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Awesome IFAK from JUMP Kits! Check out their website for more information. Only $99.99!

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Always treat a pregnancy call as if labor is possible. But, here’s a bit of info that may steer your mind towards real labor vs Braxton Hicks.

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LESSONS FROM A CPAP CME Irecently attended a CME on CPAP (with a little about BVMs). Here’s some of the take-aways from it that I felt some may or may not know (stuff not mentioned in my EMT class, at least). 
I apologize the list is kind of random. It was just the info I wrote down that I hadn’t heard before. 
CPAP
Pressure determined by PEEP (Positive End Expiratory Pressure). PEEP just means that extra pressure flows into the lungs to keep alveoli from collapsing and/or relieve work of breathing
PEEP Setting: 5-10 cm H20 (per most EMS protocols)
CPAP is step between Supplemental O2 and Positive Pressure Ventilation (PPV) 
To CPAP or to not CPAP? That is the question…
If respiratory failure is adequate to maintain mental status = YES!
(CPAP patient must be alert enough to remove mask)
If respiratory failure is inadequate, altered mental status = NO! Get your BVM and begin assisted ventilation. 
Random/Misc. 
EMS-style disposable CPAP has low FiO2 (about 30%). You may need to add supplemental O2 via nasal cannula from a separate tank.
If your BVM makes a “fart” noise = Too much pressure (or air is being restricted). Reduce tidal volume.
What is “Barrel Chest?” Size of patient from front to back (anterior to posterior) is equal to the width from shoulder to shoulder.
CHF Patients No albuterol! It opens the airway and lets more fluid in.

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DID YOU KNOW?

When we discuss a PT being able to speak in “full sentences,” how many words count as a full sentence? A full sentence is considered 5 words with only one breath.

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SEATBELT INJURIES

When assessing a PT after an MVA, always check for seatbelt marks

This is a common injury seen in MVAs, and has potential for serious underlying injury to the abdomen, rib cage, sternum, and clavicles. If no marks are seen, still palpate the approximate areas where the seatbelt was located for tenderness or pain.

[readyems]

My new favorite mnemonic for remembering possible causes of altered mental status. How could you forget this one???

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Basic Airway Management 3

Ventilating a Breathing Patient (Track Breathing)

Every so often, you will have a PT that is in severe respiratory failure that they need assisted ventilation. The PT will not have stopped breathing, but their ventilations are inadequate to properly oxygenate. As a provider, you will have to assist their ventilations with a BVM, but in complicated synchrony with the spontaneous breaths they are taking. Breathing along with a PT is known as Track Breathing. It is a difficult skill, and is not properly taught in EMT school. I much prefer a PT that is not breathing than one that is (yes, that means the PT is much sicker, so I may sound like a psychopath for saying that) but ventilating a breathing PT is very challenging. It is much easier to just breath for an apneic PT.

This skill involves a high degree of concentration and coordination. These PTs are mostly going to be unconscious or severely altered, and their rate and rhythm can be unpredictable. If a PT is alert (but in severe respiratory distress), CPAP is probably a better option before moving on to bagging. In class, I was taught I may have to bag an alert PT (which gave me a lot of anxiety. Like, really? How does that work?), but I’ve yet to have experienced this or seen it done. It is possible, and I’ve read about providers doing it, requiring coaching the PT while doing so, but never seen it in the field.

A PT that is HYPOventilating (bradypnea) is much easier. If they are taking breaths just a few times a minute, you have much more time to provide ventilations in the dead space between breaths. You will still need to predict when the next spontaneous breath will come, though this may be irregular (which means just doing the best you can). So, you will be assisting with their spontaneous inhalation. Watching the PT and learning the signs of impending spontaneous inhalation will help you prepare to ventilate with them.

Where this gets challenging is HYPERventilation (tachypnea). A PT breathing >30 breaths/min gives you little space to provide a proper ventilation. You will REALLY need to watch, learn, predict, and synchronize with the PTs spontaneous inhalations. With a high rate like this, their breaths will be very shallow and short. When you see or predict an impending inhalation, you may only be able to provide a small amount of extra volume. When done well and over some time though, you can hopefully prolong the inhalation period and increase the volume, which will help stop the PTs unconscious effort to immediately exhale. This is the goal. But, if you can’t achieve this, any extra volume you can add to each spontaneous inhalation will still help, especially when providing high flow 100% O2. This is usually a situation that will eventually require RSI due to the high level of difficulty. If RSI is not possible in the field, you do the best you possibly can to maintain oxygenation until they arrive at the hospital where a doctor can take over and provide RSI.

