Emergency Medicine, EMS, Virginia Beach June 26, 2015June 26, 2015

A few thoughts on drowning events

For 8 amazing summers, I worked as a lifeguard at Ocean Breeze Waterpark in Virginia Beach, VA. Some of the best memories in my life are from those days. However, unlike most lifeguard jobs – we actually saved drowning people, and A LOT of them, roughly 10-12 per day. I stopped counting my “saves” somewhere around 300. Looking back, this job was what lead me to EMS, and ultimately to becoming an Emergency Physician. The training provided by Ellis & Associates (E&A) created a great foundation of water rescue, first aid, CPR and leadership skills.

E&A Eastern Regional Lifeguarding Competition - Summer 1998 — E&A Eastern Regional Lifeguarding Competition, 1998

On a side note, you may be wondering how so many people can get into trouble at a water park. It’s not like the ocean, right? Well, I think as a society we have an inherent respect, and maybe some fear, of the ocean. Pools however, are clear and don’t have critters, so how dangerous can they be? People and parents let their guard down and get into trouble.

Are you a good lifeguard?

Before you read any further, I encourage you to take a little test. The two videos below both feature wave pools where there are active drowners. It’s like a high-stakes Where’s Waldo – can you spot the drowning victim? See if you could do the job.

Did you see the kids before the lifeguard blew the whistle to jump in? The kid in the first video has pretty obvious flailing; the kid in the second video – much more subtle. There’s been a great Slate.com article circulating around Facebook the last few months creating awareness that drowning doesn’t always look like what we expect.

Drowning Definitions

Before we get too deep into the medicine, let’s first talk terminology. Many of the terms I learned as a lifeguard have fallen out of favor in the medical community.

Drowning: a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium

The Drowning Process: the period beginning with submersion into liquid, followed by breathholding. As oxygen is depleted and CO2 can’t be expired, the patient begins developing hypercarbia (high CO2), hypoxemia (low O2), and acidosis. As water is inhaled, the larynx spasms shut, blocking the exchange of air. As oxygen drops further, the laryngospasm relaxes, and the patient breathes water into the lungs. Recovery from the drowning process depends on when interventions are made and the resultant level of hypercarbia, hypoxemia, acidosis and encephalopathy.

Terms no longer used:

“Dry drowning” versus “wet drowning”: all drownings require some level of liquid, so they are all technically wet. What was traditionally called a “dry drowning” was just someone who made it to the laryngospasm step but no further because they left the water. “Wet drownings” went through a laryngospasm period, but advanced in the process to include inhalation of water into the lungs.

Managing Drowning Victims

You should of course follow your local protocols, but let’s talk about how the drowning mechanism affects care. Clearly if the victim has no pulse, you’ll follow ACLS/BLS guidelines and start CPR. If you get to a victim but can’t initiate chest compressions right away because you are oh I don’t know – in the middle of the ocean or a wave pool – at least try to give rescue breaths as you bring the victim to a more suitable place. Remember, drowning is primarily an airway issue, so any early airway interventions will be beneficial until you can start CPR. As of the 2010 AHA CPR updates, abdominal thrusts in a coding patient have been discarded for good old chest compressions. So, if your drowning victim isn’t breathing, even if they have a pulse you may need to do chest compressions for management of A&B.

Regarding when to intubate, per UptoDate, “in the symptomatic patient, indications for intubation include the following:

Signs of neurologic deterioration or inability to protect the airway
Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90 percent despite high-flow supplemental oxygen
PaCO2 above 50 mmHg” which is typically unavailable prehospital.

Whether someone was pulled from fresh or salt water is not particularly relevant to prehospital care as it doesn’t change management. Consensus used to be the patients in salt water were at risk for massive pulmonary edema and electrolyte imbalance in the blood as the high sodium content of the salt water shifted in the body. The risk and consequences of these shifts are now less worrisome than once thought. In a 150lb (70kg) person, it actually takes inhaling 5.5 cups of water before you’ll see osmotic water shifts in the body, and twice that before you’ll see electrolyte shifts.

