be, guys, but could we at least make it look like we care and we tried?” I suggested. “There’s a reason everyone was upset back there, and it’s because they expected us to not care.”

“No. It’s because they’re all a bunch of animals. Those friggin’ monkeys belong in a zoo. Sick of dealing with their n****r bullshit.” The lieutenant fired back at me.

“Excuse me?” I retorted noticing the Confederate flag tattoo he  sported proudly on his right arm.

“You heard me. I’m just saying what we’re all thinking.”

“Don’t give yourself that much credit.”

“If you ask me, we should throw ‘em all in a stadium, load ‘em up with a bunch of guns, and watch ‘em all take each other out. Might even pop some popcorn and make a night of it.” He sneered.

“Why don’t you shut up before you become the second unresponsive person back here.” I could feel my blood boiling.  Our eyes locked, and in a moment of clarity I saw the real enemy in this situation. The bus slowed rolling unsteadily over a few speed bumps and came to a halt. We unloaded the pram continuing CPR on the way into the trauma bay. After a short handoff report and fifteen minutes of mopping the blood out of the back of the rig, I noticed my crimson footprints leading back out to the truck. I walked through the grass hoping that the early morning dew would clean them up. Trotting through the lawn, I recalled an excerpt from The Merchant of Venice.

“If you prick us, do we not bleed? if you tickle us, do we not laugh? if you poison us, do we not die? and if you wrong us, shall we not revenge?”

The engine crew had departed and only my partner and I were left. I could hear the squawking of my radio in the background. The impatient dispatch crew was harassing us to get back in service to take a non-emergent abdominal pain call around the corner. After a less than gracious reminder that we needed to return the scene to sign the crime log, we bought a few extra minutes before heading back.

0402. A gentle breeze started to blow and a soft rain began to fall. In a few minutes, it progressed into a full-fledged storm that sounded like pebbles bouncing off of a tin can. Our wipers couldn’t keep pace with the droplets that struck the glass. As we approached the area, fluorescent yellow tape and psychedelic flashes of blue and red filled the night sky. Sauntering over to the crime scene station, we ran into our esteemed colleagues from the fire station holding the metal clipboard, begrudgingly adding their names to the list. Slamming the notepad into my chest, the lieutenant grumbled, “Here you go Mr. Bleeding Heart.” I suggested he attempt an anatomically impossible procedure as we parted ways. Watching the ink run off of the paper, I handed the crime log back to the attending officer.

Maybe I’m different than most medics, or maybe I’m just more vocal about how I feel after difficult situations. I spent the entire drive home sitting in disbelief. I just couldn’t accept that in the 21st century someone could be so calloused about another human’s death. Not only that, but attributing ill motives and wishing harm to an entire group of people. Working in an urban setting, I will admit that I was surprised at first to hear someone attribute ulterior motives to me claiming that my performance could ever be based on racial stereotyping, but now I feel differently. Having not grown up as an African-American in Midwestern America, I admit that I was skeptical when I first heard cries of racism and bigotry in the workplace. It had never really affected me personally, and the obvious human response is to believe that movements that we aren’t invested in lack legitimacy. That night changed my mind forever. When I hear people in the field rush to denounce things like Black Lives Matter or immediately claim there is no such thing as systemic racism within our society, I shake my head and only think about how much further we have to progress. If we are honest with ourselves, we all have our stereotypes. Even if it’s not about race, it could just as easily be about socioeconomic classes, genders, or geographic regions. I can’t imagine what it must be like to wake up every day expecting to be treated in an inferior manner just because of the color of my skin. Empathy requires us to move past our own realities and embrace what someone else’s is. Just a thought…

There is no reconciliation until you recognize the dignity of the other, until you see their view- you have to enter into the pain of the people. You’ve got to feel their need.”- John Perkins

Why Your Patient Isn’t Just Drunk

Beer BottlesLet’s start off with a scenario that I am sure all of us are familiar with. You and your partner are dispatched to a reported fall outside of a bar at 0100. As you arrive to the scene, you see an approximate 35 year old staggering around with blood noted on his forehead. The patient tells you that he “only had a couple of beers” and “just lost [his] footing”. He denies any loss of consciousness or neck/back pain. The only visible trauma is a 2” laceration on the right-side of the forehead and you have controlled the bleeding. As you begin to assess the patient’s mentation, he is answering all of your questions appropriately, his vital signs are stable, and he denies any medical hx, current medications, or allergies. You and your partner attempt to coax the patient into moving into the back of the ambulance for further examination. The patient repeatedly tells you “I’m fine” and is refusing further examination and transport to the hospital. Do you allow this patient to refuse?