TIPS

If you cannot visualize the PT inhaling or exhaling via the chest movement, an easy way to see when a PT is exhaling is the BVM mask will fog up upon exhale. Then, as the PT inhales, you will see the fog quickly fade. This will help when it comes to knowing when to begin assisting inhalation.

When a PT exhales, and you try to squeeze the bag, you will feel high resistance. The bag will be difficult to squeeze, and you will hear a fart-like noise from the pressure release valve (sorry, that’s the best way to describe the sound). One trick is to VERY lightly squeeze the bag during exhalation and feel that resistance, then when you feel the bag become easier to squeeze, you know inhalation is beginning and you can begin a ventilation.

[readyems]

Basic Airway Management 2

Part 2

Ventilating An Apneic Patient

This section will discuss ventilating an apneic patient (complete respiratory arrest). Part 3 will discuss ventilating PTs in respiratory failure with inadequate breathing.

So, you have a PT that isn’t breathing. You arrive on scene and are told to bag the PT. Step 1 is to open the airway. You may have heard of a patent airway (meaning unobstructed) vs an non-patent airway (obstructed), but patency should be viewed as a spectrum. A supine PT w/ his head tilted forward has poor patency vs. a PT with corrected head position and an airway adjunct (NPA or OPA) in place has good patency. Gather you supplies, and position yourself at the head of the PT (facing from top of their head towards their feet). Now, there is some grey area about what should be done first (place an adjunct vs. beginning ventilations). If the PT has SpO2 in the 30s or 40s, I would want to ventilate for about a minute before moving on to an adjunct (if the PT is patent enough to ventilate with a head-tilt, chin-lift alone) to get some much needed O2 to the brain as quickly as possible. On your practical, placing an adjunct is always done first, so disregard what I just said during your practical! Otherwise, you may have the time to get an adjunct out and place it before ventilating. If you have a hand, one person should begin ventilating while the 2nd prepares an adjunct. An NPA should always be used an a PT with a good chance of waking up (Opioid overdoses usually wake up) or respiratory arrest WITHOUT cardiac arrest. I’ve only ever used an OPA during cardiac arrest. I’m sure this is debatable, but the last thing you want is a PT waking up and vomiting. I won’t go over how to place these airways, as you should have learned that in school.

Now get your BVM and connect to your O2 tank, and crank that baby up to 15 LPM. Bagging without O2 will dramatically slow the time it takes to bring SpO2 up to a good level. First step is getting a correct size mask and creating a good seal. A smaller mask that still properly fits over the nose and mouth creates a far better seal than an oversized mask. If you are by yourself, you will be using the C-E grip (seal the mask with your thumb and index fingers, and pull the jaw forward with your remaining fingers). A jaw thrust is usually taught as your method of opening an airway with suspected c-spine injury, but if that is not suspected, you can still tilt the head AND perform a jaw thrust with your remaining fingers at the same time. Jaw Thrusts have been shown to open the airway more than the head-tilt, chin-lift. You also want to push the face into the mask, not smush the mask down onto the face. If the PT has a large beard, one trick is to use wide medical tape (2” or 3”) to tape over the beard, which may help create a better seal. Research has recently come out about attempting to sit the PT up as much as possible when ventilating to further open the airway (like we do with PTs having difficulty breathing, we sit them up as much as possible to help them breathe easier), but I’ve never attempted this and imagine it may create difficulties when bagging, so I will refrain from a recommendation regarding this. Article below takes about this approach.