The greatest risk of drowning of any type is hypoxemia leading to brain damage, and they key strategy is drowning prevention.

Drowning Prevention

Prevention is by far the best strategy in managing drowning, and in the last 20 years, smart safety measures and public education programs have helped drop the overall incidence of drowning by 9%, which includes a 45.6% drop for infants (< 1 yr of age). In fact, my good friend David Andrews who runs a water park out in California, told me that since the water park industry implemented a policy requiring kids <48″ to wear life jackets, active drowning events have declined roughly 50%.

So, if you are taking care of a drowning victim in your ambulance or ED, just follow your ACLS protocols. And, next time you are at the water park or pool, thank the lifeguard for their diligence and dedication, and please don’t complain that your kid has to wear a lifejacket.

~Steph

Emergency Medicine, EMS, Patient Anecdotes June 2, 2015June 2, 2015

When people fall from extreme heights

I’m currently on a month of Ortho nights and was asked by the Attending to look up an article about the median lethal dose (LD50) for falls, meaning, at what height when people fall, do 50% of them die. Although 10 years old, the article is pretty interesting and got me thinking about some fall patients I’ve taken care of in the past. I once had a patient who accidently fell 11 stories from a hotel and lived. But we’ll get back to that story in a bit.

A fun fact before we dive in:

The record for a fall from the greatest height where the person survived is held by Alan Magee, a WWII USAF pilot who jumped out of his plane at a startling 24,000 feet and landed in a pine forest (some sources say a glass roof). Fortunately for him, the forest (or the roof) was covered in snow which is believed to have decreased the energy of the impact due to its deformability. If you are looking for a great book about a fall survivor, check out When I Fell From the Sky, by Juliane Koepche, a 17 year old girl who fell 10,000 feet from her family’s airplane which ultimately crashed in the Amazon jungle in 1971.

The evidence on falls

The article, Prognostic factors in victims of falls from height, by Lapostolle et al, was published in Critical Care Medicine in 2005. The study took place in France, in a city near Paris with a population of 1.3 million people. The researchers worked with the local EMS agency, Service d’Aide Médicale Urgente (SAMU), to examine both pre-hospital and in-hospital mortality (death) from falls, with the goal of determining what characteristics of a fall, if any, factor into prognosis. There were 287 patients in the study, 97 (34%) of which ultimately died. In short, they determined that patient age, height of fall (e.g. 1 story vs 8), impact surface type (e.g. concrete vs snow) and body part that first touches the ground (e.g. head vs legs) all help predict how a patient will do.

Interestingly enough, they even looked at the circumstances leading to the fall (i.e. accident, suicide, escaping a burning building), and cause did not factor in to prognosis. When you stop and think about it for a second, it seems semi-reasonable that someone determined to commit suicide might be able to jump in such a way to be more successful in his mission. Yet, of the 123 patients who attempted suicide, only 45.5% were successful. So suicide was not more deadly of a fall.

Also of interest, landing feet first was much less deadly than landing on your stomach, with death rates of 5.6% and 57.1% respectively. Getting back to my patient who fell 11 stories and lived, he fell feet first. I believe he survived because his legs acted as a sort of crumple zone, absorbing some of the energy of the impact.

Figure 1. Height of fall and related mortality. Lapostolle et al.

Figure 1 above is from the article, and shows what’s known as the median lethal dose (LD50) for falls, meaning, at what height of a fall will 50% of people die. In this study, it was determined to be just over 4 stories. You can see that in this study, with the exception of one person who fell 17 stories, 100% of the patients who fell from 8 stories or more died. Clearly there are exceptions to this in real life – the 17 story patient, my patient, Mr. Magee, Ms. Keopche – but statistically speaking, it’s extremely rare. So, next time you respond to a call or see a patient in the ED who fell 4 or more stories, know that they have a 50/50 chance of survival.

Sorry for the morbid topic, but that’s part of being on night shift I suppose.

