Stubborn Medics

Most of us in health care, especially emergency medicine, know that we make the worst patients. Even though we should know better we usually don't call 911 when we should. We wait until we absolutely have to. When I developed gall stones I was in so much pain I couldn't stand upright. I couldn't drive. I couldn't think straight. But did I call 911? Nope. Too stubborn. I didn't really want to ask my parents to watch the kids or ask my wife to take me to the ER.

So we got a call around 2 in the afternoon for a fall with injuries. When we arrived on scene we found a 60 year old man laying in a recliner. His wife informed us that he had fallen in the bathroom the day before and broken his hip. He had then crawled into the living room and into the recliner instead of calling for help. When she arrived home from work she found her husband pale with pain, but he refused to let her call 911.

She then told us that her husband was one of the first paramedics in Oakland some 30 years ago. He had had his picture in the paper and everything. That instantly explained his lack of interest in calling 911. She continued to explain his reluctance by relating the story of his last hip fracture 3 years ago. The medics just manhandled him onto the gurney with no pain medication. He didn't want a repeat of the performance.

I assured my patient that things would be different this time. I don't think the salty old medic believed me. I then started a line on him. His BP was borderline low so we only started him off with 3 mg of Morphine. We then used a KED to stabilize his hips. While we moved him onto the gurney (as smoothly as possible) we gave him a fluid bolus to bring up his BP with the hopes of being able to give him some more pain medication in the back of the bus.

Next time I hope that he will be a little more willing to call us.

Merry Christmas

I worked Christmas Eve. The firefighter relieving me came in a little early (thanks) allowing me to get home to the family for present opening.

Last night I was hoping for a shutout but we had a couple of calls. One guy couldn't breathe too well (fine, call us for something life threatening) and another was altered. I felt like telling them that I was out of it too at 4 in the morning. Oh well. At least they were legit calls.

Now, I think I hear a pillow calling my name.....zzzzzzzzzzzzzzz

For Those Supporting A Firefighter

My wife readily associates herself with my job by calling herself a fire wife. She caught a lot of grief because of that. It's not that she doesn't have her own identity. It has more to do with the fact that my job intrudes into my our personal lives a lot more than most jobs.

Because of my chosen career my life expectancy is shorter. My risk of getting cancer is increased (more than doubled in a lot of cancers), my risk of injury/death is greater, I'm often sleep deprived, the list goes on and on.

The other day I was on Fire Engineering's website and I came across an article written for the spouses of firefighters, What Every Firefighter's Spouse Should Know.

As I read through the article I started thinking that most of this doesn't apply to me (I'm sure most firefighters feel that way). But as I thought about it more I came to the conclusion that it must apply to a lot of firefighters. And there were definitely parts that apply to me.

So for those of you that support us from the home front, and for those that would like to have a glimpse at what we put our spouses through, enjoy the article.

Real Life Saver

The call came in for a choking patient. The house was just down the street from the station so it didn't take us long to get there.

We pulled up to the house and I noticed that there was no waver (someone frantically trying to get our attention). Inside, on the couch, we found a 75 year old woman. She was gently rubbing her throat. The story from family members was that she had been eating when she started choking on a piece of meat. Her daughter rushed over and did the Heimlich maneuver.

My patient said she felt as if something was still in her throat. I explained that that was a possibility, but it was more likely that the lining of her esophagus had been damaged (it's really sensitive) and that's why she felt that way. The same way you can "feel" a pill that you've swallowed without enough water.

After a thorough assessment (everything checked out great) she and her daughters decided that it would be best if they didn't go by ambulance but instead chose to take their own vehicle. We reassured them that if there were any more complications we were just a phone call away.

`Tis The Season

We were dispatched for a slip and fall. Nice and generic. I've been on "slip and fall" calls ranging from a person needing a hand to get up to a person on the third story roof that had a stroke and fell, and a lot of stuff in between.

This time we pulled up to find a waver. Someone, usually a family member, that is panicked and is out in the middle of the street to wave us in. Potentially a bad sign. In front of the one story house there was a ladder. Someone had been hanging Christmas lights. My patient, a man in his early 70's, lost his balance and took the fast way to the ground.

From 5 feet up he landed on the cement driveway but not before his head came into contact with the brick wall on the side of the driveway. He was alert and oriented and had some minor bleeding from the back of his head. His family, in a near state hysteria, explained that their father had been knocked unconscious when he fell.

We grabbed c-spine and applied a neck collar. We also placed some 4x4's over the wounds on the back of his head. The trauma assessment revealed that he had a couple of skin tears on his arm as well. Other than that and his head lacerations he appeared to be in stable condition.

The guys at AMR helped up package the patient onto a backboard. The last thing I remember after loading the old man into the ambulance was one of the sons complaining that he had told his dad to let him hang the lights.

