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EMS practice

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Did anyone else play a sport (or sports) in high school? I did, actually I played football for a few years. I was on the line, which in my small high school meant that I played every position on the line, both offense and defense, because there just weren’t that many kids out there to play. My graduating class was 83 in my small, small town.

I didn’t touch the ball though. Coach told me just to go out there and hit people. I haven’t touched a football since.

Every day after school we went out there no matter rain, shine, snow, heat, or better things to do and practiced for three hours every night. We did this all season and I hated it. It sucked and sucked bad. However, it did make me a much better football player. It kept my mind focused and kept me in shape. I was a much better “Go out there and hit people” guy than I would have been had I just taken a football class and then played parts of the game every day.

Does anybody do this with EMS? Sure, we all do Continuing Education, but do we really practice as hard as we should as much as we should?

We play parts of the game every day but just as sure as I didn’t intercept a pass and run in a touchdown every game, I don’t perform a pericardiocentesis every shift. I can plink in an IV in my sleep (and do… a lot…) and I probably can treat a STEMI as good as the next guy. Playing the parts of the game that we do more often than the others gets us good practice on what we do most often, and if we don’t allow ourselves to get complacent, that’s just fine. However, how many times have you calculated a dopamine drip lately? Even if you live in the busiest, most dopamine swillingest jurisdiction on the planet you’ve still interpreted Normal Sinus Rhythm a lot more than you’ve shown off your math chops.

The other day I missed a tube. I was caring for a patient who crashed in front of me while heading to the ER. The Pt went from CAOx3 to very obtunded in a matter of a minute or two. The first time I went to tube, (the Pt) was clenched and by the time I got the etomidate ready we were close enough to the hospital that bagging was my best option. When the Pt got sux and sedate juice in the ER I tried again…. and missed.

I freakin hate that! Man, I never miss a tube! At least almost never. I hate it when I do and beat myself up about it. Probably more hard than I should, but that’s just me. I take this stuff seriously if you can tell. The next shift I spent an hour playing with our two intubation dummies and our “Fred the head”. I tubed over and over again every way I could think of. For an hour. Yes, I know that it’s not exactly like the real thing, but it was all that I had access to for practice.

Something cool happened right after I got done with my hour long tubing pennance. I sat down for lunch and immediately got toned out to intercept a code with CPR in progress. I pointed my SUV towards the rural address and hit the gas. When I got on scene, the BLS crew told me over the radio that they were having difficulty with the airway. I walked in, and got the most beautiful tube that I think that I’ve ever gotten. Right in, right through, and right hole.

I think that my football coach would have been proud.

Posted by on February 1, 2010 • Filed under: ALS Intercept, Emergency Medical Services, EMS, ems education, EMS Health & Safety, EMS practice, ems scenario based education, EMS Topics, EMS training, EMT, ET Intubation, Fire department, intubation, Paramedic, paramedic education, Patient Management

Advances in Resuscitation – CCR If you’re not doing it now, you will be

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Visitors to my old blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at Http://www.callandpump.org But if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”

This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing, and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID protocol (I put it up in a post) you can see it by clicking here.

Today Dr. Kellum came down again for our monthly training and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them.

Posted by on October 17, 2009 • Filed under: CCC, CCR, cpr, cpr save, DNR, Do Not Resuscitate Order, EKG, Emergency Medical Services, EMS, ems 2.0, ems education, EMS practice, EMS protocols, EMS Topics, EMS training, ET Intubation, ez-io, intraosseous, IO, IV, new perspective, Paramedic, paramedic education, patient care, Patient Management, save, SMG, SMO, southern wisconsin, STEMI, technology-communications-ems-topics, Training & Development • Tagged: , , , ,

Daily Training Topics 10/16/09

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Just about every 24 hour shift that I work up in my Northern job I put together a little impromptu training session. It’s a way for me to address things that I think are important for the crews to refresh on as well as a way for me to read up on some things and make sure I remember the stuff I should know. I try to learn the latest things on the chosen topic with a bit of research before I present the class as well. It keeps me sharp, which is good.

Also, (and let’s talk about the important things here) it gives me a cheap and easy blog post which I like because I’m really trying to bump up my posting frequency with this Fancy New Blog and all that.

Today’s training topics were a refresher class on intravenous access as well as BLS Airway Management Skills. We have a good number of EMT-Basics, EMT-IV Techs (here in Wisconsin) and even an EMT-Intermediate ‘99 that are on-duty today. My partner and myself (incidentally, both named Chris) are the duty medics.

