Taking Notes in Paramedic Class




I have been listening to some of the old episodes of the EMS EduCast. There has been a bit of discussion of note taking, even criticism of the inadequate methods of taking notes.

Why are you in a class room?

To learn.

How do you learn?

Everybody learns a little bit differently There are several different ways of learning, but if the paramedic class is designed to teach you how to take notes, then note taking is important. If the paramedic class is designed to teach you how to understand how to be a paramedic, then note taking is only important, if that is the method that works to help you understand.

The purpose of the class is to have an understanding of the material. Writing, while the teacher is talking, does not help me to understand the point the teacher is trying to make. Note taking is to help reinforce later, what was learned in the class room.

Too many times I have had questions from students, who copied down what was said, but had absolutely no idea what it meant, because they were busy writing, rather than listening.

If I am talking to someone, and the person is sitting there writing, should I assume that the person is listening to me?

If I am talking to a boss, and the person is sitting there writing, should I assume that the boss is paying close attention to what I am saying, because what I am saying is so important that he/she needs to write it down?

No. I would assume that the boss, writing something down, is doing something else. Writing and listening are not all that compatible.

Note taking should probably only take place after the concept is understood.

Note taking is to reinforce understanding.

Note taking is not a substitute for understanding.

If we spend a lot of time on note taking, are we making sure that they understand, first? Too often, we do not, in my opinion.


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Sick Kid, Part 2

Finally this is the second part after my post, Sick Kid. I must apologize for the delay but work and school is killing me has me going literally days without sleep and I am still not getting caught up with anything. Anyway, I thought this would take little time to post since I am just transcribing a previous con-ed presentation I made up and a paper for my Cellular Bio class a year or two ago. I will see if there is any way to post those for anyone to use in my next part. I promise it should not take as long to come out with the final part, 3.

Let's start of by saying anyone who works in a busy urban area will experience a proponderance of "BS" calls. Most are nothing more acute than "the sniffles". This causes tunnel vision and then we go in with blinders and lead us to potentially get burned. Worse, it can be a detriment to the patient. In this case, we go in assuming something benign and find a kid who really is sick. I cannot stress more the necessity of doing a thorough assessment on all out patients.


History of Present Illness
As we approach the patient, we illicit more information from the mother in order to think of the differentials besides or in addition to gastroenteritis. Asking about PO and output would reveal valuable information such as the three "P"s: Polydipsia, Polyphagia, and Polyuria. As we know, these are classic signs of a hyperglycemic patient with Type 1 DM. Asking abouf family history would also have revealed that there was a family history of diabetes. Another clue. Walking in we see a thin kid. This is also a clue. Why? Well, if he is a Type 1 diabetic, he lacks insulin which has many functions including the following which are pertinent:

  • Controlling cellular uptake of glucose

  • Increasing glycogen synthesis from increased serum glucose

  • Increased fatty acid synthesis and conversion to triglycerides to be stored as fuel through esterification

  • Decreased proteolysis

  • Decreased lipolysis

  • Decreased gluconeogenesis

  • Increased Potassium (K+) uptake in cells

    So what does this mean? It means that lack of insulin leads to the opposite of those functions listed above. There is a decreased uptake of glucose needed for cellular respiration (including the Kreb's Cycle) to provide the energy the body needs to function.

    If you are like me, you quickly forget the process of cellular respiration and the Kreb's Cycle. There are quite a few tutorials on line, especially on youtube, if you need some furter education, reeducation, or just more in depth understanding. I advise you to occasionally look what is there.

    Okay, so we know that without insulin, the cells are starving in a land of plenty. They cannot gain access to the glucose. Since the cells are starving, and insulin is lacking, we see a breakdown of glycogen in liver and muscle tissue to create more glucose for the cells, but yet, the cells cannot take it in. This leads to a continuing cycle of accumulting glucose. So we do a bedside glucometer reading and find it is "CRITICAL HIGH". A patient in DKA will have a blood glucose > 250 mg/dl, or for those up North or across the pond, >13.8 mmol/l.


    Courtesy of http://realitycheck.org/



    The accumulating hyperglycemia causes an oncotic pressure in the blood forcing fluid out of cells and extravascular spaces into the blood. Because there is no an excess water in the vessels, the kidneys try to eliminate it. However the kidneys also need to excrete the excess glucose to limit this osmotic shift in the blood vessels. So when the glucose enters the renal tubule, it causes an osmotic pressure too, preventing the reabsorbtion of water. Therefore, the kidneys excrete glucose in urine but the water follows, and the kidneys continually excrete urine to excrete the glucose, thus the polyuria. Now the patient becomes dehydrated even down to the cellular level, causing excessive thirst and fluid intake, the polydipsia. It can also lead to hypovolemic shock. One serum lab test used to help diagnose DKA is a Blood Urea Nitrogen, or BUN, which shows us how well the kidneys are functioning and help determine if the patient is dehydrated or in hypovolemic shock.


    Courtesy of www.inkeehong.com


    Thin body and polyphagia
    It also means an increased mobilization of Free Fatty Acids (FFAs) and a switch of hepatic lipid metabolism to ketogenesis. And what does this mean? The body metabolizes triglycerides (lipolysis) and muscle (gluconeogenesis)for energy. This continuing breakdown of adipocytes, muscle and proteins causes the thin body shape. The body needs to replenish, so the patient progressively gets hungrier, thus the polyphagia. Of course with nausea and vomiting, the child may wish to forget about eating as the child gets sicker.