Smell Of Smoke

The other day we were toned out for a possible residential structure fire. When we arrived on scene the occupants informed us that two day prior their landlord had had someone come out to work the furnace. This was the first time since then that they had turned it on.

Helmet covered in insulation after pulling ceiling.

A couple hours later they smelled smoke in the house. They did the right thing. They evacuated the house and called 911. On the way out the husband threw all the breakers killing the power to the house. When we arrived we found there to be a light smell of smoke with just a little bit of haze in the house.

Once we confirmed that there was no active fire we cancelled everyone but the engine and us. The BC decided to stick around as well. We used the thermal imager to check for hotspots throughout the house. I checked the attic in the garage and found nothing. I then went to check the attic in the house but I couldn't find the scuttle hole.

We searched the entire house (it was only a 1400 sq ft house). Every bedroom, closet, nook and cranny. There was no scuttle hole. By this time the landlord had made it to the house. He said that he had had some renovations done to the house about two years ago. He never noticed that the contractor had sealed the attic.

My battalion chief explained that we needed to check the attic to make sure there wasn't a smoldering fire and that there was no way for us to do that without a scuttle hole without making a mess. The landlord then looked at me standing there with a pike pole (and a grin). I told him that was my job to which he replied that I looked like I enjoyed my job.

The property owner decided to put his new scuttle hole in the hallway. We grabbed a salvage cover and placed it below where I would be working. I then used the pole to make a 18", mostly square hole in the ceiling. We figured that if I did it smaller than the normal 24" then it would be easier for a contractor to come in and convert the opening into a proper scuttle hole.

Once the hole was made I placed into it the attic ladder. I climbed up and was just able to squeeze in my shoulders. I looked around with the thermal imager and everything looked as it should.

Afterward we cleaned up the mess, turned on the power to the house and did a final check. Having not found anything burning we figured that the furnace was probably the culprit. We informed the residents to keep an eye on it and call us back if they needed us.

I needed to go clean my gear of all the insulation and to take a shower.

Miscommunication

We were dispatched for a man feeling ill. The RP was a home health care nurse that stated her patient had a low temperature. Yeah, I was suspect too.

We walked in the house and found an old man laying in a hospital bed in the front room. It was probably the only place they had that would fit the bed without some major rearrangement of furniture. At the head of the bed stood the wife of the patient. She appeared very concerned. At his bedside, the "nurse" (I'm not sure if she is an CNA, LVN or RN).

The home health care worker, as I will refer to her, informed us that the patient had a temperature of 94º F. I quickly placed my hand on the patient's head to see how he felt. He felt like someone with a normal temperature.

The worker then informed us that his blood pressure was low, 94/52. I again touched the patient. This time I checked for a radial pulse, which I easily found. Nice and strong.

While we were getting a proper BP the worker then explained that my patient was altered (our BP was 142/82 by the way). Knowing that that phrase can mean something totally different to someone that doesn't practice emergency medicine I asked for clarification (also because he seemed to be acting normal to me). I was informed that the patient had not been responsive for the last 30 minutes of the 90 minute visit. I then asked the nurse how well she knew the patient and she said this was her first visit.

At this point I turned to the wife and talked to her. The home health "professional" was useless. His wife said that he appeared to be tired. The nurse kept interjecting that she was worried about sepsis. Every time I acknowledged her concerns but she didn't get that (there was a major language barrier).

About then AMR showed up. The CNA/LVN/RN told the AMR medic that the patient was altered. He looked to me for confirmation and didn't get it. The transporting medic was again told that the patient was altered. He looked to me again and I did a quick eye roll. He immediately got the picture. We loaded the gentleman onto the gurney and helped the guys out to the ambulance. After making sure they were all set we headed out.

Car Crash

Just after dinner the tones went off. We were dispatched to the freeway with a neighboring agency for a single vehicle accident in the center divider.

Pulling up to the scene we saw several vehicles pulled over but only one appeared to have been in the accident. We nosed in Big Red behind the accident to give us a little protection as we worked. Some people are like moths to the flame with fire trucks.

We found our patient sitting and leaning up against the center divider. It was a chilly night and someone who had stopped had offered her a blanket. The victim said that she was cut off and had been forced into the median. She had been wearing her seatbelt and the airbags did deploy. There was only moderate damage to the vehicle.

The lady was initially complaining of pain to her right forearm and to the right side of her jaw. While assessing C-Spine I found that she had point tenderness around C4 and C5. As we were going through the process of placing her in full spinal precautions AMR showed up. While I finished strapping the patient to the backboard the AMR medic that was ready to strap her head down said alarmingly, "She's not breathing!"

We did a another check. She wasn't breathing, she did have a strong pulse but she wasn't responding to verbal or painful stimuli. I kept thinking, "Crap, what did I miss." While the EMT grabbed the BVM we loaded the patient onto the gurney and headed for the ambulance.