~Steph

Emergency Medicine, EMS May 18, 2015July 13, 2015

Interview with a Charge Nurse: How to be an EMS provider respected by the ED

I had a great response to one of my earliest posts, 5 Things I Learned in Medical School I Wish I’d Learned in EMT School, with many people asking for more tips on improving as an EMT.

With that in mind, I realized that learning how to interact with the staff in the Emergency Department (ED) is also an art not often addressed in EMS education. Clearly you need to know and execute your protocols effectively – but how can you stand out as a respected EMS provider? Fortunately, I’ve been friends with an awesome charge nurse named Katie Arnold since junior high. She was kind enough to answer a few questions.

Steph: How long have you been a nurse, and how did you get to be a charge nurse?

Katie: I have been a nurse for 14 years this May 2015 – I have spent my whole career in the emergency department. I was selected for charge nurse by my manager, trained by another charge nurse and then started on my own around 2006-2007.

Steph: What do you like most about your job?

Katie: As an emergency nurse in general I love the unpredictable and unexpected. I tell new nurses, patients and their families all the time that it’s like a jigsaw puzzle: you get a piece here and a piece there but you don’t figure out the whole picture until all the pieces are in place. I love that I can have 5 patients all with the same chief complaint and each will be managed totally differently. As a charge nurse I love being a representative for the department, working with ancillary staff, patients, families, nurses, and EMS. I am there to control the flow of the department, to be a professional example for everyone and handle many administrative duties. It adds a whole other dimension to the role of nurse that allows further development of a holistic nurse.

Steph: Can you explain the goals and responsibilities of a charge nurse, in particular, ways you interact and work with EMS?

Katie: The duties are numerous and in depth. With EMS, we are the liaison between rescue and the ED. EMS providers are the eyes, ears and hands in the field; they are going to paint the picture the charge nurse needs to determine how each ambulance patient that arrives will affect the balance of the ED at every moment. You must appreciate their role in addition to the roles of the ED staff. Their resources are vastly different than the staff in the ED. I think staff nurses as well as some charge nurses lose sight of that fact.

Steph: What makes a good EMT in your mind?

Katie: A good EMT knows their role, provides an accurate concise report of what they are transporting to the ED. They demonstrate professionalism despite the stresses presented by the patient, the scene and the ED. A good EMT knows when to address concerns and when not to.

Steph: Do you have any pet peeves of EMS providers?

Katie: Lengthy reports of extraneous information and lack of recognition about valid concerns of the ED staff. One cannot expect the ED staff to appreciate EMS constraints but then not care about the concerns of the ED staff.

Steph: What can EMS providers do to make your life as a charge nurse easier?

Katie: As Charge Nurse, I have to decide what type of bed is appropriate for the patient based on the EMS report. Do they need a heart monitor, a psych bed or oxygen? Not all rooms are equipped with the same capabilities. A good report provides me with the information to make this decision. Helpful EMS providers also note when the ED is busy, and go the extra mile to be team players. Whether it’s cleaning a bed or hooking a patient up to the monitor, while not the job of the EMS provider, it helps the patient get care faster.

Steph: Which EMS providers impress you and why?

Katie: Those who are clear, concise, professional both in front of their patient and amongst colleagues on the EMS and ED side. Providers that are open to and understanding of constructive criticism.

Steph: Any tips for a brand new EMT?

Katie: I believe that when a new group of EMT’s are coming out they should have an initial interaction with a charge nurse or liaison at the ED to discuss these topics and allow for questions they may have to be asked prior to starting on the road. If that’s not done formally, then an individual EMT should feel free to introduce themselves to ED staff and seek feedback on reports.

Steph: And finally just for my own curiosity, what’s it like to be charge nurse on July 1 when the new Intern doctors start?

Katie: I love to teach and educate, so it does not bother me as it does others. ED Staff tend to become frustrated because each new class of Interns is unaware of how each ED operates with different patterns and order sets, goals and metrics. Some doctors are more receptive to that fact than others. It can drastically slow the flow of the ED and directly affect the care of the patients. New Interns are successful as long as they are willing to listen.

