Paramedic Blog

The University of Arizona recently released the results of an important study to the media with the headline, “UA-Led Initiative Doubles Survival Rates After Severe Traumatic Brain Injury“. Dr. Dan Spaite, Chair of Emergency Medicine at the UA was the lead author on the study which was published May 8 in JAMA Surgery: The Journal of the American Medical Association.

The study looked at the success of the Excellence in Pre-hospital Injury Care Project, or EPIC. The initiative was led by the University of Arizona, the Arizona Department of Health Services and more than 130 fire departments and pre-hospital EMS agencies across the state. They compared the results from those using the new guidelines to the results of those not using the guidelines.

The project was funded by a $3.6 million grant (NS071049) from the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health.

They trained more than 11,000 paramedics and EMTs in a new treatment protocol for patients who have a Traumatic Brain Injury or TBI. When the EPIC protocol was applied, the survival rate of severe TBI victims doubled. The survival rate tripled among TBI victims who were also intubated. These are astonishing results.

EPIC is the first major pre-hospital interventional project to evaluate the impact of new TBI treatment guidelines that contradicted decades of widely practiced treatment protocol.

The findings have huge implications for field treatment of severe TBI. Implementation of this new protocol nationally could save many lives.

Under EPIC, first responders are taught to treat and prevent the “Three H-bombs”, hyperventilation, hypoxia and hypotension.

Prior to the implementation of EPIC, first responders were taught to hyperventilate TBI patients with a BVM. This was thought to reduce intracranial pressure and improve survivability. Recent research shows that while hyperventilation reduces intracranial pressure it also deprives the brain of blood and oxygen by constricting blood vessels.

First responders tend to ventilate too fast, leading to hyperventilation. The solution they implemented was simple, using a timing light on the BVM.

The second “H-Bomb” is hypotension. So initiating an IV early is critical.

The last “H-Bomb” is hypoxia. To prevent this, first responders are taught to use high-flow oxygen as soon as possible.

While similar guidelines have been widely used in acute care, this is the first large-scale study that looked specifically at the results of their implementation in the field.

For the complete paper see https://jamanetwork.com/journals/jamasurgery/fullarticle/2732443?guestAccessKey=56106b98-fc45-40b1-a457-dd839a691457&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=050819

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Mercury Medical has a truly innovative nasopharyngeal airway, that they don’t even really market that much to EMS. But it is very cool. I’ve rarely used NPA’s. They are just an awkward fit in EMS.

If a patient is breathing, most of us lean towards a non-rebreather mask. If they aren’t we lean towards an ETT or SGA and a BVM. But this product has changed my mind about both when and how we treat a significant subset of patients we serve regularly.

The typical narcotic overdose is somebody still breathing, but maybe not breathing that great. Respirations 6-8, obviously diminished and dropping respiratory drive. Dropped O2 Sats, Increasing CO2. So what do you do?

Most folks immediately start bagging to assist respirations. Then they bang a big load of Narcan. What happens is the patient wakes up in a few seconds going through withdrawals. EMS looks like a street hero. The patient suffers unbelievable pain.

What if we did this a little differently? The Naso-Flo Nasopharyngeal Airway Device is a soft and gently placed NPA which has an oxygen port. It both helps improve airway control and passively delivers oxygen at the same time.

The real beauty of an NPA is the patient can easily and safely self-remove it. No balloon, they just yank and it’s over. No harm, no foul. Now imagine an airway which is that inherently safe, that can also improve O2 Sats. Clever don’t you think?

The way I would use it is to lubricate the Naso-Flo, slide it in and then hook it up to O2. Then I’d start a line and very slowly start giving small slow carefully titrated doses of Narcan. Just enough to get them breathing decently. Not enough to wake them up or send them into the screaming heebie jeebies.

I don’t have to become an aging WWF wrestler, the patient does not unduly suffer, and we get to take him somewhere where there are professionals that can be his detox support. When you leave a guy on the street after an OD, anything can happen. Maybe they die later today and then you look kinda bad. It has happened.

I love the Naso-Flo because it’s a kindler gentler way. We do what the patient needs, airway and O2 support. We don’t do a bunch of stuff they don’t really need. A good idea don’t you think?

Take a look at https://mercurymed.com/product/naso-flo-nasopharyngeal-airway/

Most EMT’s and Medics measure their abilities on a metric of regurgitation. They are proud of their memory. They are easily able to recite algorithms and treatments, drug doses and protocols effortlessly. They think this is what matters. It’s not.

There are very few things in EMS that are really that time sensitive. By itself that is probably a tough nut to swallow. But it’s true.

We race to the scene with lights and sirens, risking our own lives and those on the roads around us. How many times have you seen a driver on the road suddenly hear your emergency warnings and make about the least logical lane change imaginable?

The most time running hot can save you getting on scene is two minutes. Ditto the trip to the hospital. The trip to the hospital running hot is even less wise. Who can hear, feel, or see much of anything while they are being bounced around in the back of a piece of repurposed farm equipment?