      Ketogenesis
      Normally with high serum levels of glucose, acetyl-CoA metabolizes the glucose to make FFAs to then be stored as fat in adipose tissue. But, as we discussed the cells are starving so there is a breakdown of adipose tissue into FFAs to be used as energy by muscle and cells and also to be transferred to the liver bound to albumin to be broken down into acetate, to be broken down further into the ketnone body, acetoacetate. The brain can use ketone bodies as fuel when glucose levels are low. There, and other places low in adipose tissue the ketoacids are oxydized back into acetyl-CoA to be used in cellular respiration. I know this is getting deep, but...well try to hang in there. Acetyl-CoA needs the organic chemical oxaloacetate to push it through the Kreb's Cyle. But oxaloacetate is used up during gluconeogenesis, so there is not enough to process the acetyl-CoA, which means the excess goes back to ketone body formation. Here is the reaction:
      Acetyl CoA < > Acetoacetic Acid (acetoacetate) < > Beta-hydroxhybutyric Acid
      This leads to ketosis, the build-up of excess ketones. Not usually a bad thing as it is can be common in fasting or ketogenic diet, but this time it is a bad thing.



      Along with glucose, the kidneys try to excrete the excess ketones and on a urine dipstick, ketones >3+ indicate ketoacidosis. Urine dipstick? They are commonly done in the ED. Since the patient has polyurea, collecting a urine sample is quick and it only takes a minute to dip the urine stick and read it. I foresee, if our roles in EMS increase, we may have the option of using these in 10 years. Far fetched I am sure, but if we take advantage of the patient's need to urinate, we can learn many things from the dipstick such as not only determining DKA by identifying large quantaties of ketones and glucose in the urine, but recognizing kidney stones and UTIs as well.


        Acetone
        I mentioned a smell when we walk in the room similar to that of nail polish. This is acetone. While acetone smell is a highly reliable sign of
        ketosis, not everyone has the gene to smell it on someone's breath. It is estimated that only about 30-50% of people have the gene to smell it, but if it is smelled, it is a significant sign. What causes that "fruity odor"?


        So as I mentioned above, when the acetoacetate that cannot be metabolized back into Acetyl-CoA or used as fuel are then broken down further into Beta-hydroxybutyrate, a ketoacid like ketoacetate, and acetone as a byproduct. Acetone, as a byproduct cannot be synthesized back to acetyl-CoA. No problem. It is easily excreted in the urine. Acetone also has a high vapor pressure meaning it is easily evaporated through exahalation. Alsa, the infamous "fruity" or acetone odor. This odor is very specific to identifying ketosis. If you are like me in that you cannot smell it, don't feel to depressed. Though I have seen and heard varying numbers, the consensus seems to be more than half the population does not have the gene to smell it. But if you do, and you smell it, then consider it a very important indication of ketoacidosis.


        Acidosis
        If you are weak on acid base basics, here is a basic overview:


        Courtesy of http://www.mountnittany.org/




            Our patient is very weak in bed. Why is he weak? A couple of reasons. He is dehydrated and lacking energy since the the cells are having a tough time getting at the glucose they need. There may be a build-up of lactate which fatigues muscle cells. But not only that, Acetoacetate and betahydroxybuterate are ketoacids. They are very acidic and with enough ketoacid accumulation, the pH drops to dangerously low levels, leading to the state of Ketoacidosis. Acidic states hinder enzymatic reactions, and this includes skeletal muscle contractions. The acidotic state leads to the GI symptoms such as the abdominal discomfort, nausea and vomiting, though the exact etiology of these are unknown. Part of the diagnostic criteria for DKA is an arterial pH<7.30.>


              Now the body will try to buffer this acidotic state, and one way is Kussmaul breathing. Actually, a peson will develop tachypnea or hyperventilation first,and then the Kussmaul breathing at later stages. Hyperventilation and Kussmaul breathing are not necessarily the same. Kussmaul breathing is more like deep, fast and labored breathing and is a later sign and can lead to respiratory fatigue. Still, you will see hyperventilation of some sort, like we saw in our sick kid. Why? To blow off CO2 of course. Most of us know that but for those providers who are not sure of the relevance of "blowing off CO2", let me explain briefly. An acidic environment in the blood means more excess H+ ions. To counter this acidosis, the H+ ions need rid of. The body has many buffering systems to keep the pH between 7.35-7.45, but we will focus on the following equation:




              We see when H+ ions accumulate after being donated by the ketone bodies, to become hydronium H3O, they are buffered by HCO3 (bicarbonate, a.k.a bicarb), which binds to the H+ to become H2CO3 (carbonic acid) and H2O, then to be broken down to CO2 and H2O, both of which are exhaled. The increases in H+ ions stimulate central chemoreceptors (tha aortic bodies in the aortic arch and carotid bodies in the carotitids) which in turn stimulate the respiratory centers in the medulla and pons in the brain stem to increase rate and depth of respirations. So the more the body hyperventilates to compensate, the more O2 is inhaled to eventually bind with H+ to make H3O and the more H2O and CO2 is exhaled, trying to raise the pH or keep it level. Remember, a low pH state is actually acidotic. So thus, the reason for the hyperventilation and Kussmal breathing. Usually we start to see the Kussmal breathing when the patient is starting to fatigue from the hyperventilation.
              video
              Courtesy of www.Jumpstarttriage.com


                What is interesting is the HCO3 is used up in the buffer system- one for each H+ buffered so serum labs and ABGs will show a decrease in HCO3 as well as a normal or decrease in the CO2. This is due to the compensatory mechanism via buffers and hyperventilation. But you knew that. A bicarbonate level of 18 mEq per L or less is part of the diagnostic criteria of DKA, but again, we in the field usually don't have access to serum labs. Another one of the blood tests done in the ER will be an Anion Gap, wich in DKA, will be >12. It is used to help diagnose metabolic acidosis.




