What To Know Going Into EMS

As a student, I remember being stoked up about EMS. You're excited to start using your skills, diagnose people, and get in on all of the car accidents, cardiac arrests, and child births. Sure, after being in class for a while, you realise that it's a little different from what you expected, but still exciting, especially when you get into your ride-alongs.

As time goes by, your perception of the field begins to change, you start to see the truth about it. It's like dating someone you are highly attracted to. You see all the great things about the person, but after a year or so, you begin to see the flaws. EMS is similar. I have only been in EMS for about 4 years at the time of writing this, but I have learned a lot in these last few years. It seems like the more you see about the profession the more you realise the downfalls of the job, but also learn some of the greatest joys you wouldn't imagine when you're in class. Here are some things I think I've learned the most in past few years.

Becoming an Asset

I've always tried to be the best employee I can be and do my best to make my boss's job easier. I've tried to keep a good work ethic. And what you will find is if you make yourself an asset to the company it will mean 2 things: 1) you will be valued and appreciated as an employee and 2) there will become a high demand for you. It's great to be valuable employee. But the downside is when you become an asset to a company, there will be a high demand for you which means a lot of your time and energy will be demanded of at work. If you don't learn to say "no" sometimes, you will be pushed to your limits and taken advantage of. 

Burnout is Real

As a student and a new EMT or paramedic, you want to put in all the shifts you can and experience all you can. That's great and really, that's a good time to do it. It seems like when you are new to the profession, burnout seems impossible. But don't kid yourself, anyone is vulnerable to burnout; it only takes time. As a student, I decided I would never fall to burnout, but when you are worked to the bone with very little sleep and constant stress from the job, it's not hard to become irritable and even question staying in the profession. Sometimes it's not even the field but the internal issues within the company built up on the stress of the job. Find a hobby or two and make time to relax and leave work at work. I know it sounds cliche but you need time to go home and not think about work. It's when you have constant exposure to work over a long period of time that burnout occurs. 

You Will be Underappreciated

It's nice to think about the movies where the medic saves someones life and the patient is forever grateful. In reality though, you will encounter many patients that you will care for and do all you can to help and they will turn around and spit in your face, swear at you, try to assault you, or become abusive. If the patient doesn't, there's always family who is dissatisfied with how you treated their family member, just because you did things different from what's on TV. Just learn to brush it aside and move on. People will be critical of your work and will be unappreciative. 

People Will Question Your Skills or Competency

Unfortunately, too many people have a warped view of EMS. There's the side where they think everything should be just like on TV. Then there is the other side who think all we do is drive and transport. There will be many people who think you can't make medical decisions (or have the authority to do so) and people who will question whether you are competent in a skill just because you're and "ambulance driver". This is especially true if you are young. I can't even say how many people questions whether I can read a 12 lead or start an IV or know what medications to give, not to mention drug doses. 

People Will Try to Tell You How to Do Your Job

Whether it's hospital staff, a nursing home nurse, or a patients family member who's best friend has a cousin who had a roommate 30 years ago who was a medic. You will have people who think they know your job better than you and think they know your protocols better than you. Unfortunately, this happens a lot. Don't let other people squash your confidence, though. If you know what you're doing, competent in your skills, and know your protocols, stand up for yourself and don't let these people make you second guess yourself.

Speaking of Standing Up For Yourself...

When I started as a new medic, I tried to be as diplomatic and friendly as I could regardless of how patients or family treated me. As time has gone by I've come to learn that many people will push you and try to press your buttons. Know that you still have a right to stand up for yourself. If a patient is verbally abusive or giving threats, it's OK to become stern and tell them that you won't put up with it. It's OK to tell a patient that if they don't cooperate and cause problems, you don't have to treat, transport or be near them until law enforcement arrives. You have the right to defend yourself, verbally and physically, if need be. 

Call Preference Changes

As an inexperienced EMT, medic, or student, you may look forward to the gunshot wounds, car accidents, fatalities, cardiac arrests, and childbirths. These calls are exciting, but only for a while. After you have had a 20 year old hang herself and have to tell the mother her daughter is dead, or you have your first infant death, those calls don't seem too desirable anymore. After while, those calls just become "another call". Yes, they may get your adrenaline going, but in the end, it's another call. I've found that the calls I look forward to the most are the ones where I accurately diagnose and treat a critical illness and have the patient genuinely grateful for it. As time goes by, the calls you look forward to begin to change. 

Most of these things I've learned and shared with you seem negative, but as time goes by, you start to see the downfalls of the job. However, you also see and experience things that you wouldn't expect as a new provider. Things like keeping a child calm while on an inter-facility transfer, to have that child wanting you to stay with him. Things like a hug from a patient or family member, a thank you letter from a patient, or successfully reviving someone from a code. EMS is a special calling. If it wasn't rewarding, most people wouldn't stick around long. The negatives and low pay need to be out-weighted by the joys of working the job. Find what you enjoy and find time to relax and forget the job while at home and this job can be the most enjoyable.

