Stuff They Don’t Teach You In Paramedic School

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If you’re a paramedic, then you’ve done so many teaching scenarios that you are probably sick of them by now. If you do any amount of teaching paramedics, I’m SURE that you are sick of them by now. Scenarios are a long standing part of EMS teaching and the real challenge is coming up with ones that are interesting and challenging, while not overwhelming the students. When I teach, I try to use real cases, which sometimes puts me at odds with traditional teaching and the root of that problem is that a lot of scenarios reflect what’s in the text books, not what we see (and smell) in the field on a daily basis.

All of which is an introduction to a real call that would make a very good teaching scenario. Which is the point of this post and rather long introduction. So, here goes.

We were dispatched along with a BLS ambulance and the fire department first responders for a generic “Difficulty Breathing” call. Some days this seems like our most frequent call type and in reality it can range from a baby with a stuff nose to someone in acute respiratory failure who is about to die. Or try to die, since we frown on that sort of thing here at Sorta Big City EMS. Contrary to what seems to be the current trend, we arrived after the FD and BLS.

On the way to the call I had looked at the computer for the additional information that the call taker had made up carefully gleaned from the caller. Who didn’t appear to be the patient and probably was not medically trained. There wasn’t anything interesting in the call, but the BLS unit had updated that the patient was “large” and had requested a supervisor with the heavy duty stair chair and “the ramps.” My back started to hurt.

We arrived, grabbed our life saving gear, and walked up the front stairs of the apartment building and down the hallway. Unlike most large patients, this one lived on the first floor. That alone mitigated against his being really ill, because we all know that sick people always seem to live on the top floor. The sicker the higher.

There are exceptions to every rule and this proved to be one.

The patient was sitting on one of those plastic shower chairs, the ones that elderly people use in their showers or bathtubs. You’ve probably seen them, but don’t think much about them. To be a bit more accurate the patient was sitting around the chair, all 475 pounds of him. This in itself was a testament to the engineering marvel that is the shower chair. It was also proof that the patient had never been able to answer “No.” to the question “Would you like to super size that?” Did I mention that my back hurt already?

The BLS crew, one new EMT and his experienced partner were examining the patient, who for some reason didn’t have oxygen on. I looked at the patient and had one question. “Is he breathing?”. Before the EMTs could answer, the patient picked up his head, looked at me and said “Yes, I am.”. Well, that’s always a good thing, breathing that is.

One EMT was busily engaged trying to get a blood pressure while his partner was busy attaching to the sensor of the pulse oximeter to the patient’s finger. Since we had another new EMT riding along with us, I directed him to put the patient on Oxygen. I was distracted by a constant beeping sound and my attention was directed to the annoying pulse oximeter. Which was really annoying because it was beeping very quickly. Stupid thing must be broken I thought as I glanced down at the numbers. 82 and 225. 82 being the alleged percentage of Oxygen in the patients blood stream and 225 being the alleged heart rate. Remember the old adage, “Treat the patient not the monitor”? Or in this case the O2 sat machine. So, I looked at the patient and then looked at the O2 sat machine. Then I asked the EMT trying to get the BP if she had a number for me yet. “No, I can’t get one, but that can’t be right”.

My sharp as a razor brain processed all of this information and came to a rapid answer. “SHIT!” I managed to get the attention of my ever so easily distracted partner and suggested that he apply electrodes that had suddenly appeared in my hand to the patient. I don’t know what had distracted him from the patient, but sometimes he focuses so intently on something that has nothing to do with the patient that I’m tempted to call him “Rain Medic”. While he did that, I asked one of the EMTs to set up an IV line for us, since I was pretty sure that we were going to be treating whatever it was that was going on with him.

The leads were attached, the monitor came to life, and this is what I saw.

I’m not all that good at math, but I the numbers that I saw added up to one very sick patient. 475+82+225+0 = Oh shit.

If you read through the ACLS protocols you’ll find that they recommend that acutely ill patients in SVT be immediately cardioverted, which is also know as “Better living through electricity”. In our system we’ve never been really big on cardioversion because there are down sides to it (like all treatments) the second worst being causing a clot to come lose from the Atria and travel to the brain causing a stroke. As a result we generally try pharmacological treatments first. After a brief discussion my partner, who was now fully focused on the patient, and I decided to try Adenosine. So, while he completed the IV I prepared the medication. Generally I like Adenosine, since it usually works, is short acting so the side effects are limited, and it’s kind of fun (in a perverse way) to watch the faces on new EMTs who haven’t seen it at work before.

Anyway, we gave the standard dose of 6 mg and it did… nothing.

Hmm.

