Prehospital Intubations and Mortality - comment from RevMedic

RevMedic is not a name that signifies driving very fast - revving the engine - but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.

RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.

Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality - comment from Herbie.

"I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill."

Absolutely. I can't tell you how many times I've seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.

How is it that we graduate EMTs and medics, who are not skilled at airway management?

How is it that we graduate EMTs and medics, who do not understand airway management?

It isn't as if the courses suggest that there is a skill that comes before airway.

Excellent BVM use is all about assessment.

BVM excellence is the cornerstone of airway management.

Without excellence in the use of the BVM, the rest of airway management does not matter.

I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.

We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.

There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.

One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.

One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?

If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

RevMedic finishes up with:

BVM is the lost art of airway control.

There is only one appropriate response to that:



PediCap Product Recall

This is the Pedi-Cap.

For comparison, here is the Pedi-Cap next to its big brother/sister, the Easy Cap II.

It is tiny. To give you another idea of the size, here it is being used on an itty-bitty baby, who could fit in my hand.

Photo credit

This device is a simple piece of litmus paper. CO2 (Carbon diOxide) is acidic. In the presence of CO2, this paper will change from Purple to Yellow. The concentration of CO2 determines how yellow the paper becomes.[1]

Some of the problems with this are due to it being nothing more than a piece of litmus paper with a supposedly airtight plastic cover, airtight except for the connections. When litmus paper becomes moist, it does not do what we want it to do in the presence of CO2. It does not tell us if there is any CO2 present.

We are looking for the CO2 because that indicates that the tube is connected with a place that either has a reservoir of CO2, or to a place that is capable of exchanging CO2 for O2 (Oxygen).

If you have been providing mouth-to-mouth ventilation, but have been filling the belly, rather than the lungs, that would be one source of a CO2 reservoir at the end of the esophagus. After a while, the CO2 should be removed. In the mean time, you may be misled into leaving the tube in the esophagus and ventilating the stomach. This may not turn out well.

• Not to be used for detection of hypercarbia.
• Not to be used to detect main stem bronchial intubation.
• Not to be used during mouth-to-tube ventilation.
• Should not be used to detect oropharyngeal tube placement.
Standard clinical assessment must be used.[2]

This is a description of a problem with the Pedi-Cap.

Began ventilating patient with pedi-cap and peds ambubag. Patient began to desaturate immediately. Could not force air thru ambu with Pedicap on. Removed pedi cap and ventilation was accomplished. O2 sats improved. Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap "size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance." Testing other lots to see if same problem exists.[3]

Let's look at this step-by-step.

Began ventilating patient with pedi-cap and peds ambubag.

No problem, yet.

Patient began to desaturate immediately.

Not a good sign. PALS (Pediatric Advanced Life Support) teaches a 4 step assessment for sudden deterioration of an intubated patient using the mnemonic DOPE (not something to say out loud in front of family). D = Dislodged; O = Obstructed; P = Pneumothorax; E = Equipment failure.

Could not force air thru ambu with Pedicap on.

That would be D for Dislodged. E does not really apply, since that is supposed to be for patients on a ventilator, but use whatever works.

Removed pedi cap and ventilation was accomplished.

Problem solved, but I am guessing that the reason for the assessment of CO2 has not been addressed.

O2 sats improved.

I'm assuming that the CO2 was evaluated in some way. Maybe they just kept ventilating and figured that the response to ventilation with bagging was confirmation enough. The immediate improvement in oxygen saturation is unlikely to be a false positive.

Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap "size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance." Testing other lots to see if same problem exists.

Image modified from the Nellcor product manual.

Nice work by the person ventilating the patient in quickly recognizing a problem and reacting appropriately.

August 14, 2009

Dear Valued Customer,

We are informing you of an urgent voluntary medical device recall regarding the PediCap End-Tidal CO2 Detector (PediCap and PediCap 6).

We have received a customer report in which they experienced difficulty manually ventilating an intubated patient through the PediCap. While we continue to investigate, we believe that a recent modification to the PediCap End-Tidal CO2 Detector may result in increased resistance to airflow through the PediCap. This could result in ineffective ventilation of the patient and/or inadequate detection of CO2 levels, so that the indicator paper will not change color.

Although we have received no reports of patient injury, we have determined that all PediCap and PediCap 6 End-Tidal CO2 Detectors from the lots listed below must be returned. We are requesting your assistance in conducting this activity. Please review your inventory and segregate any product with the affected lot numbers and return affected product according to the directions below[4]

Likewise, it is nice to see a company responding with a recall, rather than waiting for a patient to be injured. Only one week between the FDA notice and the company recall. While it could be faster, some companies will keep denying problems even after there are a bunch of dead bodies from their product.


^ 1 CO2 detection sheet
Free PDF

^ 2 Pediatric End-Tidal CO2 Detector PediCap®
Free PDF

^ 3 FDA Medical Product Safety Report
I cannot get Blogger to accept the html for a link to the FDA page. Cut and paste this link:"-O%3D%25_X%20%0A

^ 4 URGENT MEDICAL DEVICE RECALL for PediCap™ End-Tidal CO2 Detectors
Covidien (owner of Nellcor)
August 14, 2009
Free PDF

All necessary information, to contact the company, is in the pdf. Also included are the numbers of all of the lots involved.


What Every Paramedic Student Should Know

I've been a paramedic for fifteen years. I've been an instructor for six months longer than that.

Once upon a time, the Little Ambulance Service That Could sent me, a brand new EMT-B, to EMS Instructor School. We were competing with a much larger service in the area, and they were shutting us out of most of the available slots in the EMT courses. So when an opportunity arose for them to have their very own in-house instructor, I was drafted for the job. I assisted with my first EMT course six months before I earned my paramedic patch. With time and teaching experience, I became one of the cadre of senior instructors tasked with training and mentoring new EMS instructors in Louisiana. I did that for close to ten years.

I still get e-mails and phone calls from instructors I trained or mentored back then, seeking advice on one classroom issue or another. Through my blog, I get e-mails from instructors and students alike, seeking my opinion on a variety of subjects. Instructors ask how to deal with clueless administrators or problem students, students seek advice on dealing with problem instructors, and some who haven't even begun their education seek counsel on how to prepare for the rigors of paramedic school. Sometimes I have good advice to offer, and for others I have no answers, able only to commiserate and say, "I feel your pain, brother."

I have been a student forced to sit through a boring lecture, and I have been the instructor struggling to make esoteric medical trivia relevant to a classroom of disinterested people who would likely never use the information. I have worked for companies –as a medic and an instructor - who didn't give a rat's ass about education, and I've worked for others who considered it a cornerstone of good patient care. Some of the poorest companies, like the Little Ambulance Service That Could, invested far more time, money and effort in education than other companies with a hundred times their resources.

I have juggled school, work and family commitments. I have felt the frustration when the company that is paying for your education refuses to give you the time and support to actually learn something from it. I have paid money from my own pocket to hire a subject matter expert to lecture my class, and I have sat through a class when one of those subject matter experts – a PharmD – put everyone to sleep with a lecture that would have made a research biochemist slit his wrists to put an end to the boredom. To this day, I remember nothing of the chemical structures of the drugs he was supposed to cover, but I'm reasonably sure that if you could synthesize his voice, it would be a chemical analogue to Diprivan.