About the time that we had the BVM set up our patient started breathing again. She was also alert and oriented. The husband (who, from home, had beat the ambulance to the scene) told us that his wife had severe panic attacks and that she often passed out. I'm not sure if that was what happened here but it's something that I would have liked to know when I asked her about her medical conditions!

Before leaving I checked with the AMR crew to find out if they needed anything else. They had a paramedic intern there so they didn't feel they needed a rider.

Learning Curve

You gotta love frequent flyers. Ok, maybe not. Especially at 0430. But at least one of mine (featured in blog posts here and here) is learning.

In our most recent visit to her house she didn't bother to act like she was in severe pain. She complained more about nausea. But while we were waiting for AMR to arrive she asked if she could ask the ambulance crew for some morphine. I think she's finally learning that if she's not really in a lot of pain she's not going to get treated for being in a lot of pain....at least from us. I have no idea how successful she is at getting some of the good stuff from the medics at AMR.

What Changed?

I knelt down in front of my patient and gently felt for a radial pulse. "Hello, what's your name?" After introductions I asked her what was going on that day. She said that she was having "severe fatigue."

In just that short amount of time it was painfully obvious that she had some psychiatric problems. Her father said that she wasn't really able to take care of herself but wasn't bad enough that she was on a conservatorship. He had given her a cell phone in case she got lost while walking around the city but now she used it to call 911. Dad didn't seem too happy about that.

Severe fatigue, not just tired. Fair enough. Also generic enough to have all sorts of causes. My next set of questions changed my thought process. I asked how long she had been experiencing this severe fatigue. She stared at me blankly. I asked again, this time giving her the choices of minutes, hours, days, weeks, months or years (don't know why I stopped there, I should have thrown decades in as well). She thought for a minute and then said that it had been going on for months.

At this point I'm starting to see where this is going but I persist. I asked what made her call today, after months of severe fatigue? What had changed to make her call? Her answer....she had severe fatigue. That was about as far as that conversation went.

At this point I decided to backtrack a little. I asked her if she knew where she was (trying to determine if she was altered or not). She rattled off her complete address, zip code included. I then asked her what day it was. She immediately opened her cell phone, check the date and day, and repeated them back to me. I looked at my engineer and we both laughed. If she's knows enough to check her phone for the day and date I think I'll let it slide. I could tell you those things without doing the exact same thing.

Finally the ambulance showed up. We walked her over to the gurney and sent her on her way. What do you want to bet that we'll be back?

Fire Alarm, Sort Of

Just before 11 in the morning we went shopping for dinner.We grabbed a shopping cart and headed into the store. As we turned down the first isle our radios beeped the familiar tones of someone getting a call. "District 51, engine 53, truck 51, commercial alarm sounding...." They were playing our song.

We jogged back to the truck the whole time thinking the same thing. We've been there before, often. Engine 53 will get there first. We're going to get canceled. Because of that thought process we all decided to just throw on our turnouts over our wool pants and buttoned shirts. After all, we would only be in them for 5 minutes. I jumped in the rig and sat in the jump seat.

Lights flashing and siren growling we split traffic much like a modern day Moses. The radio crackled again, "Engine 53, truck 51, we're getting reports of black smoke coming from the roof. We're upgrading this to a full alarm assignment."

At that point my first thought was regretting not getting out of my blues before donning my turnouts. I decided I better slip into my BA as well. I went through my quick checklist preparing for a fire. Turnouts were good, SCBA was on with straps tight, mask ready to go, release valve closed, axe belt on.....ready.

Engine 53 was first on scene. They reported having a commercial building with multiple occupancies with roll up doors, heavy black smoke coming from the roof. They initiated IC and let everyone else responding know that they were starting fire attack and could handle their own water supply.

Pulling around the corner we had a good view of the building. We nosed in the driveway behind engine 53. We jumped off the rig and started setting up for aerial operations. My captain chalked the front tire on our side while I set out the plate for the stabilizer. My engineer took care of his side. While he finished setting the stabilizers and getting the ladder in place I grabbed both the chainsaw and the K-12.

Once everything was set my captain headed up the aerial with the rubbish hook. Once at the tip of the aerial he pounded down hard on the roof to make sure it would hold our weight before we stood on it. He would repeat this process of sounding out the roof everywhere we went. I stepped off the ladder behind him I set down the chain saw. We were on a metal roof so the circular saw was the tool of choice.

The roof had a shallow grade and at the peak there were several vents about 6 feet long and 3 feet wide. The super heated smoke and gases were using them as a natural escape from the confines of the building. We decided to help things along. Using the rubbish hook we ripped the thin metal from around the bolts holding the vent in place. Once the the vent covering was removed we cleared the opening of any insulation allowing for a good ventilation hole. Our job done, we checked with fire attack to make sure they didn't need any more holes in the roof and then headed back to the ladder.