So, without further ado, here’s what I taught them. Remember, this was a BLS class, and is geared to newer providers.

- IV Skills: I didn’t do anything on my own here. One of the benefits of the EMS blogosphere is that I have a wealth of training information at my fingertips. A lot of the time, I’ll pop on over to see what Greg Friese is doing on Http://www.everydayEMStips.com – And if I’d like some in-depth EMS knowledge, I’ll head over to Http://paramedicine101.blogspot.com.

For this training, however, I took the tips laid out by Steve over at Http://www.theEMTspot.com – where he wrote “Six Techniques to Nail the IV Every Time” I put it up on the projector and wrote down the bullet points on the white board. (and I gave him the credit for the easy and valuable training both in the class and on here)

- BLS Airway Management knowledge:

For this one, I pulled out every airway and oxygenation management tool we carry in the truck, which in my service includes:

- The Oropharyngeal and Nasopharyngeal Airways

Do you know when to use one over the other? Here’s some tips. First, if the patient is unresponsive enough to take an oropharyngeal airway without triggering a massive gag reflex, the patient NEEDS an oropharyngeal airway. (or an ET tube/Combitube/King LT for that matter)

Nasopharyngeal airways are used for patients unresponsive enough to need an airway adjunct but that still have an intact gag reflex. DO NOT USE nasopharyngeal airways in cases of head or facial trauma. (Why? Because the nasopharynx is separated from the rest of the cranial vault by the Cribiform plate, which is a very thin piece of bone that can be fractured very easily with significant head trauma. If it is fractured, you run the risk of placing the nasopharyngeal airway – or the nasogastric tube for that matter – right into the cranial vault… which is bad. 

The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw. The Nasopharyngeal airway is measured from the nare (nasal opening) to the earlobe.

On a side note, do you know how to check for a gag reflex? My almost never-fail method is to use the eyes. If the patient is unresponsive, running your finger lightly through their eyelash should elicit a response (i.e. wiggling) if the patient has an intact gag reflex. Further, a variation on the theme is to lightly open their eyelids with your gloved fingers and lightly blow into their eye. Don’t do it hard, and certainly don’t blow hard or use any pressure with your fingers, but if a person isn’t unresponsive and can tolerate that without flinching… they aren’t human.

- The Combitube

Honestly, I’ve not had a good track record with the combitube. I prefer the King LT. (Sorry Happy)

- The Endotracheal Tube

For this part of the training I looked at the various parts of this procedure that an EMT-Basic might be asked to participate in, such as preoxygenation with a BVM before the procedure, setting up the equipment for the ALS provider before he/she needs it, choosing the various adjuncts to assist the ALS provider in confirming tube placement, and various methods to secure the tube.

- CPAP

This is a miracle treatment. CPAP, or Continuous Positive Airway Pressure has revolutionized the management of congestive heart failure and pulmonary edema. Every EMT should know how to use this, when to use this, and how to properly apply this wonderful thing.

- Non-Rebreather O2 mask, Nasal Cannula (Adult and Peds)

If you don’t know how to use this, you probably should.

- The Nebulizer set up (We use Albuterol (Proventil) and Ipatropium Bromide (Atrovent)

We covered the proper set-up of the nebulizer and the various differing ways that it can be employed. Sure, you can use the duckbill for the patient to hold, but you can also pull the reservoir bag off of a Nonrebreather mask, insert the nebulizer chamber where the bag went and you’ve got yourself a handy mask neb.

We also went over the proper way to connect the nebulizer to the Bag Valve Mask. Depending on your equipment this setup could vary. Ours did like 3 ways. Check yours.

- Bag Valve Masks of assorted sizes

Learn how to properly seal the masks, the proper ventilatory rate (8-10 per minute) and the proper size for each variation in patient population.

- A Pocket Mask

Haven’t used one of these in a while, have you?

- The Surgical and Needle Cric kits

The basics don’t need to know how to use these, but it’s good to practice. Three of us had to hold the student down to do it, but we got it in on the second try!

I’m really liking my new home.

Posted by on October 17, 2009 • Filed under: Emergency Medical Services, EMS, ems scenario based education, EMS Topics, EMS training, ET Intubation, intubation, paramedic education, patient care, Patient Management
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