This morning, I received the horrible news that a fellow instructor for the wilderness medicine education company I work for, a flight nurse/paramedic, was killed in a medical helicopter crash. I knew him only by reputation, but given our small community it's a safe bet that we would have become good friends, as with so many of the other instructors I've worked with in my time with the company.
This is the second instructor that our professional family has lost to an airmedical crash in roughly 5 years, which is difficult to accept because our company has always believed, and taught our students, that helicopter rescue/transport is inherently high-risk and to be reserved for patients who will truly benefit from that risk. Lest we leave any ambiguity in our students' minds about "risk", we define it into two components; probability and consequence. I make it a point in every class I teach to say that although the statistical probability of a helicopter crash is low (http://helicopterannual.org/portals/27/pdf/ann_p2c5.pdf), the human consequences of a crash are often gut-wrenching.
Ironically, this concept (readily understood by professional guides, wilderness education college students, and outdoor enthusiasts) is largely misunderstood or ignored by medical professionals.
We frequently call for helicopter transport of trauma patients who will not benefit from it (http://www.ncbi.nlm.nih.gov/pubmed/16766969). This study identified that over HALF of patients transported by helicopter had minor injuries. A quarter of them were discharged from the hospital within 24 hours; internal data from a trauma center in the state I previously lived in upped that number to 50%. This overtriage of patients not only increases the probability of a crash, but also reduces the cost-effectiveness of helicopter EMS to society (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999834/). And even for those patients with "major trauma", the published research doesn't clearly show a significant benefit to helicopter usage (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009228.pub2/abstract;jsessionid=F0489278656882C0B38725F70F5A44D3.f03t01).
We need to take a deep breath and evaluate how we use helicopters.
I use the CDC's most recent field triage guidelines to make risk-benefit decisions about flying patients to a trauma center (http://www.cdc.gov/fieldtriage/pdf/decisionscheme_pocketcard_a.pdf). As a general rule, patients with physiologic instability (step 1) will probably get flown. Patients with anatomic injuries (step 2) might get flown, based on distance to the appropriate trauma center and time sensitivity of their injuries. Patients with a concerning mechanism of injury (step 3) or special considerations (step 4) probably WON'T get flown; I'll either take them by ground to the trauma center or to a non-trauma center that has the diagnostic capabilities the patient needs (X-rays, CT scanners, etc.). Many providers I've worked with in the past have used the mechanism of injury as their sole basis for flying a patient; this is not a very accurate gauge of what care the patient needs (http://www.ncbi.nlm.nih.gov/pubmed/24165248).
It's time to focus on the injuries a patient HAS, not ones they MIGHT have, when we ask three people to risk their lives to transport that patient.
Our colleagues, friends, and mentors are counting on us for that.
Friday, July 18, 2014
Thursday, June 19, 2014
“Why are paramedics not given the same recognition as firefighters and police?"
I read a column on EMS1.com the other day that posed a
question; “Why are paramedics not given the same recognition as firefighters
and police?”. The contributor gave his
reply about EMS being new, and still defining its’ role in the world, and then
opened it up for comments. The comments
were what you’d expect:
“Because fire departments and the IAFF are trying to absorb
us to pay for their shiny things!!!”
“Because those idiot volunteers keep public expectations
low!!!”
“Because we don’t play well with the media and the public!!!”
(and my personal favorite)
“If you’re in it for the glory….you’re in it for the wrong
reasons…”
I’ve listened to and participated in discussions/debates/passionate
arguments about all of these issues, and I definitely have strong opinions for
each, but I’m here today to tell you that if your mind wanders to any of these when
this question comes up, you’re wrong.
Dead wrong. Let me show you what
our problem is…
I’m working in a different part of the country for the
moment, taking a break from trying to combine education and clinical work
(which also explains why this blog has been silent for a while). A copy of an email was posted on the bulletin
board of the EMS station (a 3rd service one) from a member of the
city fire department. To summarize, “Brother”
XXXXX, a member of the fire department, had a heart attack and was in the ICU
recovering. His coworkers were keeping
him company in the hospital while he recovered, were assisting his family with
the bustle of daily life while making sure that they had time to spend with
their husband/father, and were setting up an account at a local bank so that
Brother XXXXX’s family would have some financial assistance while he recovered
from his heart attack (I assume this in addition to whatever sick time and
short-term disability insurance they already had).
This morning, I received a text from my friend and former
partner on the truck about a former coworker.
I’ve not really seen or talked to this coworker in at least a couple of
years; he was working his normal shifts one day and just disappeared the
next. I heard through station chatter
that he had suffered a work injury, something with his back. That was it.
Turns out, worker’s compensation missed the spine fracture he had
suffered and cut his compensation off.
He summarily ran out of what little money he had managed to save for his
family, lost his house, and is now staying with family along with his wife and
son to avoid being on the streets. I’m
told he’s in litigation with worker’s comp, but I also imagine it’s difficult
to do that when you’re broke. I was a
little shocked to hear this update, because I had no idea; no one had let me
know what he was going through.
Do you see the contrast?
Our basic problem isn’t about big fire, or large private
ambulance corporations, or volunteers, or media relations, or education, or
whatever else is being hotly debated in social media right now. We don’t receive the attention, recognition,
and support that the fire and police services do because we don’t care for each
other like they do. We don’t look out
for each other like they do. When one of
our own needs a hand, most of us look to someone else, like management, an EAP,
or worker’s comp to step in…let me rephrase that. We look away from the “brother” or “sister” (we
all like to say that EMS is a big family, right?) that needs help, and to
someone else to assume the responsibility of helping out. If we don’t change that, no amount of
legislation, advocacy, or education will truly give us the appreciation and
recognition that we deserve, and deep down crave (not for ourselves, but rather
our profession).
