Some notes on cardiac arrest

When I work in the field as a paramedic, there are many strange things that I come across. Strange things in relation to a cardiac arrest situation are no different. Here are a few things I've noted that are funny (though not in the circumstance) that made me take a step back when I got there:

Here's the picture: dispatched out to a 70 year old man in a nursing home..."cardiac arrest". We get there and the patient is, indeed, in cardiac arrest. He is on the bed (which has little cushioning...but it not a firm surface in the least bit) and the staff are doing "chest compressions". Instead of really doing chest compressions, all they are doing is pushing the guy into the bed and letting him bounce back up. No compression of the chest is occurring -- just a lot of bouncing.

This is useless. You can bounce the patient to high-heaven...but unless you compress their chest to squish (really technical terms here) their heart between the sternum and spinal column, you are not going to get a pulse back. Sorry. Compress the chest and there's a chance.

A Grammar Lesson

Bryan Bledsoe wrote an article for JEMS.com (found here) in order to give a grammar lesson for those writing in some official capacity (i.e.: EMS run reports). I could not agree more with what he had to say. I'm going to share some of that, and add a bit more from in and outside the realm of EMS.

You don't need an English degree to understand that phrases like "LOL" or "2morrow" do not belong in any report the fills an official capacity, or even in the corporate world. These are meant solely for the purpose of text messaging between two friends. I heard the other day (from an unofficial source) that "no one" under the age of 20 is sending emails anymore but rather relying on text messaging.

The fact that young people are using grammar like this in their every day life should worry the professional world. We don't need this kind of thing in the workplace. But what's worse is that they don't know how to use words that they attempt to use in every day life. For example:

Staffing the ambulance

I saw a story on JEMS.com about possible staffing changes coming to Austin-Travis County EMS. (Here's the video story of that if you're interested. Here's another story about the same issue.) I have a particular interest in this EMS system. Our former assistant medical director for my place of employment is now the medical director for this system. He's been there for a little over a year now. We miss him up here, but we have a new assistant medical director trying to fill his shoes.

Anyway, the current staffing of those ambulances in A-TC is with two paramedics. A lot of places do that. A lot don't. What they are trying to move to (from what I heard in the story) is to a system with a paramedic and an EMT on each truck. Every rig will still have a paramedic on it.

Here's my take on this:

Pulmonary embolism: diagnosis and treatment in the hospital setting

I know this will be very exciting for many of you. For work, I was asked to read an article and give a summary of it. This is a review article on acute pulmonary embolisms and how they are treated and dealt with, mainly in the hospital setting. 

For your pleasure, if you want to go and find the article:

Agnelli, Giancarlo and Cecilia Becattini. (2010). Acute Pulmonary Embolism. The New England Journal of Medicine, 363(3), 266-74.

A pulmonary embolism is a serious problem that should be considered in several classes of patients.  Those with new or worsening difficulty breathing, chest pain or sustained hypotension without an obvious alternative cause should be assumed until proven otherwise.

Each patient should undergo a clinical probability assessment to determine the likelihood of the patient experiencing a PE through either clinical judgment or clinical decision rules (Wells and revised Geneva scores). During the assessment, the patient is determined to be hemodynamically stable or unstable. The stable category is split into two further categories: low/intermediate clinical probability and high clinical probability. Those with the high clinical probability will proceed to the CT scan to confirm or rule out the presence of a pulmonary embolism. The low/intermediate clinical probability group will receive D-dimer testing. The results of that test will determine the next step for the patient. Caution should be used for elderly patients, pregnant women and patients with cancer as the specificity of an increased D-dimer level is reduced in these populations. A normal D-dimer result rules out a pulmonary embolism. If it is elevated, the patient is sent to the CT scanner to determine the presence or absence of a PE.

Deoxyribonucleic acid

DNA.

It is a complex code of our genetic material that can predict most of who we are, particularly physical characteristics (emotional, personality and mental characteristics are more "nurture" than "nature").

DNA sample

So, what is it's physical structure?

This is a structure called a "double helix". A double helix is a pair of parallel helices intertwined about a common axis. Great...but what is a helix? That is a curve that lies on the surface of a cylinder or a cone and cuts the element at a constant angle. Still confused? The way I think about it is a ladder that is wrapped up into a coil. Here is an artists rendering of a piece of DNA.

See what I mean? So what is it's purpose?

Dangers of detergent suicide

Detergent suicides are gaining popularity in the US after getting their start in Japan a few years ago (that's when we first started hearing about them). Unfortunately, as they gain popularity, emergency responders have a new level of danger that we need to be on the look out for. What's even more problematic is that we are not always aware of this danger until it is too late.

So, just how prevalent is this? Honestly, I do not have any figures or data to show how frequent these are becoming. With that said, this is something that as I searched Google for stories about detergent suicides. I turned up several articles very quickly about where and when this has occurred. I found a story of a man in Pennsylvania who used this method of suicide earlier this month and one that occurred in Florida in March earlier this year.

There are also articles about detergent suicides that are readily available that provide the "recipe" for creating this disaster. Ethically (and morally), I am unable to provide this "recipe" for you, nor will I provide a link to it. However, if you really want it, you can easily find it. When I did a search, the first few results were, on the whole, about how to commit suicide using this method, and not about the lives that have been lost as a result of people believing this is a way out.

There have been a few of these in my response area -- 2 that I can recall with the most recent that I am aware of being only 6 months ago. So, the question becomes "how can we protect ourselves?"

