Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Nearly Silent Respirations


The NSR cabal is at it again this week. The target this time is relations of EMS with others.

Few things are as frustrating as dealing with other health care providers who do not see things the same way we do. One area where we are especially short sighted in EMS is in dealing with hospice patients and their care givers. The misunderstandings are similar to those between the doctors and nurses in the hospital on the one side and EMS on the other. We have little, if any, training in dealing with hospice patients.

There is not a lot of comfort with the term palliative care – trying to help the patient be more comfortable, rather than trying to cure the patient. As if EMS were in the curing business. Almost all of what we do is temporizing – buying time until the patient is transferred to those who will attempt to cure the patient. Even in the hospital, hospice care makes many uncomfortable.

What is hospice?

An attempt to make the last days of a patient, someone who is dying much more quickly than the rest of us, an attempt to make those last days as comfortable as possible.

What do you mean “dying much more quickly than the rest of us?”

Hospice patients are generally considered to have less than 6 months left to live, at least that is the amount of time I continually hear, but we are all dying.

Well we can’t just let them die, we have to save them.

Save them from what?

Death.

Why do we have to fight against death. All of us will die. The cutest little baby and the nastiest old misanthrope. Dead, eventually. Nothing we can do to prevent that.

But we can keep it from happening now.

Why, because it makes you uncomfortable?

Of course it does.

So, in order to make you more comfortable, we must make the patient less comfortable. We will decrease doses of pain medicine, or give naloxone (Narcan) to reverse the effects of their appropriately prescribed and administered medications, because it makes us uncomfortable?

We have to. What if the narcotics are causing the patient to die faster?

That is a possibility. It is a risk that the patient and family should understand better than most in EMS. They are living with it. Some are uncomfortable with the risk, while others are not. Our discomfort may only be a sign of our lack of understanding, not of bad care by hospice.

What if the hospice worker is on of those “Angel of Death” people we see TV movies about?

That this is the basis of TV movies tells you that this is extremely rare. It is much more likely that we just don’t understand the care being delivered. This is the area where hospice nurses earn their money. They could probably make much more money working in a hospital, but they choose to do this because it allows them to provide the nursing care that is being regulated out of the other areas of patient care by JCAHO, CMS, Press Ganey, . . . .

Showing up and “taking control” of the scene is usually exactly the wrong thing to do. Sit down, ask the hospice nurse, or family member, what is going on that is different today. Why did they call 911? What do they want us to do? Are we just there for transport? To provide some oxygen, because there was a problem with delivery of oxygen? To provide morphine, because there was a problem with the delivery of the prescription?

How can we help the patient?

We certainly aren’t going to cure the patient, but we can always make things worse by coming in and bossing everyone around.

I was on one call for a man in his late 40s. He was dying of emphysema and had other serious medical conditions, but the emphysema was going to kill him first. The ambulance crew was very upset when they found out that he had a DNR (Do Not Resuscitate) order. Both of these EMTs were older than the patient and insisted that they would never honor that DNR.

Unfortunately, the way the rules are written, if you don’t want to honor a DNR in that state, you can do whatever you want to the patient, just so you do not have to feel so old, just so you don’t have to deal with your mortality. You won’t get in trouble, because we are so afraid of dying that we will inflict extreme pain just so we do not have to accept our own ephemeral existence.

Face it. You will die. If you are lucky, it will be a long time from now, and that time will be spent in good health. Why punish those who are not as fortunate?

It will not affect the length of your life. It will not affect the quality of your life. If you do believe in an afterlife, the punishment you deliver to people just for being sick, may be returned in that afterlife. If you do not believe in an afterlife, just treat them as you would treat a relative in the same condition (a relative you care about, not the typical mother-in-law type of relation).

The focus of health care is often on maximizing the health. Here it needs to be on maximizing the care.

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Needle Stick Regrets


Photo credit

First, I couldn’t resist – AD, check out her veins!

Well, Gertrude at Ridin’ the Bus has been writing about her fun with the recreational drug community. She even received a standing ovation from them. She mentions that she is also part of this vast Normal Sinus Rhythm blog conspiracy. Shhh. Don’t tell.

I still like the naloxone scene from Bringing Out the Dead.

Too Old To Work, Too Young To Retire has been trying to get Gertrude to give naloxone as an IM (IntraMuscular) injection, instead of IV (IntraVenous). One of the problems with an IV is that there is more blood on the needle. IM doesn’t completely avoid contamination with blood, but unless you stick the needle through a vein or artery, you are going to have significantly less blood/serum contamination. IM sites are supposed to minimize the chance of hitting a blood vessel, not eliminate the possibility. Another route of administration is IN (IntraNasal). A MAD (Mucosal Atomizer Device) is used to mist the medication so that it is more easily absorbed.

More blood = More risk.