                Now if you put the kid on the monitor, you may see peaked "T" waves. Why? Insulin pushes K+ back into cells, but there is no insulin, remember. Not only that, but the acidosis pulls the K+ out of the cells. This leads to hyperkalemia, which gives us the peaked "T" waves on the EKG. But remember, the, body's cells don't have the needed K+ as it is in the vacular space. Making matters worse, along with the glucose and ketones, the patient will excrete the K+ and the Na+, leading to hypokalemia and hyponatremia later, especially after fluids are started. But we will discuss that later.


                  Courtesy of www.learnTheHeart.com


                  Another EKG finding that though not common, but occasionally occurs, is a prolonged QTc. You should know about prolonged QT from Adam in Long QT Part 1 Part 2, Part 3. This is a reason these kids need cardiac monitoring.Just remember that hyperkalemia is in no way diagnostic criteria but something you may see before rehydration and insulin therapy. Afterward you may see hypokalemia (hopefully not), such as when you may be tasked with doing an interfacility transfer of this kid.


                  Again, this is not something to expect to see and not used for diagnostic criteria but just another reason to monitor your pediatric DKA patient.


                  So, to rehash, I just went over some of the obvious signs we will see and why we see them. Basically what is going that is reflected in the signs and symptoms. I understand for many of you this may have been a little deep, and quite boring. However, maybe not as boring as this guy (who is thorough though).




                        Referrences:

                        Barbour, L.A., Friedman, J.E., Chapter 26, "Management of Diabetes in Pregnancy", Influence of Metabolic Changes in Pregnancy on Diabetes Management. March 6, 2003: http://www.endotext.org/diabetes/diabetes36/diabetesframe36.htm


                        Brandis, Kerry. "8.2.1. What is ketoacidosis?, Acid-base pHysiology", Anaesthesia Education Website<>, http://www.anaesthesiamcq.com/AcidBaseBook/ab8_2.php

                        Chansky Michael E, Lubkin Cary L, "Chapter 211. Diabetic Ketoacidosis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e:
                        http://www.accessmedicine.com/content.aspx?aID=606036

                        Crandall, Jill P. MD, "Diabetic Ketoacidosis (DKA)", The Merck Manuals Online Medical Library, May 2007, http://www.merck.com/mmpe/sec12/ch158/ch158c.html

                        "Diabetic Ketoacidosis Pathophysiology", slide presentation, The Diabetes Monitor: http://www.diabetesmonitor.com/dmemerh/tsld005.htm

                        Faulke, Dan. DKA Mechanisms Anaesthetist.com June 2008
                        http://www.anaesthetist.com/icu/organs/endocr/dm/Findex.htm#dka.htm


                        Gundstream, Stanley, E., Anatomy and Physiology: With Integrated Study Guide, 4th Ed., McGraw Hill, 2010

                        King, Michael W., Ph.D / IU School of Medicine / miking at iupui.edu, Gluconeogenesis, The Medical Biochemistry Page
                        http://themedicalbiochemistrypage.org/gluconeogenesis.html

                        Klabunde, Richard, E., “Chemoreceptors”, Cardiovascular Physiology Concepts, http://www.cvphysiology.com/, 04/01/07

                        Kuppermann, N, Park, J, Glatter, K, Marcin, J, Glaser, N. Prolonged QT Interval Corrected for Heart Rate During Diabetic Ketoacidosis in Children,
                        ARCH PEDIATR ADOLESC MED/VOL 162 (NO. 6), JUNE 2008
                        Downloaded from http://archpedi.ama-assn.org/ at University of Pittsburgh, on October 20, 2009


                        Musa-Veloso, K, Likhodii, S., Cunnane, S. "Breath acetone is a reliable indicator of ketosis in adults consuming ketogenic meals", American Journal of Clinical Nutrition, Vol. 76, No. 1, 65-70, July 2002: http://www.ajcn.org/cgi/content/full/76/1/65


                        Patlak, Joe, "ISF-Plasma Exchange/Capillary Pressures", Body Fluids lectures of Medical Physiology 301, http://physioweb.med.uvm.ed%2011/01/00


                        Place Frederick, Mayer Thom, "Chapter 128. Diabetic Ketoacidosis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=597225



                        Sateesh, B, "Glucose Homeostasis and Diabetes", Pharmainfo.net, Vol. 5 Issue 4, 08/09/2007: http://www.pharmainfo.net/reviews/glucose-homeostasis-and-diabetes




                        The ECG Tutorial

                        I'm not sure how many of you out there are fallowing along with the ECG tutorial. I started doing it in response to a request for more basic stuff. It is a great review for anyone who has already been taught this stuff and I have found that some of my EMT partners have been interested in the information.


                        Anyhow here is a list of links to the different parts of the tutorial:

                        The Electrocardiogram - Part VI


                        The Systematic Approach






                        I strongly believe that it is important to look at every ECG the same way. If you have a methodical way of interpreting ECGs you will miss very little. You can do this in any manor you would like as long as it is the same each time. I am going to go over it in the way in which I look at ECGs. I think this is probably the most common system.