So there you have it, straight from the boss’s mouth. My advice, pick one thing to try and start there. Good patient reports are 90% of the game. Once you nail that, the rest falls into place.

~ Steph

EMS, Patient Anecdotes May 17, 2015May 17, 2015

Did you know it’s National EMS Week?

Did you know that May 17-23, 2015 is National EMS Week? There are over 825,000 certified EMS providers in the United States. In addition to being an exciting job, it’s also a dangerous one – with an estimated 27,800 ED visits annually by EMS providers as patients themselves!

While donating to a local rescue squad is a great way to show your support for EMS Week, I can tell you from first hand experience that a simple gesture to say “thank you” goes a long long way to keep an EMS provider motivated and inspired.

TeamLouka Gets a Sweet “Thank You”

A few years ago on a hot Summer day, Amir and I were dispatched to a house for a child having a seizure. The little girl had a history of frequent seizures, so her parents were pros at giving her Diastat, her emergency medication designed to stop a seizure. By the time we arrived just a few minutes later, her seizure had stopped, and her Dad just asked that we check her vital signs. He had spoken to her Neurologist who agreed she could stay home if her heart rate, blood pressure and breathing were all stable. Fortunately, everything checked out ok, so the family was able to avoid another hospitalization.

As we collected the equipment and marched back downstairs, we heard the Dad pop the top on two bottles and shout “I really want to thank you both!” Hoping not to embarrass or insult him, Amir and I discussed the best way to tell him we couldn’t accept an alcoholic “thank you” while on duty. As we rounded the corner to the kitchen, we saw him holding two ice-cold bottles of Coca-Cola. We drove away feeling appreciated and recharged – ready to take on whatever 911 call came next.

255764_10151483529319545_1320742665_n — The sweetest kind of “Thank You”

Hopefully you won’t have to have such a close encounter with your local EMS providers, but don’t let that stop you from giving the next crew you see a pat on the back.

~ Steph

Art & Design, Family & Friends May 14, 2015February 28, 2016

DIY Yard Yahtzee!

After another successful Crab Bake with Giant Jenga, I was thinking about other classic games that would translate well into a “giant” version. Then of course I was at Target this week and came across 6 wooden blocks designed for home arts & crafts projects. An idea was born!

What you need:

5 square wooden blocks (4″ cubes or larger if possible)
Acrylic paint in multiple colors
Paint brush(es)
A quarter or something else circular to use as a stencil for the dots
Mod podge or other sealant
Chalk board paint or pre-fab chalk board
White chalk

6 Wood Blocks - Target $14.99 — 6 Wood Blocks – Target $14.99

Mod Podge sealant - $4.99 — Mod Podge sealant – $4.99

Chalkboard Paint - $9.97 — Chalkboard Paint – $9.97

Step 1: Paint the base of your blocks

Solids are great, but you can also make each block a mini work of art. Just remember you’ll have to apply dots as well, which might cover up some of your artwork.

Step 2: Stencil your dots

Use a quarter, glass or other round object to trace the dots onto your blocks.

Step 3: Fill in your dots

I used paint pens for ease, but you can certainly paint in your circles with a paintbrush, or make it simple and apply stickers or paper with Mod Podge.

Step 4: Seal your surface

I like Mod Podge with a gloss finish. It’s great if you used paper or just paint to create your design. Paint on multiple layers for a good seal as you’ll be rolling these dice in the grass and will want to be able to clean the surface.

Step 5: Create your scorecard

You can find easy, printable score sheets online, or you can keep everything large scale and create a “giant” scorecard on a chalkboard. And, don’t forget to print the rules for Yahtzee! if your family likes to argue about technicalities.

Screen Shot 2015-05-13 at 4.32.10 PM — “Giant” Chalkboard Score Sheet

Step 6: Enjoy!

~Steph

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