I’ve always wondered if we drove to every scene with no lights and sirens and then did the same thing to the hospital would any patient really be affected? We don’t actually know. But here’s my real point. You can do a great job on every call without remembering much of anything. You don’t need to be in a rush.

In my last paid EMS gig I made a bunch of EMT/Drivers completely crazy because I never went to the hospital hot. I’m not saying I was morally opposed to it or anything. I’m just saying the absolute necessity to do it never came up. I could handle it. Two minutes would not have made a difference. Sure, multi-system trauma with low BP might have pushed me to roll hot. But in a very long time I never had one of those.

You probably carry a smart phone. You can use it to look up almost any information available on the planet. Can’t remember a drug dose? Just look it up, it will only take 30 seconds. Can’t remember how to estimate a burn? Just look it up. Can’t remember how to calculate proper ETT size on a peds patient? Just look it up.

I learned this lesson long ago, when I worked in a busy Emergency Department. One of the best nurses gently reminded me to always use the reference books on the med cart before I gave some drug I was not very familiar with.

I vividly remember the time right before I first gave a patient IV Fentanyl. Long before this was a household word. As I read the reference, my pupils dilated and my heart skipped a few beats. Boy I’m glad I followed her advice and took just a few seconds to pick up the dang book. Now you don’t even need a book. You have a smart phone.

What the phone can’t tell you is how to care for your patient. It can’t teach you compassion. It can’t teach you respect. It can’t teach you empathy.

But it can do pretty much everything else. My advice is to concentrate on what matters. Communications, understanding, compassion and respect. You can’t get that on a smart phone. But honestly, you can get pretty much everything else. You don’t have to trust your memory anymore. Besides, human memory is pretty frangible. Eyewitness testimony in court is notoriously flawed.

Let’s all slow the heck down and concentrate on what makes a real difference in our patients’ perception of our care. Speed doesn’t matter that much if you are a competent clinician. Being able to instantly spew the latest ACLS revision probably isn’t either.

What really matters is communicating that you care and how committed you are to your patient getting better. If you measure your performance on memory you need to understand, memory is a fickle master and is probably not what matters most.

One of my pet peeves with EMS providers is how they introduce themselves to their patient. So many seem to feel this is unimportant and what really matters is their clinical skills. You could not be more wrong. How you forge your relationship with your patient in the first few seconds can be determinative in the outcome.

“Hi, my name is Dan and I’m here to help you.” Look them directly in the eyes. No sunglasses. You need to see into their eyes and they need to see into yours. Don’t erect artificial barriers. Then smile. Shake their hand. I use two hands, one above and one below. It’s an embrace. Be totally sincere. If I had a dollar for every time I’ve seen a Medic skip this important step I could ride buses for free until the day I die.

Let me break it down for you. If they don’t trust you immediately then they are likely to omit telling you things that directly affect your treatment. Sure, you will figure it out eventually. But how long will it take? Isn’t it kind of stupid to build in delays to your care? Aren’t you EMS?

When I worked in an Emergency Room, the smart ER doctors built in a cooling off period. It gave them a chance to sort things out. How many times have you run lights and sirens to the hospital, only to have your patients inexplicably put on a gurney to chill? Sometimes it is because they are busy. But trust me, more often than not it was done on purpose. A little time gives a chance for truth to percolate to the surface. Medics have a very different job.

You need all the information, now. It is so much easier when the patient just tells you up front what all the mitigating factors are. Do you really want to be a veterinarian? That’s the hardest medical job in the world. Imagine you have a 2000-pound patient who cannot say one single word. They can’t even tell you where they hurt or how long this has been going on. I have major respect for vets because they have to do everything based solely on their assessment and clinical findings.

Don’t try to be a human vet. It’s just too hard. We have the incredible blessing of patients that can tell us everything we need to know. All it requires is your willingness to listen and their willingness to tell you. Their willingness to share will largely be based on how you introduce yourself. They have never laid eyes on you before. It’s all they know about you. Think about the implications of this simple but essential step in delivering quality care.

You think you look cool in sunglasses? Fine, leave ‘em in the truck and look cool on the way back to station.

I’m struggling to understand the many posts and stories of LEO’s overcome by trace topical skin exposure to Fentanyl. The typical story line is this stuff is so toxic if it touches you at all you could die. The “victims” wind up getting a lot of paid time off and sympathy.

One of my earliest calls in EMS was to a Baptist church on a Sunday morning. We entered the church and a very large woman was lying on the floor non-responsive. Other women were crowded around her, one of them furiously fanning her face. I could see she seemed to be breathing fine. I shouldered through the crowd and knelt down to take a pulse while asking what happened.

“She fell out” was the reply. I responded, “What did she fall out of?” while scanning around quickly to see if there was a balcony or something she might have fallen from. Boy was I green. Most of you in EMS can probably guess the rest of the story.

More recently I’ve seen FB posts with funny videos of fainting goats. Goats that very similarly to that church lady so long ago, “fall out” with the slightest provocation. I think a version of this behavior is what we are seeing today with these media reports of cops topically exposed to fentanyl.

