Category Archives: Tips/Tricks

Cool The Jets

Be cool!

Easier said than done. Well, unless you’re me, and even I have to tell myself to be cool sometimes. It’s easy to forget.

So why is it so hard for the new guy to be cool? It’s pretty easy for the new to get flustered. The business of an emergency scene can be overwhelming for that person without much experience around them, so it falls to the more experienced to carry most of the way while a new EMT copes with the shock of the dead and the actively dying. Even EMT’s that have been EMT’s for a while but have never touched a 911 scene can get nervous when presented with a scene that involved the need for quick wits and thoughts. It can be exhausting and in some more seasoned providers it gets expressed as frustration.

I can see why those thoughts might be racing by. The directions of a seasoned EMT or Paramedic seem like commands from a god on high as they always have the right timing for a procedure or their own system of doing things that seems so organized it makes what the new EMT would be doing seem too easy.

The answer is simply exposure. The more memory cards a provider gets based on what he or she is exposed to, the faster their recall becomes, and the faster and better organized the thoughts come about what to do next. Especially if a new EMT and an experienced provider are paired together, if the senior provider is a good teacher then it’s likely that healthy habits will develop and continue on the health of the organization towards a more… sublime existence.

So, experienced providers, don’t get so frustrated with your green folks. Teach them and have patience enough to guide them towards healthy habits and patterns, you might need those habits in a pinch some day.

Waveform Capnography Part 3

Wow, it’s been a LOOOOOOONG time since I visited this category. Sorry for taking so long with Part 3, if you need to knock the cobwebs out of what I’ve written on this topic in the past here is Part 1 and Part 2.

Ok, so what did I promise you the last time? Oh yes, patterns in different respiratory issues.

So the last time we talked about this we played with the normal pattern for a ETCO2 waveform, which is the equivalent of a plateau with fairly sharp delineations between phases and the normal values of exhaled CO2 being between 35-47 mmHg. So now that we’ve established what “normal” is, let’s look at some things that aren’t normal.

Abnormally High Numbers and Funny Looking Waves

“Hey RJ, the numbers were like 50 mmHg and up the last time I used capnography!’

High numbers indicate CO2 retention (bonus question: which is common found in what respiratory condition?) which means that the patient isn’t moving any CO2. You can fix this with mechanical means such as a BVM or CPAP (if the assessment indicates obstructive
pulmonary disorders) or if the respiratory depth is adequate, you can try using a non-rebreather mask.

I will tell a story. When I was a medic student riding at Xenia Township in Ohio, we responded to a report of an unconscious female out in the sticks. On arrival, we found a 60-some odd female lying on her couch. She was obtunded, with questionable pupil size, normal blood glucose, depressed respiratory drive, sinus rhythm, normal 12 lead ECG, and a slightly elevated blood pressure. We expedited her transport, and we couldn’t wake her up despite the use of naloxone (we suspected she had overdosed on recently prescribed pain medication) and a questionable CVA screen. Turns out, it was none of the above. Had we placed a capnography probe we would have found her PETCO2 to be in the 60-80 mmHg range and could have corrected her mental status change using mechanical ventilation.

Why tell you this? Because the technology was brand new to EMS then (it was a new feature on our recently upgraded LifePak 12’s) and if we had dug a little deeper we would have found COPD in her history, specifically chronic bronchitis. We could in-lined a breathing treatment through the BVM and created positive pressure in her alveoli and open them up, creating the release of trapped air and bringing her back to normal level. The next time we encountered her with the same issue (which was about 3 months later) I knew exactly how to correct her problem. 80% of all diagnosis is history related (and we do diagnose, don’t get me started) so make sure your history is as complete as the situation allows.

In bronchospasm (which is a form of pulmonary obstruction), the waveform, when analyzed closely, may look like something of a shark fin. Why is that?

Well, the Expiration phase (which is the Phase I and II waves) is prolonged due to obstruction. This makes the wave kind of smooth out a bit as the patient attempts to force air through the obstruction. This patient may exhibit the classic respiratory distress signs such as tripoding, nasing flaring, etc, and will appear in trouble before you even put the probe on. As you remember, those breathing patterned are typical when the patient is attempting to increase the PEEP (positive end expiratory pressure) in response to air trapping.

I’ve also seen the numbers high in a post arrest in the presence of DKA, the science indicates that PETCO2 is an accurate measurement even for regular patients in DKA for PCO2, which can help you determine if DKA is present.