SOBRIETY V. INTOXICATION

BreathalyzerSo is merely drinking “a few beers” grounds for calling someone intoxicated? At what point can we call someone intoxicated and use the rules of implied consent in treating patients even against their expressed wishes? After scanning several different definitions of intoxication, there are a few disparities. Definitions like this: “a state in which a person’s normal capacity to act or reason is inhibited by alcohol or drugs” (Encyclopedia of American Law) are widely accepted, but where does that leave us? Obviously, these situations are handled differently depending on your medical direction, but here are some things to consider. Sure, your patient may be able to answer all of your questions appropriately, but what is their environment like? What are the chances that if you leave this patient exactly where you found them, that the patient or someone around them will be harmed? What is your patient’s speech like? Are they slurring or able to speak without difficulty? What is their motor function? Are they able to walk with steady gait? Are they aware of their surroundings, or are they going to wander off into traffic without intervention? Is there a chance that maybe their alcohol consumption could be masking other problems?

ALCOHOL, BLOOD, AND HYPOVOLEMIA

Alcohol does two different things to the cardiovascular system. It inhibits platelet aggregation as well promotes platelet aggregation. Yes, you just read that correctly. Alcohol accomplishes two polar opposite things within the blood stream. A way of looking at it is that platelets stick together in the bloodstream from consistent alcohol consumption leaving the chronic alcohol drinker with a higher risk of stroke, MI, PE, etc. The problem from platelet aggregation inhibition comes when there is a source of bleeding within the body whether due to a traumatic or a medical cause. A study linked here, shows that alcohol can actually “inhibits platelet adhesion to fibrinogen-coated surface under flow”. symptoms-blood-clot-knee_d9b3c4b45c84d7f1

So once your chronic alcohol drinker starts to bleed, it is very difficult to get said bleeding under control, BUT that’s assuming that you have discovered the bleeding to begin with. Anyone that has been in the field for any length of time should have a healthy fear and reverence for the intoxicated patient that has fallen and struck their heads. Even if not recently, immediate signs of brain hemorrhage can lie dormant, and for the patient that is potentially already altered, the subtle changes could easily be masked. Due to the corrosive nature of alcohol, chronic drinkers are much more likely to develop intestinal bleeding. There is a communal eyeroll anytime someone complains of hematemesis or melena, but for alcoholics, this is a potentially life-threatening problem that is often blown off in the emergency department and in the prehospital world. Hypovolemia whether due to blood loss or sheer volume depletion because of vomiting from conditions like pancreatitis or being on diuretics like lactulose (commonly prescribed for patients with cirrhosis to assist in filtering out toxins within the body) is a common problem that needs to be addressed. Was that a long enough run-on sentence for you? I promise I can do better. subarach ct

ALCOHOL: THE GREAT DECEIVER

Let’s roll with another scenario here. You and your partner are dispatched to a report of an unconscious party at a private residence. A landlord went over to check in on a tenant and found him “unresponsive” on the ground. The patient is bradypneic and is unable to awake with painful stimuli. The patient wreaks of ETOH, but can you definitely say that this patient is just intoxicated? Can you as a prehospital provider state that the patient did not suffer a cardiac, neurologic, or diabetic event? Can you definitively say that there are no other intoxicating agents onboard; i.e. barbiturates, opiates, etc? Obviously, being unable to prove a life-threatening problem is not a reason to suspect that every intoxicated patient is suffering from one, but as critical thinkers prehospital providers have to be on the lookout for deterioration. We are not advocating for cookbook medicine or performing innumerable diagnostic tests for the sake of doing them, but when clinical and vital signs are not adding up, maybe it’s time to stop assuming that our patient is just intoxicated.

D.O.S.E. (Direct On-Scene Education)

The Indiana Emergency Response Conference, August 24 – 27, 2016 has a variety of educational opportunities! D.O.S.E: Direct On-scene Education great class offering will be on Thursday, August 24, 2016 that will give both fire and ems responders the resources needed when on-scene.

What is DOSE? DOSE is an innovative attempt at eliminating sleep related infant death due to suffocation, strangulation or positional asphyxia by using First Responders to identify and remove hazards while delivering education on-scene. First Responders are trained to identify and remove hazards from an infant’s sleep space while on scene during emergency and non-emergency 911 calls. DOSE was created and developed by Captain James Carroll and Jennifer Combs, MSN, ARNP.

If interested make sure to check out the IERC website!

EMS-IERC DOSE

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The Mute Medic Volume II

Fatigue -/fəˈtēɡ/- extreme tiredness, typically resulting from mental or physical exertion or illness

I, like many others before me, looked in the mirror today and said “to hell with this life”. It wasn’t the pay. It wasn’t the hours. It wasn’t the autonomy. Maybe it was the fact that I had to strip my uniform off in the laundry room before heading upstairs because I was afraid of tracking in the last drunk’s vomit or having my kids see blood on my uniform from the 19 year-old that was shot in the head in a drive by…

As much as you try to turn off the camera in your mind, the internal hard drive can’t be erased. Why didn’t anyone warn me about this before I became a paramedic? I almost gave it up today. I was teetering on the precipice of futility and purpose. That makes it sound like I emerged victorious. I didn’t, but I came away reminding myself that I can get through one more day. Maybe help one more person. The truth is, every shift is a choice.