                        Systematic approach:
                        • Rate
                        • Rhythm
                        • P wave
                        • PR interval
                        • QRS Complex
                        • Axis

                        The Rate & Rhythm are the first thing you should interpret. We went over this in Part V. You will determine the heart rate in beats per minute and whether the rhythm is regular or irregular.

                        Below is a regularly regular rhythm

                        Below is an example of an irregularly irregular rhythm

                        Below is a regularly irregular rhythm.
                        It may take a longer strip to determine the pattern.


                        The P wave:
                        • Are they present?
                        • Are they all the same?
                        • Are they of normal morphology?
                        • Are there more P waves than QRS complexes?
                        Are they present?
                        The P wave is indicator of a functioning sinoatrial node. Rhythms that have an adequate P wave are termed Sinus. P waves should be less than 120 ms and the amplitude should be less than 0.25 mv. Certain pathologies may alter this.

                        Below is an example of a sinus rhythm

                        Below is an example of a rhythm without P waves

                        Are they all the same?
                        Does each P wave on the ECG strip resemble each other? This is important.

                        Below are two examples of rhythms that have multifocal P waves

                        Are there more P waves that QRS complexes?

                        This may indicate an AV block or even worse.


                        Below is an example of an instance where you have more P waves than QRS complexes

                        PR Interval:
                        • Is the PR interval long or short?
                        • Does the PR interval change?
                        Is the PR interval long or short?
                        The normal PR interval range is 120ms to 200ms

                        Below is an example of a long PR interval

                        Below is an example of a short PR interval

                        Does the PR interval change?
                        The PR interval shows the correlation between the P wave and the QRS complex (the atria and the ventricles). This correlation should not change.

                        Below is an example of a fluctuating PR interval

                        QRS Complex:
                        • How wide are the QRS complexes?
                        • Are they all the same?
                        • Is it low or high voltage?
                        How wide are the QRS complexes?
                        They should be between 40ms to 120ms

                        Below is an example of QRS complexes of normal width

                        Below is an example of an ECG rhythm with wide QRS complexes
                        All ECG images courtesy of Pace Symposia's ECG simulator

                        Are they all the same?
                        Each QRS complex should resemble the last. Certain pathologies may alter this.

                        Is it high or low voltage?
                        Make note of extremes in QRS voltage. This may indicate certain pathologies.


                        Axis:

                        Our concern is the QRS axis. The axis is the frontal view of the mean electrical vector.

                        To learn how to determine the axis within 15 degrees I will refer you once again to the prehospital 12 lead blog. Click here for the axis tutorial.

                        Here is a simple method to determine axis deviation which I will elaborate on in the future.

                        Look at leads I, II, & III. Another method uses just aVF instead of II & III, but is less specific.


                        [+] = positive
                        [-] = negative

                        Normal Axis: [+] I, [+] II, [+] III

                        Physiological left axis deviation: [+] I, [-/+] II, [-] III

                        Pathological left axis deviation: [+] I, [-] II, [-] III

                        Physiological right axis deviation: [-] I, [+] II, [+] III

                        Extreme right axis deviation: [-] I, [-] II, [-] III



                        Below is the lead I and aVF method:





                        Cardiac Arrest - Response Times - Part I


                        It's been over 6 years since the USA Today published Bob Davis' series Six Minutes to Live or Die. If you've never read it, you need to, because it's one of the most important EMS-related publications of our lifetime.

                        Consider this excerpt:

                        When baggage handler Andrew Redyk, 64, collapsed on the job at Los Angeles International Airport, his co-workers leaped into action. One called for help. Another did CPR.

                        The Los Angeles Fire Department sent a nearby fire engine and an ambulance, which arrived at the airport in six and seven minutes, respectively. Officially, their response time was quick enough to save Redyk.

                        In truth, almost half an hour passed before rescuers actually reached Redyk. He died.

                        This official deception is not unusual. Los Angeles is one of many cities that routinely lie to themselves about their true response times to medical emergencies. The result is needless deaths.

                        There is no nationwide standard for measuring emergency response times. A USA TODAY study of the 50 biggest U.S. cities found that most report only the slice of the response that looks most favorable: the time it takes for the emergency crew to drive to the scene. On many emergency runs, that is just a fraction of the time that passes between the call for help and the arrival of rescuers.

                        Yet most cities base quality-control decisions on these official response times, which are misleading and incomplete. As a result, people die, and attempts to improve survival rates fail.

                        This official deception is not unusual ... Yet most cities base quality-control decisions on these official response times.






                        There must be some mistake. How could a misunderstanding like this happen?

                        Consider Bruce J. Moeller, PhD, Obstacles to Measuring Emergency Medical System Performance, EMS Management Journal, Vol 1, Number 3, April-June 2004.

                        "[P]aramedic agencies continue to use various definitions of response time. More importantly, the response time definition employed by agencies provided a more favorable image of agency performance than may otherwise be deserved. There was no effort being made by agencies to establish a shared meaning with others or to communicate their definition of this key performance measure. These obstacles, therefore, limit the ability of providers to benchmark their performance against other systems and to engage in meaningful outcomes based research.

                        Obstacles to measuring performance in EMS systems were hypothesized to include both definitional ambiguity and conscious errors..."

                        Every good researcher knows that a scientist must observe the "fact/value" distinction. A good researcher does not make "value judgments." So how does a social scientist call someone a liar? He says that the liar makes conscious errors.

                        To someone like me, who prefers classical philosophy to modern science, a liar by any other name is still a liar.





                        Moeller explains in his paper why someone might make a conscious error.