All this is to say that I have been there, done that, and currently own a closet full of EMS tee shirts emblazoned with witty sayings like "Just tube it!" or "EMS: Our day begins when yours is about to end." I consider myself well qualified to speak to the issues faced by paramedic instructors and students alike.

Therefore, let there be no pretense between us when I offer a few observations about you, the paramedic student:


You don't know shit.

I'm not calling you stupid, just ignorant. Ignorance, if not curable, is at least treatable with education. Stupid, however, is utterly incurable and untreatable, as you will soon discover from many of your patients. Unfortunately, stupidity is not uniformly fatal. Instead of killing off its host rapidly, thus chlorinating the gene pool a bit, the stupidity virus often becomes latent, lying in wait for a moment of weakness. Then, like an attack of shingles, it blooms forth in an epic display of "Hey y'all, watch this!" splendor. This outbreak is what transforms the latently stupid into EMS patients.

Back in my freshman year of college, I had a professor who called this little truism "man's capsule of knowledge." Simply put, there is what man knows, and what man does not know. And the more man learns, the more he realizes how truly ignorant he really is. It is humanly impossible to ever make our knowledge outpace our ignorance, and there is no shame in admitting that. Unwillingness to recognize and acknowledge your ignorance, however, is just stupid.

And make no mistake, most of your more experienced or educated peers are operating from a position of ignorance, too. Lucy Hornstein, MD, explores this unfortunate fact in Declarations of A Dinosaur: Ten Laws I've Learned As a Family Doctor. In her book, Law #8 states, "Half of what is taught in medical school is wrong, but no one knows which half."

Change "medical" to "paramedic," and there you have the state of current EMS education. The only constant in this profession is the certainty that things will change. In five or ten years, you're going to discover that half of what you learned in class is wrong… but you won't know which half until then.

So, got that? You're ignorant, your partners are ignorant, and your instructors are ignorant. For that matter, so am I.

After all, I taught all sorts of wrong information over the years, just like your paramedic instructors and the professors at Dr. Hornstein's medical school. We taught students that spinal immobilization was beneficial and rarely harmful, that volume resuscitation in trauma patients saved lives, that the Golden Hour was based on scientific research, and PASG could auto-transfuse blood from the lower extremities to the trunk.

Now we know better. We know that spinal immobilization benefits very few, if any, patients, and may indeed harm some. Aggressive volume replacement, at least among trauma patients with uncontrolled internal bleeding, does harm. The Golden hour was a PR tool, not scientific fact, and as it turns out, the length of time spent outside the hospital makes very little difference in mortality most trauma patients; some die immediately despite our best efforts, some die weeks later from infection or organ failure, and the ones who make it out of the operating room alive don't seem to notice the difference between twenty minutes or three hours in getting there. Lately, it even seems that supplemental oxygen administration - the most sacred of EMS cows - doesn't make much difference for many of our patients, and may even harm some.

So yeah, we're ignorant. But the difference between you and your instructors is, at least they have some inkling of how ignorant they are. So until you learn a little more, listen to what they have to say. Pay attention in class. Don't ever let the words, "Why do we have to learn all this shit we're never gonna use?" escape your lips, because right now, you're too ignorant to know what information you will or won't find useful. Much of the knowledge I've found useful over the years wasn't even covered in my initial paramedic training, while much of what we spent the most time learning us has proven utterly irrelevant to patient care.

You're going to be performing procedures on real, live people. You're going to be administering chemicals that alter the function of the human body. It behooves you to know how that body works, and that requires a helluva lot more than being able to accurately label a diagram of the abdominal organs or the bones in the human body. When your car breaks down, are you going to take it to a mechanic, or to the pimply-faced kid behind the parts counter at Autozone? Because if your knowledge of the medications you give, and their effect on the body, extends no further than, "That's the next drug in the algorithm," all of your expensive paramedic education has done little more than make you the EMS equivalent of that pimply-faced kid manning the parts counter at Autozone. And would you really want to be that guy's patient?

Whether it's the intricacies of the Krebs Cycle and electron transport or membrane thresholds and action potentials, or a million other pieces of medical minutiae you may not appreciate now, a functional understanding of human anatomy and physiology is imperative to your success as a paramedic. You may not need to know the inner workings of the human body as deeply as, say, a physician, but you almost certainly need a greater depth of understanding than paramedics educated not even ten years ago. EMS as it is practiced today is a different creature than it was ten short years ago, and ten years from now if will be a different profession than you're practicing today.

Your understanding of the human body will help you adapt to ever advancing changes in medical theory. That understanding will serve you in good stead when faced with the surprising revelation that something you've done for years doesn't really help patients at all, or may even do them harm. Like aggressive volume resuscitation, for example. Or spinal immobilization. Or PASG application. Learn how the human body works, and you'll be more likely to face those revelations with a bemused smile and a, "Well, that makes sense, when you look at it that way," equanimity. What you don't want to be is that dinosaur who looks around and no longer recognizes his profession, forever grousing, "That's not the way we learned it in school."


Experience ain't all it's cracked up to be.

Hardly a week goes by where I'm not asked a variation on the question, "So, I'm trying to figure out where I go from here. Do I work as an EMT for a while, or do I go straight into paramedic school? How much experience do I need before I'm ready for paramedic school?"

You see, "experience" is such a nebulous word. Speaking as an educator, I find that for every EMT whose street time has honed his assessment skills and taught him the clinical presentation of various disease pathologies, there is another who has learned little more than the location of all the fast food joints that offer EMT discounts.

If I'm lucky, that's all he's learned. All too often, that street experience has taught him how to be lazy, cynical and rude, and I have to devote precious classroom time to helping him unlearn all that experience. Give me the green EMT every time; they're easier to teach.

Many of my colleagues would advise green EMTs to gain several years of street experience before enrolling in paramedic school. They fail to consider the great variable in the equation: the partner.

Every new EMT envisions being paired with a grizzled veteran who can take a green individual under his wing, mentor and teach him the tricks and wisdom that can't be taught in the classroom. Frequently, they get the other type of partner — the one who despises rookie EMTs and couldn't teach an armadillo to dig a hole in the ground.

As the saying goes, "There are a few paramedics with 20 years of experience, and there are many more with one year of experience, twenty times."

That's the value of education, folks. It gives us the framework to learn from our experiences. It gives us the context to interpret that unusual presentation correctly, and realize that a clinical zebra is simply a horse with a custom paint job.

I've learned that every student views a new learning opportunity through a prism of their past experiences. If they have the right attitude and a strong educational background, that prism can refract a muddied clinical presentation into something much clearer. With the wrong attitude, however, or a weak education, that prism can distort the clearest of pictures into something unrecognizable.

From this ambulance driver's perspective, that experience is best gained in an educational program with a strong clinical component - not on the job. Many prospective students shy away from such paramedic programs because they often take longer or are more expensive. Don't make that mistake.