We have no right to demand respect and appreciation from
others until we demonstrate that we respect and appreciate ourselves.
Friday, March 14, 2014
Why do we ignore mental illness?
A colleague from the Internet recently posted this on social media; in reading it I felt that they had very eloquently stated some of the same ideas that had been rolling around in my head. "A" (they asked to remain anonymous) graciously gave me permission to repost their thoughts.
"We had one of our medics commit suicide Wednesday.
While enjoying my dinner of chocolate pudding cups and beer (don't judge me), I started to get a bit philosophical (and tipsy).
The idea that EMS eats our young has come up a bazillion times before; But what if we're not eating our young, what if we're killing them? As healthcare professionals we should know that mental health problems are more common that most people realize, and that millions of people with a mental health disorder function in society every day with no one knowing the wiser.
How many of those people are our co-workers?
I can't remember how many times I've heard co-workers b**** about all the psych patients they had that day, or how stupid/worthless/horrible "those patients" are, or laugh at self harm or a failed suicide attempt. It is a never ending stream of putrid hate that spills out of their mouths where psych patients are concerned. The overwhelming vibe is that they aren't real patients. They don't have real problems. They just need to suck it up and get over it.
What kind of effect is that having on those among us who are in a bad place? We talk about having a "work family" and the "brotherhood", but when s*** gets real and someone is struggling, are they going to remember all those rants about psych patients or are they going to remember that bond?
People keep arguing that talking like that is just blowing off steam, and is part of the job, and whatever other BS they can come up with to justify their abysmal behavior.
F***. That. Why do we tolerate that kind of behavior?"
I think that "A" hits the nail on the head; we get so caught up in the flashy parts of our job; the cardiac arrests, STEMIs and multisystem trauma patients, that we can forget the much more common patients that we see.
Our system of education doesn't exactly help...my paramedic training spent two whole semesters on medical emergencies, and exactly 16 hours on behavioral emergencies. Many times, our education in behavioral emergencies is heavily focused on "scene safety" and patient restraint; how many of us have had education on how to speak to a delusional patient properly? Who wrote that chapter in the textbook anyway? The quality of education has significant implications down the road...
One of my first partners committed suicide. At the time, I didn't think much about it; I went to the memorial service and muttered the appropriate condolences. Then I went back to work with a new partner and promptly forgot about Bekka. Since then, I'd taken care of many, many psych patients; every now and then I would remember, almost as an afterthought, that they shared a common affliction with Bekka (as if "mental illness" truly describes the spectrum of problems these patients face), but it would take almost a decade for the realities of mental illness to really sink in.
About a decade after I started in this field, I wound up with a live-in girlfriend and her daughter from a previous marriage; our relationship seemed good enough, but gradually the bad days began to outnumber the good ones. She went to her doctor, got a referral, and told me one day that she had been diagnosed with a mental illness. I was supportive and understanding; after all, I was a medical professional, right? I knew how this stuff worked.
Wrong.
Our relationship grew strained; fights, days when she could barely drag herself out of bed, followed by days when I'd come home to a 5-course meal because she got bored. There were trips to therapy that I never got a chance to go to, which became a point of contention for me; why was I excluded from this secret side of her? There were days when the slightest whimper from her daughter would trigger a full-scale meltdown; I would scoop up her daughter and take her away to "let Mommy rest" for a few hours. Her migraines grew daily, and I would get concerned about the amount of medicines she was taking; we would fight. Eventually, we broke up; suddenly, while I was away working. I was hurt, pissed off, and confused.
If mental illness affected my life to that degree, I can only imagine what it was like for her.
Those two experiences dramatically changed the way that I approach the "cuckoo for Cocoa Puffs" patient; sadly, it took real, prolonged, and painful experiences for me to learn how mental illness affects people and the ones close to them. And it makes me wonder...why can't we EMS educators find ways to pass those lessons on to students? We have fantastic, high-fidelity simulation mannequins that can automatically adjust 40-some odd different hemodynamic parameters; why can't we reach out and find a way to relate to our students the effect of mental illness on people?
I'm sure we can find a way, in time, to effectively educate our young to be sensitive to the mental wellness of our patients....but how do we teach people to be attentive to themselves? One of my favorite quotes about EMTs and paramedics is that we "know just enough medicine to be dangerous to ourselves"; we will self-diagnose and refuse care until we absolutely have to. But mental illness, depression, etc. isn't something we can ignore until it becomes unbearable and just go get a Z-pack; when it becomes unbearable, we eat a gun in the car. Or realize that an 18-pack of beer is only enough for one day off-shift. Or get served divorce papers.
We need to get in touch with ourselves as providers and know that it's not being weak of "pussing out" (the favorite phrase at my workplace). We need to demand that our employers take our mental health as seriously as they do back injuries. And we need to starting nurturing our young, instead of eating them; set them up for success and healthy longevity instead of substance abuse, relationship problems, and depression/suicide.
After so many years, I think I finally understand where Bekka was coming from. And I'm slightly ashamed that it took me so long.
I'm sorry, Bekka.