MODERN APPROACH TO AIRWAY MANAGEMENT

(This article also has a lot of new approaches to airway management, some of which may not be in your protocols, but hopefully will soon)

Time to Ventilate! Most Adult sized BVMs have a volume of about 1600 ml, but the average adult only has the tidal volume of between 500 and 700 ml (depending on height). So, you do NOT want to squeeze the whole bag. I’m not quite sure why they make them with such high volume, as I don’t think there is any adult who needs 1600 ml of air per breath. Most pediatric BVMs have a volume of about 750ml, so many EMS agencies are taking Adult BVMs out of their ambulances and ventilating adults with Pediatric BVMs (with adult masks, of course) to avoid hyperventilation (which can cause gastric distention leading to vomiting, and low CO2 levels, which can be very dangerous). So you’re going to want to squeeze the bag slowly (1.5 to 2 seconds) and only half way or a little less. One way to practice is to use a BVM on yourself (not kidding, you can do this) and see how much feels like too much, too little, and just right. You may have been taught to watch for adequate chest rise and fall, but with the new AHA recommendations of doing asynchronous ventilations during CPR (Ventilating and doing compressions at the same time, instead of 30:2) even without an advanced airway, how are you going to watch their chest rise while someone is slamming on it 100 times a minute? You can also monitor how well you are doing by watching to see if the SpO2 is rising (this will only tell you if you are bagging too little, but can’t show if you are bagging too much) and, if possible, watching the ETCO2, if your ALS has capnography attached to the BVM (this will tell you if you are bagging too much or too little). The ideal range for ETCO2 is between 35 to 45 mm Hg (below 35 mm Hg means too much or too fast, and above 45 mm Hg means too little or too slow). Capnography is not within most BLS training or protocols, but learning just a little about it can be very useful during respiratory emergencies. It’s also important to stay calm and not bag too fast, which is a VERY common problem. Adrenaline is flowing, and you may not even recognize you are going too fast. So, concentrate on counting in your head to achieve one breath every 5 to 6 seconds (10 to 12 breaths per minute). It may help to count to 4 seconds in your head, then begin squeezing, which will hopefully take 1.5 to 2 seconds, then begin counting again.

That’s it for now. Stay tuned for Part 3: Track Breathing

[readyems]

Basic Airway Management 1

BASICS

This first discussion in airway management will talk about the WHY of good basic airway management, but not the HOW. We will get to the HOW.

WHY is Basic Airway Management an extremely important skill to know and practice?

It is NOT well taught in EMT school. You may practice on a mannequin a few times, then do it once in your practical, but it is a VERY difficult skill, and much different in real life. EMT school is short and a lot of info in jammed in your brains, so there isn’t a ton of time to work on these skills.

You’re going to do it much more than you think! Except for 1 cardiac arrest, it was my job to ventilate with a BVM (commonly called “bagging”). On most of these calls, First Responders are going to show up in droves. Everyone wants to be apart of “The Show” of saving someone from death. Now, let’s assume you have First Responders and ALS on scene. 99% of the time, it should be the First Responders (usually Fire) doing compressions. This is a fairly easy skill that doesn’t require advanced medical knowledge. EMS should be doing them as a last resort or if you have enough manpower to assign an EMT to do it. ALS will be applying the monitor, starting an IV or IO, analyzing the ECG, shocking, pushing drugs, and running the show. So, providing ventilations is NOT their first concern. Intubation usually only happens if you have TWO ALS providers, one of which is not busy assisting with the above tasks. SO ventilation is on you! ALS may be monitoring you, or giving instructions, but plan to be on your own for awhile. Also, once the PT has been tubed, you’re still the one squeezing the bag.

Bagging is HARD. It’s rare we have 2 qualified people available to do 2 person ventilation, as you textbooks tell you you should do. PLAN ON DOING IT ALONE. I’ve only had a 2nd person twice to help me bag a PT. Doing it alone is very difficult and takes practice. Mannequins are VERY easy to ventilate. Humans are NOT. It takes skill, practice, and knowledge. If you haven’t done it, don’t presume you’re going to nail it because you aced the station in the practical. The whole point of this discussion to get you ready for your first time, or help you do it better. Believe me, I’ve done a poor job many times of bagging, even when I thought I was a pro.

This, in my opinion, is the most difficult skill for an EMT, and a good reason you deserve to be called more than an Ambulance Driver. If you are good at airway management, you are a hell of a valuable asset in cardiac arrests and respiratory failure calls.

The HOW is coming soon!

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An easy to check clinical finding for several illnesses. I think the C should stand for COPD, which also causes fingernail clubbing. 

DID YOU KNOW? Clubbing has been recognized as a sign of disease since the time of Hippocrates!!!

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Hacked

I got hacked. Sorry everyone for all the weird, sex posts. I have taken care of it, and deleted all the posts. Sorry!!!

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ECG: quick and dirty

I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career. 

WHEN LOOKING AT ECGs FOR THE FIRST TIME:

1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough. 

2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number. 

3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on.

4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II. 

up in lead I, up in lead II: normal axis

up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)

down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)

5. did someone say HYPERTROPHY?

look at V1

is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.

is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.

  6. P-waves

look at lead II

is it wide? left atrial enlargement.

is it tall? right atrial enlargement.

7. PR interval

should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].

long PR interval means there’s some sort of block at the AV node. 

1st deg block. PR interval is long. everything else is normal. cool. 

2nd deg block

type I: PR interval progressively gets long. eventually a dropped QRS.

type II: PR interval is constant, but randomly dropped QRS. 

3rd deg block “complete block”

there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg. 

8. QRS complex

narrow or wide? 

narrow: good. signal coming from somewhere above ventricles. 

wide: think BBB (bundle branch block)

LOOK AT V1 ONLY.

if the last deflection of QRS is DOWN, then it’s a left BBB

if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap. 

9. ST segment

always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval). 

elevated/depressed… STEMI… duh. indicates ACUTE ischemic changes. 

look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:

posterior up, anterior down

anterior up, inferior down

inferior up, lateral down

lateral up, septal down.  

LBBB can look like STEMI. How to tell?

disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)

concordant changes is abnormal. 

massive discordance is abnormal. (STEMI is greater than 5mm)

this isn’t that important. Moving on. 

Inferior STEMI. Could right ventricle be involved? 

DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.

order a 15 lead

is STE in lead III > lead II? likely RV involvement

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

10. T waves

is it inverted? indicates recent ischemic changes. 

11. Q waves

is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs). 

I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart. 

  Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.

[readyems]

Question of th Day

What is most often the cause of bradycardia in pediatric patients?

A.) Respiratory issues

B.) Cardiac issues

C.) Fever

D.) Immature immune system

Answer is the fifth letter BCDCABACDB

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Contradictions in Medical Education

Atul Gawande From "Complications: A Surgeon's Notes on an Imperfect Science"

"This is the uncomfortable truth about teaching... a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden..."

"As patients, we want both expertise and progress. What nobody wants to face is those are contradictory desires."

"We need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon."

“Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.”

[readyems]

Real World Medicine

Varicose Veins and Bleeding

My first entry of Real World Medicine, which will be cases and topics that are not typically in your EMS textbooks, but you find through experience.

Life threatening bleeding is typically associated with arterial bleeds, and some venous bleeding. But on a recent call, we had a woman go into hemorrhagic shock from a small cut to her foot. We were toned out for “uncontrolled bleeding” and arrived to find a female in her 90s on the floor of her bathroom. There were blood soaked towels everywhere, and the carpet was stained red. The PT had bumped her foot on the side of the table, and gotten a small cut on the side of her foot. She noticed the bleeding while in the bathroom, and tried to control it with towels, but the bleed could not be controlled. When we arrived, the bleed had actually stopped, but the blood loss was close to a liter. The PT was able to speak to us, but quickly went unresponsive. ALS was called and we rushed the PT to the Ambulance. Her SBP was around 90, and she was still unresponsive. ALS was able to provide fluids and bring her BP up and she became responsive. After transferring the PT to the ED, the Dr. told us it was her varicose veins that caused the heavy bleeding. I had never heard of this.

Points of The Story:

1.) Varicose veins can cause severe bleeding when injured

2.) Remember that elderly PTs have impaired ability to coagulate and any bleed will be more difficult to control

3.) Also, elderly PTs can go into shock with higher blood pressures than younger adults. <110 mm/Hg SBP can send a elderly PT into shock

[readyems]

Dating Tip for EMS

On a first date, use SAMPLE questions for conversation starters!