This is kind of a quick end to a long standing series but I wanted to put out an ending like I had promised so long ago.

http://en.wikipedia.org/wiki/Positive_end-expiratory_pressure

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001153/

http://emscapnography.blogspot.com/

http://www.capnography.com/

The Art of the Narrative

I was jogged back into training mode the other day by a trainee (and a supervisor) when we were discussing narratives. While I feel that his presentation of a patient care report was a bit dramatic and over-reaching, I think it’s something that may need to be touched upon while the thought is in my head.

What exactly does the narrative do for us in a patient care report?

It is written that a narrative completes the permanent record of a patient contact.

My take is that it provides details about the contact that otherwise were not available in other parts of the report. It functions as an overall summary of the contact and findings noted in the report. When instructing trainees or students how to write narratives, I start with the two standard formats that I was taught as a young padawan.

The first was SOAP

  • Subjective
  • Objective
  • Assessment
  • Plan

I remember this format in a way that when I’m writing in this format it is always “what I’m told, what I see, what I examined and how, and what I did about it.” It’s not my favorite format mainly because a lot of times I gather history from places other than what the patient tells me because often the patient doesn’t even know their own history.

I prefer CHARxT

  • Chief Complaint
  • History
  • Assessment
  • (Rx) Treatment
  • Transport

I like this method because it allows me to meld different sources of history into one concise location. It makes no sense to me, when you mention history as in SOAP, that you make multiple notes from where you got all the history from. Examples include one source of past medical history (PMH) from the family (whom I usually ignore unless they sound like they know what they’re talking about) and the medications you have on hand that belong to the patient what they are saying conflicts. The weakness of this format is that cardiac arrests usually fall under both Treatment and Transport, so it gets a bit confusing unless you combine to two.

Basic Components

Each contact you document, SHOULD have at minimum 4 components and at maximum 5.

Those 5 are:

  • Patient Contact/Chief Complaint
  • History
  • Assessment
  • Treatment
  • Disposition (Treat and Release or Transport)

Patient Contact/Chief Complaint

This is where you contact the patient and figure out why they (or someone else) called 911. If grand-daughter called 911 because grandma was snoring very loudly and wouldn’t wake up, her words should be placed in DIRECT QUOTES. If JuneBug called because his arm felt numb after sleeping on it, what he tells you should be in DIRECT QUOTES. Are you getting the feeling that what the patient tells you should be in direct quotes?

Why direct quotes?

It highlights the best reason why you were there (as legitimate or ridiculous as it sounds) in the patient’s own words.

Other information about initial delays to contact like access delays, unsafe scenes/staging, language barriers, patient belligerency, etc, should go in this section.

History

You should SUMMARIZE patient history in this section. 80% of your initial working diagnosis and that of the hospital is based upon how well you gather history. Putting notes in about grandma’s toe jam and recent ingrown toe nail surgery isn’t that significant unless you are talking about possibly sepsis or a problem with that area. It may be significant in diabetics, but if grandma is otherwise healthy, usually not significant. Use your clinical judgement.

Assessment

This section will include all of your medical findings. I always include a head-to-toe summation of findings similar to what the transcriptionists use with hospital summary of findings but in a paragraph format. I also put information in here about invasive findings like blood glucose levels and a detailed interpretation of 12 lead ECG’s and monitor showings. If the initial blood pressure was anything but within a “normal range” and requires some sort of intervention, then I include some vital signs here, but that’s not a usual occurrence.

Rx (Treatment)

This is all the stuff you did. IV starts should include the bore size and location as well as number of attempts, and intubations are the same way and should include information regarding the number of passes required, capnography findings, depth at the teeth, and so on.

Disposition

How you ended the call is just as important as everything else. If you released the patient (with or without treatment) then you should note mentation and other competency proving items. If you transported, then you should include how you got them onto your cot/stretcher/pram/whatever you call it and to the ambulance, what happened on the way to the hospital, and information about the hand-off like how you got them off your bed. Notes on the patient’s condition en route and at transfer of care should also go here.

These are guidelines, and you should always follow what your organization orders you to do, but it will usually fall back to a basic diagram like what I have shown.

Stay Classy.

Just An Observation

I find it interesting that, nearly 2 years after posting it, my post regarding IV starts is still among the top visited pages in my entire collected works. I may have to follow up on that, maybe go over some other videos on skills necessary for technicians and clinicians alike.