The fire was small. It was limited to a vehicle in the auto repair shop and a couple of racks with supplies on them. We were able to limit most of the damage to the space in which the fire started.

Semper Fi

While blog hopping I came across this post. It was too good not to re-post.

Watch that first step.

Soothing Effect

I was working at one of our slower stations on an overtime shift. That morning we had the 1st and 2nd graders from the school down the street stop by for a tour. The rest of the day was spent working out, shopping, cooking and eating. There were no calls. I was looking forward to getting a good night sleep at the station as well.

I went to bed around 11 p.m.

At 1 in the morning the lights clicked on and I could hear the sound of the speakers as they turned on as well. About a half second later the tones went off signaling that we had a medical call.

We arrived at the house of a 40 year old male having trouble breathing. We were met by his wife who led us into the dining room. Her husband started having difficulty breathing about 10 minutes before. AFter talking with him for a few minutes we determined that he was having an anxiety attack. He had been having about one per year for the last several years and they always feel the same. And every time, after we show up, he calms down and is ok.

This time we canceled the ambulance and then spent another 20 or so minutes talking about his options as far as treatment. He really didn't want to take medication for it but after we explained a little more about anxiety he decided we had a point.

He was very grateful that we would spend that extra time with him, in the middle of the night.

Just as I drifted back to sleep (at least it seemed that way) the lights clicked on again....

We had 4 calls after midnight that shift. So much for a slow station and a good night sleep.

Yo Quiero Taco Bell

We got a call about 11 in the morning to one of our local strip malls. The call was for a woman that had fallen asleep in her car. Seriously.

My patient said that she had shown up to get something from one of the stores only to find out that it didn't open for an hour. So she took one of her Xanax and relaxed. She ended up dozing off for an our in the car that was not turned on. Eventually someone noticed her and called the cops. They came out and woke her up, then called us.

Because my patient had a rather significant medical history she wanted to go in and get checked out. The only problem was that she had a "dog." It was actually a Chihuahua. You know, the dog that is super skittish and yappie and is smaller than some rats. She didn't want to leave the dog. We finally convinced her to call a friend to come get the pooch. We also decided that the dog could wait in the back of the squad car so that we could get the anxious woman to the hospital.

One of the officers handed me a leash (did you know they carry those?). I tried to get it onto the dog without gets bit. Finally, my patient was able to slip on the leash and I picked up the dog. I held it upside down the same way I do with my cat so as not to get bit or scratched. It worked really well. Once in the back of the cop car the dog started barking at us again. It clearly didn't like its situation.

Now that we had the little terror secured we were able to get the patient onto the gurney. She later admitted to us that she took more than one of her Xanax. No wonder she fell asleep.

The last thing I saw as we cleared the scene was this small dog barking and growling in the back of the police car waiting for a family friend to come get it.

N̶a̶t̶i̶o̶n̶a̶l Local Healthcare Plan

National healthcare. A subject sure to get any group into a debate if not a flat out argument. Been there, done that. But instead of sitting around and debating the subject or worse, just waiting for the federal government to actually do something, the Alameda County board of supervisors have decided to fund a project put forward by the county's Health Care Services Agency. 

The pilot program would make use of five local fire stations to provide "federally qualified clinics" to those neighborhoods which they serve. Alex Briscoe, the director of the Health Care Services Agency asks, "What happens if we co-located a nurse practitioner from one of the community clinics with a paramedic and ran the public sector’s response to the retail clinic?”

The clinics would address minor medical problems such as minor infections and immunizations helping to relieve the ever increasing pressure on local emergency departments.

In an article on the National Association of Counties website they said that "in addition to providing a limited array of on-site services, including follow-up from emergency room visits, the health portals will:

• respond to “sub-acute” 911 calls under the county’s new Medical Priority Dispatch System (approx. 30,000 calls annually), which triages response to non-life-threatening calls 
• provide discharge follow-up for residents in a defined area within 48 hours of discharge from emergency department care, and
• take direct referrals from the county’s 211 call center for medical advice or consultation."

Chief Gilbert, the fire chief for the Alameda County Fire Department is quoted in the article saying,  "The fact that we can build upon that trust and meet that ever-growing need in our community that ultimately impacts the quality of life and public safety of our community is absolutely consistent with our mission and something that we're excited to be able to do."

It wouldn't be the first time that fire departments in Alameda County have been involved in preventative care. According to an article in the San Lorenzo Patch "in 2009, Alameda County became the only county in the state where paramedics were given permission to immunize residents against the H1N1 flu virus."

 

Recently my wife and I were having a discussion about the feasibility of a local government run health care system. I don't know if that is possible, but Briscoe seems top think so. He said, "We have to do something to reinvent the health care system. We believe we have the answer."

Boom

Some Time Off

For those of you that live in southern California or are planning a vacation Knotts Berry Farm is offering free admission for Police and Fire personnel plus a free admission for one other person. In addition they offer discounts for up to 6 more people.

Enjoy.

Heart Rhythms Part 6: Blocks

A heart block is a disease in the electrical system of the heart. This is different than coronary arterial disease. The muscle tissue and vascular system is ok but the electrical impulses are not traveling in a normal fashion through the heart.

There are 3 main types of blocks, conveniently, first, second and third degree blocks. Second degree blocks are then broken down into two subtypes. We'll get to those in a minute.

First Degree Blocks 

More correctly called a first degree atrioventricular block, it is a condition in which the PR interval (the length between the beginning  P wave and the beginning of the QRS complex) is lengthened beyond 0.20 seconds.

What that means is that the electrical impulse generated in the SA node is delayed by the AV node before going on to the ventricles. Management includes identifying and correcting any possible electrolyte imbalances or withholding any offending medications.

Second Degree Blocks

A second heart block is a conduction block between the atria and ventricles. A second-degree AV block is when one or more (but not all) of the atrial impulses fail to make it to the ventricles due to impaired conduction.

There are two types of second degree heart blocks, types 1 and 2. A type 2 heart block is considered to be a much more malignant block than a type 1.

Second Degree Heart Block Type 1

A second degree heart block type 1 is also known as a Mobitz 1 or a Wenckebach. 

A Wenckebach is characterized on the EKG by having an increased amount of time between the P wave and the QRS complex until a QRS complex is dropped, or missed. This is because of a diseased AV node.

The arrows point to the P waves. Not the increasing distance between the P waves and the QRS complexes.

Second Degree Heart Block Type 2

A second degree heart block type 2 is also called a Mobitz 2 block. A Mobitz 2 is characterized on the EKG by having intermittent QRS complexes dropped without a change in the PR interval. When this happens in a regular pattern the number of P waves to QRS complexes is stated as in 3:1, meaning 3 P waves for every QRS complex. 

A second degree type 2 block is caused by a a disease of the His-Purkinje System. It may also rapidly progress into a complete heart block.

Treatment may require an implanted pacemaker.

Third Degree Blocks

A third degree heart block is also known as a complete heart block. A complete heart block is a medical condition in which the electrical impulse generated in the SA node does not propagate to the ventricles. On the EKG this is characterized by having  regular P waves and regular QRS complexes but they are independent of one another. Essentially there are two separate heart rhythms on the EKG. One for the upper chambers of the heart and one for the lower ones. Usually the rate of the P waves will be higher than that of the QRS complexes. Some of the P waves will be buried behind the QRS complexes.

The most common cause is coronary ischemia. Treatment is an implanted pacemaker.

Heart Rhythms Part 1: Basic Anatomy
Heart Rhythms Part 2: Sinus Rhythms
Heart Rhythms Part 3: Junctional Rhythms
Heart Rhythms Part 4: Ventricular Rhythms
Heart Rhythms Part 5: Premature Beats
Heart Rhythms Part 6: Heart Blocks

Dose Of Humility

After one of our medical aids last tour I was getting some restock from our ambulance provider. As I leaned in to grab an IV catheter I cracked my dome on the ambulance. @#$%!!! So much for the smooth fireman to the rescue.

Not my actual skull

Two days later, it still hurts.

Repeat Customers

Over the last couple of shifts we've responded back to several of the patients that we saw a month ago (not always for the same problem). In the cases of a couple of the febrile kids that had seizures I'm happy to report that none of the parents were in a panic and no one tossed their kids to me. This is a major improvement.

A couple of the other calls involved people with major medical issues. You can tell that there is a sigh of relief when their local firefighters can walk in and call them by name. And that they know the history of what's going on.

On the other hand, I find that I have to be more vigilant in my assessment when I know the patient. Lest I assume something that may not be true. And while I hope that these patients won't have the need to call me again, I know it's only a matter of time.

TC Down The Street

The tones went off (insert sounds here...maybe I'll have to try that sometime). We were being dispatched for a TC just down the street from the station. We jumped into our turnouts and pulled out of the station.

As we approached the scene we could see a four door late model sedan in the middle of the side street. Along the curb was a late model mid size pickup. There was moderate damage to the front and sides of both vehicles that happens when to cars try to occupy the same space at the same time. Airbags had deployed and both occupants had self extricated.

As the air brakes set I jumped off the rig and went to see what we were dealing with. I first came upon the driver of the car. He said that other than the minor cut on his hand, he was fine. He didn't want any medical attention. I then walked over to the other driver who was talking on his cell phone.

After convincing him to hang up (repeatedly) I did a quick assessment. While my engineer held c-spine I did a neuro check to see if the patient warranted full spinal immobilization. Fortunately, he did not. While I questioned my patient I noticed that he was a bit slow in answering my questions. He would answer everything correctly but just seemed a little slow. He was also complaining of a burning sensation on his forearm. This was probably from the airbag. Once AMR showed up we loaded him on the gurney and sent him to the hospital. The poor guy was probably just shaken up from the accident.

Once he was taken care of we turned our attention to the debris field around the scene. My engineer grabbed the push broom and I grabbed the shovel. While we were tending to the patient the engine crew put absorbent down on the fluids in the roadway. Now, we cleaned everything up. While it may look like we are just being helpful it actually serves to prevent an accident later on at that same location. Once everything had been cleaned up we headed back to the barn, leaving PD to wait with the wrecks for the tow trucks.

Heart Rhythms, Part 5: Premature Beats

There are 3 main types of premature beats. PAC's, PJC's and PVC's.

PAC

PAC's are Premature Atrial Contractions. While the SA node normally regulates the heartbeat during a sinus rhythm, PACs occur when another region of the atria depolarizes before the sinoatrial node and thus triggers a premature heartbeat. 

Clear as mud? In English, another part of the upper chambers of the heart prematurely fire off an electrical impulse causing an early beat. On the EKG it will have a deformed P wave (because it's not originating in the SA node), will have a narrow QRS complex, and be earlier than the other beats. After the PAC there were be a compensatory pause, a delay, after the premature complex, before the next regular complex. 


What does it mean? Nothing. Lots of perfectly healthy people have PAC's. Don't stress about it. I don't.

PJC

PJC are Premature Junctional Contractions. While the SA node normally regulates the heartbeat during a sinus rhythm, PJCs occur when AV node depolarizes before the sinoatrial node and thus triggers a premature heartbeat. 

Yes, it sounds a lot like a PAC. Very similar, just with a different origin. On the EKG they will look like a PAC except that there may not be a P wave, the P wave may be inverted, or after the QRS complex. Just like with a junctional rhythm.


Once again, these can happen with healthy hearts. Not too much to worry about.

PVC

PVC is a Premature Ventricular Contraction. While the SA node normally regulates the heartbeat during a sinus rhythm, PVCs occur when ventricles depolarize before the sinoatrial node or the AV node and thus triggers a premature heartbeat. At times PVCs can be felt as chest palpitations or a "missed heart beat" but they also occur in healthy hearts. Since the ventricles are contracting before they have time to fill with blood a PVC is not as efficient at pumping blood.

When PVCs happen more that once they can fall into a number of categories.  If every other beat is abnormal, you can describe it as bigeminal. If every third beat is aberrant, it is trigeminal; every fourth would be quadrigeminal. 


If you have 2 PVCs back to back they are considered couplets. 3 are considered triplets. More than 3 PVCs in a row is considered a run of V-Tach. Unlike PACs, PJCs and the occasional PVC, runs of V-Tach is something to be concerned about.


Some possible causes of PVCs include:

• Ischemia
• Certain medicines such as digoxin, which increases heart contraction
• Myocarditis
• Cardiomyopathy, hypertrophic or dilated
• Myocardial contusion
• Hypoxia
• Hypercapnia (CO2 poisoning)
• Smoking
• Alcohol
• Drugs such as cocaine
• Caffeine
• Tricyclic antidepressants
• Magnesium and potassium deficiency
• Calcium excess
• Thyroid problems
• Chemical (electrolyte) problems in the blood
• Heart attack
• Adrenaline excess
• Lack of sleep/exhaustion
• Stress

When PVCs all look the same on the EKG they are considered monomorphic or unifocal. This happens because the PVCs are all origintaing in the same location. If the PVCs have more than one look to them they are considered polymorphic or multifocal. This means they are stemming from multiple focal points in the ventricles.

Heart Rhythms Part 1: Basic Anatomy
Heart Rhythms Part 2: Sinus Rhythms
Heart Rhythms Part 3: Junctional Rhythms
Heart Rhythms Part 4: Ventricular Rhythms
Heart Rhythms Part 5: Premature Beats
Heart Rhythms Part 6: Heart Blocks

Heart Rhythms Part 4: Ventricular Rhythms

As we learned in Part 3 the AV node will initiate an electrical impulse if it fails to receive one from the atria in a timely manner. This is also true for the ventricles. If they fail to receive an electrical impulse from the AV node they will fire on their own, albeit at a much slower rate (20 to 40 beats a minute). On the heart monitor a ventricular rhythm is characterized by a wide QRS complex. In other words, if it has a wide QRS complex, it's a ventricular rhythm of some sort.

There are several ventricular heart rhythms/arythmias and all of them have the potential to be lethal. Some of them are always deadly.

I'll start with ventricular rhythms. The ventricles have an intrinsic rate between 20 and 40 beats per minute. Clearly, if you're at this point, you are having some major issues medically speaking. So now that you can recognize a ventricular rhythm (by the wide QRS complex) the rate becomes important.

• <20 - Recheck for a pulse, I bet they're dead.
• 20 to 40 - Ideoventricular rhythm
• 40 to 100 - Accelerated ventricular rhythm
• 100+ Ventricular tachycardia (V-Tach), again, check for pulses. Often a lethal heart rhythm.

An ideoventricular rhythm. Note the wide QRS complexes.

A sinus rhythm going into V-Tach. This photo demonstrates how much wider the QRS complexes really are from a sinus thythm.

Ventricular fibrillation I think is best described as your heart having a seizure. The entire muscle just spasms and ceases to pump blood. This is always a lethal heart rhythm.

A is course V-Fib, B is fine V-Fib

The last ventricular arrhythmia is Torsades De Puentes which means twisting of points. This is a form of V-Tach with some specific characteristics on the EKG:

• Rotation of the heart's electrical axis by at least 180º
• Prolonged QT interval
• Preceded by long and short RR-intervals
• Triggered by an early premature ventricular contraction (R-on-T PVC)

You can actually see the "twisting of the points" best in leads II, III, and aVR.

Heart Rhythms Part 1: Basic Anatomy
Heart Rhythms Part 2: Sinus Rhythms
Heart Rhythms Part 3: Junctional Rhythms
Heart Rhythms Part 4: Ventricular Rhythms
Heart Rhythms Part 5: Premature Beats
Heart Rhythms Part 6: Heart Blocks

Hydration And LODD

There appears to be some interesting findings about hydration levels and Line Of Duty Deaths in the wildland environment. It seems that reducing the workload of wildland firefighting crews during high ambient temperatures will do more to prevent a LODD than just making sure your crew is drinking water.

Read the article here on Wildfire Today.

Assault With A Deadly Weapon

The tones interrupted my morning workout. And for the second time that morning we were dispatched to a stabbing.

This call was again in district 52 at one of the local hotels. One of the nicer ones actually. As we approached we could see the sea of police vehicles (most of which were at our last call) and the AMR unit. For once they had beat us on scene.

As the air brakes set I jumped off the truck and walked over to the victim. The AMR medic gave me a quick run down. The patient appeared to be in his 20's and had been robbed. Or at least someone attempted to rob him. I don't know if they got anything. The poor guy had a defensive stab wound on one of his hands and another minor wound on his arm. The cut that we were worried about was the one in his chest.

He had about a on inch laceration about 3 ribs down from the middle of his clavicle. The puncture was bleeding slowly but steadily. The patient denied any trouble breathing and his lung sounds were equal bilaterally. He would be closely monitored all the way to the ER. With his vitals stable we bandaged him up and sent him on his way to the trauma center.


As we were leaving we were joking about the poor people trying to check into the hotel. They would be met at the front by several police cars, crime scene tape blocking the entrance and bloody clothes on the sidewalk. I can hear it now, "Honey, let's get another hotel."

Fillet Knife

Engine 52 was off at training and that left us covering their district. First think in the morning the tones went off. We were being dispatched to a stabbing in 52's district.

When we arrived on scene the Barney Fife patrol was already there. They directed me to the top of the stairs in the apartment where, just inside his bedroom, I found my patient.

According to his son the old man was in the late stages of dementia and had been hallucinating. That's when he took a knife and stabbed himself about 3 inches to the left of his belly button. It was very obvious where he had stabbed himself because the fillet knife was still embedded in his abdomen.

While the officers held the hands of my patient I carefully stabilized the knife with bulky dressings and a lot of 2 inch tape. The bleeding had been minimal, at least on the outside, and had already stopped. After taking care of the wound we decided to get a quick check of his vitals. They were all within normal limits.

By that time AMR was there and we packaged him up. On the gurney he was placed into restraints. This was as much for his own protection as for ours. He was obviously willing to stab himself once and we weren't going to take a chance since the knife was well within his reach.

The patient was lucky that he didn't hit anything vital or this call would have been a little more intense.

Not Breaking But Entering

The radio chirped, "Truck 51, respond for a lock out. The RP states they locked themselves out of their apartment and they may have left something on the stove."

 Photo borrowed from: http://report-on-conditions.blogspot.com

Hearing that reminded me of a Friends (I think) episode where one of them did the same thing. I remember the firefighter say to that to discourage people from calling to often for this they just chop down the door with an axe. I bet that would be effective.

When we arrived on the dark street we were met by a couple. The man said he had locked the door when they stepped out assuming that his girlfriend had the keys. Well, she didn't. Luckily the windows on their second floor apartment were unlocked.

I went back to the truck and grabbed one of our ground ladders. I went over to one of the larger windows and threw the ladder up to it. My captain footed the ladder while I scampered up to the window. I gently removed the screen and raised the blinds. I tried to move as much of the stuff in my way as I could. I really didn't want to break anything while entering.

Once inside I walked through to the kitchen. Just as we thought, nothing on the stove. I opened the front door and bid the tenants farewell.

By this time the neighborhood kids had heard our rig and were all out watching. They knew that we, like all good firemen, would have stickers. While my engineer put away the ladder I made sure each of the kids got their junior firefighter badge.

What Are Fire Lanes For?

Recently an Orange County Fire Authority (OCFA) crew took their HAZMAT unit to a neighboring city to watch one of their kids play in a Pop Warner football game. The incident made the local paper. You can read the article here.

I'm not going to try to defend them. It was, according to the OCFA official statement, against policy. So they are handling it. The part of the story that I thought was funny was that people were complaining that the rig was parked in the fire lane. Hello! It's a fire truck. If they can't park a fire truck in the fire lane then what is it for?!



Map of the route between the station and the stadium.


Oh well. Made me laugh and shake my head (at both the firefighters and the citizens) so I thought I'd share.

Burnt Out? Get Out!

If you hate your job, quit. Find something else. If you choose to stick around, you lose your right to complain. Especially in EMS.

Despair.com

We had a call in the middle of the afternoon. It was for an overweight woman that was walking home from the local carnival. She had been out in the sun all day and hadn't been drinking much. She also has diabetes and hadn't exactly been eating like someone that should be watching their sugar levels. She was in her mid 40's, had already had a heart attack, had high blood pressure and some obvious psychiatric issues.

When we arrived we found her talking to PD. They had found her sitting on the sidewalk. She said that she was feeling weak, dizzy and had some nausea. She had also vomited once. She was pale and sweaty. We checked her vitals. BP 98/66, pulse 116, respiratory rate 20, pulse ox 94%, sinus tach on the monitor, 12 lead was unremarkable, blood sugar 308. She lived just a block and a half away and was unsure if she wanted to go to the hospital.

Enter AMR and the burnt out medic. She took one look at the patient after hearing my report and decided that she was an AMA. The Burn Out then spent the next 5 minutes trying to talk her into not going to the hospital during which time the mother and neighbor of the patient showed up.

The mom and the medic now double teamed my patient trying to get her to just go home. My patient was still wishy washy and wouldn't make a choice either way. To me, she clearly thought that going to the hospital was the thing to do but she wanted someone else to back her up on the idea. I finally stepped in on the AMR medics toes. I simply asked if she still felt ill? When she said yes I asked her what it would hurt if she went and got checked out. At that point she happily walked over to the ambulance and climbed in. The last thing I saw was the transporting medic giving me a dirty look.

If you hate taking care of people that much, QUIT! We don't need you.

Contra Costa Fire Rescue

This is what we see and hear. There was moderate smoke in the house. The firefighter was still able to stand and see a little bit. A lot of the time we aren't able to see 3 inches in front of our face. Good save ConFire.

Thank You OSHA

So this last tour we went to a district quite a ways away for our annual infectious disease class. It's 3 hours long and can be summed up in one sentence. Use proper PPE and wash your hands, often. So the other 2 hours, 59 minutes and 45 seconds is used to go over data and trends across the country and in our county. We also went over what to do when we think (or know) that we've been exposed to some creepy crawly bad stuff. The entire class is meant as a review. In other words, BORING!

I've found over the years that it doesn't matter who is presenting the class. It's a dry subject. Throw in the fact that the AC unit was not working in our class room and you have a recipe for nodding heads. zzzzzzzzz

About half way through our class we were on a break. While we were milling about our radios crackled to life. We heard all the engine companies in the districts that borders ours (yes, the one we were not currently in) get toned out for an apartment structure fire, reports of black smoke coming from a second floor window. So those of us that were outside immediately switched our radios to the tactical channel. All of us from Station 51 kept our fingers crossed hoping it was "a pot on the stove."

As the first in engine company arrived on scene we heard them give the size up. "Engine 52 is on scene, we have a 2 story, garden style apartment with nothing showing. This is Main Street IC, engine 52 is investigating."

So far, so good. At least for us. We were expecting to hear that they had smoke and flames showing and that we'd miss our structure fire. About a minute later the IC reported that they had light smoke showing. They asked that the next in engine lay in a supply line. They then went into attack mode (sounds kinda like a guard dog going after a criminal).

Just about a minute after that the report came in that the fire was out and that it was just a pot on the stove. Hehehehe. We didn't miss "the big one."

In talking with the crew the next day we found out that the firefighter, after forcing open the security door, simply walked in, picked up the pot, and walked right back outside. All that was left for them to do was smoke removal. Oh yeah, and to find some way to secure the now really broken front door.

So thank you OSHA (or it may be Cal OSHA) for nearly making me miss a structure fire so I could learn how to wash my hands, again.