So I prepared the second standard dose and we gave it. Which gave us this,

What a tease. This was only getting worse by the minute. The underlying rhythm looked like Atrial Flutter, but the truth is that the exact rhythm was academic right now. All of the drugs we have to treat that dysrhythmia require the patient to have some blood pressure to work with and the patient had none. I looked at my partner and he looked at me. “We’re going to have to cardiovert him.” I don’t remember which of us said that first, but we both reluctantly agreed.

I couldn’t remember the last time I’d cardioverted a real patient and my partner confessed that he’d never done it to a patient. It’s just that rare that we do it. Not that we didn’t know the procedure, it’s just that we hadn’t done it on real people in a long time. Well, in my partners case, ever. Cardioversion also hurts like hell, which is why we give sedation prior to doing it. We use Versed which is not only a powerful sedative, it has amnesic qualities as well, so the patient doesn’t remember what happened.

At this point the supervisor showed up with the large person chair. I suggested that we might want to have the patient move over to the chair and strap him in place before we gave the Versed and cardioverted. Just in case, you know. Everyone thought this was a good idea and so we maneuvered the patient onto the chair, fastened the straps, and then gave the Versed. Once that took effected I set pressed the synchronize button, set the energy setting to where it needed to be, charged the machine, asked if everyone was clear, and pressed the “SHOCK” button. And held my breath.

After about a second or so to sync up, the machine discharged, the patient’s arms flapped once, and we were rewarded with,

We all started to breath again, one of the EMTs tried to get a blood pressure, and we made sure that the patient was still breathing.

All was well as the patient had good pulses now, a good blood pressure, was breathing, and was still out.

We decided to move him out to the ambulance and start the process of loading him into the ambulance. That took a bit although we’ve done this before and are actually pretty good at it. It’s never pleasant, but it’s part of the job. We wheeled him out to the front door, used the tracks on the back of the stairs to make it *easier* to get him down the stairs and then out to the ambulance. We have this ramp system that we use to get large patients into the ambulance without risking injury to ourselves. If you’ve ever seen a ramp truck haul a car up onto it’s flat bed, it’s not much different. Except that we don’t have the entire back of the ambulance on a platform that tilts and slides back. Which, when you think of it, would be an interesting design for a specialized bariatric ambulance.

It’s funny, but I don’t remember reading anything about 400+ pound patients or moving them in my paramedic text books all those years ago. Maybe the newer books mention it, but there is just so much that neither the paramedic nor EMT curricula even mention, let alone cover sufficiently. It’s why EMS is sometimes more about ingenuity than knowledge.

But I digress.

Now in the back of the ambulance, the patient was starting to wake up. He wasn’t having trouble breathing and he didn’t remember anything that had happened. That was good. He was able to give us a bit more history, which didn’t include any sort of SVT, but did include Type II diabetes. Which not too surprisingly he didn’t treat all that well. His blood glucose was 438, which wasn’t quite his weight, but was yet another ugly number.

Having nothing else to do on the way to the hospital we decided to acquire a 12 lead.

The ischemia was more or less universal and in the larger scheme of things wasn’t horribly worrisome. We decided not to tempt fate with nitroglycerin and continued on to the hospital.

Where we had a lot more help moving the patient over to the hospital stretcher.

I gave my report, got a signature, and went off to write my report while the doctors and nurses tried to figure out what was going on with the patient.

And count our blessings that no one had been injured on the call.

16 COMMENTS

  1. Hey TOTYTR, good case presentation. To me the 12-lead looks slightly concerning for LMCA Stenosis vs. Dig effect. I actually have a different take on cardioversion; I think it is much more benign than any of the “selective cardiotoxins” that we administer. Think about what you are doing with adenosine vs. cardioversion. Adenosine isn’t simply a negative chronotrope, it actually converts the rhythm through pausing AV nodal conduction; this could throw the same clot a shock would. The only time I am concerned about an embolus is with cardioversion of a chronic a-fibber. I agree, that would truly be tragic, and I would surely try Cardizem if they’re pressure could handle it. Anyhow, just wanted to join the discussion, thanks again for the great post.

    Adam

    • It’s certain that there is no “right” answer to this, which why the AHA couches there recommendations they way they do. I think the advantage of Adenosine (if there is one) over Cardioversion is that there is less physical shock to the body. Or maybe it’s just the appearance. If the patient has a known history of Atrial Fib and sufficient BP, we usually go with whatever class of medication they are on first. So, if the patient is beta blocked, they get a beta blocker. If they are Calcium channel blocked, they get one of those drugs, typically Cardizem. Fortunately the days when we used Verapamil are long gone. I always hated that drug.

      • That seems like an interesting and effective approach for choosing your chronotropic agent. Unfortunately we don’t carry beta-blockers anymore. Our agency is 100% inline with AHA recommendations, whether good or bad, our guidelines are adapted every 5 years to the AHA. We do however, have latitude if we can prove we are acting in the best interest of our patient.