                        "Juran characterized one of the more significant problems in performance measurement as conscious errors. Such conscious errors result in 'a deliberate distortion of the sensed data, for a variety of (usually) self-serving human purposes: reduction of workload, avoidance of unpleasant tasks, self-aggrandizement, fear of being punished as the bearer of bad news (Juran [1992]).'"

                        But isn't the failure to save people the worst possible news of all?

                        Not if you don't measure it.

                        I suspect this is the reason so many EMS chiefs become impatient with discussions about cardiac arrest survival and claim that it doesn't really measure an EMS system's performance.

                        In South Carolina, the Attorney General's office recently said that details on EMS operations, including ambulance response times, can't be released to the public. Apparently doing so could compromise patient privacy.

                        The opinion was an interpretation of a law, the wording of which was composed by the Department of Health and Environmental Control (DHEC), which oversees EMS in South Carolina.

                        Beaufort County Administrator Gary Kubic was pleased with the opinion. He said it was unnecessary for information about EMS operations to be accessible because "we have people -- professionals -- in positions to make sure the level of service provided is commensurate with the demands of the community."





                        One thing is certain. As long as EMS leaders believe they are not accountable to the public, then tens of thousands of cardiac arrest patients will continue to die needlessly every year in the United States.

                        Research and EMS What are We Missing: EMS Garage Episode 53





                        I write a lot about research. EMS research, medical research, and non-medical research. The reason is simple. If we want to know how the world works, research is the way to find out. The scientific method is the formula to tell us what works. What worked yesterday, what works today, and what will work tomorrow.

                        Some people become confused when there are changes in the science. They see this as science being unreliable. Just the opposite. This is science responding to new information. Science is correcting itself.

                        An analogy is driving a car down a road. If you do not turn, when there is a bend in the road, you will crash. The car is not defective, just because it has a steering wheel, because occasionally the wheel is used to change direction. The car is effective because it has a steering wheel.

                        In science, the research is the way we learn what works. We then create hypotheses about the ways that new information (the latest research) may be used to learn more about things we want to know about. Science does not progress in a straight line. Science needs to respond to new information.

                        Science is about making mistakes. A lot of mistakes. A few will not be mistakes. these non-mistakes, or not complete mistakes, will lead to more opportunities to make mistakes. This is what we need to encourage. It is by making mistakes that we learn.

                        Expert opinion is a hunch that is used by someone with experience, but it isn't specific research. Expert opinion should include all of the relevant research, but in many areas, the research is vague, or non-existent. In EMS we have had all sorts of expert opinions inflicted on our patients. Spinal immobilization. Epinephrine for cardiac arrest. Antiarrhythmics for cardiac arrest. Antiarrhythmics for chest pain patients. Furosemide for CHF. 50% dextrose for hypoglycemia. High flow oxygen for everything. Helicopter transport for almost everything. Lights and sirens. CISM/CISD. Et cetera.

                        We have learned that many of these treatments are not just ineffective, but harmful. Some claim that this is evidence that science does not work. No. When an expert makes a guess, and later that guess turns out to be wrong, the guess can be a part of the scientific process. The correction of the incorrect idea is the science.

                        Learning from our mistakes is science. Ignoring our mistakes is something that defines itself. Ignoring our mistakes is ignorant.

                        Some of the things I mentioned have been removed from our protocols (almost everywhere), and some are still in the protocols (almost everywhere).

                        These were, some still are, based on expert opinion.

                        All of them.

                        Every single one.

                        Expert opinion. There may have been some research that suggested that there might be some benefit from using these treatments. As those initial studies, vaguely related to the specific treatments, have been followed up with specific studies; We have learned that the expected benefit; The hoped for benefit; The wouldn't it be great idea that led to the treatment; Was not what we had hoped for. Maybe the treatment had side effects that cancelled out any benefit. Maybe the side effects were much worse than the benefits. Maybe there were no benefits.

                        Unfortunately, in spite of abundant evidence of lack of benefit, some of these treatments are still used. Epinephrine, antiarrhythmics, and other ALS (Advanced Life Support) treatments for cardiac arrest. In stead, we have learned that the percentage of patients we have been resuscitating is a just small fraction of those we should be resuscitating. If only we would ignore the ALS and focus on compressions and defibrillation. In many places, the resuscitation rates have tripled with the focus on continuous compressions.

                        Tripled.

                        There is not any research to support the use of these ALS treatments in cardiac arrest, but we insist that we must use them. Why? Because we do not understand science. We have more faith in old discredited hunches, that have not worked out, than we have understanding of the current science.

                        Spinal immobilization.

                        The evidence for it? What if? What about the lawyers? But we were taught . . . .

                        Given that solid basis, somebody must be doing research to determine if there actually is a benefit to the patient. Or to find out what the rate of side effects is.

                        Not a chance.

                        Everybody is afraid of the harm of depriving patients of this essential treatment - this Gold Standard. The IRBs (Institutional Research Boards/Institutional Review Boards) consider it unethical to deprive patients of the standard of care. In their eyes, it is much better to force an untested treatment based on expert opinion on patients. The lack of ability to provide accurate information to the patient, so that actual informed consent would be possible - this ignorant consent is essential (according to the behavior of the IRBs). This is unethical behavior.

                        We are required to provide information to the patient, so that the patient may make an informed decision, when possible. The IRBs are against informed consent.

                        The IRBs prevent us from having accurate information to provide to patients. The EMS Yahoo screaming, Do you want to be a quad?! is not really providing less information than is available from the best research in these areas. We make King Lear look like a man with vision.