While enjoying my dinner of chocolate pudding cups and beer (don't judge me), I started to get a bit philosophical (and tipsy).
The idea that EMS eats our young has come up a bazillion times before; But what if we're not eating our young, what if we're killing them? As healthcare professionals we should know that mental health problems are more common that most people realize, and that millions of people with a mental health disorder function in society every day with no one knowing the wiser.
How many of those people are our co-workers?
I can't remember how many times I've heard co-workers b**** about all the psych patients they had that day, or how stupid/worthless/horrible "those patients" are, or laugh at self harm or a failed suicide attempt. It is a never ending stream of putrid hate that spills out of their mouths where psych patients are concerned. The overwhelming vibe is that they aren't real patients. They don't have real problems. They just need to suck it up and get over it.
What kind of effect is that having on those among us who are in a bad place? We talk about having a "work family" and the "brotherhood", but when s*** gets real and someone is struggling, are they going to remember all those rants about psych patients or are they going to remember that bond?
People keep arguing that talking like that is just blowing off steam, and is part of the job, and whatever other BS they can come up with to justify their abysmal behavior.
F***. That. Why do we tolerate that kind of behavior?"
I think that "A" hits the nail on the head; we get so caught up in the flashy parts of our job; the cardiac arrests, STEMIs and multisystem trauma patients, that we can forget the much more common patients that we see.
Our system of education doesn't exactly help...my paramedic training spent two whole semesters on medical emergencies, and exactly 16 hours on behavioral emergencies. Many times, our education in behavioral emergencies is heavily focused on "scene safety" and patient restraint; how many of us have had education on how to speak to a delusional patient properly? Who wrote that chapter in the textbook anyway? The quality of education has significant implications down the road...
One of my first partners committed suicide. At the time, I didn't think much about it; I went to the memorial service and muttered the appropriate condolences. Then I went back to work with a new partner and promptly forgot about Bekka. Since then, I'd taken care of many, many psych patients; every now and then I would remember, almost as an afterthought, that they shared a common affliction with Bekka (as if "mental illness" truly describes the spectrum of problems these patients face), but it would take almost a decade for the realities of mental illness to really sink in.
About a decade after I started in this field, I wound up with a live-in girlfriend and her daughter from a previous marriage; our relationship seemed good enough, but gradually the bad days began to outnumber the good ones. She went to her doctor, got a referral, and told me one day that she had been diagnosed with a mental illness. I was supportive and understanding; after all, I was a medical professional, right? I knew how this stuff worked.
Wrong.
Our relationship grew strained; fights, days when she could barely drag herself out of bed, followed by days when I'd come home to a 5-course meal because she got bored. There were trips to therapy that I never got a chance to go to, which became a point of contention for me; why was I excluded from this secret side of her? There were days when the slightest whimper from her daughter would trigger a full-scale meltdown; I would scoop up her daughter and take her away to "let Mommy rest" for a few hours. Her migraines grew daily, and I would get concerned about the amount of medicines she was taking; we would fight. Eventually, we broke up; suddenly, while I was away working. I was hurt, pissed off, and confused.
If mental illness affected my life to that degree, I can only imagine what it was like for her.
Those two experiences dramatically changed the way that I approach the "cuckoo for Cocoa Puffs" patient; sadly, it took real, prolonged, and painful experiences for me to learn how mental illness affects people and the ones close to them. And it makes me wonder...why can't we EMS educators find ways to pass those lessons on to students? We have fantastic, high-fidelity simulation mannequins that can automatically adjust 40-some odd different hemodynamic parameters; why can't we reach out and find a way to relate to our students the effect of mental illness on people?
I'm sure we can find a way, in time, to effectively educate our young to be sensitive to the mental wellness of our patients....but how do we teach people to be attentive to themselves? One of my favorite quotes about EMTs and paramedics is that we "know just enough medicine to be dangerous to ourselves"; we will self-diagnose and refuse care until we absolutely have to. But mental illness, depression, etc. isn't something we can ignore until it becomes unbearable and just go get a Z-pack; when it becomes unbearable, we eat a gun in the car. Or realize that an 18-pack of beer is only enough for one day off-shift. Or get served divorce papers.
We need to get in touch with ourselves as providers and know that it's not being weak of "pussing out" (the favorite phrase at my workplace). We need to demand that our employers take our mental health as seriously as they do back injuries. And we need to starting nurturing our young, instead of eating them; set them up for success and healthy longevity instead of substance abuse, relationship problems, and depression/suicide.
After so many years, I think I finally understand where Bekka was coming from. And I'm slightly ashamed that it took me so long.
I'm sorry, Bekka.
Tuesday, March 4, 2014
Why Should A Study Mean The Same Thing to Everyone?
While staying current in EMS/medical research today (OK, I admit it....I was on Facebook), I came across a blogpost by Brooks Walsh, who has a great blog (if you've not seen it, go look at it and subscribe!);
http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html
In it, he looks at the LUCAS device, a mechanical CPR device that's gotten a lot of media attention in both local news and trade magazines like JEMS. He then provides info and commentary on a study published in JAMA last year, which evaluated the LUCAS against well-trained human CPR providers and found that there was no clinical benefit to using a LUCAS versus human hands. Here's the abstract in PubMed; you can find some tables from the article in the blogpost above.
http://www.ncbi.nlm.nih.gov/pubmed/24240611
I mostly agree with the conclusions and statements that Dr. Walsh made, particularly his stressing that humans, not technology or advanced treatments, make the difference in cardiac arrest. And I love that several of my Facebook friends were sharing the post and the article so that more EMS providers can become aware of relevant EMS research.