I guess you could say that this inner monologue started a few months ago. It was 0300. I woke up, drenched in sweat. Hyperventilating. I was there again. Like it just happened. She was 25. I remember standing over her flaccid body, staring at the tube in her mouth wondering what I could have done differently. The monitor illuminated the room, the apnea alarm shrieked like an animal caught in a trap. Nothing. No pulse. No breathing. No soul. Her eyes were wide and pupils dilated, like she could see everything we did. Everything we tried to do.

As the wind drifted through the cracked window, I could almost hear her whisper, “Why couldn’t you save me?”

A disheveled shadow came out from another room. His burnt fingertips continued to feed through his hair as his eyes darted back and forth. The Pink Floyd shirt he wore was tattered and had numerous stains on it. The stench that followed him around was a mixture of bleach and tobacco. With tremulous hands he reached for his pockets, and then continued to fidget with his hair.

“Any of you have a light?”

My partner and I shook our heads and continued about our business. The lanky man stepped over the fluorescent red bio-hazard bag and reached into the lifeless woman’s pocket.

“Hey, what the hell are you doing?!” I yelled.

Retrieving a pack of cigarettes and tie-dyed lighter, the man turned and winked at me. “These will do.” The hairs on the back of my head stood up straight like soldiers waiting at attention. A few officers stopped him and began to question the sordid figure about his involvement with the girl. My partner was speaking with the coroner on the phone, while I went back to picking up the Epi vials and wiping the emesis off of the defibrillator cords. I heard two small voices downstairs. A younger officer came up to me.

“They want to see their mother.”

Two unkempt children climbed the narrow staircase. The boy was maybe five and the girl around seven. Their hair oily and teeth crooked and yellow. It was 1230 in the afternoon, and they were getting hungry for lunch. Mom hadn’t fed them all day long, probably because there was no food in the house. The children’s grandparents had dropped the kids off that morning at the dilapidated residence. What we found out later was that the children’s grandparents were actually their legal guardians. After several heroin related arrests, their mother had her parenting privileges revoked. She pleaded with the grandparents to let her see her children. After months of begging, they agreed to let her have a “trial day”. Instead of buying food for her children, a “friend” came over and the mother disappeared. As the children’s stomachs grumbled, they went in search of their mother, and they found her…

“Is she going to wake up?” the boy asked.

I fought back the tears trying as hard as I could and tried to cushion the truth. “No… She’s not going to wake up…” I didn’t know what else to say. Never in my absurdly short training period did anyone ever cover explaining death and grief to school-aged children to me. I escorted them back downstairs and sat them on the couch. Clicking on the remote, Dora the Explorer emerged on to the t.v. screen. Both of them sat their. Silently. I rummaged through the cabinets and the refrigerator only to add to my disappointment. Running out to the bus, I grabbed my lunch box and came back in with a cheese stick, apple slices, and half a sandwich. Before the next commercial break, all that remained were plastic baggies that the kids had wadded up and thrown on the couch.

A green station wagon pulled up to the front of the house and both of the kids bolted out the door. An officer and I followed them out, as they piled into their grandparent’s vehicle. A few minutes later, they turned off down the street and on their way back to what I can only pray was a reprieve from the insanity that they had just experienced.

A few minutes later, our equipment was organized and thrown back into the ambulance. Maybe it was a blessing in disguise that we worked for a high-volume urban service and didn’t have time to think about what we just witnessed. Maybe that’s why I’m thinking about it now. For the rest of the shift, my partner and I played the nursing home shuffle and ran a few other minor medical calls. It was quiet, though. None of the normal chatter that we bandied about most days.

I find it odd that three years after this call happened, I can still remember every detail. I remember the rank smell of cat urine and the tobacco stains on the rug. I remember the holes in the planks going up the stairs and the obscenely dark room with no functional lights. The overflowing toilet that sat there stagnantly for God only knows how long. I’ve had calls like this before, but this is the one I remember. This is the one that wakes me up in the middle of the night. The one that I think about on Father’s day, wondering if those kids will ever have a steady figure in their lives to help them sort out the hell they’ve lived through.

0315.

I went out to the couch and sat down. Hunched over the coffee table, a bowl of Frosted Flakes in tow, I needed an escape. The television flickered in the background as I turned down the volume hoping to not wake anyone up. There had to be something on this late to take my mind off of my dreams. I stumbled upon an older episode from Batman: The Animated Series. Perfect. Childhood nostalgia was what I needed, but I got more than what I bargained for. What I had hoped for was that Batman would swoop in and save someone in distress while simultaneously pounding his adversary into oblivion. Because that’s how the real world works. In this episode, however, Batman was struggling with his sense of efficacy. In a rare moment of utter humanity, he sat dejected in a chair by himself in the Batcave. As his butler, Alfred, approached they had this conversation:

Alfred: Master Bruce, are you alright, sir?

Batman: I’m tired, Alfred.

Alfred: Well I shouldn’t wonder, you’ve taken no meals today, and I can’t recall when you last slept.

Batman: A weary body can be dealt with, but a weary spirit, that’s something else. Sometimes, old friend, I wonder if I’m really doing any good out there.