Gertrude writes, “My dear you are right. I should have given it IM. I would have too if I didn’t think I would get yelled at by the doc on duty.” I’m not the dear she is referring to. On the other hand, the accentuation is all mine. 🙂

Why would someone with a ton of education, who is supposed to have the patient’s best interest and the EMS crew’s best interest in mind make such a bad decision?

Maybe the doctor’s motto is, “It’s not my risk. Deal with it.”

Doc on duty – Wake Up!

Everyone seems to live to serve the almighty protocol.

The protocol can be your friend, when it is well written. Most of all, the protocol is supposed to be the patient’s friend. Somebody needs to change this protocol. This is not easy to do in most places. It is not fast, but it can be done. One way is to go to the protocol committee and sit in on meetings, if it is permitted. Talk to the doctors who are most open minded about good patient care. Present them with research supporting the change you are attempting to bring about. Pay attention to the response. Learn from it. Come back with more research and a possibly modified plan. Doctors tend not to respond to the, “In such and such place, they are doing this,” approach.

Maybe you present your position by making it personal for them, for the doctors who write the protocols.

Think about how you would react to being stuck by a dirty needle.

Photo credit

How would that change the way you view this patient, this patient who may now have some of his blood in your veins?

Sharing!

What if this patient does not want to get an HIV test, so that you can feel better?

If the patient does get an HIV test, does it mean much?

Well, the patient is confident that the test will be negative, so that is a good thing. Right?

Not really. People carrying illegal substances frequently agree to searches by the police, knowing that the illegal items they are carrying are easy to find. People are stupid. Stupidity is also one of the risk factors for HIV and hepatitis.

Of 585 drug users from northern California tested for these serologic markers, 72% were reactive for the antibody to HCV, 71% for the antibody to hepatitis B core antigen, 12% for HTLV-I/II antibodies, and 1% for the HIV-1 antibody.

Do not relax and think that you are safe from HIV, because in this group it was not common. Do worry about the extremely high rates of hepatitis.

Hepatitis is much easier to contract than HIV, so what about the Hepatitis B vaccine? It doesn’t do a thing for any of the other types of hepatitis. Hepatitis C is the biggest concern, but there are variations of hepatitis going out to almost half of the alphabet, now.

Back to HIV, if the test comes back negative, you know that months ago they were not infected. Does that help?

You need to go for follow up testing to see if you convert to HIV+.

How does this affect the way you interact with your spouse, children, friends, coworkers, even strangers on the street?

What if you get a false positive test result?

Do you take the prophylactic treatments? What is the risk of seroconversion?

For anyone too young to remember the appearance of AIDS patients before protease inhibitor cocktails, this should give you an idea. These people were photographed at the liberation of Buchenwald. Another condition that tends to resemble this is untreated diabetes. Before insulin was refined to the point where it could be regularly used in humans, this appearance was not uncommon for diabetics as they would waste away and die.

Think about the way that you deal with sharps, now.

Could it be better?

Remember the Big Bad Person with the Basically Boring Presentation? So boring that often the person presenting it is obviously bored? Well, BBP is supposed to be BloodBorne Pathogens. It is not supposed to lull you into a trance-like state or make you as neurotic as Howard Hughes. Here is the CDC site. They provide links to other sites, such as NIOSH (National Institute of Occupational Safety and Health) and their Preventing Needlestick Injuries in Health Care Settings information.

Have you been vaccinated for Hepatitis B?

What do you do with a needle when you are securing an IV? Do you drop it on the floor? Do you stick it in the seat cushion? Do you pass it to your partner? Do you have a sharps container (portable is good, as long as it does not spill) close enough that you can put the needle in without interfering with securing the IV?

It is the responsibility of the person starting the IV to dispose of the needle properly and not expose their partner to a needle stick injury. Clean up after yourself. It is not your partner’s job to clean up after you. If a medic is careless with IVs and endangers others, somebody needs to arrange for that medic to have some behavior modification therapy.

Do we use needles too carelessly?

Do we start too many IVs, heplocks, saline locks, . . . ?

Are our protocols written to protect the patients and protect us?

If not, maybe we should change the way that the protocols are written.

If that doesn’t work, let’s put our creativity to work.

“Of course I started an IV, but it became dislodged when the patient came around. Just look at his veins. He’s been stuck.” Only this would not work for Gertrude’s heroin snorting charmer.

Not that I’m advocating disobeying protocols, that would be wrong. How the protocol is interpreted is a whole different area to explore.

Here are some of the ways that naloxone may be administered. IV, IM, IN, IntraLingual (into the tongue), SubMental (about half way between the tip of the jaw and the thyroid cartilage, through the skin to the tongue for a patient who has trismus), EndoTracheal, Nebulized, and that is not all.Some of these have little use for EMS. For example, if the patient is breathing well enough to use a nebulizer, how much benefit will they receive from nebulized naloxone?

Do your protocols give you options?

If not, why not?

Protect yourself. Come home healthy, unpunctured, and sane.

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