However, I wanted to add a note of caution; your mileage may vary.
Any piece of equipment or medication that an EMS service deploys should be looked at critically periodically; and literature reviews are an important part of that process. If a device or medication can't be proven to benefit patients in meaningful ways, then it's time to take a hard look at whether or not it's worth spending additional money on it. However, the results of a study often mean different things to different people; the LINC trial is a great example of that, I think. Consider the viewpoints of two EMS managers evaluating whether or not to buy the LUCAS for their service:
System A is a large, urban or suburban system with 10-20 units on the road normally, strategically deployed around the service area. They work closely with a paid fire department that automatically responds to cardiac arrest calls. On average, there are between 6-10 medical providers who are dispatched to a cardiac arrest call, and transport times to the hospital are normally 5-10 minutes. Is it worth spending a couple hundred thousand dollars to place a LUCAS on every transporting unit? Probably not!
System B is a small, rural EMS service with 2-3 units in service at a central EMS station. Both 24-hour ambulances will typically respond to a cardiac arrest call (assuming the 2nd truck isn't already on a call), but the local fire departments are 100% volunteer, and medical training isn't required to be a member. On average, there are 2-4 medical providers who are dispatched to a cardiac arrest, and transport times to the local hospital are 30-45 minutes. Is it worth spending a few thousand dollars to place a LUCAS device in the station so an ambulance crew or volunteer firefighter can grab the LUCAS device if a cardiac arrest call comes in? I think it does!
I guess my point is this....good-quality research is absolutely essential in providing quality medical care. However, there are other system-specific considerations like cost, logistics, training, etc. that necessarily play a role in what therapies you stock on your ambulance. Evaluating the results of evidence should always be done with these other factors in mind. In the case of the LUCAS, for my EMS service (service B), "just as good" as human hands is as beneficial as "better" than human hands. At my former service (service A), we would have either not purchased the LUCAS or auctioned off the units we'd already purchased.
With everything that gets studied in medicine--your mileage may vary.
http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html
In it, he looks at the LUCAS device, a mechanical CPR device that's gotten a lot of media attention in both local news and trade magazines like JEMS. He then provides info and commentary on a study published in JAMA last year, which evaluated the LUCAS against well-trained human CPR providers and found that there was no clinical benefit to using a LUCAS versus human hands. Here's the abstract in PubMed; you can find some tables from the article in the blogpost above.
http://www.ncbi.nlm.nih.gov/pubmed/24240611
I mostly agree with the conclusions and statements that Dr. Walsh made, particularly his stressing that humans, not technology or advanced treatments, make the difference in cardiac arrest. And I love that several of my Facebook friends were sharing the post and the article so that more EMS providers can become aware of relevant EMS research.
However, I wanted to add a note of caution; your mileage may vary.
Any piece of equipment or medication that an EMS service deploys should be looked at critically periodically; and literature reviews are an important part of that process. If a device or medication can't be proven to benefit patients in meaningful ways, then it's time to take a hard look at whether or not it's worth spending additional money on it. However, the results of a study often mean different things to different people; the LINC trial is a great example of that, I think. Consider the viewpoints of two EMS managers evaluating whether or not to buy the LUCAS for their service:
System A is a large, urban or suburban system with 10-20 units on the road normally, strategically deployed around the service area. They work closely with a paid fire department that automatically responds to cardiac arrest calls. On average, there are between 6-10 medical providers who are dispatched to a cardiac arrest call, and transport times to the hospital are normally 5-10 minutes. Is it worth spending a couple hundred thousand dollars to place a LUCAS on every transporting unit? Probably not!
System B is a small, rural EMS service with 2-3 units in service at a central EMS station. Both 24-hour ambulances will typically respond to a cardiac arrest call (assuming the 2nd truck isn't already on a call), but the local fire departments are 100% volunteer, and medical training isn't required to be a member. On average, there are 2-4 medical providers who are dispatched to a cardiac arrest, and transport times to the local hospital are 30-45 minutes. Is it worth spending a few thousand dollars to place a LUCAS device in the station so an ambulance crew or volunteer firefighter can grab the LUCAS device if a cardiac arrest call comes in? I think it does!
I guess my point is this....good-quality research is absolutely essential in providing quality medical care. However, there are other system-specific considerations like cost, logistics, training, etc. that necessarily play a role in what therapies you stock on your ambulance. Evaluating the results of evidence should always be done with these other factors in mind. In the case of the LUCAS, for my EMS service (service B), "just as good" as human hands is as beneficial as "better" than human hands. At my former service (service A), we would have either not purchased the LUCAS or auctioned off the units we'd already purchased.
With everything that gets studied in medicine--your mileage may vary.
Tuesday, February 25, 2014
Why do we still allow medication errors to happen?
I went to the bank yesterday to deposit a couple of checks. I fumbled my way through the process of filling out the deposit slip; I hadn't slept well the previous night, and my dog compounded the problem by absolutely INSISTING that he had to go outside for his morning routine of pee, sniff around, poop, pee, sniff around some more....you get the idea. Anyway...when I took the checks and slip to the teller, she thankfully double-checked my math with a calculator and discovered that I had screwed up my addition, shorting myself $200. Needless to say, I was grateful!