These LEO’s are the fainting goats of public safety. At least the goats have an excuse, a scientifically explained condition. Notice nobody is pumping them full of Narcan either.

Getting a little Fentanyl on your skin has zero chance of permeating to enter the bloodstream. If it could EMS would be running a whole lot of calls on drug dealers bagging this poison up for retail. It is just nonsense without a shred of clinical evidence backing the claims.

We need to just say no to these hyped up hysterical stories. We have entered the age of The Twilight Zone, a fact free world where truth is not what you can prove but merely what you believe. Medical professionals need to hold themselves to a higher standard. Science demands we stand up to nuttiness.

Last week an important article hit the internet, written by Dr. Joe Holly. I’ve met him and his conclusions should be taken in high regard. This guy is no industry shill. He cannot be bought or sold. He conducts his research with unassailable integrity.

He has been doing cutting edge studies on resuscitation for a long time. He typically spends months if not years, developing models of evaluation which can never be called into question.

In this important article he concludes, “All SGAs aren’t equal. The King and Combitube should be avoided if the goal is to both maintain and allow for the generation of the negative intrathoracic pressure during the recoil phase of CPR.”

It’s really this simple. If you want to improve save rates, don’t hitch your wagon to an old donkey.

Contempt is an insidious disease that steals your heart and corrodes your soul. It happens quietly when you aren’t looking. It starts with seemingly harmless generalizations about the patients that are your privilege to serve. I know how it happens because it once happened to me.

The real cause of contempt is the one-sided nature of EMS work. We don’t see people at their best. We mostly see them at their worst. Recovering alcoholics don’t have much need for an ambulance. But you see folks active in their additions every day. This makes it only too easy to generalize about them negatively.

The same can be said for people from a certain geography or ethnic group. When you run calls in a tough neighborhood nobody ever calls 911 to say, “Hey, nobody on this block has called an ambulance all year.” But those blocks do exist just a stones throw from your busiest response area.

Here’s the rub. Compassion and contempt cannot exist in the same heart at the same time. They are mutually exclusive. If you are genuinely compassionate towards all, contempt cannot enter your soul. So too if you have lost your heart to burn out, real compassion will elude you. Now you are just faking it.

I’ve recently been exposed to some caregivers that are total burnouts. The contempt they feel for their patients dripped from their skin like cold sweat. Those few who were consistently compassionate stood out like rare gemstones. I concluded this was a conscious choice they made every day. I think I know why.

Because being compassionate makes life easier. Contempt is like a corrosive chemical that degrades all goodness. It steals your humanity away one stupid comment at a time. Flowers don’t grow in an acid bath. Caring is just a more natural human condition.

These angels of mercy stand out like brilliant lights in the fog. Everyone they touch feels better for the exposure. They have no room for hate because they are filled with love and gratitude. They are genuinely grateful for the opportunity to be of service.

If you catch yourself going along with someone who is filled with emotional poison know this, your soul is in mortal danger. If you merely smile and refuse to agree or acknowledge the poison, then it can’t hurt you. All it takes is a smile. Then you will be bulletproof. There will be room in your life for joy and fulfillment.

Ever notice how the worst burnouts have the unhappiest lives? Their marriages suck, their children are little monsters, and they are always broke. I’m not sure exactly why this is true but I suspect it starts with the little things. Unhappiness is a choice.

My suggestion is to make the choice to care when you put on your service uniform. Put that commitment into action by being compassionate to everyone. Be even more compassionate towards those that others might not. It will change everything for you. Your world will be brighter and more filled with joy. Your family will love you more. Life will cut you a break once in awhile.

Try it. Prove me wrong.

Finegan Lights are a patented illumination retrofit kit designed to be attached to ground ladders. The retrofit kit does not alter the structural integrity of a ladder and does not affect NFPA certification.

Finegan Lights are the brainchild of Bill Finegan, a respected career Lieutenant with the Philadelphia Fire Department. His outstanding safety innovation has already benefitted from years of testing and careful development. The company is ready to go.

Firefighting is inherently dangerous work and the danger increases exponentially in the dark. A ladder that is capable of illuminating itself and the immediate area is a game changer. Ladders with our lights will be able to illuminate the foundation, exterior walls and windows of a structure, enhancing firefighter safety and offering improved situational awareness at night.

The Finegan Lights will add vastly expanded functionality to a tool you already use. The applications are limited only by your imagination. It’s perfect for portable scene lighting in an MCI. It can be used for lighting up MVA scenes or confined space rescues. Drop four ladders on the edge of a field and you have just demarcated a helicopter-landing zone. The Finegan Lights easily adapt to many different operational requirements.

But most importantly the Finegan Lights will help rescuers see beyond or under a ladder and more easily locate the ladder itself when seconds matter most.

For full product details and participation options see https://www.kickstarter.com/projects/1911005247/finegan-lights-for-firefighter-ladders?ref=537120&token=e5a6ed31