The Confusion Matrix part 1: Infarcts (maybe?), Thomas Bayes, and we’d like to ask you a few questions.

It is a busy Friday night at the rural EMS service where you work as a paramedic. You’re dropping off a patient at the local level IV hospital but before you can even finish your hand-off report dispatch pages you again. “Please respond to a 58 year old male that is conscious and breathing, complaining of severe chest pain, no other information is available.”
Its been eight hours since you last got some food and you’d really like to hit the EMS lounge on the way out the door. You start to wonder, how likely is this to be a myocardial infarction just based on the dispatch info?
MI venn

On scene the patient is an overweight, 58-year old male sitting in a recliner. He looks like shit. He is profoundly diaphoretic, has Levine’s sign when showing you where his chest pain is, describing it as “crushing,” rating it at 8/10. When you ask if the pain goes anywhere he says it travels to both arms. He denies any trouble breathing or shortness of breath, but he does tell you that he feels more tired than usual after walking up a flight of stairs.

His chest pain started 12 hours ago when he was at work. He was hoping it was GERD but Zantac and tums did nothing for his pain and he thinks it probably isn’t GERD at this point. He tells you that he had an MI in 2014 and that this feels just like that one did. He got one stent placed in 2014 but can’t remember which artery it was in, he thinks he has some paperwork on it in a drawer on it somewhere.

You give him 162mg of ASA and obtain his vital signs. He has a heart rate of 88 beats per minute, manual blood pressures are done in both arms,  142/94 in the R arm and 140/92 in the L arm. He is breathing 18 times per minute and his room air oxygen saturation is 95% with a great “pleth” wave and he is afebrile at 98.4 degrees. Both lung sounds are clear to auscultation. When you palpate his chest wall and ask if that changes the pain he replies, “I’m not sure.”

He has a history of coronary artery disease, peripheral artery disease, hypertension, hypercholesterolemia and benign prostate hyperplasia. He takes 81mg of aspirin every day, atorvastatin, flomax, lisinopril, and some vitamins. He used to have some nitro but it expired and he never bothered with refilling it. He has no allergies. He is supposed to schedule a stress test with his doctor next month as part of a routine follow-up but hasn’t done it yet.

You establish an IV and as your partner gets the 12-lead ecg set up you begin to contemplate where to take this patient. You have two choices; there is a level IV hospital twelve minutes away and a level II hospital fifty eight minutes away. They are in opposite directions.

The level IV hospital has board certified EM physicians but there is no cath lab there, they do have TNKase available and can consult with cardiology at the level II. Due to thunderstorms in the area flights are grounded for the next few hours so they are not an option. If you bring this patient to the level IV and it turns out he is having an MI,  you will have to transfer him to the level II which is an hour and ten minutes away.

The level II hospital really likes to work with EMS and they came and did an in-service for your EMS agency last month about their cardiac alert protocol – they have started to perform urgent PCI on some NSTEMI patients in addition to the regular STEMI patients.  You can activate a “cardiac alert” there with nothing more than a gut feeling if you like. When you activate the “cardiac alert” a cardiologist or PA from cardiology meets you at the door, performs an I-stat troponin, gets a hand-off report and decides if the patient goes straight to the cath lab or they stay in the ED for more of a work-up.

The twelve lead comes back as a textbook normal sinus rhythm with no other changes noted – no subtle ST segment depression, no T wave inversion, no De Winter’s T waves, no hemi-blocks or anything else is noted, this is just a normal ecg. This is surprising as you were pretty certain you would see a STEMI on there. Just to be sure, you do a V4R and V7, V8, and V9 and still see no signs of infarct or ischemia on the ecg.

You get the patient loaded up in your ambulance and give him a quick squirt of nitro under the tongue. You set out the fentanyl because you rarely get patients down pain to a comfortable level with just nitro. 

Your partner yells from the front, “which hospital are we going to?”

This is part one of this article. Part two will be coming out next week and will look at the answers to these questions as well as look at the results from the dozens of readers of this blog.

14 in 13

A 14 gauge IV in a 13-year-old girl

Teresa Forson lost her job as a firefighter because she started a 14-gauge IV on a drunk 13-year-old and then lied about the circumstances surrounding the event.

The 13-year-old girl was alert and ambulatory with stable vital signs. Many people on social media defended the firefighter, feeling that termination was uncalled for, that it was excessive and that really, this was not that of a big deal. In one sense they are right, a 14-gauge IV insertion probably doesn’t hurt much more than a 20-gauge IV does and since no harm came to the patient from this incident, what is the big deal?

Intent is the big deal. Intent is what matters. Either these paramedics need some serious remediation on when large bore IVs are needed, or this was a punitive act. I can’t truly say what occurred in the back of that ambulance between the surly drunk teenager and the firefighter as I wasn’t there and I don’t have all the facts, but it sure sounds a lot like punitive medicine.