Now sitting in my office after a much better night's sleep, I'm struck by how the events of yesterday are similar to the circumstances surrounding medication errors in the ambulance. I've made a few myself in the years I've been working, and occasionally a student will pop in to tell me about a medication error that they made or observed during internship or clinical settings. I know that the possibility of error will always be present, no matter how mistake-proof we try to make the process. However, many efforts that I've seen hospitals take to reduce the incidence of medication errors haven't found their way onto many ambulances yet.
Why is that? Is it a matter of ego, improper education, apathy? Or some mix of all three?
Here are some ways we can start working from the ground-up to reduce medication errors in EMS:
As Providers
Double-check everything. Using the 6 Rights of medication administration is great if you're operating at 100% mentally; however, lots of things "make sense" at 0300 and ONLY 0300! The aviation industry got it right....they have a procedure called a "crosscheck" where multiple professionals check critical safety functions on an aircraft prior to it leaving the ground. A friend of mine who works in Kansas recently told me about a "Medication Administration Cross Check" that his service implemented:
http://vimeo.com/wscomd/review/40680029/9b7a58c827
Use a calculator. Nobody should have to rely on mental math in a critical situation; with all the weight-based medications we use, plus converting from pounds to kilograms, forgetting to carry the one can have significant consequences. I keep a small calculator in my fanny pack at work (I'm old-fashioned and nerdy that way), and won't hesitate at all to whip it out if needed.
Make infusion rate tables. Again, nobody should have to do a dopamine drip on the fly in a critical situation. Using a calculator can help you carry the one and keep your decimal places straight, but only if you remember the formula. I got around this by making infusion tables for every drip (weight-based or not) we would potentially use at our service. Each one has an abbreviated list of indications (the infusion rates for epi in symptomatic bradycardia are different from post-ROSC!), mixing instructions (you just can't print one off the internet and stick it on the truck....what if your dopamine vial isn't 1200mg/mL like they are in the hospital pharmacy that created the sheet, or you don't have 100mL aliquots of D5W to dilute it in?), and a table with adult weights. Laminate 'em and attach them to your infusion pump.
Bonus tip; if your service doesn't have infusion pumps (like mine), buy a small metronome and keep it stashed with your calculator. Setting a tempo that equals your gtt/min is far easier than trying to glance back and forth between your watch and the drip chamber.
Keep a medication reference handy. It's easy to forget the subtle differences between medications at times; even pharmacists screw up. Know what they always have laying around in the pharmacy? A medication guide with names, indications/contraindications, dosages, etc. If you're in a situation where there's no one else to cross check your medication administration, double-checking it in the book (protocol or otherwise) is a sign of wisdom, not wussiness. I particularly love the pocket-sized medication references because they're so portable, and they really come in handy if I encounter a prescription medication I'm not familiar with ("Paracetomoxyfrusebendroneomycin? Let me just look that up....").
As Educators
I think that we EMS educators have to shoulder some of the blame for all these medication errors....when I went through paramedic school, I was scared stiff that if I didn't have all 60 medication doses and concentrations memorized waking/sleeping/sober/drunk, our medical director would castrate me, take away my birthday, and use my EMT certification to bow his nose before using a small C4 charge to.....OK, maybe I exaggerate. But the fact is that if we truly want our students to administer medications safely, we need to take a hard look at how we're teaching them.
Use appropriate testing techniques. I don't think there's anything wrong at all with requiring students to know the formula for calculating a dopamine drip or similar infusion...but requiring students to do it on the fly during an ACLS Megacode is just asking for mistakes and student meltdowns! (Incidentally, the AHA seems to agree...they specifically state in their instructor manual that students are permitted to use their ECC Handbook to check a drug dosage) Leave the calculations to written exams or low-stress learning activities. Actually, in my most recent ACLS class I gave students blank infusion rate tables and had them fill them out. It's amazing how the formula sticks with you after calculating it 40 or 50 times....
Train the way you fight. Incorporate all the tips above into your small group simulations. There's a great quote I'll attribute to David Grossman, author of "On Combat" (which is a stellar book on how humans perform under stress); "We don't rise to the occasion, we sink to our level of training". I can preach all I want to about crosschecks and medication references, but if we don't expect our students to utilize those techniques during class, what should we really expect them to do in the field?
And will that really be best for the patient?
Now sitting in my office after a much better night's sleep, I'm struck by how the events of yesterday are similar to the circumstances surrounding medication errors in the ambulance. I've made a few myself in the years I've been working, and occasionally a student will pop in to tell me about a medication error that they made or observed during internship or clinical settings. I know that the possibility of error will always be present, no matter how mistake-proof we try to make the process. However, many efforts that I've seen hospitals take to reduce the incidence of medication errors haven't found their way onto many ambulances yet.
Why is that? Is it a matter of ego, improper education, apathy? Or some mix of all three?
Here are some ways we can start working from the ground-up to reduce medication errors in EMS:
As Providers
Double-check everything. Using the 6 Rights of medication administration is great if you're operating at 100% mentally; however, lots of things "make sense" at 0300 and ONLY 0300! The aviation industry got it right....they have a procedure called a "crosscheck" where multiple professionals check critical safety functions on an aircraft prior to it leaving the ground. A friend of mine who works in Kansas recently told me about a "Medication Administration Cross Check" that his service implemented:
http://vimeo.com/wscomd/review/40680029/9b7a58c827
Use a calculator. Nobody should have to rely on mental math in a critical situation; with all the weight-based medications we use, plus converting from pounds to kilograms, forgetting to carry the one can have significant consequences. I keep a small calculator in my fanny pack at work (I'm old-fashioned and nerdy that way), and won't hesitate at all to whip it out if needed.