So, in that vein (pun intended), please comment here on some skills that you rarely use or have never seen done (I can’t do needle thoracostomies or tracheotomies on live people but I may be able to get in position to do one on a mannikin/SimMan or similar) and I will shoot it in video or pictures for you to see.

Waveform Capnography Part 2

So we have covered the physiology of respiration, now we are going to cover the waveforms and what each part means.

We know that capnography is the measurement of exhaled CO2, so how does the monitor interpret the action of cellular respiration and ventilation into something we can use?

The capnography probe on many popular monitors used in EMS and transport services works by one of two principles, but how they measure the sample is basically the same. They both use infrared measuring of the exhaled gas and measure the absorption of the light by the gas molecules. This is called molecular coorelation spectroscopy. I’m going to expect you to understand it, I’m not even sure I understand it totally. So, on to how it measures a sample.

One method is “in line” capnography, meaning that the probe is attached directly onto the source and measured there. If you have ever seen a funny looking clip with a red light on an ET tube that leads back to the monitor, you’ve seen in line capnography. Many flight services like this because it supposedly gives a more accurate reading because it’s measuring at the source. Also it is less likely to be contaminated and is reusable because it is not in the way of being contaminated.

The other is “side stream” capnography. the probe is placed directly into the path of air travel and a small pump inside the monitor draws a sample in to the infrared sensor. This is a pretty popular monitoring method for EMS, and even now in hospital settings because the sampling devices are cheap and disposable, where as the in line devices are extremely expensive. I had a capnography probe interlinked with my pain pump during my last surgery to monitor for respiratory depression in case I accidentally overdosed myself.

So anyway, now that we know basically how the CO2 is measured and how it gets into the monitor, we need to talk about how it is displayed, and what each part of the displayed waveform means. The waveform has 4 phases, and once you understand these phases you will understand how to quickly interpret, diagnose, and treat respiratory emergencies.

Phase 0

Phase 0 is inspiration. This is where the amount of CO2 being inhaled is at 0 mmHg, which means that none is being exhaled. This is the sudden sharp drop and flat line of the waveform. Anatomical dead space is created here, where air inhaled does not come into contact with the alveoli for gas exchange. This includes gas in the mouth and trachea, anywhere but in the alveoli. The baroreceptors in the chest signal the brain that they are reaching their limit and inspiration ceases.

Phase I

This is where the expiration occurs. The pressure of exhaled CO2 rises as the respiration cycle continues as the pressure in the chest begins to drop.

Phase II

This is where the pressure of exhaled CO2 plateaus and begins to level off as expiration reaches the end of it’s cycle. The baroceptors in the chest signal the brain to stop exhalation and

Phase III

Phase III is where the CO2 level peaks and the brain’s baroceptors in the chest as well as the chemoreceptors in the brain signal that the oxygen concentration is low and to begin another inspiration cycle.

The computer in the monitor displays this in a waveform:

Next time we will talk about normal pressure ranges and the appearance of the waveform in different respiratory conditions as well as it’s usefulness in CPR.

Waveform Capnography Part 1

It’s been a long time since I’ve posted anything instructional, and looking at the sheer size of the topic I decided to separate this into multiple posts just to over it all. This post will cover the basics of waveform capnography as well as some anatomy and respiratory physiology that is important to understand as you begin to interpret waveforms.

So what is capnography?

Simply, capnography is a measurement of exhaled CO2. We already did this previously with colorimetric CO2, however, unlike colorimetric monitoring, capnography is not affected by alcoholic beverages or other carbon dioxide producing agents that are exhaled. Also capnography does not take “a few breaths” in order to display a change in the measurement, the change is instant when being viewed on the monitor.

You should also keep in mind that capnography and oxygen saturation are two different measurements. spO2 measures “how much” oxygen is attached to the available hemoglobin. As you also know, spO2 is easily fooled by carbon monoxide as it bind with hemoglobin. The spO2 sensor will detect carboxyhemoglobin and only see that something is bound to the hemoglobin and give a false reading. For an in depth video on hemoglobin, check out this video

Capnography will also be an accurate indicator of perfusion and the effectiveness of your or their respiration or ventilation at the cellular level. This is due to several physiological processes that occur with respiration. It is important to know because it is vital to understanding exactly how capnography works, and diagnosing and treating respiratory problems and illnesses more effectively.

The first thing to understand about cellular respiration is that it takes several different actions working as one. It takes oxygen from the lungs, glucose from the liver, and in the body cells it takes insulin produced by the pancreas. Insulin acts as a transporter, carrying glucose into the cells from the bloodstream. Brain cells are the only cells in the body that use glucose directly from the bloodstream without needing insulin. This is because insulin can not cross the blood/brain barrier, which is why when the glucose level in the bloodstream drops confusion and neurological disruptions result until the glucose level is restored.

When you breathe in, oxygen and carbon dioxide exchange places at the capillary beds in the alveoli. The outgoing CO2 is waste product from the cells, which means that cellular metabolism is taking place. The membrane barrier in the alveoli is in fact so thin that it allows oxygen and carbon dioxide to diffuse at the molecular level using a pressure gradient. The oxygen is then picked up by the hemoglobin forming and carried to the cells. When it reaches a capillary, the barrier thins again allowing molecular exchange using the same pressure gradient. When measuring blood gases, there are several different terms used to express this function, PaCO2and PetCO2 are the most important.

PaCO2 is the partial pressure of CO2 in arterial blood. This number should be small and the PaCO2 actually serves many functions. Your brain regulates your breathing rate and blood pH by monitoring this. If the pH of your blood stream increases, this number will increase, which increases your respiratory rate and depth in an attempt to “blow off” the additional acid. You see this in active DKA patients, as it is a very early sign of acidosis.

PetCO2 is the partial pressure of CO2 at the end of expiration. This measures the concentration of the carbon dioxide in the alveoli as they empty. This is an important indicator of many different metabolic functions. The main ones we are interested in is cardiac output and and adequacy of ventilation. If cardiac output is low or ventilation is inadequate, the measurement will be low because carbon dioxide is not being exchanged at an adequate rate.

That’s enough physiology for now. In Part II we will begin covering the waveform, it’s parts, and how it relates to the physiology of respiration.

Sources

Kodali, Bhavani-Shankar. (June 2010). Capnography In Emergency Medicine – 1911. In Capnography. Retrieved from http://www.Capnography.com.

IV Techniques – A Commentary

Since I’ve started chemo, I’ve been getting weekly and some times daily IV starts. This gives me kind of an interesting point of view on how different people start IV’s, and their techniques. I have three primary oncology nurses that I deal with, two experienced nurses and one who is relatively new to chemotherapy. Funny enough, her and I started into chemotherapy on the same day, so she is still technically “in training” but they let her do her own thing for the most part. She starts a great majority of my IV’s, so I see a lot of her technique. She does fairly well, but I get concerned over her ability sometimes. It seems she likes to palpate the vein to make sure it’s there, and this relays to me (as an experienced IV starter and teacher of technique) that she isn’t confident with her own skills on an otherwise healthy adult.

It’s amazing how just watching someone can give me an idea of how confident they are in themselves and their skills, but that’s another post.

This brings me to the whole point of the post. I have several tenets of IV starts that I think are important for your own well-being, and that of your patient:

  1. Don’t spend too much time looking around – the more time you look, the more your patient’s confidence in you degrades
  2. You don’t ALWAYS have to palpate the vein – many times, “aiming for the blue line” will work
  3. When you select a site, don’t keep palpating it with your ungloved hand – if you know where you want to go and don’t want to lose the site, I’ve found using the corner of the alcohol prep as an arrow to where to put the needle as invaluable
  4. The start should be at a low angle – you can always adjust if needed, but a high angle will increase the chance you will pass through the vein and never get a flash till you back out, and unless you are VERY skilled, you will not get the catheter to thread properly
  5. The skin penetration should be quick and fluid – the faster and smoother, the least likely that your patient will react to the pain. Indeed the hardest part of the whole IV start is the skin penetration itself.
  6. Set up before you begin – having a flush ready or a bag spiked before you even bring out the needle will make the whole start that much faster
  7. Occlude hard – I’ve found that pushing on the vein distal to the catheter, unless you have a strong thumb or fingers, will not stop the blood flow into the catheter. If you occlude on or very VERY near the distal end of the catheter you will have a much easier time stopping the blood flow. Also, it’s a general myth in medicine that as little as 5cc of air can cause an embolus, it may, but the chances are very slim. Some air between the lock and the catheter in the hub is ok, so long as you minimize the amount of air in the whole system you will be fine. The body will press into solution the oxygen and nitrogen, so unless you dump a huge quantity into the venous system, don’t worry about backing blood all the way back up to the end of the catheter hub, you will only make a mess.
  8. Withdraw and dispose of sharps properly – don’t let them stay on the floor, or the bench seat, don’t stick them in your jump bag or anywhere else other than a sharps container.
  9. If you miss, don’t worry, but don’t be vindictive – don’t make it your personal mission in life to get an IV on someone when you’ve already missed more than twice, unless they REALLY need it. Then again, if they need it that bad, we have other means and locations of access (IO devices, external jugular, etc). It makes me a little upset when a medic tries forever to get an IV peripherally when they should have moved on to other more invasive routes. I’m guilty of it happening to me, I got tunnel vision on one task and neglected all others. Learn from my mistake, miss two times, that’s a sign, look somewhere else. They may not even need it that badly to begin with, so re-examine your motives and their stability. I’m not a fan of precautionary IV’s unless I think I may actually need to use it, so save your needles for the sick ones.

That’s all I got. I have a previous post about IV techniques here and here if you need to refresh your memory.

Dealing With It Part 1

Let me preface this by saying that I have no formal training in psychiatry, psychology, critical incident stress, philosophy, religion, nor do I think that how I deal with things at work will work for you. If you have problems with stress or are abusing drugs or alcohol because of stress at work, or have considered harming yourself or others as a release of stress, you should call your local suicide prevention or employee assistance program (EAP) immediately for help. If you don’t want to talk to people on the phone, you should talk to a supervisor (they are usually trained for this) or co-workers, or a priest/chaplain/rabbi/imam/pastor. Even if you are not religious you can contact a place of worship and most have prayer rooms or pastoral care. Even your family physician can provide you with referrals to the care you need. Do not try and cope on your own, because you don’t have to.

Having served 3 years in Memphis (at fairly busy locations) I have seen a few bad nights, and a few bad days even. When I was in the suburban and rural areas in Xenia, we saw more than a few bad nights. It seems to be a constant in fire and EMS that we have some nights that just beat us into the ground and test our mental reserve, endurance, and medical meddle. A friend came to me recently with a busy night in progress, I tried my best to impart what wisdom I had acquired from the busy and mean streets of Memphis:

1) Focus on why you are there

This business is full of ups and downs, and sometimes we lose focus of the purpose of the job. We are here to help people and when something is happening in someone’s life like they just saw a fiery crash on the highway, the baby stopped breathing, grandma hit the floor and isn’t moving, you will be sent to the scene in grandiose fashion in a loud fire engine/truck or ambulance with flashing lights. If you have arrived on scene and went “oh sh*t” to yourself as you pulled up, you know this feeling. This is a people business, and bad things often happen to good people usually at the hands of someone dumb and now you have to clean it up, so you should first remember that these are people you are dealing with, not high fidelity skills manikins.

2) Take a moment to breathe

Whatever is in your head, slow it down, break it down to details. Talk it out, step by step. I’ve said it before that the devil is in the details so you should examine yourself and your crew. Before you put pen to paper, or fingers to keyboard in my case, to write/type your narrative slow everything down and breathe, slow the call down from beginning to end. Then perform step #3.

3) If you have something to say, get it out

Just what it says. If something went to hell in a handbasket or you are displeased about an action or a partner’s actions or you just have something to say, don’t leave it unsaid. But above all things, be tactful and respectful. Better your partner know where you stand and you of them, than you let there be something unsaid between you. That could make it out to be a LONG rotation. After all of this, do step #4.

4) Let it go

If you made a mistake, still hear the shrieking of a frightened parent, still see the face of the kid pinned in the car, or got upset at something that happened on the call, you need to do #1-3, then do step #4. You can’t do the next patient any good if you are still thinking about the last one, and you can’t go home if you are getting paid (unless you are sick or injured, different story). That is the difference I have noticed from when I went from volunteer to paid, I can’t quit in the middle of a shift, so it becomes less like a sprint and more like a marathon. You have to build up your endurance to run the long race. Part of that is letting go. What helps me is that once I close out a ticket, the call is over for me (unless I’m blogging about it, then I take notes) but the key is to move on to the next patient.

In Part 2 I will tell you my own story about dealing with stress, and how it applies to all of us.