A "boot camp"-style paramedic program may graduate you quicker, but you likely won't get the clinical experience under a trained preceptor that you'd get in a longer program. On the flip side, the college-based, "zero-to-hero" programs designed to take a raw student all the way from layperson to paramedic won't teach you much relevant EMS knowledge unless that program includes an extensive clinical component. Not every program is created equally, and there is more to consider in choosing a paramedic program than the tuition cost.

There are loads of paramedics out there who will sagely advise, "The real learning begins once you hit the street," and they're right.

But what is equally true, and often not said, is that much of EMS continuing education is simply a rehash of information you should already know, and many of your more experienced colleagues have been unknowingly repeating the same mistakes for twenty years. My advice is, learn as much as you can in class. Mistakes there are far less costly than the ones you make in the field.


You aren't here to save lives.

I know that flies in the face of every recruiting pitch we use to draw students into paramedic classes in the first place. It contradicts every piece of PR propaganda we use to educate the public about EMS. It may even contradict your very motives for choosing EMS as a profession.

Doesn't make it any less true, though.

Bottom line is, we don't save many lives. One the rare occasions we do, it's largely the result of luck and good timing, and pretty much any yahoo with a CPR card could have performed the lifesaving intervention. Ask any experienced EMTs how many lives they've saved, through their actions and their actions alone, and if they're honest the number will be damned few.

And frankly, if saving lives is the only thing you're about, you might as well stay an EMT-B. Of the existing research on the efficacy of EMS, the only things that are proven to reduce mortality are BLS interventions: early CPR and defibrillation. But before you go patting yourselves on the back about how wonderful EMTs are, keep in mind that those two things are also considered layperson interventions as well.

But if your motivation goes beyond the adrenaline rush of lights and sirens and the occasional code save, paramedicine has much to offer. Much of what we do, if administered appropriately and in a timely fashion, makes the patient's injury or illness less stressful, and makes the job of the Emergency Department staff much easier.

A few years ago at an EMS conference, after our respective sessions were done, a colleague and I set forth down Sixth Street in downtown Austin in search of beer and hot wings. Over a platter of spicy wings and not a few pitchers of beer, we proceeded to solve all the problems of EMS. Of course, most of those solutions were lost in the fog of the next day's hangover, but one thing my buddy said to me that night stuck with me ever since.

"Kelly," he had said, "it's not our job to score touchdowns."

"More hot wings, less beer," I advised. "You're starting to babble."

"No, seriously," he insisted, punctuated with a gentle belch of Fat Tire Ale. "We're the special teams of emergency care. It's not our job to score touchdowns. That's the job of the offense."

"I see where you're going," I mused, eyeing him speculatively. "So who, exactly, is the offense in your little analogy?"

"The Emergency Department," he answered. "The offense is the doctors and nurses in the Emergency Department, and occasionally the surgeons or the cath lab."

"And EMS is special teams… how, exactly?"

"We receive the patients and advance them as close to the goal as we can. We provide the ED staff with good field position. It's hard to score touchdowns if you're consistently stuck with bad field position. On the other hand, if your special teams are very good, it makes it that much easier for the offense to score. We don't save many lives ourselves, but we can make it much easier or much harder for the ED staff to save a life, depending upon our performance."

"We score touchdowns… er, I mean save lives," I protested.

"Yeah, but only a tiny fraction of the time," he explained, "and only if we're very good or very lucky. Our job is important, dude. We can't win the game by ourselves, but we can damned sure lose it for everyone else. You can't win consistently without good special teams. But it's not our job to score a touchdown on every play."

"Screw you, Brosius," I retorted. "I'm a game breaker, baby. I'm a threat to score every time I touch the ball."

My bravado aside, you'd do well in your careers to heed my buddy's analogy and consider yourselves the special teams of emergency care. The plain truth is, you're not going to save many lives in your career, and you're setting yourself up for a world of disappointment and disillusionment if that's what you expect.

On the other hand, if you're not all about the glory of scoring touchdowns, you can find a great deal of career satisfaction by making your patient's time in your rig a little less stressful, no matter how trivial their chief complaint, and delivering them to the hospital in a little better condition than when they started.

And occasionally, when you do score a touchdown, no one will begrudge you celebrating with a funky end zone dance.


Learn how to evaluate medical research.

It may surprise you to know this, but it shouldn't: most of the information in your textbooks is outdated, by as much as five years, by the time you read it. Moreover, the material in that textbook is written at a 10th grade reading level. If your education comes exclusively from that textbook, you're only getting half the picture, and a frightfully blurry and superficial picture at that.

But those textbooks are based upon research, however outdated it may be. At the end of each chapter, you will find a bibliography of that research. Take the time to read those studies, and any related ones that you may find. Subscribe to a few peer-reviewed emergency medical journals, or at the very least read what you can find in your college library. Learn how to use Medline and Pubmed. Keep abreast of the most current research as it pertains to emergency medical care.

That college statistics class isn't to prepare you to do dosage calculations, folks. Any fourth grader has the math tools to do dosage calculations. No, the statistics class is intended to make you a more discerning evaluator of the numbers liberally sprinkled throughout scientific research. Hopefully, you'll retain enough of it to be able to tell which study authors do or do not know their confidence interval from a hole in the ground.

The future of your profession is going to be shaped by two factors: knee-jerk reactions from politicians and regulators, and by medical research. The better you understand and use the latter, the more you'll be able to prevent the former.


You are what you write.

An EMT-B receives little, if any, training on proper patient documentation. In many EMS systems, medical documentation is not the EMT-B's responsibility. Thus, there are some of you who, when you write the report on your first patient as a paramedic, will be writing your very first patient report, ever.

I hope that prospect frightens you as much as it does me.

If your EMT instructor made you practice writing mock reports, be thankful. If your employer allows you to act as the lead EMT on BLS calls, including the documentation, be grateful for the experience. If your paramedic program requires an English composition or technical writing course, thank your lucky stars.

Because when it comes right down to it, every essay and research paper you type, every mock run narrative you scribble, is useful practice for the day you will need to document a complex patient presentation, and the treatment you provided, in such a way as to make it easily understandable by twelve people who were too stupid to know how to avoid jury duty.

And trust me, that day will come. It's not a matter of if, but when.

Clinical competence and a friendly disposition are usually enough to keep you out of court. Good documentation will be the thing that saves your ass when they aren't. The attorneys in a negligence case have fairly straightforward jobs. The job of the plaintiff's attorney is to make you look like the dumbest, laziest, sloppiest medic who ever lived. Your attorney's job is to make you look like a combination of Johnny Gage and Marcus Welby, MD. He wants the jury to see you as competent, intelligent and conscientious.

And the weapon each attorney will use is your run report.

Which side finds your run report more useful is entirely up to you. If you can't apply basic concepts of grammar, punctuation and spelling to organize your thoughts into a coherent written report, it doesn't matter if you provided stellar patient care. You are what you write.

If you gradiate hi skul not noing how too rite reel gud, it's time you learned.

Keep a list of commonly misspelled medical terms in your clipboard. There is no excuse for being unable to spell the language of your profession.

Use a report template if necessary. Doesn't matter if it's SOAP or CHART or whatever mnemonic you choose, just use some sort of organized format.

Buy and read The Missing Protocol: A Legally Defensible Report. It is an essential part of every paramedic's library. If you don't have a personal library, start acquiring one. The more you read, the better you'll write.

Put some effort into your assigned essays and research papers. The quality of your writing in class has a direct bearing on the quality of your writing in the field. And at least in class, your work will be graded in terms of percentage points in a GPA, and not zeros in a settlement offer.


Don't just do something, stand there.

It is a curious habit of the EMS profession that we insist on defining ourselves by a skill set and not a body of knowledge. You see medics do this sort of thing all the time. They make ludicrous assertions like, "We can intubate! We can do more procedures than the nurses! They ought to let us work in the ER, too!" All too often, medics are judged by how much treatment they are willing to provide. We call these folks aggressive medics, as if the willingness to intubate first and ask questions later was a quality others would wish to emulate.

You don't see other professions doing such things. Nurses don't proclaim, "I am RN, wielder of the sacred Foley catheter!" Respiratory therapists don't say, "I nebulize, therefore I am." Yet medics do it all the time.

EMS attracts action-oriented people. I know of very few EMTs, myself included, who weren't adrenaline junkies at least at some point early in their career. The thrill of lights and siren has, at one time or another, entranced us all. But at some point though, you will mature beyond viewing your patients as interesting puzzles to solve, or the ultimate high fidelity skills manikin. Hopefully you will reach that maturity level sooner rather than later, and will unwittingly harm relatively few patients before you get there.

Bottom line is, the skills are easy, and that's why we focus on them so often. It is relatively easy to learn a psychomotor skill through constant repetition and apply it according to a narrowly defined set of protocols. It is far more difficult and expensive to educate someone on why, and most importantly, why not to apply that skill. And more and more, research indicates that many of those skills are not beneficial, or so rarely needed that maintaining proficiency in them is impossible.

Much of your EMS education thus far has focused on lots of doing, and relatively little thinking, and it's fair to say that timely application of BLS will always be the cornerstone of good patient care. There will always be instances in which we must act, and act quickly, and the more we practice those skills, the more reflexive they will become.

But as paramedics, we have at our disposal an array of assessment techniques, diagnostic equipment and treatment options that are fairly sophisticated, and our thought process in applying all those things needs to be equally sophisticated. Quite often, our patients derive the greatest benefit from the treatments we don't provide.

In other words, don't just do something, stand there. More thinking, and less doing.

As new medics, you'll need to practice your newly acquired ALS skills until you gain proficiency. It will take time. But what will mark your arrival as a real medic is the realization that you render your best patient care by being what my friend TOTWTYTR calls a "stand back, big picture, non-interventional, direct-the-work-of-others paramedic."

More thinking, and less doing. Don't just do something, stand there.

Good luck in paramedic school.

The Electrocardiogram - Part I

Hopefully you have read through the basic cardiology refresher, and you are ready to move on to the electrocardiogram (ECG).

Basic Cardiology:

The Basics

What is an ECG?
An ECG is a graphic interpretation of the electrical output of the heart. The heart's conduction system is translated into different waveforms, known collectively as an ECG. The ECG records changes in magnitude and direction of the electrical activity of the heart.

What is an EKG?
Kardiogram is the German spelling. Since Einthoven, the inventor of the ECG/EKG was German, EKG is a commonly used abbreviation. Ode to Einthoven.

Why do we use the ECG/EKG?
The ECG is a noninvasive diagnostic tool that medical personnel can use to continuously monitor for cardiac conduction abnormalities.


We use electrodes to create the leads in which we view the ECG. Modern electrodes are usually pre-packaged with conductive gel on the side which attaches to the body of the patient. Some have a medal diode to which the ECG wires attach. Some have a tab that ECG wires are clipped to. It is important to follow the manufacturers recommendations on the storage of these electrodes. The conductive gel may lose it's worth if left out.

The standard placement of each electrode is on all four extremities. The distal portion of the extremity is ideal and recommended for accurate ECGs. This has been modified by many clinicians for purpose of ease. The shoulders and lower abdomen or thighs are commonly used locations. Doing this increases the magnitude of the wave forms and reduces artifact from movement.

The wires are attached to the electrodes at specific locations. The white wire goes to the right shoulder/arm of the patient. The black wire should be located at the left shoulder/arm, and the red wire below that one on the left leg/thigh or abdomen. The green wire should be attached to the right leg/thigh or abdomen.

There are common tricks of the trade when it commons to remembering electrode/wire placement. Smoke over fire, meaning black over the red. I personally teach the condiment method; salt, pepper, ketchup, relish (white, black, red, green). Starting clockwise on the right arm/shoulder of the patient, the condiment method never fails.

Note: Torso placement of electrodes is not ideal for a patient with dyspnea. This will increase artifact from movement of the chest wall and abdomen.

Why do some monitors only have three wires?

All of the limb leads can be obtained from the three lead system. The green electrode/wire is known as the neutral.


At this point of my tutorial I am going to send you over to another tutorial, and a whole other blog. Instead of writing everything I have learned about Einthoven from Tom B's blog, I am just going to let you read it from where I learned it on the Prehospital 12-lead blog. All of you really need to read at this point is part 1. I will cover most of the information from the rest of his tutorial. I dare you to try and not read the rest though.



A condition less known...

Dextrocardia situs inversus refers to a condition in which the heart is a mirror image of normal placement. With dectrocardia the main mass of the heart sits right of the mediastinum. When all visceral organs are mirrored the condition is dextrocardia situs totalis.

Dextrocardia occurs in approximately 1 in 12,000 people (according to wikipedia).

The above chest X-ray is not reversed, that is a patient with dextrocardia.
All of the heart chambers and great vessels are reversed, as seen above.
Left Ventricle (LV), Right Ventricle (RV), Left Atrium (LA), Right Atrium (RA), Pulmonary Artery (PA), Aorta (Ao).

Above is a comparison of a normal heart and the heart of a patient with dextrocardia

As you can imagine, there are multiple ECG changes found on the patient with dextrocardia. If you know the patient has this condition, it may be in your best interest to mirror normal electrode placement.

Take a look at some 12-leads of dextrocardic patients below:

Notice the obvious change in axis. A negatively deflected lead I would indicate right axis deviation. When leads II & III become deflected in addition, this would indicate extreme right axis deviation (ERAD). ERAD is most often seen when impulses originate in the ventricles as with ventricular tachycardia, or ventricular pacemakers. ERAD may appear with dextrocardia.

When you see a negative QRS in lead I, and a positive QRS complex in aVR, you should first suspect misplaced leads. If they are placed correctly, dextrocardia should enter your differential.
Common ECG findings:

not all of these are always present

- Global negativity in lead I, (a negative p wave, QRS, and negative T wave).

- Positively deflected QRS in aVR

- Negative p wave in lead II

- Reverse R wave progression in precordial leads

Causes of Dextrocardia:

- Marden-Walker Syndrome: A rare genetic disorder characterized by blepharophimosis, joint contractures and fixed facial expression.

- Kartagener syndrome: A rare genetic disorder characterized by enlarged bronchial tubes, sinusitis and cross-positioning of body organs.

- Campomelia Cumming type: A rare syndrome characterized by limb and multiple abdominal organ abnormalities. The disorder results in death before birth or soon after.

Things to consider:

So, if you ever have the idea that the ECG you are looking at, looks as if your leads are all reversed, maybe the heart is.

When defibrillating these patients, traditional pad placement should be mirrored to the right chest. Anterior/posterior placement should be just right of the mediastinum.

STEMI, N-STEMI & everything else

This is one of the better presentations I have seen online.

Give it a look, you may learn something.
STEMI, N-STEMI, and Everything else

This one isn't so bad either. If you are following along with my tutorial, don't look at this yet!!

Bedside Manner

Can you remember what you thought EMS was before you had a job responding to 911 calls? I bet you were like me, you though that EMS was comprised of trained professionals that saved lives on a daily basis. Someone had better be dying or damn near close, for you to consider calling 911. I can remember breaking bones or being ill on numerous occasions, and my mother driving me to the ER in her makeshift mommy ambulance, a Dodge Caravan. We waited and waited in the triage area of the emergency room, not once did we think we should have called 911 for quicker treatment.

I remember the first time I did call 911. I was still a paramedic student, and my mother awoke one morning with a sudden onset of shortness of breath. Pulmonary embolism was the first thought in my head, and before I knew it my fingers were punching those numbers in the phone. I expected trained professionals and I got trained professionals. The paramedics had no problem being there, and if they did they didn't show it. They moved with a purpose and treated my mother the same as if it was one of their mothers. They held her hand and they told her everything was going to be okay. I am forever grateful for that crew, thank you, wherever you are.

This post is dedicated to bedside manner. What do you consider good bedside manner? Maybe its different than what your patient considers good bedside manner, and its their opinion that matters.

I don't imagine that you respond to true emergencies for the entire length of your shifts. If you are in a system like mine, most calls are for a matter of comfort, not a matter of life or death. How seriously do you take these calls? How do you tell these patients that they should not have utilized 911? I am going to provide a few good tips on this subject. Most may seem like common sense, but sadly we aren't always surrounded by the commonly sensible.

Its not your emergency, its theirs.

I believe that statement says it all. These patients don't have the training you do, and may have no idea what is happening. Indigestion may feel like a heart attack. A little nausea may make them think they have the Swine Flu. These patients may be scared and will probably need a little reassurance from you.

Now you may have just picked up your juicy burger and had it an inch away from your mouth when a call for a sleepy granny came through. These people have no idea how hungry or sleep deprived we are. Aren't you being paid? Although we often have to work through our breaks, think of all the times you have been paid to sleep or eat. It is tough sometimes not to be upset, but it is even tougher to defend yourself for being unprofessional on a call.

It isn't our place to tell them that they shouldn't have called. It is our job to tell them when they should call.

You don't want to scare people out of calling 911. Most often, they thought about calling long before they actually did. Telling them they shouldn't have called will only make them angry. Imagine taking a patient in to the hospital and the physician telling you that you should have gone somewhere else. Instead of blaming the patient for your lack of sleep, use this time to educate. Make the patient aware of their possible risk factors, and give them advice from a medical professional. Let them know of different reasons to call 911. This passive approach may in fact decrease the less-needed calls. If they are under the impression that going by ambulance will get them seen quicker, correct them. I often offload my cut finger patients in the triage waiting room which has to leave them wondering if they should have called 911. I'm not punishing them, just opening their eyes. The patients that should be seen faster, are seen faster, no matter how they get there.

They are our customers.

We aren't salesmen at a dealership, but we do have something to sell. We have to sell ourselves and our service. If you wonder why EMS doesn't get the due it deserves, its because of customer service. Public relations can and will determine the outlook of our organizations. When you are called upon, respond as you should. Greet the responsive patient, and get on a first name basis. Use a calm and reassuring voice. These two things will help you build a personal relationship with your customer, and you better believe they will want everyone to know how great their experience was. They will also want everyone to know how horrible their experience was, if you make it that way.

What would we do if it wasn't for all the less needed calls? My agency could cut resources by at least 50% if we only responded to true emergencies. I like my job, and I will take anyone and everyone who would like to go. Even though it isn't the best use of resources, most agencies have built up their resources for such call volumes. I'm not saying that I advocate misuse of emergency services, but I am thankful for my job. Take from that what you will.

For the matters of comfort, make them comfortable! If the lonely old lady needs someone to talk to, listen to her. If someone is complaining of pain, treat their pain! If they are cold, cover them up. If they have a headache, speak softly. If they are dizzy, for God's sake, don't walk them to the truck. If the only treatment you provide is hand-holding on the way to the ER, be the best hand-holder there is. Treat every patient as if you would want your loved one treated, and you will never go wrong.

We are professionals, and we should act that way. Our patients expect that we will know exactly what is wrong with them and be able to treat it appropriately. Don't prove them wrong.

Basic Cardiology - Part II

Click here for part 1.
Click here for the next part.

Now that we know how the heart functions mechanically, it is time to learn what initiates that functioning. The following is a brief overview of cardiac electrophysiology.


Automaticity - In cardiology, the ability of an individual myocardial cell to depolarize spontaneously.

The myocardium consists of special pathways of conduction. This conduction causes subsequent contractions when working properly. The system is an integral part of healthy cardiac functioning. It is important to remember that the two atria contract almost simultaneously, and then shortly there after the two ventricles do the same thing. So imagine this as top-bottom-top-bottom. Without one set of depolarization, the body suffers greatly.

The sinoatrial node (SA node) - The SA node is the heart's physiological pacemaker. It is located in the right atrium, roughly in the top right corner. The SA node has an intrinsic rate of about 60 to 100 beats per minute (bpm). In normal conduction, all cardiac impulses originate at the SA node. Impulses travel from the SA node and right atrium across the inter-atrial septum to the left atrium. This process initiates atrial depolarization, which causes atrial contraction and the subsequent exchange of blood from the atria to the ventricles.

The atrioventricular junction (AV junction) - This is a term used to describe the next to structures, the AV node and the bundle of his. This is a term used mostly when speaking about the electrocardiogram. Certain arrhythmias may be attributed to the AV junction, because it is impossible to know exactly where the impulse is originating.

The atrioventricular node (AV node) - Named due to its placement, as the conduction link between the right atrium and ventricle; the AV node is the next stop for cardiac conduction. It is located just superior to the atrioventricular septum. The AV node is a yield sign, so-to-speak. It slows the conduction from the atria to the ventricles to prevent overlap in depolarization. This in turn allows for adequate ventricular filling, and Frank Starling's mechanism to work. The intrinsic firing rate for the AV node is 40 to 60 bpm.

It is important that the intrinsic rate of each structure is slower the further you go down the conduction system. This helps prevent an unwanted takeover of the heart's pacemaker. As you will learn, certain conditions bypass this security system.

The bundle of his - Located in the ventricular septum. The bundle of his is comprised of fibrous tissue. It is the first part of the conduction chain below the AV node.

The bundle branches - The bundle of his branches off into two main bands of conduction. These are known as the bundle branches. The right and left bundle branches facilitate further ventricular conduction. The right bundle branch has a single fascicle, while the left bundle branch consists of three fascicles; although it is common to state that the left bundle brach only has two fascicles. The left anterior, left posterior, and septal fascicles are all located on the left bundle branch.

The purkinje fibers - These are located just below the endocardium throughout the ventricular walls. They are the conduction pathways of the ventricles. The intrinsic rate for the purkinje system is about 20 to 40 bpm.

Depolarization - The firing of the cardiac cells, initiating or continuing an impulse.
Repolarization - The regenerating of the cardiac cells. When the cell is not firing, but building up the energy to depolarize again.

So to sum things up the SA node initiates an impulse which travels across both atria causing atrial depolarization. This conduction causes the atria to contract and eject it's blood into the ventricles. The AV node pauses conduction momentarily while the ventricles fill. The atria then repolarize while the ventricles depolarize. The ventricles depolarize when the conducted impulse travels down the bundle of his, bundle branches, and purkinje fibers. This depolarization causes the ventricles to contract and eject it's blood. The ventricles then repolarize and the cycle begins again shortly after.

There are many pathologies that distort the normal flow of cardiac conduction. These will be described as I describe the ECG interpretation for each.

The electrocardiogram (ECG) is a transthoracic interpretation of the heart's electrical activity over time.

I am not going to get in to action potentials and electrolyte exchange just yet. This is just the basics. The next post in this series will begin our ECG tutorial.

Pain Management

[Pubmed 1]

Severe pain is a common presenting symptom for emergency patients. One major challenge in the management of severe pain is the objective measurement of pain. Due to the subjective nature of pain, it can be very difficult for clinicians to quantify pain intensity and measure the qualitative features of the pain experience. A number of measurement tools have been validated in the acute care setting, with some appropriate for use in the prehospital setting. This paper reviews the characteristics required of a prehospital acute pain measure and appraises the relative utility of a number of currently used pain measures. At present, the verbal numerical rating scale appears the most appropriate pain measure to administer in the prehospital setting for adult patients as it is practical and valid. Either the Oucher scale or the faces pain scale is suitable for prehospital care providers to assess pain in children.
[Pubmed 2]
OBJECTIVE: The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting. METHODS: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, chi2 test, and logistic regression. RESULTS: Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84). CONCLUSION: Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.
The first study tells us to use the number scale, "rate your pain from one to ten, ten being the worst". If we use this scale we have to believe our patients. Its not your emergency, remember? These patients may only complain of pain, and that may be the one treatment you should provide for them. Ice packs are a form of pain management, so often forgotten. Take their pain seriously, and you won't lose their respect. Treat them like they are over-exaggerating, and you won't deserve their respect. Think of the last time you were in serious pain. It may be difficult to convey how it feels, or how much it hurts. A back spasm is an awfully weird feeling, like a tightening that can restrict breathing. Pain management is indicated, and should be initiated in the prehospital setting.

The second study is just some interesting information on how we treat different genders in pain. This was touched on in this month's JEMS. Men get the Morphine.

Cardiocerebral not Cardiopulmonary


PURPOSE OF REVIEW: To discuss recent findings surrounding the role of ventilation during cardiopulmonary resuscitation for individuals with out-of-hospital primary cardiac arrest. RECENT FINDINGS: Active assisted ventilation during primary cardiac arrest may not always be beneficial and, in some circumstances, may lead to worse outcomes. By interrupting chest compressions and thereby decreasing vital organ perfusion, rescue breathing may be deleterious. In addition to the time required to administer breaths, the delay due to the insertion of advanced airways, even by well trained individuals, is often extensive. Furthermore, once intubation is completed, excessive hyperventilation occurs frequently, even by recently trained medical providers. Although most experts agree that excessive ventilation is harmful during out-of-hospital cardiac resuscitation, the optimal rate, tidal volume, timing, and technique of ventilation is still unknown. There is increasing evidence that, in patients with witnessed arrests and a shockable rhythm, the optimal form of ventilation is passive oxygen insufflation. SUMMARY: Assisted ventilation during the initial provision of cardiopulmonary resuscitation is less important than previously believed. It is hypothesized that, by training prehospital medical providers to utilize passive oxygen insufflation for individuals with primary cardiac arrest, critical organ perfusion will increase and, therefore, survival after out-of-hospital cardiac arrest will improve.
Just another study that emphasizes the need for us to restructure our thinking. Airway is not our first priority when treating a cardiac arrest. The evidence is there, and I know it is hard to put down the laryngoscope, but we need to practice evidence-based-medicine. So there is your quick read for the day. Provide your opinions in the comments section.

Induced Hypothermia Part IV

Read below for more information on induced hypothermia for cardiac arrest.

Most recent studies:

Background: Several investigators have emphasized the positive effect of hypothermia therapy on patients who have suffered from cardiac arrest. Salvaging patients from circulatory collapse is a pivotal task, but it is unclear whether additional hypothermia can practically contribute to an improvement in the neurological outcome. Methods and Results: Since December 2005, our hospital has been using hypothermia therapy. Forty-six comatose patients after recovery of spontaneous circulation were consecutively enrolled in the present study. Twenty-five of the enrolled patients received hypothermia therapy and 21 did not because they were treated prior to 2005. The time from collapse to spontaneous circulation (P=0.09), the rates of performance of bystander CPR (P=0.370) and presence of a witnessed collapse (P=0.067) were not significantly different between the recovery group (n=28) and the non-recovery group (n=18). The additional hypothermia therapy was an independent predictor of neurological recovery (P=0.005, OR 6.5, 95%CI 1.74-24.27). The recovery rate was significantly higher in patients who received hypothermia therapy (80%) compared to those who did not (38%). Conclusions: Hypothermia therapy is very useful for treating patients who have had an out-of-hospital cardiac arrest; it should be induced rapidly and smoothly.

BACKGROUND: ILCOR recommend the use of therapeutic hypothermia (32-34 degrees C) for 12-24 h in unconscious adult patients with spontaneous circulation after cardiac arrest with a VF rhythm. Among various methods of inducing hypothermia, the rapid infusion of ice-cold intravenous fluid has been used. METHODS: To investigate the time required to cool intravenous fluids in a domestic refrigerator and freezer, bags of compound sodium lactate were placed on the upper shelf of a refrigerator. Continuous temperature measurement was performed for 2 h for 10 500 ml and 10 1000 ml bags. The procedure was then repeated in the freezer. RESULTS: The mean time for 500 ml bags to cool to 4 degrees C or below was 90 minutes or more in a refrigerator and 60-90 minutes in the freezer. 1000 ml bags are cooled to 4 degrees C or below within 120 minutes in the freezer, but it takes longer in a refrigerator. CONCLUSION: As induced hypothermia should be started as soon as possible in eligible patients, crystalloids should be stored in a refrigerator.

An interesting story about a different in hospital cooling method:

[Sarasota Memorial Healthcare System]
Below is a story which involves a new and innovative technology to help prevent brain damage in cardiac arrest patients.

On a recent evening at his Sarasota home, Jim Owens went to bed as usual. During the night, he suffered sudden cardiac arrest. The 63-year-old man's heart had stopped beating effectively, unable to pump oxygenated blood to the brain. His wife called 911, and paramedics rushed Mr. Owens to Sarasota Memorial Hospital. He was resuscitated, but had slipped into a coma, at risk for serious brain damage.

In Sarasota Memorial's Intensive Care Unit, physicians and nurses employed state-of-the-art cooling technology to chill his body quickly yet precisely to 93 degrees, protecting his brain function and helping to heal damaged tissue. Sarasota Memorial currently is the only hospital in the county using this new cooling catheter.

Owens was rewarmed and woke up about 18 hours later. After thorough evaluation, it was clear he had suffered no neurological damage. Physicians soon implanted a pacemaker and defibrillator to restore his cardiac function.

While Owens, a retired sales marketing executive with Procter & Gamble, has little memory of his high-tech treatment at Sarasota Memorial, he is happy to have fully recovered from his cardiac arrest and resume his normal activities -- particularly those requiring a great deal of mental acuity.

“I knew I would be fine when I came home from the hospital, and within a short time, I was answering final Jeopardy questions correctly,” he said.

Cardiac arrest causes about 350,000 deaths in the United States, with the vast majority of victims dying before they ever get to the hospital. It occurs suddenly and brain death can occur in four to six minutes. Even after successful resuscitation, the brain can be damaged from chemical reactions that occur when the blood starts to flow again.

Recent landmark studies show that reducing the body’s temperature below normal can prevent brain damage and save lives. In fact, the American Heart Association recently recommended that medical personnel cool cardiac arrest patients. Several studies also stress the importance of avoiding fever, which can be common, difficult to control and responsible for additional brain damage in cardiac arrest victims.

“Research consistently shows that therapeutic hypothermia can lessen or prevent neurological damage from cardiac arrest and subsequent oxygen loss to the brain,” said Mauricio Concha, MD, medical director of the Acute Stroke Program at Sarasota Memorial. “The catheter technology gives us a vital tool to aid brain healing and enhance patients’ recovery.”

Induced hypothermia has been used to treat cardiac bypass patients, but only recently has the therapy been employed for cardiac arrest.

Here’s how the cooling catheter technology works:

First, a temperature probe catheter is inserted into the bladder of the patient to monitor body temperature. The catheter is connected via a thin cable to the Alsius CoolGard 3000® temperature control system. Next, a heat exchange catheter, a long, thin, soft tube with three balloons, is inserted through a vein at the top of the leg and guided over a wire to its resting place below the heart. Cooling saline runs from the CoolGard 3000 system through tubing into the catheter, down through the balloons. The fluid is then re-circulated back to the system in a closed-loop. Blood is cooled as it passes by the balloons. No fluid is infused into the patient, nor is blood circulated outside of the body. In addition to allowing staff to cool the body more precisely than previous methods, reducing the brain's need for oxygen, the catheter also gives better control over the warming process, permitting physicians to bring patients’ temperatures back up a fraction of a degree at a time.

“The intravascular cooling catheter has been an effective means of inducing hypothermia in patients resuscitated after cardiac arrest, and is an example of the kind of state-of-the-art technology that has made Sarasota Memorial a nationally ranked provider of top-quality care,” said Kenneth Hurwitz, MD, medical director of Critical Care Services at Sarasota Memorial.

Previously, staff would have used chilled blankets and ice packs, a cumbersome, less exact method to lower body temperature.

The catheter technology was purchased with a generous donation from Louis and Gloria Flanzer.
JEMS Webcast - Brent Myers, the medical director for Wake EMS, delivers an excellent presentation.

Do Not Resuscitate Orders and You

Also posted at Star of Life Law.

This post was generated from an email I received from Mark over at Medic999. One of Mark's readers posted the details of a call he ran wherein the patient had a valid DNR order, and he was uncomfortable with the way the the DNR limited the available treatment options. You can visit Mark's blog for a full run down of the opinions there.

For the readers outside of the United States, you should be aware that each State sets its own laws and regulations regarding DNR orders; there is no nationwide standard. Each State's law may be different.

First a bit of a disclaimer: I am educated in United States common law and most specifically educated in the law of South Carolina, the State of my bar admission. I am also registered as a NREMT-P in South Carolina so I am most familiar with South Carolina’s laws on DNR orders.

I will focus first on the law within the jurisdiction I practice law and ride an ALS truck. I will then discuss my thoughts as to the call posted by Matt, and will end with a sampling of DNR regulations from other States for comparison.

Here in South Carolina we have the Emergency Medical Services Do Not Resuscitate Order Act. To establish a DNR order in South Carolina, the patient must: (1) have a terminal condition; and (2) the terminal condition must have been diagnosed by a health care provider and the health care provider's record establishes the time, date, and medical condition which gives rise to the diagnosis of a terminal condition. Thus, it is a pre-requisite to have a physician established terminal condition.

When EMS personnel are presented with a valid DNR order EMS personnel must not use any resuscitative treatment. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.

Okay, that is some great lawyer-speak, but what constitutes the “resuscitative treatment” we can’t give, and what does “that degree of palliative care called for under the circumstances which exist at the time treatment is rendered” mean for those of us in the street?

For that guidance we must consult South Carolina Department of Health and Environmental Control Regulation 61-7, Sections 1406 and 1407. In the event that the patient has a valid DNR order, the following procedures shall be withheld or withdrawn: (1) CPR; (2) Endotracheal intubation and other advanced airway management; (3) Artificial ventilation; (4) Defibrillation; (5) Cardiac resuscitation medication; and (6) Cardiac diagnostic monitoring. These 6 items are defined as prohibitive resuscitative treatment in the presence of a valid DNR order.

The following treatments may be provided as appropriate to patients who have executed a valid DNR order: (1) Suction; (2) Oxygen; (3) Pain medication; (4) Non-cardiac resuscitation medication; (5) Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management; (6) Control of bleeding; and (7) Comfort care. These 7 items are defined as the permissible palliative measures that can be given in the presence of a valid DNR order.

Okay, so that is what I can do and can’t do in the presence of a valid DNR order. But wait, there is more. When presented with a valid DNR order, I must honor it, regardless of the circumstances. If I can’t or won’t honor it, then I must immediately transfer patient care to another EMS provider or other health care provider who will honor it.

That is the law in the State I work.

Let’s restate Matt’s patient presentation: Elderly male, lungs full of fluid, SpO2 mid to high 60s on a nasal cannula, improved to about 69-70% with a non rebreather, respirations about 24, mental status , about a GCS 5. Nursing home staff states aspiration of vomitus, suction attempted with no relief. Valid DNR presented to EMS on arrival.

If I was presented with the above in my jurisdiction, right off the bat there are several things that I cannot do for this patient in the presence of the valid DNR order. I cannot drop an ET tube, King Airway or LMA. I cannot use a BVM to artificially ventilate. I cannot attach my LifePak 12 for cardiac monitoring.

My patient revoked my ability to use these tools, and I will respect their decision, but I won’t just watch them circle the drain. There are things I can do that may really help this patient. First, I will do my own assessment, as I do not trust NH assessments. I can still suction, so I would try to clear the airway as best I can. Here, an OPA is a basic skill, so dropping an OPA to maintain an open airway would be permitted. I can administer oxygen via non-rebreather over the OPA. (A tougher question would be whether CPAP or BiPAP is considered artificial respiration. I’ll punt on that one for now.)

I can also establish an IV and check a BGL. Who knows, maybe his blood glucose is 20 and an amp of D50 perks him up. I can…well, you get the idea. There are things we can do and should do to care for our patients.

I encourage you to become familiar with your State's laws and regulations regarding DNR orders and your local protocols on DNR orders so that when presented with a valid DNR order you know what you can and can't do to care for your patient.

These are tough situations for us because we are used to doing all we can with all we got. But we must remember that our primary purpose is quality patient care, and sometimes that means respecting our patient’s wishes regarding the end of life too.

Other State DNR order regulations for comparison:

State of California

State of North Carolina

State of Texas

Basic Cardiology - Part I

This tutorial is dedicated to getting back to basics. I am going to give a pretty thorough review of electrocardiogram (ECG) interpretation. For some of you this will seem elementary and could just be a good refresher. For others this could be the first time you have been taught this information. I am not sure how many parts there will end up being, quite a few I presume. After I finish I will create another blog with the tutorial and nothing else, for quick reference.

So lets get started.

I don't feel it is pertinent for me to show you a single ECG strip or try and teach you your first rhythm until I give a simple cardiology review.

Basic Cardiology


When talking about the function of the heart, it is required for you to think of the two different types of functioning; electrical and mechanical. The electrical functioning of the heart has to do with impulses sent through its electrical pathways. These impulses are regulated by the brain and cellular electrolyte exchange. I will get further into this. The mechanical functioning of the heart is initiated by the electrical functioning and has to do with the actual pumping of blood.

One way I like to explain this is by establishing two separate values with commonly interchanged terminology. When using the term heart rate (HR) you should be referring to the electrical impulses, and when using the term pulse (P) you should be referring to mechanical output. You see a HR and you feel a P. They can be different, and this will be explained in this tutorial. The value the monitor (not pulse oximeter) gives you is a HR. The P is what you feel when conducting vital signs. It will behoove you to look at the HR while taking a P, this can indicate malignant ectopy.

Note: During this tutorial I will provide definitions for certain terms, they will be in italics.

Ectopy - when used in electrocardiography, an unnatural presentation. Possibly a premature beat (ectopic beat).

Pathological - altered or caused by disease.


Heart location - The heart sits in the middle of the thoracic (chest) cavity. It is slightly tilted to the left which causes most of the mass to sit just left of the mediastinum. The heart is protected by the sternum and ribs. The apex of the heart is located behind the fifth left intercostal space, slightly medial to the midclavicular line. There are pathological conditions that alter the location of the heart, dextrocardia, COPD (chronic obstructive pulomonary disease/disorder), and CHF (congestive heart failure) are the most common. I may briefly touch on these conditions later on.

Heart chambers - The heart consists of four chambers. Two atria and two ventricles. Blood enters the atria and is pumped into the ventricles, during atrial contraction. The ventricles then pump the blood out of the heart, during ventricular contraction. There are pathological conditions that may effect each chamber, hypertrophy being the most common.

Heart layers - The four chambers are lined by the endocardium which is surrounded by the myocardium (heart muscle). The pericardium then surrounds the entire heart. The pericardium is a protective sac that consists of two layers. The visceral pericardium (epicardium) is the inner layer and lines the heart (visceral tissue always lines the organ). The parietal pericardium which is a fibrous outer layer. In the pericardial cavity is about 25 ml of fluid between the two layers of the pericardium; this reduces the friction caused by the beating and moving of the heart. There are pathological conditions directly involved with each layer of the heart endocarditis, myocardial infarction, pericarditis, and pericardial tamponade. I will explain these conditions as they become pertinent.
Heart valves - In total, there are four heart valves. There are two heart valves which separate the atria from the ventricles, collectively called the AV (atrioventricular) valves. These are named by how many chordae tendineae are attached to them. Between the right atrium and ventricle is the tricuspid valve (three chordae tendineae). Between the left atrium and ventricle is the bicuspid valve (two chordae tenineae) which is sometimes called the mitral valve. An easy way to remember which valve is which is that tri has the letters R and I and right starts with R and I. The chordae tendineae keep the valves from folding back into the atria.

There are two valves that blood must flow through as it leaves the heart. These are collectively referred to as the semilunar valves. These are named due to there shape in relation to the moon. The pulmonary semilunar valve connects the right ventricle to the pulmonary artery, and the aortic semilunar valve connects the left ventricle to the aorta.

The heart sounds that can be auscultated, commonly referred to as "lub-dub" are actually the sounds of the valves flapping closed. The AV valves close first and then the semiunar valves.
Below is a cross section as if you were looking down at the valves.

Heart size - The normal heart is about the size of your fist. The left ventricle predominates in size and has a much thicker wall of myocardium. This is due to the higher pressure needed from the left side to perfuse the entire body. Certain pathologies may alter the size of the heart, and hypertrophy is almost always the result.

Hypertrophy - The opposite of atrophy. In cardiology, abnormal growth of heart muscle due to added stress on the heart.

Above is a good example of the blood flow of the heart.

Frank Starling's Mechanism/Law - The more blood that enters the ventricle during diastole, the greater the contraction during systole.

Systole - Cardiac contraction, when the heart contracts
Diastole - Cardiac relaxation, when the heart fills


1 - Starting with the superior & inferior vena cavas blood flows into the right atrium. The force put on the atria to allow optimal atrial filling is referred to as preload.

2 - After the right atrium is full of blood the tricuspid valve opens, allowing blood to flow freely into the right ventricle. The right atrium then contracts filling the ventricle even more; this is part of the Frank Starlings mechanism.

3 - The right ventricle then contracts while the pulmonary semilunar valve is open and blood enters the pulmonary artery (the only non-oxygenated artery).

4 - Blood flows from the pulmonary artery into the lungs. Blood fills the pulmonary capillaries which surround the alveoli of the lungs. This is where CO2 is exchanged for O2. After the blood becomes oxygenated it leaves the heart through the pulmonary veins (the only oxygenated veins).

5 - The pulmonary vein dumps it's volume into the left atrium using the residual pressure put on it by the right ventricle and pulmonary system (preload).

6 - The left atrium sends blood through an open bicuspid/mitral valve in a manor similar to the right side of the heart.

7 - The oxygenated blood enters the left ventricle, ready to be sent to the rest of the body. The left ventricle then contracts and the blood passes through the aortic semilunar valve into the aorta. The force that the ventricles have to contract against is known as afterload.

8 - After ventricular systole the aortic semilunar valve flaps closed and the blood passes over the aortic arch. Blood that doesn't make it over the arch falls back onto the closed aortic semilunar valve and into the coronary arteries. The right and left coronary arteries are the first exits attached to the ascending aorta. They are used to perfuse the heart.

9 - Most of the blood ejected from the left ventricle passes over the aortic arch and enters into the arteries of the body. From the arteries the blood enters into arterioles and then the systemic capillaries. O2 is exchanged for the bodies waste CO2. The blood then needs to head back towards the lungs. The blood enters into venules and then veins. All the systemic veins eventually lead back to the vena cavas.

In part II I will discuss the electrical conduction system.