Make infusion rate tables. Again, nobody should have to do a dopamine drip on the fly in a critical situation. Using a calculator can help you carry the one and keep your decimal places straight, but only if you remember the formula. I got around this by making infusion tables for every drip (weight-based or not) we would potentially use at our service. Each one has an abbreviated list of indications (the infusion rates for epi in symptomatic bradycardia are different from post-ROSC!), mixing instructions (you just can't print one off the internet and stick it on the truck....what if your dopamine vial isn't 1200mg/mL like they are in the hospital pharmacy that created the sheet, or you don't have 100mL aliquots of D5W to dilute it in?), and a table with adult weights. Laminate 'em and attach them to your infusion pump.
Bonus tip; if your service doesn't have infusion pumps (like mine), buy a small metronome and keep it stashed with your calculator. Setting a tempo that equals your gtt/min is far easier than trying to glance back and forth between your watch and the drip chamber.
Keep a medication reference handy. It's easy to forget the subtle differences between medications at times; even pharmacists screw up. Know what they always have laying around in the pharmacy? A medication guide with names, indications/contraindications, dosages, etc. If you're in a situation where there's no one else to cross check your medication administration, double-checking it in the book (protocol or otherwise) is a sign of wisdom, not wussiness. I particularly love the pocket-sized medication references because they're so portable, and they really come in handy if I encounter a prescription medication I'm not familiar with ("Paracetomoxyfrusebendroneomycin? Let me just look that up....").
As Educators
I think that we EMS educators have to shoulder some of the blame for all these medication errors....when I went through paramedic school, I was scared stiff that if I didn't have all 60 medication doses and concentrations memorized waking/sleeping/sober/drunk, our medical director would castrate me, take away my birthday, and use my EMT certification to bow his nose before using a small C4 charge to.....OK, maybe I exaggerate. But the fact is that if we truly want our students to administer medications safely, we need to take a hard look at how we're teaching them.
Use appropriate testing techniques. I don't think there's anything wrong at all with requiring students to know the formula for calculating a dopamine drip or similar infusion...but requiring students to do it on the fly during an ACLS Megacode is just asking for mistakes and student meltdowns! (Incidentally, the AHA seems to agree...they specifically state in their instructor manual that students are permitted to use their ECC Handbook to check a drug dosage) Leave the calculations to written exams or low-stress learning activities. Actually, in my most recent ACLS class I gave students blank infusion rate tables and had them fill them out. It's amazing how the formula sticks with you after calculating it 40 or 50 times....
Train the way you fight. Incorporate all the tips above into your small group simulations. There's a great quote I'll attribute to David Grossman, author of "On Combat" (which is a stellar book on how humans perform under stress); "We don't rise to the occasion, we sink to our level of training". I can preach all I want to about crosschecks and medication references, but if we don't expect our students to utilize those techniques during class, what should we really expect them to do in the field?
And will that really be best for the patient?
Sunday, January 12, 2014
The Truth About Blood Pressure: Conclusion (for now)....
Since my new semester of classes is due to start in less than 24 hours, I wanted to put up a tentative ending point on this discussion of blood pressure. With all the talk about Ohm's law, the major role of arterioles in autoregulation, and major changes to flow based on vessel resistance, I feel a little like Thomas Dolby:
(Image source: www.uproxx.com)
To use blood pressure measurements appropriately, we need to both appreciate what it's actually measuring (which we've done) and consider what we use the monitoring tool for. I would suggest that we use blood pressure monitoring for two main purposes;
1) Detect hypoperfusion
2) Initiate and guide therapies like intravenous fluid and inotropes/vasopressors to correct hypoperfusion
Let's look at how we can use blood pressure appropriately for both these goals.
Detecting Hypoperfusion
Until new technologies like microcirculatory flow monitoring becomes available in the field (are you listening, Zoll and Physio???), we can't actually quantitatively measure perfusion where it matters, the capillary beds. Making guesses about perfusion based partially on blood pressure is the best we can do. However, using the traditional measurement of systolic/diastolic blood pressure is a poor way to go about it. Remember, systolic and diastolic pressures are measured at the extremes of the cardiac cycle; height of contraction and depth of relaxation, respectively. A more true measure of arterial blood pressure is calculating the mean arterial pressure; most monitors will do this automatically for you at this point, and if not there are simple calculators available online and in app stores for this. A caveat; the calculation is based on relatively normal heart rates; as heart rate increases the duration of diastole decreases. I've not yet found a formula or calculator that adjusts for heart rate.
However, keep in mind the major limitation; whether it's systolic/diastolic or MAP, it's still a pressure reading above the site of the action! Autoregulation via the arterioles can go a long way to maintaining flow, so it's not just about the numbers. Look for additional signs of hypoperfusion instead of an arbitrary threshold number.
Initiating/Guiding Therapies
Once you'vedecided made an educated guess that the patient is suffering from hypoperfusion, often times you need to do something about it. Depending on the clinical situation, we often turn to either fluid therapy or medications such as inotropes or vasopressors. There's obviously a cutoff point where additional fluids are bad; when I was in paramedic school it was drilled into me to listen to lung sounds before starting a fluid bolus, and periodically to make sure that the patient wasn't fluid-overloaded. Waiting until you've put your patient into pulmonary edema to switch to something different is ridiculous...we need to be looking for something better.