For starters, you need to be aware of the locations which this type of suicide usually occurs. Most often, it is done in some vehicle -- but it needs to be in a relatively small and enclosed space.

CPR Standards

Over the past decade, CPR standards have drastically changed. We have seen a change from what health care workers have done and also what lay people are being instructed to do if someone happens to go into cardiac arrest (this is when someone stops breathing and their heart stops -- this is different from a heart attack, although one can precede the other).

What we were once told was, after we determined that the person is not breathing, to perform a series of rescue breaths and chest compressions. Compression and breathing ratios have changed over the years, as well. We have seen a 30:2 ratio and also a 15:2 ratio. I honestly don't know what the current standards are because, well, we don't follow them where I work. We do something a little different and it works.

We do continuous chest compressions. These chest compressions are not stopped except for two things: to check a rhythm and to defibrillate (shock the heart). Even though we stop for these times, our goal is to minimize the time that compressions are not being performed to next to zero. The more time that you are not performing these chest compressions, the patient has an exponentially higher chance of not surviving. We want to give them every chance we can and thus we do everything we can to bring them back. Sometimes this happens and sometimes it doesn't. That's just the nature of the problem.

When I have talked about this in the past, I have been asked why we don't breathe for patients anymore. Well, we do. When EMS gets to the patient, we breathe through the compressions. However, what is now being recommended to the lay population if they witness a cardiac arrest is to also do the continuous compressions and not breathe for the patient, either through mouth-to-mouth or with some kind of barrier device (which also is a good thing because it eliminates part of the "eww...gross" factor from helping someone in need). This article caught my attention from Fox News about this very thing. I have not seen the study but I can tell you that with what we have done where I work, we have increased survival rate just by changing the way we do CPR with continuous compressions rather than some ratio of compressions to breaths.

"Top ten words that should be in the EMS dictionary (but aren't)"

First off, I'm borrowing this from EMS1.com. Somehow, they got my work email address (not sure how I feel about that one because I certainly don't give that one out) and they end me emails about some of their columns. Anyway, one of their columns last week was written by Kelly Grayson, who I quickly recognized as the author of a book I have: A Paramedic's Story: Life, Death and Everything In Between. Good book. If you're interested in some of the finer points of EMS and don't think I share them completely, his book might give you some insight. (Either his, or I would recommend Blood, Sweat and Tea by Tom Reynolds.)

But you came to hear about the top ten words that should be in the EMS dictionary but aren't...not Suzanne's book club recommendations.

At number 10 -- "incarceritis: a constellation of medical complaints brought upon the imminent threat of legal confinement. Symptoms include, but are not limited to: dyspnea, chest pain, syncope, seizures, incontinence and coma."

Number 9 -- "malignorance: combination of the words 'malignant' and 'ignorance,' when ordinary, every day 'stupid' doesn't even begin to describe the patient's behavior."

Number 8 -- "tachylawdia: condition in which the patient or family member repeats 'Lawdy!' more than 100 times per minute. The condition often presents with PJCs (Premature Jesus Complexes) and, depending upon the patient's religious fervor, intermittent 'Amens.' Often considered a hallmark sign of status dramaticus.

Example: 'The patient exhibited tachylawdia with bigeminal PJCs and intermittent Amens.'"

Coming in at number 7 -- "polybabydaddia: condition affecting females under age 25, who have three of more children by different fathers."

Number 6 -- "status dramaticus: disorder in which the patient exhibits seizure-like activity characterizes the lack of urinary incontinence, presence of coordinated muscle movements, and the absence of an appreciable postictal state.

Patients suffering from status dramaticus usually skips the tonic phase altogether. The condition is often exacerbated by an audience of medical professionals or concerned family members. Usually, the seizure-like activity is broken by the insertion of a nasopharyngeal airway or the phrase 'hold still, big stick...'

Sub acute status dramaticus may often mimic tachylawdia, and many experts believe they are the same disorder."

Splashed Saddness

This is taken from a blog called "Life Under the Lights" about EMS. The article is entitled: Splashed Saddness - A Look at Negative EMS Emotions. While this is not the entirety of the artile, this is a nice excerpt that made me laugh (particularly the last part). Basically, there are three different stories from the writer, all of these are calls that he has run in his career. I find the comparison of the reactions between the two groups (laypeople and EMS folks) to be very accurate. Now, after reading this, perhaps you will understand part of why I am weird. (If you want to read the entirety of the article, here is the link.)

· A 16yo male takes his 24yo soon-to-be brother in law out into the city for the 24yo’s bachelor party. On the way home, they’re both just obliterated after drinking all night. The 16yo boy is driving home and is going way too fast to notice the semi hauling gravel that pulls into the right hand lane of the 4-lane road they’re driving on. The kid notices it at the last second, swerving just in time to impact the passenger side of the car against the back of the semi trailer. The impact shears off the left side of the 24yo’s skull, popping out the left side of his brain and leaving it, mostly intact, in between the front seats of the car (I almost put my knee into it). The 24yo dies a not-so-immediate death (I don’t want to get into it. Hopefully it was mostly painless). I pronounced the 24yo dead and took care of this very intoxicated 16yo. He was barely able to comprehend the terror of the situation and was covered in blood and brains that formerly belonged to the man his sister was going to marry. He was unhurt but I ran him into the hospital anyway. How could I leave him there immersed in the terror of that scene, in the terror of what he was more or less responsible for?