Alfred: How can you doubt it? The lives you’ve saved, the criminals you’ve brought to justice.

Batman: I’ve put out a few fires yes, won a few battles, but the war goes on Alfred, on and on…

The rest of the episode went on to validate Batman’s calling to protect those around, and to the seven year old me, I’m sure it would’ve been awe-inspiring. This time it was different. This time I sat alone in the dark just like my childhood idol wondering what fires I was going to try to put out…

Pediatric Tachyarrhythmias

You are dispatched to a residence on a report of a child with an altered mental status. Upon arrival, you find an 8 year old boy lying on the couch responsive to verbal stimuli. His mother states he had been playing outside today when he came inside and complained of extreme weakness. He laid on the couch to rest and the mother was unable to rouse him.

HISTORY

  • WPW syndrome

MEDICATIONS

  • None

ALLERGIES

  • Penicillin

VITALS

  • BP -90/58
  • HR -190
  • BSL- 98
  • O2 sats – 95% with clear lung sounds

BROSELOW

  • 50 inches tall, 57 lbs (25.9kg)

INTERVENTIONS

  • Monitor applied showing a rapid, narrow complex tachycardia.
  • Oxygen via NC at 2lpm
  • Vagal maneuvers

Attempts to slow heart rate by vagal maneuvers prove inadequate. The pt is seemingly becoming more lethargic. IV 22g is established in the right AC.

  • Adenosine
    • 0.1 mg/kg = 2.6 mg
      • IV
      • Rapid flush with 20 ml saline
    • repeat double the original dose x1 = 5.2 mg

Adenosine proves ineffective in reducing heart rate and child continues to deteriorate in condition.

  • Medical control contacted for Synchronized cardioversion
    • 1 J/kg = 26 j
    • Repeat to 2 J/kg = 52 j

Patient is successfully converted to a normal sinus rhythm. He becomes alert and is able to answer questions appropriately,  though he complains of some weakness and tiredness.

  • Causes of SVT in children

    • Wolff-Parkinson-White syndrome
      • Most common type of SVT in children
      • Extra pathway within the heart’s electrical system that connects the atria to the ventricles
        • Typically only AV node is the connection (causing a short circuit)
      • Most of the time this doesn’t affect the rhythm
        • Early beat (PAC,PVC) will cause the impulse to travel through AV node and back through extra circuit
            • “Dog chasing its tail”
      • Be conscientious of using AV blocking medications (i.e. Adenosine, diltiazem, verapamil, etc.) in A-fib with accompanying WPW; can result in V-Fib; cardioversion is the gold standard for unstable A-Fib with WPW patients

A-Fib wWPW

Atrial Fibrillation with WPW

    • Atrioventricular Reentrant tachycardia
      • 10% of cases of SVT in children
      • “Pacemaker” or extra focus that is located above the SA node and beats faster.
      • Diagnosis and treatment of both are similar to all forms of SVT

pediatric svt

Pediatric SVT

    • Almost all SVT cases have excellent outcomes and quality of life
      • Avoid caffeine
      • Certain medications
    • Generally, no restrictions are necessary unless extenuating circumstances. Activities involving climbing or heights are discouraged due to dizziness/fainting associated with episodes, resulting in a fall.
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The Mute Medic Volume I

Hero -/ˈhirō/- a person, typically a man, who is admired or idealized for courage, outstanding achievements, or noble qualities

She walked up to me and gave me one of the hardest hugs I have ever gotten from someone. Her husband patted me on the back with tears welling in his eyes. “You saved her life; I don’t know what I would have done without her.” Their daughter was in that awkward pre-teen phase with multi-colored hair trying to emulate the hipster movement with her thick-rimmed glasses and ironic mismatched clothing. Her son brought his toy ambulance with him and continued to blare the siren while crashing it into my foot. I didn’t know what to say. When you become a paramedic, there is this twisted fantasy you have about doing something daring and risky and receiving praise when it’s over. Today was different, though. My partner and I had quite literally saved this woman’s life, but I felt numb to the adoration. This woman continued to hug me while crying, expressing her heartfelt gratitude over and over again, but the only thing I could muster was, “glad everything worked out, okay.”

Who the fuck says that?

My chief came into the room, camera in hand, and asked if he could get a group picture. After several minutes of arranging and rearranging, he seemed content with the set up, and snapped a few photos. My mind continued to wander off to that fateful day. I tried not to come off as a deer in the headlights, but I am confident my acting skills were not up to snuff that day, as the woman continued to try to engage me in conversation. In the background, I listened to my partner over-dramatize his involvement in the run and make it sound like he was a stunt car driver in a chase scene instead of just transporting a patient in the back of the bus. Inwardly I rolled my eyes; four months of exaggerated war stories were taking its toll on my stomach, adding to the ulcer that was already there.