Practicing punitive medicine is indefensible. It points to low levels of emotional intelligence and poor impulse control. I certainly have had moments in my career where I have contemplated doing it to patients. When I first started in EMS, I believed that “drunks get 14’s,” and I was more than ready to plug some 14-gauge IVs into the next drunk patient I encountered. It would take a few years of working in EMS before I realized that there might be a better way to learn how to care for patients than teaching via war stories from people who had repeated their first-year twenty times over.

A lack of emotional intelligence training in healthcare education.

Healthcare education rarely teaches about soft skills like emotional intelligence. These skills will be used on almost every EMS call, on almost every shift and yet we don’t talk about them. Time is sent on garbage like the KED and taping people to plastic boards.

Emotional intelligence may not be real form of intelligence, there certainly appears to be a debate about that. It may be more pop-psychology than an actual science, but the skills and attributes emphasized by it are very real and can save or prolong a career.

Increasing emotional intelligence can change how you relate to the bullshit calls. If you have worked in EMS for some time you have probably encountered people that were extremely intelligent in the conventional sense yet had astoundingly low levels of emotional intelligence. These people are smart but they tend to explode over small things or end up doing some sort of punitive thing to a patient that ends their career.

“If your emotional abilities aren’t in hand, if you don’t have self-awareness, if you are not able to manage your distressing emotions, if you can’t have empathy and have effective relationships, then no matter how smart you are, you are not going to get very far.”
-Daniel Goleman

Emotional intelligence has four or five components to it depending on the source you read; self-awareness, self-regulation, motivation, empathy and social skills.  Each component is important but self-regulation  might be the most important when it comes to not getting fired and not fucking up your life in general.

Having impulses to punish a patient is not the problem; not being able to control the impulse is a problem. You can hate your patient, you can get pissed off at them, you can find them annoying, but then you move on and do your job like a professional. I have had more than one fantasy where I tell  my partner to pull over on the side of the road and kick a patient out of the ambulance in the middle of nowhere because they annoyed the shit out of me.

The obstacle is the way.

The impediment to action advances action. What stands in the way becomes the way.” -Marcus Aurelius

The Obstacle is The Way by Ryan Holiday is a short book that might change the way you look at the world. Anyone working in healthcare should read it. It transforms how you relate to all the bullshit encountered in healthcare.

In EMS there really are only two kinds of calls—bullshit calls and good calls.

The drunks, the pointless nursing home runs, the patients with back pain that should just harden up and deal with it, the rambling psych patients who went off their meds, the uninjured person that “just wants to be checked out” in the middle of the night, the repeated accidental life alert alarm activations, a pair of piss soaked pants rubbing on your pants, patients with shit packed under their fingernails that keep trying to touch you, drug-seekers, COPD patients smoking while on oxygen and complaining of shortness of breath, the 25-year-old male with chest pain at the jail, and the morbidly obese that are will blow out your back. These are the kinds of patients that suck the life out of healthcare provider. These are the kinds of patients that on bad day are easy to hate. You might even tell yourself that these patients are the obstacle to your happiness at this job—that if it weren’t for the bullshit calls you would be happy at work.

The bullshit calls are the obstacle and they are the way.

You can still be annoyed or pissed about these calls. I certainly am from time to time, but it happens less than it used to, and it has becme more of a passing thought than anything else. It is not a strong reaction. I may not like the patient, or I might be mad, but it is not a big deal. It does not linger; it does not ruin my day most of the time and it certainly doesn’t cause me to lose control. It is more along the lines of when I want Coke and must settle for the apologetic “is Pepsi okay?” Being annoyed about these calls doesn’t accomplish anything, being pissed off about these calls is a waste of time and energy.

Marcus Aurelius asks, “Does what happened keep you from acting with justice, generosity, self-control-sanity, prudence, honesty, humility, straightforwardness?”
No? Then brush it off and move on. If an asshole patient can control your actions, you probably are not really in control as much as you like to think you are.

Making it a practice.
If I get mad, they win.

When presented with an especially difficult patient I remind myself, I get mad, they win.

If a patient can provoke me to a point where I lose my composure, they win. Don’t get me wrong, I’ll escalate appropriately and professionally when needed; I’ll stab someone in the ass with 400mg of ketamine without a second thought and I’ll fight if I have no other choice. But I won’t act out of anger and I won’t give out punitive measures.

A drunk 13-year old girl certainly could be considered just another bullshit call. Or it could be an exercise in patience and self-regulation; it could be a lesson in managing your emotions.

“I don’t want to be at the mercy of my emotions. I want to use them, to enjoy them, and to dominate them.
-Oscar Wilde