                        However, the IRBs say that the research is unethical, and the IRBs are the ones who are there to protect patients from unethical treatment.

                        So, if we learn later on, from studies carried out in other countries, that the treatment itself is more harmful than beneficial, and therefore unethical to use; When you learn this remember that the IRBs are there requiring these harmful treatments, because they are protecting the patients from progress.

                        It is not the job of the IRB to protect the patient from progress. It is not the job of the IRB to force harmful treatments on patients. But that is what IRBs do. Rather than know more about the safety of treatments, we are forcing experimental treatments on the patients, because the IRBs will not allow the research to find out if the treatments are effective, or even safe. If there is not research to show that a treatment is effective or safe, then the treatment is by definition experimental.

                        Part of the role of the IRB is to protect patients from unauthorized research, but here they are forcing everyone treated to be part of a huge, uncontrolled, unapproved, undeclared, undocumented, unethical experiment. The IRBs have abandoned the patients they are supposed to be protecting.

                        The IRBs seem less concerned with making mistakes, than with appearing to make mistakes. If we are afraid of making mistakes, then we are afraid of learning. If we are afraid of appearing to make mistakes, then we take that ignorance to a much more dangerous level.

                        I was on the EMS Garage episode that is the title of this post. You didn't forget about the title already? So, now it is time to get to the point of the title. The topic of the show is research. There were many important research points brought up in the show. There was a lot of frustration among the participants - frustration with the obstacles to research in EMS. This was the topic I ranted about for a little bit.

                        We need to educate the IRBs about ethics. Their superficial understanding of what is good for patients is harmful and unethical. They turn down far too many studies. There needs to be more coordination among IRBs, rather than having IRB approval be a scavenger hunt for the researchers to participate in.

                        We need to oppose ignorant consent.

                        Well, that is an expanded version of my little rant from the broadcast. I will write more about this episode, but I needed to cover this rant, first.

                        Listen to the whole episode. It is longer than average, but the material is very important.

                        Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way:

                        Science is the belief in the ignorance of experts. Richard Feynman.


                        Science works differently from the way most people think. Science shows that hypotheses are valid when we cannot prove them wrong, no matter how hard we try. Most people approach hypotheses with the goal of protecting them. This hypothesis is my pet idea. I must protect it. That is the wrong approach. If we never test hypotheses to the point of failure, we never learn if the hypotheses are failures. Then we end up protecting these failures. In medicine, and EMS is a part of medicine, untested hypotheses (probable failures) kill patients.

                        Or we could go back to bleeding patients. If it makes you feel that bad, and even kills some patients, it has to be strong medicine. We could do that. But even the IRBs are not that unethical.



                        Research and EMS What are We Missing: EMS Garage Episode 53
                        Sep.19, 2009
                        Links to broadcast and downloads.


                        .

                        EMS EduCast/EMS Garage #48 Quality - comments





                        In the comments to EMS EduCast/EMS Garage #48 Quality, commenting about Dr. Eisenberg's quote,[1] 30 ff/pm wrote -


                        "We've recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice."


                        Great teaching tool but if an ambo chasing attorney gets hold of it, there could be some $$$ payed out even if no one did anything wrong.

                        My city attorney is great at throwing cash around just to avoid going to court.
                        The feeling is that the jury might be swayed by claims - even if they're not true and didn't really have anything to do with the outcome. Sucks and isn't right, but that's the world we live in.



                        Assuming that you are describing the activity of this city attorney accurately, the attorney appears to be encouraging law suits, rather than protecting the city or protecting the patients. If other lawyers realize that the lawyer representing the city is afraid to go to court, they will find any excuse to bring a suit.

                        As long as the city attorney will throw money at them to go away, what do they have to lose? A better question is, Why would the city hire someone like that?

                        The city managers hire somebody to provide a specialized service that they are not qualified to perform themselves, whether it is legal defense, or EMS, or something else. They trust these experts to provide them with competent services. It is possible that there were legitimate reasons to justify the lawyer settling in all of these cases, but even though I am not a lawyer, I would bet that it is more of a fear of going to court, than a valid claims on the parts of all of the plaintiffs. The city attorney probably does not understand a thing about EMS. Ignorance leads to fear. Fear leads to settlement out of court. Or whatever Yoda said about fear. It appears that the city attorney would rather pay out the city's money. Rather than demonstrate his/her profound ignorance of all things EMS.


                        If their approach to EMS is how do we avoid getting sued, rather than how do we improve patient care, it is a bit of a Catch-22 situation. They are discouraging attempts to improve quality of care, because anything they find out about how bad the quality actually is, could be used against them. Ignore it, pay out money now and then, here and there, but pretend that you cannot improve things, because some things are too dangerous to know?

                        Stay the same?

                        Avoid change?

                        Ignore problems?

                        There is only one way to stay the same in medicine. Only in death do things stop changing. Even then there are changes, but the person no longer has any reason to care.


                        How does one form of medical record create more liability than other forms? And an audio recording of the events is just that - another form of medical record. In some places, video recordings are used.

                        The city attorney appears to be looking at this only from the perspective of the harm it might do. In other words, the city attorney has absolutely no understanding of risk management. A recording may help the jury to understand what happened better than they would with a paramedic mumbling through the reading of a chart. Paramedics are not hired for their ability to read out loud. Paramedics are hired for their ability to treat patients on scene. A recording of the paramedic doing what he/she has actually been trained and hired to do. This might work for the defense much better than anything else the city attorney could present. Yet, the city attorney would probably prohibit this, because of ignorance - a level of comfort hiding behind ignorance that is scary.