Unfortunately, looking for changes to systolic blood pressure or MAP isn't particularly sensitive. Measuring the diameter of the inferior vena cava with portable ultrasonography makes great theoretical sense and is currently being used in some hospitals, but exactly how accurately it predicts the need to switch to vasopressors is still being debated and studied.
One potential way is to measure the pulse pressure over time; remember, pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. Doing so theoretically represents the amount of blood ejected by the left ventricle, or stroke volume. Theoretically, then, pulse pressure could be multiplied by the heart rate (and probably some sort of coefficient) to determine cardiac output. There's an abstract I found that studies just that, and it looks promising. Think about it...a non-invasive way to quantitatively measure cardiac output!
However, there's more....following that same train of thought, changes in pulse pressure measured over time (pulse pressure variation) can help us determine if the patient will respond to additional IV fluids. This is a topic for a whole other blogpost, which I intend to do, but the short version is that measuring the pulse pressure can help us figure out where the patient is on the Frank-Starling curve:
(Image source: http://ccforum.com/content/11/3/131)
Some research has been published demonstrating that pulse pressure variation might determine "fluid responders" in various types of critical illness or injury; that is to say, pulse pressure variation might help you decide when the patient's had enough fluid and it's time to try something different. I've not had a chance to really read anything but the abstracts yet, so I don't think this is ready for use in clinical practice yet, but it's certainly interesting enough that I want to know more about it!
The Bottom Line
Now that we've reached a temporary stopping point about blood pressure, let's recap what I think is appropriate use of blood pressure measurements:
Until next time!
To use blood pressure measurements appropriately, we need to both appreciate what it's actually measuring (which we've done) and consider what we use the monitoring tool for. I would suggest that we use blood pressure monitoring for two main purposes;
1) Detect hypoperfusion
2) Initiate and guide therapies like intravenous fluid and inotropes/vasopressors to correct hypoperfusion
Let's look at how we can use blood pressure appropriately for both these goals.
Detecting Hypoperfusion
Until new technologies like microcirculatory flow monitoring becomes available in the field (are you listening, Zoll and Physio???), we can't actually quantitatively measure perfusion where it matters, the capillary beds. Making guesses about perfusion based partially on blood pressure is the best we can do. However, using the traditional measurement of systolic/diastolic blood pressure is a poor way to go about it. Remember, systolic and diastolic pressures are measured at the extremes of the cardiac cycle; height of contraction and depth of relaxation, respectively. A more true measure of arterial blood pressure is calculating the mean arterial pressure; most monitors will do this automatically for you at this point, and if not there are simple calculators available online and in app stores for this. A caveat; the calculation is based on relatively normal heart rates; as heart rate increases the duration of diastole decreases. I've not yet found a formula or calculator that adjusts for heart rate.
However, keep in mind the major limitation; whether it's systolic/diastolic or MAP, it's still a pressure reading above the site of the action! Autoregulation via the arterioles can go a long way to maintaining flow, so it's not just about the numbers. Look for additional signs of hypoperfusion instead of an arbitrary threshold number.
Initiating/Guiding Therapies
Once you've
Unfortunately, looking for changes to systolic blood pressure or MAP isn't particularly sensitive. Measuring the diameter of the inferior vena cava with portable ultrasonography makes great theoretical sense and is currently being used in some hospitals, but exactly how accurately it predicts the need to switch to vasopressors is still being debated and studied.
One potential way is to measure the pulse pressure over time; remember, pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. Doing so theoretically represents the amount of blood ejected by the left ventricle, or stroke volume. Theoretically, then, pulse pressure could be multiplied by the heart rate (and probably some sort of coefficient) to determine cardiac output. There's an abstract I found that studies just that, and it looks promising. Think about it...a non-invasive way to quantitatively measure cardiac output!
However, there's more....following that same train of thought, changes in pulse pressure measured over time (pulse pressure variation) can help us determine if the patient will respond to additional IV fluids. This is a topic for a whole other blogpost, which I intend to do, but the short version is that measuring the pulse pressure can help us figure out where the patient is on the Frank-Starling curve:
Some research has been published demonstrating that pulse pressure variation might determine "fluid responders" in various types of critical illness or injury; that is to say, pulse pressure variation might help you decide when the patient's had enough fluid and it's time to try something different. I've not had a chance to really read anything but the abstracts yet, so I don't think this is ready for use in clinical practice yet, but it's certainly interesting enough that I want to know more about it!
The Bottom Line
Now that we've reached a temporary stopping point about blood pressure, let's recap what I think is appropriate use of blood pressure measurements:
- Throw away the notion that blood pressure or mean arterial pressure alone identifies hypoperfusion. Most of my protocols define hypoperfusion as "systolic blood pressure >90mmHg". It's not about the numbers, it's about the numbers AND the patient.
- Mean arterial pressure is more representative of arterial pressure than systolic/diastolic measurements of blood pressure. I'm going to continue to focus on the MAP rather than systolic blood pressure measurements alongside other clinical indicators to detect hypoperfusion.
- We can potentially use both measurements of blood pressure (MAP and systolic/diastolic) to measure hemodynamic parameters previously unavailable in our patients; pulse pressure variation may turn out to be a very useful clinical tool in measuring cardiac output, as well as guiding management of hypoperfusion
Until next time!
Thursday, January 9, 2014
The Truth About Blood Pressure, Part 2: (measuring) Resistance is Futile
In the last post, we saw how blood pressure is not a measure of perfusion, because perfusion is all about flow. We also saw how resistance within a tissue bed or organ can significantly affect flow:
(image source: www.cvphysiology.com)
So, can we use blood pressure as a measure of vascular resistance to get a sense of the biggest factor that determines blood flow? At one point, I believed that diastolic blood pressure was a good indicator of "afterload", which I interpreted as systemic vascular resistance.
Let's look at the factors that affect resistance; in a single blood vessel with non-turbulent flow we can use Poiseuille's equation:
(image source: my computer. I can't remember which website I got this from)
There are three main things that effect resistance (R); length of the blood vessel (L), the viscosity of blood ("n" is the closest I can get to the symbol you see), and the diameter or radius of the vessel (r). The viscosity of blood stays within such a small range except in extreme cases that it's typically considered to be a constant. As you can see, vessel radius has a huge impact on resistance; small decreases in resistance can cause dramatic increases in resistance and decreases in flow.
We typically assume that all portions of the arterial vasculature have equal responsibilities of blood distribution and resistance, but that's not the case. Large arteries play a much larger role in distribution than in resistance; the arterioles have the biggest impact on resistance because of their size (less than 200 micrometers). Where do we typically measure blood pressure? A large artery.
Blood pressure isn't a good measurement of vascular resistance.
Now, Poiseuille's equation might lead us to believe that since the radius of a blood vessel is so important at determining resistance, small changes to the size of a large artery (say, the brachial one) during hypotension can significantly decrease distal blood flow to the capillary beds and cause hypoperfusion. However, there's another factor to consider; arterioles, capillaries and venules exist in parallel networks to bathe the individual cells with opportunities for microcirculation.
(image source: http://yr8science2011.wikispaces.com/Siobhan)
Even this image can't accurately describe the sheer number of tiny blood vessels in the tissue bed of an organ; there are thousands, probably tens of thousands of them. This is hugely important, because parallel vessels decrease the overall vascular resistance of the tissue bed or organ. We also have to consider that the total resistance in this vascular bed is the sum of the individual vessel resistances;
So, can we use blood pressure as a measure of vascular resistance to get a sense of the biggest factor that determines blood flow? At one point, I believed that diastolic blood pressure was a good indicator of "afterload", which I interpreted as systemic vascular resistance.
Let's look at the factors that affect resistance; in a single blood vessel with non-turbulent flow we can use Poiseuille's equation:
There are three main things that effect resistance (R); length of the blood vessel (L), the viscosity of blood ("n" is the closest I can get to the symbol you see), and the diameter or radius of the vessel (r). The viscosity of blood stays within such a small range except in extreme cases that it's typically considered to be a constant. As you can see, vessel radius has a huge impact on resistance; small decreases in resistance can cause dramatic increases in resistance and decreases in flow.
We typically assume that all portions of the arterial vasculature have equal responsibilities of blood distribution and resistance, but that's not the case. Large arteries play a much larger role in distribution than in resistance; the arterioles have the biggest impact on resistance because of their size (less than 200 micrometers). Where do we typically measure blood pressure? A large artery.
Blood pressure isn't a good measurement of vascular resistance.
Now, Poiseuille's equation might lead us to believe that since the radius of a blood vessel is so important at determining resistance, small changes to the size of a large artery (say, the brachial one) during hypotension can significantly decrease distal blood flow to the capillary beds and cause hypoperfusion. However, there's another factor to consider; arterioles, capillaries and venules exist in parallel networks to bathe the individual cells with opportunities for microcirculation.
Even this image can't accurately describe the sheer number of tiny blood vessels in the tissue bed of an organ; there are thousands, probably tens of thousands of them. This is hugely important, because parallel vessels decrease the overall vascular resistance of the tissue bed or organ. We also have to consider that the total resistance in this vascular bed is the sum of the individual vessel resistances;
Total resistance (Rt)=RA + Ra + Rc + Rv + RV
(A=artery, a=arteriole, c=capillary, v=venule, V=vein)
The take-home point to this is that decreasing the diameter of a large or small artery will have very minor effects on the total vascular resistance of the tissues in question because it's such a small percentage of blood vessels involved in perfusing that area. As a matter of fact, a large or small artery has to have it's diameter increased by more than 60-70% before it starts to have a significant effect on tissue perfusion!
The reason our tissues can get away with this goes back to the relationship between resistance and flow; even at low perfusion pressures you can increase flow to the tissues by decreasing resistance in the arterioles (known as "autoregulation"). And it just happens that I have some research to support this :)
http://www.jccjournal.org/article/S0883-9441(12)00060-3/abstract
In this study, researchers measured mean arterial pressure and microcirculatory flow in hemodynamically unstable patients; they found that microcirculatory flow changed significantly despite a relatively unchanged MAP.
Hypotension does not always mean hypoperfusion.
So, at this point we've determined that:
1) Blood pressure doesn't measure perfusion, or even perfusion pressure.
2) Blood pressure doesn't measure vascular resistance.
3) Because of the concepts of total vascular resistance, hypotension in an artery doesn't always equate to hypoperfusion in the tissue bed.
In the next post, we'll wrap it all up by looking at traditional blood pressure measurement versus mean arterial pressure, and figure out how to use blood pressure measurement in the clinical environment. Stay tuned!
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