*Click*

As the room was buzzing with the chatter of awkward strangers, my chief meandered around the room snapping pictures. There was a natural decline in conversation, and as the topics grew stale, the woman handed my partner and I two boxes and a couple of thank you cards. Inside, were baked treats; everything from chocolate-covered strawberries to cookies to cannolis. The selection was overwhelming, and you could tell that the family spent a pretty penny on all of the bakery options that were presented to us. The supervisors were in the middle of shift change, and kept filing in and out of the room. There were big smiles and attaboys flying around the room at unprecedented rates. It was nauseating. After three years of hard work, bad hours, and poor sleep, I was being recognized by a patient for a job well done. This was the first time I had heard a word from my management team, though. The woman gave me one last hug and a quick kiss on the cheek thanking me for my 45 minute contribution to her life.

“I owe my life to you.”

Those words reverberated off of the walls in my head, and I knew that I couldn’t live with them. My mind continued to drift elsewhere; mainly the day that I met this woman.

It was late March. There was dew on the grass and still had that spring nip in the air. I knew it was going to be a bad day at work. For the last two weeks, my partner and I had been attempting to bridge up an EMT trying to become a paramedic. It had been very painful, and I could feel my patience becoming increasingly thinner. As we were finishing our truck check that morning, I heard dispatch come over the air.

“Medic 23.”

“Go ahead for Medic 23.”

“For your information, the paging and mapping system are down today. You’ll have to use your mapbooks and call into dispatch for your call times.”

Could we have one fucking day where something actually works?

“Medic 23 is clear, thank you.”

I was driving while my partner was taking his morning nap on the bench seat and the EMT we were cross-training rode shotgun. This was the fourth time this EMT was attempting to become a paramedic; she had failed every other time, and this time wasn’t going much better than the previous ones. Her phone rang once, and she proceeded to let it ring.

That has got to be the most annoying ringtone I have ever heard.

“You going to answer that?”

“It’s my daughter.”

“You going to answer that?”

I think she finally got the hint that she either needed to answer the phone call or shut her ringer off. I am not a morning person, but still, there wasn’t enough coffee in this world to make that bearable. After five minutes of bickering and occasional yelling, she hung up and there was a long pause.

“Trouble in paradise?”

“I need to go home.”

“What’s going on?”

“My daughter just got into a wreck and my son’s about to get arrested.”

Ladies and gentlemen, I present another episode of Young and the Restless.

“Mmmmkay. I’ll let the supervisor know.”

I called my supervisor and informed dispatch over the radio that we needed to turn back around to the base. After dropping her off, I yelled back to the patient compartment to see if my partner was still alive. I saw the lights flicker on while my partner stumbled around as if he were reenacting Frankenstein. He sulked in the front seat.

“I’m tired, and I don’t feel like doing anything.”

“Join the club.”

“No… I’m really, tired.”

“I have two kids, a full-time job, and I’m going to school. Sympathy is in short supply today.”

I felt like an asshole responding like that, but I had already filled my complaint quota for the day and we hadn’t even made it to our first post. My stomach was growling, and all I could hear was coffee and a breakfast burrito calling my name. Wrong again.

“Medic 23.”

“23, go ahead.”

“We’ve got an emergency call on a pregnancy just around the corner from you.”

Dispatch gave us the address as well as some additional directions into the subdivision.

Too fucking early for babies…

I flipped on the lights and sped up to the house. It was a well-kept subdivision; a pleasant break from the dilapidation we normally worked in. My partner and I unloaded our gear and strolled up to the house. We knocked on the door with no answer.

“EMS. Paramedics.”

I knocked one more time, and then turned the door handle. The door wasn’t locked and opened into a full living room. There was hardwood everywhere as well as modern art and sculptures. The house was clean and free of the normal debris that we normally had to navigate through. As I cleared the door and turned to my right, my stomach sank.

Shit.

There she was. Lying on the floor with her pants around her ankles in a puddle of blood. Sweeney Todd kept a cleaner barber shop. Blood covered the floor and had saturated her pants. Her skin was a translucent gray and her voice quivered.

“I think I waited too long to call.”

I grabbed for a radial pulse and felt nothing. My partner and I quickly exchanged looks and came to the same conclusion. We were behind the eight ball. The woman whispered to me that she had had a miscarriage days ago and hadn’t gone to the doctor for follow up care. I had to take my ear piece out to hear her as her faint voice said that she had soaked five pads and passed five large clots. I fumbled with the automatic blood pressure cuff.

58/20.

Goddammit.

My partner grabbed the EKG cables and place them on the patient’s arms and legs. She was bradycardic and profoundly hypotensive. We both reached for the tourniquets trying to find a place with a palpable vein. I knew I was only prolonging the inevitable. I scanned her neck for an EJ and saw nothing. I didn’t have a choice. I rummaged through the first-in bag and took out the IO kit. I depressed the trigger for a second and heard the whirl of the drill. As I prepped my needle and saline lock set, I reached for the lidocaine.

Why the fuck isn’t there any Lidocaine in my IO kit? You’ve got to be fucking kidding me… Could resupply for one fucking day do their jobs!?