        • We still carry them, we still use them for dysrhythmias. We used to use them for some STEMIs as well, but one of our folks kind of screwed the pooch on that, so we don’t any longer.

    • Given the generally sound clinical picture I think I’d be dubious about LMCA occlusion, Adam. I’d like to put my own eyes on the patient, of course, but particularly if symptoms mostly resolve with the rate normalization, I’d expect to see those ischemic-looking changes resolve as well. If not, maybe worry more…

      • I don’t know that I’ll be able to get follow up, but I’ll try. Given the general self neglect and poor condition of this patient, it could be anything. We had a 600+ pound patient who actually took better care of himself (comparatively) who had the same thing happen to him. Again, symptoms resolved when we fixed his rate. In his case he had plenty of blood pressure and we used Diltizem. He broke our heavy duty chair which was only rated at 500 pounds. It still worked well enough to move him, but it was done after that. Again, the ramps and winch saved our asses (or backs).

  2. Wow! Quite the exciting call. I can’t say that I have cardioverted a patient in a long time. Back in the day (we were using an LP5, so that should give you a sense about how long ago…) I can remember my partner getting orders for cardioversion from a very excited doctor. As my partner started to draw up valium (we didn’t know about versed back then) the doctor called on the radio and told us to stop messing around with sedation and just, “pop them, right now! I mean right now! Don’t wait!” My partner grabbed the paddles and I helped get sync…we charged and then discharged. The patient suddenly sat up and say “what the …. did you do?” looking as if he had been kicked in the chest by a horse. All was well. The patient had converted and was perfusing.

    Hmmmm…how will I put that into a scenario for my students?

    • I don’t know that you can put non sedation into a scenario with a conscious patient these days. If the patient has any sort of mental status at all, he’s going to feel a lot of pain. Even if you can’t get IV access, chances are you can get IO access and give sedation. We’ve advanced a lot in that regard since the LP5 days.

  3. Nice example of a strip that meets the criteria Dr. Mattu and others have raised awareness for regarding left main occlusion (widespread ST depression, aVR elevation) yet is probably nothing more than general rate-related ischemia.

    • Once again, you have to look at the strip in the context of the patient. Which of course you know, but seems to be lost on too many paramedics and even doctors these days.

    • The STE in aVR w/ global ST-depression is why I said the ECG looked concerning for LMCA stenosis (would be more concerning with some STE in V1). Of course we have to consider the company it keeps (i.e. The patient). The st-segments look somewhat like dig-effect as well. It’s just an observation of the ECG, not that I have any idea what actually occurred with this patient.

      • Many years ago I brought a patient with tachy-brady episodes into a pretty well renowned ER. The attending physician was kind of a pompous ass and he looked at the mile or so of paper I had printed out and proclaimed, “That’s CLASSIC for digitalis effect!” To which I replied, “That would be great, except the patient has never taken dig.” You’re not pompous, but the answer is the same. In fact, I wonder if anyone is on dig any longer, I haven’t seen a patient on it in years.

        • Really? Down here in Florida, we see it all the time. Who said I’m not pompous? 🙂 I am a medic, just as pompous as the rest, lol. Anyhow, that would pretty much exclude that. Okay, so… ischemia it is sir.

  4. Excellent case!

    I don’t think you have to be so cautious with the electricity though. No palpable pressure and a rate > 200, go for it! With regard to the “clot-throwing” thing, we only worry about that in AF > 48 hours duration. Even then, if you can’t get a pressure… In PSVT we never worry about clots. Just never.

    As for the issue of “physical shock” to the body, it seems to me that the patients who get adenosine seem to have a far worse experience physically than the people we sedate and shock!

    Only one suggestion – if you have time to get a line and sedate, you have time to throw on some leads and get a 12-lead, so we can figure out what happened, e.g. AVRT vs AVNRT. It can be very helpful for cardiology,planning out medications versus ablation, for example.

  5. I’m a bit rusty with acute cardiology now, it’s been a few years, but isn’t Adenosine used just in SVT which is regular, rather than AFib/Flutter which is irregular? I never liked adenosine, only saw it work as it was supposed to about 10% of the time, and the patients always felt worse afterwards with unstable rate, rhythm and BP afterwards. DC shock every time usually does the trick, although doing it out in the field is a new one on me. Great case, thanks for sharing.

    • The latest revision of ACLS includes using Adenosine for diagnostic purposes when the rhythm is unclear. At the rate this person was perking along at, it wasn’t clear (at least to us) what was going on. When the rate is that fast, it’s very hard to discern if the the rhytym is regular or not.

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