How Much Do You Know About RVI

As a paramedic, 12 lead EKGs are pretty well standard for diagnosis of possible MIs. In class, we are taught how to read 12 leads on a basic level and to pretty well look for ST depression or elevation and recognise bundle branch blocks. But there is a lot more that a 12 lead can tell you. Anything from LQT syndrome, to RVI. When I went through class, we talked about right sided 12 leads, but not so much on how to read them and even less on when to do one. I think some people are intimidated by the idea of a right sided 12 lead, even experienced medics, because of the lack of familiarity and lack of usage. However, in some cases, it can be very critical.

One of the things you can almost surely diagnose with right sided 12 lead is a right ventricular infarction (heart attack of the right ventricle). This is actually much easier than is sounds. I think any paramedic can "diagnose" an MI by obtaining a good medical history and history of the illness, along with signs and symptoms (chest pain, shortness of breath, left arm or jaw pain, back pain between scapula, diaphoresis, paleness, nausea, vomiting, hypotension). When these signs show up, we suspect an MI and also obtain a 12 lead to look for signs of ischemia or infarct. I think most paramedics know how to do that. But some things aren't what they seem.

On a 12 lead, ST depression can indicate ischemia, but can be relative to infarct (mirroring a different lead). For example, ST depression in anterior leads can just be mirroring a posterior infarct, leading to a posterior 12 lead. The same can be used to diagnose a right ventricular infarction, which isn't seen on a standard left sided 12 lead. An RVI will present with the same symptoms as any other MI, but may also be accompanied by severe hypotension. These are also commonly associated with a right bundle branch block. If a RBBB is present along with these EKG changes, suspect a right sided MI.

An RVI is usually the result of the RCA being occluded. The RCA also supplies blood to the inferior walls of the heart. An inferior infarct, or ischemia, can be seen in the inferior leads (II, II, aVf). When a 12 lead shows possible inferior MI, you should suspect a right ventricular MI as well. You should also suspect RVI if there is depression in V2 and V3.

An RVI can be seen by performing a right sided 12 lead. To do a right sided 12 lead, just move V3-V6 to the right side, mirroring the pattern for a left sided 12 lead. All of these leads can show a right sided MI, but if the patient is experiencing an RVI, it will be definite in lead V4R. When I do right sided 12 leads, I will oftentimes just move the V4 electrode. Keep in mind that if you perform a right sided 12 lead, label the right sided leads with an "R" on the strip to remember which ones were done on the right side.

Treatment of RVI actually differs slightly from any other MI and that's why it's important to perform a right sided 12 lead. The preload of the right ventricle is significantly less than that of the left simply because it has less work to do. The left ventricle has to supply blood to the whole body whereas the right only circulates blood to the lungs. If the left ventricle preload is decreased, the afterload and cardiac output will decrease, but since there is a higher preolad, it takes more altering to drop it significantly. That is why nitrates can generally be used. With the right ventricle, if preload is decreased, there is less afteroad to the heart compared to the left, resulting in less oxygenated hemoglobin. In short, a poor right sided preload will affect left sided preload because of the lack of oxygen and blood returning to the left side.

Since the right side has less preload, the blood pressure can drop faster if the patient is having an RVI. And since an RVI is sensitive to nitrates, nitroglycerin can drop the blood pressure more significantly than any other type of MI. Because of that, nitrates should be used with caution, if they are used. In this case, it is important to give fluids. Generally, fluid overload is advised against in patients with an MI, but with these patients, their preload is diminished and need fluid resuscitation. Just be sure to monitor blood pressure and lung sounds as to not overload them. If nitroglycerin is to be given, be sure to have an IV established with fluids running beforehand and preferably have 2 IVs. Follow your own local protocol if NTG is required. Most protocols are a guideline and can be altered to treat the patient how they need to be treated.

Another treatment change will be in pain control. We have learned the treatment mnemonic "MONA" (morphine, oxygen, nitro, ASA), but in the case of RVI, morphine should be avoided or used with extreme caution, as with nitro. Morhpine initiates a histamine release (hence the itchiness as a side effect) and a part of the histamine release is vasodilation. This is something we are trying to avoid with these patients and that's also why we want to use caution with NTG. For these patients, something like Fentanyl may be considered instead.

Remember that these patients can go downhill rapidly and develop cardiogenic shock if we don't treat them properly. We can treat them with Aspirin and oxygen, though we should be avoiding high flow O2 as is can cause higher PaO2 levels and should be primarily used in hypoxia. Treat with pain control and use caution with nitrates and morphine. Up to half of inferior MIs are accompanied by RVI, though RVI is almost never alone. It is accompanied almost always by inferior changes as well. Remember, though, that early onset of an MI may not result in 12 lead changes. Perform a thorough exam and get a good history.

Metabolic Acidosis Made Easy

Well, this is my first go at a "written" blog on medical type stuff. As you may know, I try to make things easier for students, or maybe those who just don't understand, to understand different medical concepts. When I was a student going through paramedic class, there was a list of things I initially struggled with. Anywhere from drug doses, to respiratory issues, gastric issues, and so on. But what always seemed like a hard thing to understand was acid/base balance. As a student, that was something that made my eyes glaze over and my ears tune out, but when I started working as a paramedic, I began to realize just how important it is to understand all of this stuff.

Most illnesses, or even traumas, rely on labs for diagnosis, and particularly this acid/base balance deal. In all honesty, this is something that simply cannot be explained in one post because it involves knowing about metabolism, respiratory drive, homeostasis, cell energy, etc. But I would like to explain one thing that you may see most often, most subtly and that is metabolic acidosis. That can be a scary word and seem hard to understand, but I want to break it down for you.

First we have to understand respiration, not ventilation but respiration. Respiration is, in easy terms, the transfer of gases in the lungs. By now, we should all know that O2 goes in and CO2 comes out. Respiration is essentially transferring O2 into the blood stream and transferring CO2 out of the blood stream, into the lungs to be exhaled.

Now lets put that aside for now and talk about ischemia. Essentially, ischemia is when cells are starved of O2. We often understand this in terms of cardiology, but any cell can suffer ischemia. Ischemia can be caused by all sorts of things. COPD, CHF, sepsis, respiratory failure, and drug OD are just a few examples. What happens is oxygen cannot reach the cells for some reason and that's when we start to run into trouble.

Through food intake, we get what's called glycogen (essentially sugar) and through glycolysis, becomes pyruvate (I don't expect you to remember that). Pyruvate reacts with other enzymes (that we don't care about right now) in a process called "synthesis" to create adenosine triphosphate. That is a big word, so just remember ATP. ATP is pretty much just food for the cells. The synthesis may also be called Krebbs Cycle which you probably learned in class. This ATP is used in normal metabolism to create energy for the cells to make them happy and not lazy.

Now this is when ischemia comes in. For the synthesis to take place, there has to be oxygen, but if there's no O2 (or lack of), the metabolism turn into anaerobic metabolism (metabolism without O2). Since there is no O2, the pyruvate turns into lactate or lactic acid. This is when we become acidotic, hence forth, the "acidosis".

When we become acidotic, hydrogen ions are released. The body does not like that imbalance and will try to buffer it with bicarbonate (HCO3). The bicarb binds to the hydrogen ions creating "hydrogen bicarbonate". This new molecule breaks down and separates from H2CO3 to H2O and CO2. Look familiar? After it breaks down and separates, you end up with CO2 and water which now travels to the lungs to be exhaled. That is why someone with metabolic acidosis has HIGH CO2 (too much produced) and LOW bicarb (diminished by binding to hydrogen).

As a paramedic, you may not be able to initially tell if the patient is acidotic or not because you don't have labs to determine pH or bicarb. But there are some tricks to figuring it out. First is to get a good history. If the patient has a medical history or current issue that might cause acidosis (ischemia), take that into consideration. Next is to use you're ETCO2 device. If the person has a history that would lead you to suspect acidosis (such as infection from UTI), and the ETCO2 is high and respiratory rate is high, chances are, it's metabolic acidosis.

Let me explain how I came to that conclusion. The body has a compensatory mechanism (keeps everything in the body normal). When you see high CO2, it means one of two things. They are hypoventilating and not blowing enough off, or they are producing too much (acidosis). If the respiratory rate is high, you know that they aren't hypoventilating and holding it in. The hyperventilation is the body's natural way of getting rid of the CO2.

Now, let's take a couple things into account and I hope this makes things easier for you in regards to respiratory rate and ETCO2. If the cause of the changes is respiratory, the two will be opposite. Example could be hyperventilation from a panic attack, or hypoventilation from a kid holding their breath. If they are breathing too fast, they will start blowing off too much CO2 and that's why they say breath into a bag, to rebreathe that CO2. So if the rate is high and the CO2 is low, they are hyperventilating and the cause is respiratory. If they don't breath fast enough, they trap the CO2. In that case, you will see a low rate and high CO2. That's why when you see a high CO2 and a high rate, you know something metabolic (inside the body) is going on. That is how you can field diagnose sepsis (with vitals, temp, etc. along with it). Also remember that the initial hindrance to the metabolism is lack of O2, so their Spo2 will most likely be low as well and these patients need oxygen.

That is simple metabolic acidosis. It is important to understand this stuff because it may change the way you diagnose and treat patients in the field, especially in a critical care setting. A general treatment for this will be oxygen, fluids, and bicarbonate replacement. But chances are, you won't be messing with the bicarb in a pre-hospital setting.

I hope this has been helpful and I hope it has helped you to better understand a little of acid/base balance. Stay tuned, and I may have more posts in the future on acid/base.