I thought I was going to have an aneurysm, but I couldn’t convey that. My partner at the time, God love him, fed off of every bit of chaos and uncertainty that he saw and heard. I so much as said the word “problem” and there was instant panic. As calmly as I could, I asked him to check the drug bag for Lidocaine. Goose egg. Despite my deeply pessimistic tone, I do believe in divine intervention. Our supervisor was making his round that morning and just so happened to be heading to that very same run. With Lidocaine. Simultaneously, our supervisor and the woman’s husband walked in the door.

No pressure.

I explained to the patient and her husband what I had to do. I was going to have to place an IO in her tibia because she had no veins that I could start an IV on. I prepped the site and said the infamous line.

“You’re going to feel a little pressure.”

I could feel the grinding of the needle into her bone. Her screams reached near animalistic tones as I had to repetitively coach her to lie flat on the ground until I was done. I pulled back on the syringe and saw bone marrow. I was in. With every milliliter of Lidocaine and saline that I pushed in came more screaming until she was hoarse. I couldn’t sedate her because of how unstable her vital signs were. My partner got up front and drove. Correction. He flew. Like a bat out of hell. It was as if I was auditioning for a program at NASA trying to construct something in an anti-gravity simulator. The OB/GYN specialty center was at least twenty minutes away and I was alone for all of them. For 19 minutes I worked my ass off. I was a sweaty mess at the end of them. From hanging saline and TXA to running 12-leads to calling the hospital…I felt drained. There was one minute though, where I stopped and recollected my thoughts. She reached out her hand and asked if she could hold mine.

“I’m scared.”

So am I. “I’m not going to let anything bad happen to you back here.”

It was a promise said with utmost confidence. One I knew that I couldn’t keep. Despite hawk-like vigilance, there was no guarantee I could make to her or her family that everything was going to be okay, and I knew it. All of us want to be in control, and loathe the times that we feel we can’t be. I felt out of control, though. We rolled into the emergency department and while passing off report to the nurses there, they treated my report with zero sobriety.

“Thank God for ambulance drivers,” one of the nurses echoed.

Thank God for doctor helpers.

*Click*

She took one more photo with me before the clan climbed into their SUV and drove off. She rolled down her window and signaled for me to come closer.

“You were my hero that day.”

She teared up, put on her seatbelt and their vehicle backed out of the lot and faded away down the street. I felt the pain in my stomach sharpen…

Hero. Not by a damn shot…

Growing up, I idolized Atticus Finch, Bruce Wayne, and Matt Murdock. They were my heroes. While all fictional, they never compromised their values and continued to fight social injustice and human suffering. I can honestly tell you I don’t feel like I fit the bill and will continue to feel that way. For all of the successes in my career, I feel like there are just as many, no, more failures. If we are honest with ourselves, none of us are heroes. Heroes don’t have to go home and drink just to feel normal. My heroes never screamed at drunks or practiced punitive medicine… Compassion fatigue and cynicism were never traits of my heroes, but if I am truly introspective, they are qualities that I possess. Maybe one day, my sons will hear the stories I have lived through and think I am a hero. I hope they don’t. I hope they never have to witness or imagine the things I see daily. Maybe one day there won’t be a need for heroes…

           

 

Anxiety as a Clinical Finding

Anxiety JPEGIt’s 0200. Your shift is dragging on, and all you want to do is go home. You and your partner get called for a complaint of difficulty breathing in an apartment complex. As you roll up to the scene, you see a mid-20s female walking out to your ambulance. You disregard the engine coming to assist you and walk the girl to your truck. She’s hyperventilating and appears markedly anxious. You attempt to coach her through her breathing, assess her lung sounds and hear clear and equal breaths throughout, and note an SpO2 of 98% on room air. She’s just anxious, right? You secure the patient for transport, and transport her to the emergency department with no other interventions. How many of us have done this? Why are we so quick to dismiss anxiety as a non-issue?If you listened to Episode 14: The Suspected Pulmonary Embolism Patient, you can probably see where we are going with this… We are wrong most of the time when we blow off the anxious patient, but we keep doing it…

WHY DON’T WE ASSESS ANXIOUS PATIENTS?

It’s time to cut the bravado bullshit… I remember the first time I did a 12-lead on a 20 year old complaining of chest pain. I would have bet my paycheck that this patient wasn’t experiencing a STEMI, but I did one anyway knowing that there are other things to look out for. dirty harry jpegNone of my co-workers took me seriously. I was called a cookbook medic.  I could have easily documented that my patient that was hyperventilating and experiencing musculoskeletal chest pain and would have gotten away with it. 99 times out of 100, you might be right, but is it really worth it to be wrong that one time? Even if the patient is just experiencing an exacerbation of an underlying psychological problem, when did a mental health crisis stop being classified as a medical problem? Our job is to help figure out any additional causes of these situations, and not to write them off and make them someone else’s problem. 

WHAT MAKES A PATIENT ANXIOUS?

  • COMPENSATED SHOCK
    • One of the most overlooked causes of anxiety especially after a traumatic incident (i.e. MVC, assault, etc.) is the early stage of compensated shock.
    • We tend to brush off patient complaints of anxiety if the evidence of obvious injuries or abnormal vital signs aren’t present immediately.
    • Restlessness is one of the first signs that patients are starting to trend downwards; if we aren’t trending vital signs in the anxious patient, we aren’t doing our due diligence.
  • RESPIRATORY DISTRESS AND HYPOXIA
    • A 2013 study in the journal of Respiratory Care found that patients with COPD and severe nocturnal hypoxemia have been found to experience significantly higher levels of anxiety to the helpless feeling of “suffocation”.
      • As a result of this, it’s not uncommon to see COPD patients on antidepressants and mood stabilizers; don’t ignore their growing restlessness, though. Plan ahead and be ready for the worst.
      • Patients that have experienced medical emergencies know when they are declining, and as a result can start to panic.
    • PE patients frequently don’t show any clinical signs in the prehospital setting beyond anxiety, hyperventilation, and tachycardia before rapidly declining and even arresting. Remember that these patient will continue to have clear lung sounds and even decent Spo2 saturations for awhile.
  • ANXIETY DISORDER
    • For someone who already struggles with an anxiety disorder, how else would you expect them to react when they are encountered with a new stressor, let alone a legitimate medical emergency.
    • The simple fact that someone has a mental illness history is not a reason in and of itself to disregard a detailed assessment; while it is a piece to the puzzle, it is not the entire picture.
  • ARRHYTHMIAS AND HEART FAILURE
    • A little while ago, a friend of the show donated a set of 12-leads from a mid-60s female experiencing PSVT… the only symptom she was experiencing? Anxiety. Yes, I’m being a bit patronizing, but I think we’ve made our point that anxiety is a clinical sign of bad things going on in the body.
    • American Heart Association classifies some of the most common symptoms of arrhythmias as:
      • Dizziness
      • Shortness of breath (often manifesting in hyperventilation)
      • Palpitations
      • Fast heart rates
    • All of these are symptoms that can be caused by just the sheer sympathetic surge from a purely anxiety-driven episodes, but due to the gravity of what else could be causing them, we need to be better investigators.
    • Patient’s that have experienced heart failure leading to pulmonary edema often present with… anxiety, tachycardia, and dyspnea in the form of hyperventilation.
      • We need to be vigilant in our heart failure patients that are experiencing anxiety; prepare for the worst case scenario up to and including EKG monitoring, IV access, nitro therapy, high flow 02/PPV, and possible airway management.
  • HYPER/HYPOGLYCEMIA AND SEIZURES
    • Whether someone is postictal or is experiencing mild AMS due to a glucose related event, having multiple strangers enter your home while you feel out of control of your own body is a scary event.
    • Be calm, be concise, be firm, be respectful.
    • The American Diabetes Association released a study in 2004 that revealed acute hyperglycemic spikes in Type II diabetic patients that can reduce cognitive function and lead to extreme agitation and anxiety.
    • Anybody try to reason with an anxious and agitated hypoglycemic patient? How did that work for you? What were they like once you corrected the hypoglycemia? Night and day difference. 
  • PAIN
    • Have you broken your ankle? Have you had an appendectomy? Talk to someone who has… It’s a horrible experience that makes you feel out of control and miserable. It sounds simple, but sometimes we forget. Controlling pain can help reduce anxiety.
    • A 2001 study in the Journal of Neuroscience even suggests that anxiety amplifies underlying pain.

ASSISTING THE HYPERVENTILATING PATIENT

  • THE PAPER BAG
    • For the few of you that still think that using a paper bag is a good idea to help a hyperventilating patient…please stop. Here’s why. Hyperventilating patients are experiencing respiratory alkalosis. By placing the bag in front of the patient, you remove the ability of the patient to receive oxygen, and they begin to breathe in CO2.
    • IF the underlying etiology is anything beyond purely hyperventilation, the chances of you causing hypoxia and hypercarbia is enormously high! There are several documented cases of patients that have experienced underlying MIs and hypoxemia that have had fatalities linked to this…
  • HYPERVENTILATION SYNDROME
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • Any questions?
    • Hyperventilation syndrome is now starting to be referred to as psychogenic dyspnea.

DIAGNOSTICS

  • EKG MONITORING
    • Placing continuous EKG monitoring on your patient helps you do a couple of things:
    • Discover possible arrhythmias; especially PSVT, bouts of atrial fibrillation/flutter, and WPW.
    • Underlying cardiac strain, ischemia, or MI.
    • S1Q3T3 suggesting pulmonary embolism; even if this phenomenon isn’t present remember that it only appears in approximately 20% of all PE patients.  Sinus tachycardia is the most common presentation of PE.
  • GLUCOSE MEASUREMENT
    • Any patient that is acting anxious or altered needs to have their glucose evaluated. There is enough literature in circulation that supports loss of cognitive function and coping mechanisms due to hyper/hypoglycemia. It takes five seconds, just do it.
  • EtCO2
    • Someone that is experiencing hyperventilation syndrome (pschogenic dyspnea) will more than likely experience a lower EtCO2. Where this comes into play is that patients experiencing lower cardiac output or other signs of obstructive shock and have a lower EtCO2 should be suspected to have a PE.
    • Continuous waveform capnography can show the beginning stages of bronchoconstriction when audible wheeze may not be present.
  • SPO2
    • I’m not going to go into great detail about this now because we will eventually be doing a show about this, but don’t always trust your SpO2. There are delays in readings and hyperventilation may give an overly optimistic view of your patient’s needs.

SUMMARY

  • We do not have the capability to diagnose that someone is just anxious.
  • There are too many other serious conditions that have similar symptoms to panic disorders or psychogenic dyspnea for us to be cavalier about how we treat patients.
  • Are you going to get in trouble for overtreating (within reason) your patients, or for neglecting to do enough?

EKG Case Study #14: Mid-70s Male C/O Acute Weakness and Diarrhea

You and your partner work for an urban ALS system. At approximately 2300, you are dispatched to a choking with an unresponsive party. As you arrive on scene, a BLS engine crew member alerts you to the fact that they have a mid-70s male in full cardiorespiratory arrest just outside of a downstairs bathroom. Family members advise that the patient starting to feel “ill” around 2100, complaining of a sudden onset of weakness followed by an acute onset of diarrhea around 2230. They also relay that they heard the patient “struggling” in the bathroom and becoming notably dyspneic. You note frothy sputum around the corners of the mouth. As your crew initiates chest compressions and an OPA/NRB combo due to local CCR protocols, you find a med list and history that reveals: A-fib, HTN, COPD, CHF. Patient’s family also state that the patient has a history of DVTs, PEs, and has had three cardiac stents placed. Your partner places the defib pads on the patient and you take a look at your initial rhythm.

INITIAL RHYTHM

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PULSE CHECK

  • Due to potential respiratory etiology of arrest, crew bypasses local CCR protocols and assumes standard ACLS procedures, placing OPA and ventilating patient approximately 8-10bpm.
  • Chest compressions continued
  • IO established in L tibial tuberosity
  • First round of 1.0mg 1: 10,000 Epi IO
  • Crew recognizes PEA and no defib delivered

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • IO fluids hung with pressure bag placed wide open
  • EtCO2 line placed and measured at 12mmHg
  • BGL assessed and noted to be 92mg/dl
  • No obvious signs of trauma noted; no forms of ETOH use or illicit drug use noted; patient is not on any known opioids

PULSE CHECK

  • Patient remains in PEA
  • Second round of 1.0mg 1: 10,000 Epi IO
  • Chest compressions resumed
  • Patient vigorously suctioned due to foaming secretions; intubated with first pass success with channeled blade video laryngoscope and bougie stylette
  • EtCO2 improves to 22mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Secondary IV access obtained with fluids hung wide open with pressure bag; approx. 750ml have been infused thus far
  • 50meq Sodium Bicarbonate IO
  • EtCO2: 20mmHg

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Third round of 1.0mg 1: 10, 000 Epi IO
  • EtCO2: 23mmHg
  • Crew begins to approach family about the fact that ten minutes of resuscitation have taken place with no gross changes and initiates conversation about end of life decisions; family states that the patient has no known end of life arrangements in place, and request that despite no gross changes, patient be transported regardless of ROSC.

PULSE CHECK

  • Patient remains in PEA
  • Chest compressions resumed
  • Approximately 1.2L of 0.9% NS have been infused at this time
  • Crew gathers backboard and other packaging equipment, but stop long enough to note that the EtCO2 has risen to 67mmHg from the low 20s
  • Confirmed ROSC noted at this time

ROSC 12-LEAD

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  • BP: 102/48
  • EtCO2: 49mmHg
  • HR: 116
  • Pupils are dilated and unresponsive
  • Patient remains GCS of 3
  • What do you see on the 12-lead?
  • Crew initiates transport to local PCI center approx. 10 minutes away from residence; approximately five minutes into transport, patient arrests a second time.
  • Chest compressions initiated again.

PULSE CHECK

  • Patient is found in PEA
  • Chest compressions resumed
  • Fourth round of 1: 10,000 Epi IO
  • EtCO2: 25mmHg; towards end of cycle of CPR, crew notes another spike in EtCO2 to 56mmHg
  • Crew confirms that they have ROSC again

SECOND ROSC 12-LEAD

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  • BP: 74/42
  • HR: 88
  • EtCO2: 52mmHg
  • Patient continues to ventilate without difficulty
  • What do you see on the 12-lead?
  • Approximately 2.5L of 0.9NS have been infused at this time
  • Crew initiates norepinephrine drip at 2mcg/min per crew’s protocol

ED HANDOFF

  • Patient codes a third time
  • Ongoing resuscitation in the ED lasts for another 30 minutes with no ROSC
  • Patient found have to have pulmonary embolus and pronounced in the ED

DISCUSSION

  • What would you have done differently?
  • Do you think that there is a place for thrombolytics in routine care for post arrest patients from possible thromboembolism?
  • What do you think the role of prehospital ultrasound is?