                        I know what people are thinking - How do I know that is what the city attorney would do? I don't know it. I am speculating. Unfortunately, I believe that 30 ff/pm is correct in concluding that the city attorney would act this way. I have dealt with attorneys in hospitals, where I taught ACLS. In 2 of these hospitals, I was informed that the attorneys had instructed the hospital emergency response teams to never touch anyone, who does not exhibit evidence of being a patient. The emergency response teams are only called to suspected emergencies. If a family member of a patient experiences cardiac arrest, they are not to touch the family member of the patient until after the patient is registered.

                        No wrist band, no treatment. You get treated the same as if you were trying to sneak into a night club. Actually, the night club staff would probably provide CPR if your heart were to arrest.

                        The attorneys believe that the potential harm is greater than the benefit. Yet, these are the same people, the paramedics and emergency response teams, who will be treating the patient visitor after the patient is registered.

                        Is the emergency response team's care going to become better, just because the visitor has been registered?

                        No. Delaying CPR is possibly the worst thing they can do, but that is what the lawyers are insisting they do. The lawyers are making the medical decisions.

                        Is there any way the attorneys can claim that the unregistered patient is really not a patient?

                        No. According to EMTALA (the Emergency Medical Treatment and Active Labor Act), anyone presenting with a complaint within 250 yards of the hospital, or anywhere within the hospital, is automatically a patient. These patients may not be turned away, until after a medical screening and stabilizing treatment, even when being transferred to another hospital.

                        Cardiac arrest is one of the most time sensitive conditions. Delaying care is just as bad as refusing to deliver care, because there is a very limited time during which treatment is likely to be effective. Supposedly, the chance at resuscitation decreases 10% for every minute of delay in initiating treatment, or every minute of inadequate treatment. Such as an 80 year old Grandma performing compressions on her husband, while the emergency response team stands around digitally monitoring their own sphincter tone. Look Grandma, no prostatic hypertrophy!

                        While I am still not a lawyer, there is one word that comes to mind, when describing this approach - indefensible. OK, not just one word. There are plenty of adjectives that could go along with indefensible, but none of them are good.


                        A different approach might be to only hire competent personnel. I am not stating that the emergency response teams are not competent, or that the paramedic coworkers of 30 ff/pm are not competent. The problem is that the city attorney presumes that these medics are incompetent, or that more evidence would only work against the defense.

                        If the attorneys were comfortable with the competence of the paramedics and emergency response teams, then the attorneys should be much more confident that more facts will lead to a better defense, not the other way around. But they do not. If they are that uncomfortable with the employees, they either need to learn about what the employees do, demand higher standards, or find some other way to improve quality - such as using audio recordings of cardiac arrests. You know that I am in favor of both. Even if the standards are already high, make them higher. Quality is about improvement - never being satisfied. not in a 6 Sigma way, but in always looking for ways to improve patient care. Actively participating in research.

                        Dr. Eisenberg mentioned that some cities, that were studied, had ridiculously low resuscitation rates. The reaction, when the news was published? Apathy. nobody cared. Less than 1% successful resuscitation. While where Dr. Eisenberg works, the resuscitation rate is about 50%. This is not a minor difference, so how is it that people do not care? But, they don't care.


                        The other comment was from Greg Friese, one of the hosts of the EMS EduCast, where the broadcast with Dr. Eisenberg started. Greg's response to 30 ff/pm was -

                        I would rather defend a recording of the facts than speculate about facts based on the recollections of all involved.



                        Much more succinct than what I wrote. I completely agree. I think that 30 ff/pm also agrees, but his city attorney is the one, who does not agree.


                        Footnotes:


                        ^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
                        EMS Garage
                        Links to broadcast and downloads.

                        A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

                        How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27


                        .

                        ECG Simulator


                        I am fortunate enough to have the opportunity to review the ECG Simulator by Pace Symposia.
                        You will be seeing a few ECGs from this simulator on paramedicine 101 within my ECG tutorial.

                        Tom B wrote a review on this same simulator not long ago. Click here to read his review on the prehospital 12 lead blog. He has a few very good examples of the kind of stuff this ECG simulator can do.

                        The Interface:

                        Pros
                        - Very clean and easy to use
                        - Full screen mode
                        - Random ECG mode with ability to hide rhythm information

                        Cons
                        - Only a single lead
                        - The logo is always in the background
                        - Unable to change the color
                        - No print option


                        The Rhythms:


                        Pros
                        - Very easy to switch between rhythms
                        - A vast list of rhythm selection
                        - You can add ectopy to select rhythms
                        - Easy to change the heart rate

                        Cons
                        - Only one example of each rhythm
                        - No option to save a scenario with multiple rhythm presentations
                        - The heart rate limitations are too narrow
                        - Some rhythms should allow a manipulation of heart rate, but don't.


                        Other Features:


                        A ruler pops up when you pause the rhythm. You may hide it, but it is a pretty useful tool.



                        You can hide the grid for a monitor screen appearance.
                        Also, the ECG simulator can be controlled from the keyboard.



                        Overall:

                        I am a fan of the software. I believe all of the cons that I mentioned can be easily changed. I will be using this software for my ECG tutorial, which should give you some good examples of the rhythms available.

                        EMS EduCast/EMS Garage #48 Quality





                        Again returning to the EMS Garage post with Mickey S. Eisenberg, MD on resuscitation,[1] the rest of the episode was great. One of the points brought up was, at about 52 minutes in, Buck Feris mentions a quality assessment/improvement method in a system, that has a supervisor respond to debrief the crew after every arrest. Reviewing what went right and what went wrong.

                        Dr. Mickey S. Eisenberg earlier had talked about methods of improving outcome and the approach of reviewing every unsuccessful resuscitation by asking, Why wasn't this patient resuscitated?

                        These are excellent approaches. If we are not reviewing our calls, how do we expect to improve? I think that both of these approaches are still too limited. We should review all calls that fall into certain categories. For example, all cardiac/potentially cardiac calls, all respiratory calls, all calls involving any level of pain, et cetera. Maybe not right after the call, but as soon as is practical.

                        In my opinion, people who are opposed to continually improving patient care are not needed in EMS.

                        What kind of ignorance is needed to claim that we should not be improving our care of patients? Real medicine is about continually improving patient care.

                        Dr. Eisenberg goes on to make an essential point about a method used to improve quality. Audio recordings of cardiac arrests by the defibrillator. He states,


                        We have found that immensely valuable. We've used it in our system from day one. We've recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice. That has been a very valuable tool, to reconstruct for educational purposes, what exactly was going on in the resuscitation and when. Because, without it you can't really tell when there are gaps in CPR, you can't even tell when ventilations are occurring, you can't tell reasons why there was the delay in this or that.

                        And if it's done for the purpose of education and never for the purposes of discipline. We've never, ever, used these tapes for disciplinary reasons. They've always been used for education. You can learn an awful lot, and begin to piece together what went on.



                        If we want to improve quality, we need to make it safe for people to bring up and discuss mistakes. If the employees are afraid of punishment for raising concerns about things that went wrong, we will never learn about many of the problems in the system. We need more people in EMS, who understand this.

                        Again, in my opinion, people who are opposed to continually improving patient care are not needed in EMS.


                        Footnotes:


                        ^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
                        EMS Garage
                        Links to broadcast and downloads.

                        A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

                        How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27


                        .

                        The Electrocardiogram - Part V



                        Rate & Rhythm


                        Calculating the heart rate:

                        One thing I always teach is that there is a difference between pulse and heart rate. These terms are used interchangeably, but if you think of them as two different values, you may understand things better. Remember, there is a difference between an electrical pulse and a mechanical pulse. We are going to label the electrical pulse as the heart rate and the mechanical pulse as just plain, pulse. You can see a heart rate, but you have to feel a pulse. They are usually the same value but may be different. The heart rate is the rate at which your heart is sending an electrical impulse. This can be determined with an ECG. A pulse is the beats per minute that are actually sending blood throughout the body. This can be determined by feeling one of many different pulse locations. As you read on in this tutorial, I will eventually explain instances when these two values may be different.


                        The first method in determining the heart rate using an ECG, 'The Box Method', is probably the most accurate. This method requires you to remember a set of numbers. These numbers are: 300, 150, 100, 75, 60, 50... I only remember to the 50. Anything less than 60 is slow, right?

                        Now, the first thing you must do is find your R waves, or QRS complexes. Remember those?



                        Next, count how many big boxes (the 5 x 5 box) are between the two R waves (the RR interval). . This is easiest if you find the R wave closest to a solid line.



                        Now using this method, how ever many big boxes you have will determine the heart rate. Starting with 300, divide by the number of big boxes. Only one big box would give me a rate of 300 bpm (300 divided by 1 = 300), two big boxes would equal 150 bpm (300 divided by 2 = 150), and so on.

                        The ECG strip above shows a RR interval of just over three boxes. This means that the heart rate is between 75 - 100 bpm. Since the R wave is just right of center I will stay on the low side and call it a rate of about 80 bpm.


                        When we talk about rhythm, we are talking about the RR interval. Is the rhythm regularly regular, regularly irregular, or irregularly irregular?


                        Regularly regular - The RR interval does not vary. This is not hard-fast. RR intervals vary on everyone, when you are having a normal change in heart rate. This just means that there is no pattern of variation or complete irregularity.

                        Regularly irregular - This is a pattern of irregularity. The RR interval will change but there will be a method to the madness. It may be 600 ms then 200ms, then 600 and then 200 again. Each RR interval is not the same, but a group of RR intervals may mimic the next group.

                        Irregularly irregular - This is a chaotic irregular rhythm. The RR intervals will be constantly changing without a set pattern.

                        Below is an example of an irregularly irregular rhythm. To use the rule mentioned above to determine heart rate, you must measure more than one RR interval.


                        Measuring the shortest RR interval and the longest RR interval will give you the range of the heart rate.

                        If we measure this strip we see that the smallest RR interval is just over two big boxes wide and the longest RR interval is just over 6 boxes wide. I'd say the range for the heart rate of this ECG is between 45 - 110 bpm.


                        An ECG ruler, similar to the one below, may be another useful measuring device. These usually use a similar method to the one above, but require less memorization.


                        The other method that I use to determine the heart rate is by counting the RR intervals on a six second strip. You count each RR interval and then multiply by 10. This gives you a rough estimate of the heart rate. This is much less accurate than the first method.


                        Depending on the machine you use for ECGs, you may or may not have your second, three second, and six second points marked. Above is a sample ECG strip from my monitor. The hash marks on top, some circled in red, denote one second intervals. One second equals five big boxes. The yellow circles are around the six second hash marks, which are shown on the bottom of the strip.


                        Give one a try. Tell me about the rhythm of this strip and give the heart rate: