September 18, 2023 • 45 mins
Research is constantly changing EMS practice. It's difficult to keep up with everything happening and even more challenging to interpret these voluminous papers. This is where the EMS Avenger comes in. A popular social media figure who talks understandably and frequently about research. Each 7 Things relate to one piece of literature that has the potential to change everything from current thinking to practice to protocols.
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Welcome to Seven Things EMS, a continuing education offering from LIMMER Education.
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Seven Things EMS is designed to give you what you need to succeed in EMS, it's conversational,
informational and without the fluff.
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Alright welcome to another episode of Seven Things EMS.
I think I always probably start and say I'm excited too, but perhaps today, most excited,
we have a topic that's got a great clinical look and an outstanding guest who you will
recognize the voice relatively quickly if you're on a tiktok.
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The topic Seven Things research tells us about EMS practice and the guest for this episode,
Jimmy Apple.
Now I'll tell you he's a 20 year paramedic, 911 and critical care experience, but where
you're going to know him from is as the EMS Avenger on tiktok.
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You're going to recognize this voice, you're going to recognize the advice and if you don't
follow him on tiktok or if you don't do tiktok, I would recommend doing it just for this.
I'd like to welcome you Jimmy and let's do some conversation.
Okay, I do want to mention that I know that a lot of people are averse to tiktok and
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so for that reason, I have started reposting some things to Instagram where I am EMS Avenger
and I have a Facebook group called EMS Avenger where you can find my videos.
Awesome.
And they really are worth doing.
I literally looked forward to your tiktoks.
They were great, insightful pieces of information and that's quite frankly why I reached out
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to you, to have you.
You're appreciated.
So we have seven things that research tells us about EMS practice.
Now we can put the caveat on like we do in a lot of clinical podcasts that you of course
have protocols and the interpretation of science can vary between person to person,
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but I found Jimmy's information on tiktok to be very relevant and how it's going to
affect your practice.
And the seven things he provided are things that you're going to think about.
I don't think you'll go by a week of any EMS experience without encountering most of these.
So let's go to number one.
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Let's start in this.
It's our hallmark here is that we get to it, you drive through it, keep people's interest.
Working codes on scene increases survival.
Correct, and I am always surprised on how this is information that people didn't know.
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This has yet to be the prevalent practice in the US and I practically broke tiktok
on my first video about this almost a year ago, but it's true.
Normally in EMS we're accustomed to showing up, getting our interventions in place and
then getting out of there as quickly as possible to the emergency room.
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But we have one study after another now that has informed us that moving a patient intra-arrest
results in lower survival.
One study in particular, one of the most recent one suggested that working a patient on scene
could double your rates of survival.
The conclusion was actually that transporting would have your rates of survival, but you
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can look at it either way.
I think there's several elements in here that are very relevant to EMS.
I think the first is that we have to change our mindset that we can do this and in not
every case it's about going to the hospital.
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With that we also have the subsequent benefits or side effects of that we're doing better
CPR.
We have more concentration, more continuity.
I'd even venture to say more safety because working a code and a moving truck is certainly
no fun and potentially dangerous as well.
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Absolutely.
I actually have a pretty popular video and I need to pin that, but I have a sealed baggie
that is filled with red fluid to simulate blood and that bag is filled up all the way
to the top.
I demonstrate how I can take that bag and I can hold it upside down, I can move it to
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the left, I can move it to the right, I can shake it and that blood is always filling
that bag.
Somebody who is in cardiac arrest doesn't have the same hemodynamic tension anymore
that is keeping that bag nice and tight.
I have a second bag that's filled about halfway through that would recommend the relative
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hemodynamic status of someone in cardiac arrest.
If you tip that bag or hold it upside down or move it to the left or to the right or
shove it forward or shove it back, that fluid sloshes all around.
That's exactly what happens when you transport someone in cardiac arrest.
They don't have that vascular tension and so you can have a lot of volume distribution
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when you're transporting somebody and that affects your coronary perfusion and affects
your cerebral perfusion and that is the primary challenge in transporting someone in cardiac
arrest.
So you are much better off leaving them exactly where they are and not moving them and subjecting
them to that sort of inertia and that sort of force that can be so detrimental to their
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survival.
Anything that you would say to systems now that feel they have to transport, that transport
is their priority and we're going to go into number two which is going to bridge this very
nicely.
But what would you say to the agencies or the medics, sometimes it's older time medics
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that feel they've really got to move, that they don't want to work to go down?
A lot of the rationale is but there's doctors there or but the cath lab is there and what
they don't really understand is that there is a cap to expertise when it comes to cardiac
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arrest.
85% of cardiac arrests are cardiac in origin in our boilerplate cardiac arrest where there
was some sort of major cardiac event and it doesn't require a lot of brain power to
resuscitate them.
It requires diligence in your resuscitation practice and there are diminishing returns
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on putting academia in front of them and if you don't bring a salvageable patient to the
hospital they don't go to the cath lab anyway.
And they also for the most part practice some sort of variation they see a less when you
get them to the hospital they're not doing things any differently than you would and
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in some cases their resuscitations may be a lot worse than yours.
You know resuscitations in a clinical environment are still subject to the same dedication and
passion that they are in the field and if someone is running it in a disinterested manner
or not in a diligent manner it you know bringing them to that scenario doesn't benefit them.
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All right and I think we need to have some confidence and some mojo and get out and work
those codes and keep our survival rates going.
I did a podcast early in this series with the American Heart Association's director
of education and he said that the Heart Association has been trying to get the national survival
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rate over 10% for a long time.
We've hit a certain plateau with that and I think that this and maybe even the next
point we're about to go into might help that process.
Sure and let me just add that I said a lot of things there earlier but what I need to
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emphasize is that it's all about your compression fraction which is the amount of time in a
two minute cycle compression cycle that you're doing quality compressions and the lower your
compression fraction the lower your chance of survival.
So anything that interferes with that is not conducive towards survival and one of the biggest
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interferers in your compression fraction is moving a patient and that's what I would ultimately
say to somebody that has questions about transporting is that because it interferes with that compression
fraction.
Well let's roll to number two then.
The more that we go into advanced life support the more we bring in technologies we decrease
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survival.
I think that's going to kind of hit the bedrock of a lot of people out there doing ALS.
Absolutely when it comes to survival and cardiac arrest what you need to do is actually very
simple.
You need to perform high quality compressions and you need to provide timely defibrillation.
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Those are the only two interventions in cardiac arrest that have any quality evidence behind
it.
And so the more technology that you bring into that practice the more you have the potential
to interfere with those two things that we know improve survival and cardiac arrest.
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And that includes things like IVs and IOs.
The practice of access itself doesn't necessarily infer a benefit.
It brings in you know pharmacological technologies such as epinephrine or lidocaine or amiodarone
or you know going down the rabbit hole of bicarb and calcium.
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None of those things have a body of evidence behind them that they improve survival and
with bicarb and calcium in particular the evidence suggests that routine administration
of both of them lower survival.
You have advanced airways of you know different types of advanced airways including endotracheal
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intubation and supraglottic airways like the king and the eye gel.
There's no body of evidence that infers a benefit to the patient with those advanced
airways.
The only benefit is essentially the positive pressure that you're doing to keep the lungs
from collapsing.
And then we get into more of what I call the toys that are coming out now including impedance
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threshold devices, the active compression, decompression devices, mechanical CPR, the
heads up CPR devices.
All of those things have either no evidence or low quality evidence behind them.
And so if you're not dedicated to the two things that improve survival which is quality
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compressions and timely defibrillation, the way I look at it is that you are putting your
patient into a technological circle of death.
And there are multiple studies out there that show that survival is higher with BLS as compared
to ALS.
One of the most notable shows survival with BLS being 13% and ALS being 9%.
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And even comparison of bystander compressions to ALS shows higher survival rates.
I'm going to take that technological circle of death and makes me instantly want to make
a graphic for it.
I'm actually working on a talk about that and I'll tease it.
It's going to be called Kevin Costner and the Circle of Death.
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That's all I'm going to say.
All right.
I want to see that.
What would you say to the ALS provider that says, hey, wait a minute, I went through and
learned how to do all this stuff.
I went through ACLS.
I did this.
What should I really do?
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You should be focusing on improving your compressions.
It's all about compressions, compressions, compressions, compressions and then reducing
time to defibrillation.
And the AHA has finally caught up to precharging the monitor.
So you have that monitor ready to defibrillate.
You hit the charge button 15 seconds before your rhythm check.
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So you have that finger on the shock button.
So as soon as compression stop, you can rule in or rule out a shock within seconds.
You should be able to, as soon as this compression stop, you should be able to recognize VFib
or VTAC.
Either one of those are there, then you clear your shock and you keep going.
If one of those are there, then you hit the shock and you immediately resume compressions,
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but you should be able to reduce that peri-shock pause to three seconds.
Because the thing is, is that it takes 16 seconds to build up enough intratherastic
pressure to perfuse the heart during compressions.
From the start of compressions, it takes 16 seconds.
It only takes three seconds to lose all of that pressure.
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So your job should really be about never losing that pressure if you can avoid it.
Now you can start getting mastery of that process.
And when you're a service like Hilton Head Fire Department or Seattle's Medic One program
in King County, they've mastered the basics.
And so at that point, they go on to master some of the advanced practices like endotracheal
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intubation.
But if you don't have a mastery of those advanced practices like intubation, then you shouldn't
be disrupting a quality resuscitation with those practices.
Yeah, a couple things come to mind.
The first is that Hilton Head is Seattle.
We often have very passionate profits of things done there.
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I think that's beneficial.
And I think EMS also hangs our hat on our skills.
They're the badges, the rockers we used to put on our patches.
And what I really would say in this, I'm kind of the big picture, differentially diagnosis,
critical thinking guy, is that advanced providers bring good assessment, experience, and judgment
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in.
And I think those things have value.
And we can't ignore those.
We should put more preference on some of that than on the things we do.
Absolutely.
All right.
Number three, I don't know.
If there's one that I would pick might be the biggest lightning rod here.
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I would say it's this one.
And nitroglycerin with an inferior in-park and right side is safe.
And I think I have probably heard more spirited discussions on this than anything else, that
those conference dinners and all the side conversations.
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Tell us about it.
Yeah.
So there is this dogma that we have in EMS that you should either use caution or they'll
say it's nitroglycerin is completely contraindicated in the presence of an inferior myocardial
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infarction.
So first of all, to clear up a little bit of misinformation, the risk is not with an
inferior myocardial infarction.
The risk is with a right-sided ventricular infarction.
And that's because an inferior myocardial infarction anywhere from 30 to 50% of the
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time are accompanied by a right-sided ventricular infarction because it's a proximal RCA occlusion.
So let's just say that there is a risk to administering nitro in that situation.
If you have an inferior MI, literally the first thing you should be doing is switching
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your V4 to a V4R to confirm whether or not there's a right-side accompaniment.
And in the absence of that, then that nitro administration would be completely safe.
But the fact of the matter is, is that that risk really isn't there.
And we can trace that dogma back to a 1989 study that was a single-centered low-powered
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study of 28 patients that claimed that there was a risk of cardiovascular collapse due
to preload dependency of the right ventricle.
And that pathophysiology has started to come into question at this point, but that those
results were amplified by several papers but never actually reproduced.
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And it fed into this kind of like cyclical intensity that created this wariness of administering
nitro to patients experiencing a right ventricular infarction.
But there have been multiple studies since then that have had much larger cohorts that
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have not reproduced those results.
And so the conclusion is, and pretty confidently so, is that nitroglycerin is safe in the presence
of any infarct of any location, and that really your should concern should be just about giving
nitro to somebody with a soft blood pressure.
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In fact, this year at the Gathering of Eagles, which is a very large conference that's attended
to by some very influential researchers and medical directors, people who are really the
movers and shakers and decision makers in EMS, and they declared that nitroglycerin is
safe in the presence of a right ventricular infarct.
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So this is some of the most classic EMS and emergency medicine dogma that there is, but
unfortunately it's baseless and there's no evidence behind it.
We have issues changing our mindsets about things in EMS, sometimes significant.
The number of people at the EMT level that are still taught to give everyone oxygen or
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oxygen calms people down is pretty dramatic.
And I do agree with you that this pronouncement at the Eagles is big.
I think that it's an outstanding place to get information, get some of the current thinking.
I hope that it gets, I hope it gets to be more current thinking than some other things we've
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had trouble accepting.
I heard from this or I had this one patient who leads what we do too much.
Sure.
And I mean, everyone is going to have that patient who had an inferior MI or even right
side involvement that they gave nitro to and they become unstable.
And the claim is not that this doesn't happen.
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The claim is that it doesn't happen with any increased frequency as compared to other
regions of the heart.
Given that your concern should really be just on focusing on the patient's hemodynamics
and avoiding something that could cause hemodynamic collapse if they don't have a solid blood
pressure.
But even then, the half-life of nitroglycerin is like five minutes.
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And so if you did cause somebody to go down a little bit, you have the ability to combat
that with several types of medications.
And that should resolve on its own relatively quickly.
I think we've all had the lower the head, the brunt some fluid, let's see if we can
keep this from happening patients.
Absolutely.
No matter where it is, that could happen.
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I think that's an important message.
Number four, minorities are treated for pain differently.
That's true.
And this is probably one of the most well-studied things in medicine.
And it's based on common teachings back during the slavery era and beyond that kind of sought
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to justify our abuse and treatment of slaves by stating that they had different physiologies
than that of white people.
They were more pain tolerant.
They had thicker bones, thicker muscles, less sensitive nerve endings.
And that infected our medical practice.
And as we've progressed on as a society and become a more progressive society when it comes
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to race, that has become more influenced by socioeconomic status.
But the data is pretty clear on it.
One study showed that with people who presented to the emergency room with fractures in the
emergency department that about 57% of them received some sort of pain management as opposed
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to 75% of white people who received some sort of pain management.
And when it comes to patients that have some sort of like recurrent or metastatic cancer,
the WHO Standards for Pain Management, the World Health Organization Standards for Pain
Management for those patients were not met in 65% of minority cases as opposed to 50%
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for non-minority cases.
Wow.
Wow.
Yeah.
I think we can let that stand as it is and move on to number five.
Okay.
Actually, before we go on, I think we should acknowledge that minorities really weren't
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ever studied.
And now that we're learning a lot more, is there anything else you want to add to this
before we go on?
Yeah.
I mean, it's one of the biggest disparities is between the pain that minorities are reporting
and how we're actually assigning their pain.
There was one study that examined the pain when they were asked about their pain score,
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what they were reporting versus how the MDs were actually scoring them.
And there was huge disparities between what black patients were reporting and what white
patients were reporting.
And 47% of the time for black patients, physicians reported lower pain scores for them as opposed
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to only about 33% of the time for white patients.
So black patients are not even given the benefit of the doubt as far as how valid the pain
that reporting is.
I think this is really important.
And going forward, something all clinicians really have to keep on their radar for not
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only this pain difference, but in the other changes in care.
Recently we talked about pulse oximetry not being as accurate and darker skin patients.
So I think that all is important.
And it also underscores that overall, we still, as a whole, we under treat patients when it
comes to pain.
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Mentor of mine, a medical editor in my EMT books, would even in times before there was
big QI, he'd say, okay, well, good, you got the pain from eight down to four with nitroglycerin.
You realize it's still a four.
You know, all of our concepts of analgesia and what we do in EMS probably are still
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maturing.
Yes, absolutely.
Cardizan number five, maybe more effective and safer for patients than a denizen.
Correct.
Who doesn't like to give that a denizen and everybody holds their breath?
Man, that's a big thing.
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We as providers, we love to give a denizen.
I mean, it's fun to give a denizen, right?
But patients hate being given a denizen.
And they report that feeling of impending doom and they really do feel like they're going
to die.
And we need to start considering that to be an adverse event.
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There are people that can actually become traumatized by that sensation.
They don't forget it.
But there was a study done, it was a smaller study, but it compared conversion rates between
Cardizan and a denizen, they looked at 52 patients who were given either Cardizan or
a denizen in some sort of superventricular tachycardia.
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And out of those 52 patients broken down into two even cohorts, 100% of them were converted
with Cardizan and about 80% of them were converted with a denizen.
That's not a large compelling study.
But the thing is, is that you should be able to look at the pathophysiology of what's happening
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in SVT and reentry rhythms and understand that those are both calcium channel blockers.
And one is converting a denizen by essentially hitting the patient over the head with a shovel
while the other is converting that SVT by giving them a foot massage, which is the Cardizan.
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I know the visual for this.
This might be a podcast you'll listen to, but you're not getting it out of the park
today.
That's right.
But it makes pathophysiological sense.
So if you're protesting the size of this study or how underpowered it is, it makes pathophysiological
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sense and Cardizan is given all the time in the field and in the emergency room to convert
SVTs.
And it's just a more compassionate way to treat your patient.
They don't need to become asystolic for six seconds and to feel like they're going to
die.
It works very, very well in this regard.
And there's no huge, large, overpowered RCTs, but there are other similar studies that have
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demonstrated the same effects.
Again, now you're going to see where I am, the big picture person.
I do think it's fascinating about what you say about what type of event that causes for
our patients.
You know, we're the masters of you're going to feel a little sick with this 16 gauge,
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or you're going to, you don't always think about those concepts.
We're used to not an austere environment, but certainly a much different environment
than a hospital and a certain different attitude.
I think it's time that we start considering these things as part of a bigger picture.
Absolutely.
I can remember, it was about two years ago, I had this sudden stomach cramp and it was
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so painful.
It wasn't like that sudden bowel urgency, like you see these people that have that
vagal response, but it was just this big cramp.
And suddenly I started getting diaphoretic.
And then I felt like I was going to pass out and I just could feel the world slipping away.
And for, you know, I'm in medicine and I can coach myself through these things.
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I knew it was a vagal response, but I was terrified.
That was a year and a half, two years ago.
And I still think about how terrifying it was to see consciousness slipping away from
me.
And I can't imagine what it's like to have already had this condition that you may not
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understand.
Maybe you're just having it for the first time, or maybe it's the sixth time you've
had it.
And you're just terrified about having this condition overall and somebody is giving
you this medication that you literally feel like that you're about to die.
I could not imagine the trauma that patients feel.
And I've had patients and a lot of people have had these patients that just would rather
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be cardioverted than being given a dentism.
When people write any EMS agency, they don't say, you checked my distal pulses and put
the splint on appropriately, or you chose this medication.
Patients have an objective sense of being taken care of.
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And there's a place for that in medicine as well, I think.
Absolutely.
All right, going on to number six.
I think this is one that people are probably going to agree with.
I do a lot of exam preparation, obviously.
Everybody says, well, how do I remember the Glasgow Coma score and what to do?
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And under stress, we don't always do judgment or math particularly well.
Glasgow Coma-scaled scores aren't consistent between EMS providers.
And I think in the bigger picture in the healthcare provider scheme, we're certainly
not the best at it.
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And what does that mean to us?
So we're not good at it at all.
In fact, not many healthcare providers are very good at it.
And to back that up, there was a study conducted by Brian Bledsoe at AL, and everybody should
be familiar with Brian Bledsoe because if you are a paramedic practicing right now,
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you have probably learned a lot of what you learned from Brian Bledsoe because he's the
author of many paramedic textbooks.
But he had a study that looked at over 2,000 observations made where a Glasgow Coma score
was factored.
And that was from every single provider.
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M.T., paramedic, critical care paramedic, nurse, residents, and ED physicians.
The overall accuracy was 33%.
And there was only about a 9% variability between the three categories.
So they were accurate between 60 to 69% between the three categories.
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The lowest scoring was nurses at 29%.
The highest scoring were residents at 51%, probably because they're just brimming with
all that knowledge they just learned.
There was another smaller RCT that looked at just EMS scores, and 60% of their scores
were inaccurate.
And that's even when one cohort was actually given a scoring tool to use.
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Their accuracy was still only 57%.
And so it's pretty evident that we just aren't good at accurate GCSs.
Now there may be a utility for GCS for the clinical environments and the surgical environments
and then the trauma room environments.
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But there's almost no utility for EMS.
We don't do anything because of GCS other than document it for someone else.
Unless you're still one of these people who are doing GCS less than they innovate, which
is also dogma, not backed by evidence.
So it's really just a cognitive sinkhole for the EMS provider.
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Is there value in it clinically?
Not for our clinical practice.
It's the sort of thing that we have to document when we're filling out vital signs.
Or it's a QA requirement, but I have never in my 20-year career made a decision guided
by Glasgow Coma Scale.
I'll go with that.
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I think about providers and APCAR scores, how we do those often retroactively.
Nobody is looking right after a birth thinking about APCAR.
No.
How we use these tools and what we do.
I think is certainly open to more discussion.
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And it's not something that lends itself to easy memorization, neither the APCAR nor
the GCS.
I've been in EMS for 20 years.
And if you were to tell me right now that I needed a factor, this patient's GCS right
in front of me, I would need a tool.
Because from a cognitive standpoint, I don't have the bandwidth to deal with that because
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it doesn't guide my practice.
It is always something that I'm filling out after the fact or put on the spot for by the
emergency room.
And so I've learned to keep something on our action area that I can refer to during
that call in, but it's certainly not something I can calculate quickly.
And I have no problem admitting that.
No, me either.
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No, I'm totally there.
I think it's probably also worthy to note that the lower the GCS, the higher the acuity
and the more mental processes are taking taking elsewhere.
Absolutely.
But there are things that can actually still help us guide acuity that are not as complicated
as that.
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I mean, GCS was never even intended to be used the way we're using it.
It was used, I think it was post surgery for patients that had head injuries to track how
they were trending following that surgery.
And they were three separate individual scoring systems that were never meant to be combined.
So it's just interesting how it's adapted itself into a very not useful tool for EMS
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in spite of that.
All right.
Number seven, and this is of interest to me.
I've talked about the most controversial things like that, but I think that this pegs pretty
high on the relevant scale, even though it's not done all the time.
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Number seven, orthostatic vital sign changers aren't as valuable as we thought.
That's correct.
And orthostatics in and of itself for either EMS or for a clinical environment were really
something that were put in place by consensus, not by some sort of body of evidence that
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said this provides some sort of great utility, particularly for field providers.
But the formal orthostatic change is that somebody who is in a semi-thaler position
or in a supine position who has been in that position for at least 10 minutes, you would
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have them either stand up or put them at a 60 degrees sitting up angle.
And you would be looking for a change of 20 millimeters of mercury for your systolic blood
pressure or 10 millimeters of mercury for your diastolic blood pressure after three
minutes.
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It's not sit them up, get your blood pressure, say, oh, their blood pressure dropped, they
are orthostatic.
That is not how it was designed to be used.
And it's not informative in that regard.
And that's not even a pragmatic or practical tool for EMS.
Despite that being the formal changes that we're looking for, there's never been a gold
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standard that has been established as far as what a positive change is for us.
We have in the field, we probably say the 10 millimeters of mercury in your blood pressure
or a heart rate change of 10 beats a minute.
But there's no evidence that we're actually getting accurate results even then.
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Up to about 50% of healthy patients will have what we call positive orthostatic changes following
the test in the way that we do it in the field.
And then a high number of patients who are actually hypervolemic will have no change at
all.
So you might as well just flip a coin instead of actually doing the test.
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Is there any validity in there anywhere?
And I'm sure there are patients, perhaps the elderly, where it might be normal.
We know that I come back from writing textbooks and all the TV days.
And back then you could only do capillary refill on kids.
(38:16):
And the fact is, is that it could be used on adults, but geriatric patients could be
normal at four seconds.
And geriatric patients may also be more prone to these changes normally or through medication.
And then to wrap up, I'm not getting too long-winded here, is there a benefit when you stamp somebody
(38:38):
up to put them on the stretcher and they say, whoa, I'm dizzy?
That right there means that they're orthostatic.
There is no test required right there.
Any person that has had a sinkable episode or is reporting dizziness standings should
already be considered to be orthostatic.
And between the history that you're taking and the vital signs that you're getting, you
(39:02):
should have a relative suspicion for what their hemodynamic status is relative to that
history.
They may be compensating in a lying down position, but if they tell you they got dizzy standing
up and they've been sick for the last couple of days and they haven't been hydrating, you
don't need to stand them up and take their blood pressure and risk inducing syncope to
(39:24):
confirm their, to confirm that relative hype of a lemak status.
You just got all that information from your history.
To relatively unnecessary and cruel.
That's right.
I just don't find any value in it whatsoever.
And the other thing is, is I see it used inappropriately all the time.
I see it used more often in patients who are already hypotensive.
(39:47):
I get to a call and a responder tells me, yeah, their patient, their blood pressure is
90 over 60.
We stood them up to do a orthostatic and I'm like, why?
What were you looking for?
And I think that happens very frequently.
And so I think that it's something that should just be abolished from our practice.
I don't think it's informative.
(40:08):
And in some cases, I think it's harmful.
All right.
I do think coming back to something we talked about earlier, all providers and certainly
advanced providers should learn the value of this critical thinking and what the appropriateness
and risks are to people.
(40:29):
I think what I'll do, I've got a couple of minutes left here, which makes me happy.
I'm going to throw, I do two things at the end of these.
One, is I give you a last word, but I'm going to pop a question to you first.
Okay.
I'll give you the option.
Maybe we'll cover your last word or not.
I want to say, I want to ask the EMS Avenger.
(40:51):
I say that because I just think that's very cool.
That's the big picture advice that you would give people to not only use this information,
but how do they get this type of information on their own?
I'll plug your TikTok and Instagram and Facebook channels again, because I obviously think
(41:12):
a lot of it and having you hear me select me.
What would you say to people listening this going forward saying, wow, this is really
cool.
How do they do it themselves and how do they implement and practice?
I get that question all the time, which is, how do you get this information?
The short answer is that you have to live and breathe to a certain degree within an EMS
(41:38):
community.
Think of some of the providers that are out there that are doing good work as far as getting
information to people.
Foam frat for one, Tyler Christofouli with foam frat.
Flippery Jed and there's recognizable names with people who work within Flippery Jed.
Eric Bauer, IA med.
(42:01):
All good people.
Gwynni Lawson who works for IA med, great creator.
You just have to start following a couple of these organizations on social media.
This information starts coming to you.
When you start doing that, when you start surrounding yourself with these content creators
and the people who create this content based on evidence-based medicine and best practices,
(42:27):
you start rubbing shoulders with other interested parties and you start learning who else to
follow, who else to talk to.
The crane rises to the top and when you start operating within that community, this information
is always going to rise to the top, the really good vetted information.
(42:47):
Not only that, but the misinformation and the myth-busting of it is also going to rise
to the top.
Simply just being in that community is going to be very helpful and having that information
literally just coming to your phone screen as you're scrolling.
I think that that's great advice.
(43:08):
You certainly mentioned some very talented people.
I think that sometimes it takes one person or a couple of people, even in an agency,
to start these conversations.
You get out there, you join these groups, you listen to people and you bring it back
and then you can be part of a discussion in your own agency.
(43:31):
You can also be a messenger as well.
Absolutely.
And your last word, anything else you'd like to add to this?
I always try to counter discussions on evidence-based medicine with something philosophical.
When I teach, I actually lead with a philosophical talking point first so that we remember to
(43:52):
ground ourselves in something human and real.
I always go back to a conversation I had with somebody who literally asked me, how can I
save more lives?
My answer to that has always been that first and foremost, you have to recognize the innate
value of life in every person that is on your ambulance.
(44:15):
And when you elevate their humanity and when you affirm the value that their life has,
you save more than their life.
You save other lives and you elevate humanity as a whole.
I don't know if I could have picked a better way to end that.
We put some science in with some good humanistic thinking.
(44:37):
I think that's just awesome.
And we're right on time.
There will be a few things we always say.
The show notes will accompany this, will list some of the research that's been referenced,
as well as ways to contact Jimmy, the EMS Avenger through social media sites.
(44:58):
And I think it's also something I'm very happy about that it sounds like you'll be hitting
the comfort circuit a little bit.
And I think that people will benefit from that as well.
This has been Seven Things EMS.
Seven Things Research tells us about EMS practice.
And we look forward to seeing you next time.
(45:21):
Thank you for listening to a Seven Things EMS podcast by Limmer Education.
If you've listened to this podcast on a streaming service and you're interested in getting continuing
education credit, please go to lc-ready.com for more information.
Welcome to Seven Things EMS, a continuing education offering from LIMMER Education.
(00:12):
Seven Things EMS is designed to give you what you need to succeed in EMS, it's conversational,
informational and without the fluff.
(00:32):
Alright welcome to another episode of Seven Things EMS.
I think I always probably start and say I'm excited too, but perhaps today, most excited,
we have a topic that's got a great clinical look and an outstanding guest who you will
recognize the voice relatively quickly if you're on a tiktok.
(00:53):
The topic Seven Things research tells us about EMS practice and the guest for this episode,
Jimmy Apple.
Now I'll tell you he's a 20 year paramedic, 911 and critical care experience, but where
you're going to know him from is as the EMS Avenger on tiktok.
(01:16):
You're going to recognize this voice, you're going to recognize the advice and if you don't
follow him on tiktok or if you don't do tiktok, I would recommend doing it just for this.
I'd like to welcome you Jimmy and let's do some conversation.
Okay, I do want to mention that I know that a lot of people are averse to tiktok and
(01:39):
so for that reason, I have started reposting some things to Instagram where I am EMS Avenger
and I have a Facebook group called EMS Avenger where you can find my videos.
Awesome.
And they really are worth doing.
I literally looked forward to your tiktoks.
They were great, insightful pieces of information and that's quite frankly why I reached out
(02:03):
to you, to have you.
You're appreciated.
So we have seven things that research tells us about EMS practice.
Now we can put the caveat on like we do in a lot of clinical podcasts that you of course
have protocols and the interpretation of science can vary between person to person,
(02:24):
but I found Jimmy's information on tiktok to be very relevant and how it's going to
affect your practice.
And the seven things he provided are things that you're going to think about.
I don't think you'll go by a week of any EMS experience without encountering most of these.
So let's go to number one.
(02:44):
Let's start in this.
It's our hallmark here is that we get to it, you drive through it, keep people's interest.
Working codes on scene increases survival.
Correct, and I am always surprised on how this is information that people didn't know.
(03:09):
This has yet to be the prevalent practice in the US and I practically broke tiktok
on my first video about this almost a year ago, but it's true.
Normally in EMS we're accustomed to showing up, getting our interventions in place and
then getting out of there as quickly as possible to the emergency room.
(03:31):
But we have one study after another now that has informed us that moving a patient intra-arrest
results in lower survival.
One study in particular, one of the most recent one suggested that working a patient on scene
could double your rates of survival.
The conclusion was actually that transporting would have your rates of survival, but you
(03:53):
can look at it either way.
I think there's several elements in here that are very relevant to EMS.
I think the first is that we have to change our mindset that we can do this and in not
every case it's about going to the hospital.
(04:13):
With that we also have the subsequent benefits or side effects of that we're doing better
CPR.
We have more concentration, more continuity.
I'd even venture to say more safety because working a code and a moving truck is certainly
no fun and potentially dangerous as well.
(04:34):
Absolutely.
I actually have a pretty popular video and I need to pin that, but I have a sealed baggie
that is filled with red fluid to simulate blood and that bag is filled up all the way
to the top.
I demonstrate how I can take that bag and I can hold it upside down, I can move it to
(04:55):
the left, I can move it to the right, I can shake it and that blood is always filling
that bag.
Somebody who is in cardiac arrest doesn't have the same hemodynamic tension anymore
that is keeping that bag nice and tight.
I have a second bag that's filled about halfway through that would recommend the relative
(05:16):
hemodynamic status of someone in cardiac arrest.
If you tip that bag or hold it upside down or move it to the left or to the right or
shove it forward or shove it back, that fluid sloshes all around.
That's exactly what happens when you transport someone in cardiac arrest.
They don't have that vascular tension and so you can have a lot of volume distribution
(05:40):
when you're transporting somebody and that affects your coronary perfusion and affects
your cerebral perfusion and that is the primary challenge in transporting someone in cardiac
arrest.
So you are much better off leaving them exactly where they are and not moving them and subjecting
them to that sort of inertia and that sort of force that can be so detrimental to their
(06:07):
survival.
Anything that you would say to systems now that feel they have to transport, that transport
is their priority and we're going to go into number two which is going to bridge this very
nicely.
But what would you say to the agencies or the medics, sometimes it's older time medics
(06:32):
that feel they've really got to move, that they don't want to work to go down?
A lot of the rationale is but there's doctors there or but the cath lab is there and what
they don't really understand is that there is a cap to expertise when it comes to cardiac
(06:52):
arrest.
85% of cardiac arrests are cardiac in origin in our boilerplate cardiac arrest where there
was some sort of major cardiac event and it doesn't require a lot of brain power to
resuscitate them.
It requires diligence in your resuscitation practice and there are diminishing returns
(07:17):
on putting academia in front of them and if you don't bring a salvageable patient to the
hospital they don't go to the cath lab anyway.
And they also for the most part practice some sort of variation they see a less when you
get them to the hospital they're not doing things any differently than you would and
(07:39):
in some cases their resuscitations may be a lot worse than yours.
You know resuscitations in a clinical environment are still subject to the same dedication and
passion that they are in the field and if someone is running it in a disinterested manner
or not in a diligent manner it you know bringing them to that scenario doesn't benefit them.
(08:04):
All right and I think we need to have some confidence and some mojo and get out and work
those codes and keep our survival rates going.
I did a podcast early in this series with the American Heart Association's director
of education and he said that the Heart Association has been trying to get the national survival
(08:29):
rate over 10% for a long time.
We've hit a certain plateau with that and I think that this and maybe even the next
point we're about to go into might help that process.
Sure and let me just add that I said a lot of things there earlier but what I need to
(08:49):
emphasize is that it's all about your compression fraction which is the amount of time in a
two minute cycle compression cycle that you're doing quality compressions and the lower your
compression fraction the lower your chance of survival.
So anything that interferes with that is not conducive towards survival and one of the biggest
(09:11):
interferers in your compression fraction is moving a patient and that's what I would ultimately
say to somebody that has questions about transporting is that because it interferes with that compression
fraction.
Well let's roll to number two then.
The more that we go into advanced life support the more we bring in technologies we decrease
(09:37):
survival.
I think that's going to kind of hit the bedrock of a lot of people out there doing ALS.
Absolutely when it comes to survival and cardiac arrest what you need to do is actually very
simple.
You need to perform high quality compressions and you need to provide timely defibrillation.
(10:00):
Those are the only two interventions in cardiac arrest that have any quality evidence behind
it.
And so the more technology that you bring into that practice the more you have the potential
to interfere with those two things that we know improve survival and cardiac arrest.
(10:23):
And that includes things like IVs and IOs.
The practice of access itself doesn't necessarily infer a benefit.
It brings in you know pharmacological technologies such as epinephrine or lidocaine or amiodarone
or you know going down the rabbit hole of bicarb and calcium.
(10:46):
None of those things have a body of evidence behind them that they improve survival and
with bicarb and calcium in particular the evidence suggests that routine administration
of both of them lower survival.
You have advanced airways of you know different types of advanced airways including endotracheal
(11:06):
intubation and supraglottic airways like the king and the eye gel.
There's no body of evidence that infers a benefit to the patient with those advanced
airways.
The only benefit is essentially the positive pressure that you're doing to keep the lungs
from collapsing.
And then we get into more of what I call the toys that are coming out now including impedance
(11:31):
threshold devices, the active compression, decompression devices, mechanical CPR, the
heads up CPR devices.
All of those things have either no evidence or low quality evidence behind them.
And so if you're not dedicated to the two things that improve survival which is quality
(11:53):
compressions and timely defibrillation, the way I look at it is that you are putting your
patient into a technological circle of death.
And there are multiple studies out there that show that survival is higher with BLS as compared
to ALS.
One of the most notable shows survival with BLS being 13% and ALS being 9%.
(12:16):
And even comparison of bystander compressions to ALS shows higher survival rates.
I'm going to take that technological circle of death and makes me instantly want to make
a graphic for it.
I'm actually working on a talk about that and I'll tease it.
It's going to be called Kevin Costner and the Circle of Death.
(12:37):
That's all I'm going to say.
All right.
I want to see that.
What would you say to the ALS provider that says, hey, wait a minute, I went through and
learned how to do all this stuff.
I went through ACLS.
I did this.
What should I really do?
(12:58):
You should be focusing on improving your compressions.
It's all about compressions, compressions, compressions, compressions and then reducing
time to defibrillation.
And the AHA has finally caught up to precharging the monitor.
So you have that monitor ready to defibrillate.
You hit the charge button 15 seconds before your rhythm check.
(13:19):
So you have that finger on the shock button.
So as soon as compression stop, you can rule in or rule out a shock within seconds.
You should be able to, as soon as this compression stop, you should be able to recognize VFib
or VTAC.
Either one of those are there, then you clear your shock and you keep going.
If one of those are there, then you hit the shock and you immediately resume compressions,
(13:44):
but you should be able to reduce that peri-shock pause to three seconds.
Because the thing is, is that it takes 16 seconds to build up enough intratherastic
pressure to perfuse the heart during compressions.
From the start of compressions, it takes 16 seconds.
It only takes three seconds to lose all of that pressure.
(14:06):
So your job should really be about never losing that pressure if you can avoid it.
Now you can start getting mastery of that process.
And when you're a service like Hilton Head Fire Department or Seattle's Medic One program
in King County, they've mastered the basics.
And so at that point, they go on to master some of the advanced practices like endotracheal
(14:31):
intubation.
But if you don't have a mastery of those advanced practices like intubation, then you shouldn't
be disrupting a quality resuscitation with those practices.
Yeah, a couple things come to mind.
The first is that Hilton Head is Seattle.
We often have very passionate profits of things done there.
(14:56):
I think that's beneficial.
And I think EMS also hangs our hat on our skills.
They're the badges, the rockers we used to put on our patches.
And what I really would say in this, I'm kind of the big picture, differentially diagnosis,
critical thinking guy, is that advanced providers bring good assessment, experience, and judgment
(15:24):
in.
And I think those things have value.
And we can't ignore those.
We should put more preference on some of that than on the things we do.
Absolutely.
All right.
Number three, I don't know.
If there's one that I would pick might be the biggest lightning rod here.
(15:47):
I would say it's this one.
And nitroglycerin with an inferior in-park and right side is safe.
And I think I have probably heard more spirited discussions on this than anything else, that
those conference dinners and all the side conversations.
(16:09):
Tell us about it.
Yeah.
So there is this dogma that we have in EMS that you should either use caution or they'll
say it's nitroglycerin is completely contraindicated in the presence of an inferior myocardial
(16:31):
infarction.
So first of all, to clear up a little bit of misinformation, the risk is not with an
inferior myocardial infarction.
The risk is with a right-sided ventricular infarction.
And that's because an inferior myocardial infarction anywhere from 30 to 50% of the
(16:53):
time are accompanied by a right-sided ventricular infarction because it's a proximal RCA occlusion.
So let's just say that there is a risk to administering nitro in that situation.
If you have an inferior MI, literally the first thing you should be doing is switching
(17:14):
your V4 to a V4R to confirm whether or not there's a right-side accompaniment.
And in the absence of that, then that nitro administration would be completely safe.
But the fact of the matter is, is that that risk really isn't there.
And we can trace that dogma back to a 1989 study that was a single-centered low-powered
(17:41):
study of 28 patients that claimed that there was a risk of cardiovascular collapse due
to preload dependency of the right ventricle.
And that pathophysiology has started to come into question at this point, but that those
results were amplified by several papers but never actually reproduced.
(18:07):
And it fed into this kind of like cyclical intensity that created this wariness of administering
nitro to patients experiencing a right ventricular infarction.
But there have been multiple studies since then that have had much larger cohorts that
(18:28):
have not reproduced those results.
And so the conclusion is, and pretty confidently so, is that nitroglycerin is safe in the presence
of any infarct of any location, and that really your should concern should be just about giving
nitro to somebody with a soft blood pressure.
(18:48):
In fact, this year at the Gathering of Eagles, which is a very large conference that's attended
to by some very influential researchers and medical directors, people who are really the
movers and shakers and decision makers in EMS, and they declared that nitroglycerin is
safe in the presence of a right ventricular infarct.
(19:09):
So this is some of the most classic EMS and emergency medicine dogma that there is, but
unfortunately it's baseless and there's no evidence behind it.
We have issues changing our mindsets about things in EMS, sometimes significant.
The number of people at the EMT level that are still taught to give everyone oxygen or
(19:33):
oxygen calms people down is pretty dramatic.
And I do agree with you that this pronouncement at the Eagles is big.
I think that it's an outstanding place to get information, get some of the current thinking.
I hope that it gets, I hope it gets to be more current thinking than some other things we've
(19:56):
had trouble accepting.
I heard from this or I had this one patient who leads what we do too much.
Sure.
And I mean, everyone is going to have that patient who had an inferior MI or even right
side involvement that they gave nitro to and they become unstable.
And the claim is not that this doesn't happen.
(20:19):
The claim is that it doesn't happen with any increased frequency as compared to other
regions of the heart.
Given that your concern should really be just on focusing on the patient's hemodynamics
and avoiding something that could cause hemodynamic collapse if they don't have a solid blood
pressure.
But even then, the half-life of nitroglycerin is like five minutes.
(20:42):
And so if you did cause somebody to go down a little bit, you have the ability to combat
that with several types of medications.
And that should resolve on its own relatively quickly.
I think we've all had the lower the head, the brunt some fluid, let's see if we can
keep this from happening patients.
Absolutely.
No matter where it is, that could happen.
(21:03):
I think that's an important message.
Number four, minorities are treated for pain differently.
That's true.
And this is probably one of the most well-studied things in medicine.
And it's based on common teachings back during the slavery era and beyond that kind of sought
(21:29):
to justify our abuse and treatment of slaves by stating that they had different physiologies
than that of white people.
They were more pain tolerant.
They had thicker bones, thicker muscles, less sensitive nerve endings.
And that infected our medical practice.
And as we've progressed on as a society and become a more progressive society when it comes
(21:55):
to race, that has become more influenced by socioeconomic status.
But the data is pretty clear on it.
One study showed that with people who presented to the emergency room with fractures in the
emergency department that about 57% of them received some sort of pain management as opposed
(22:23):
to 75% of white people who received some sort of pain management.
And when it comes to patients that have some sort of like recurrent or metastatic cancer,
the WHO Standards for Pain Management, the World Health Organization Standards for Pain
Management for those patients were not met in 65% of minority cases as opposed to 50%
(22:51):
for non-minority cases.
Wow.
Wow.
Yeah.
I think we can let that stand as it is and move on to number five.
Okay.
Actually, before we go on, I think we should acknowledge that minorities really weren't
(23:12):
ever studied.
And now that we're learning a lot more, is there anything else you want to add to this
before we go on?
Yeah.
I mean, it's one of the biggest disparities is between the pain that minorities are reporting
and how we're actually assigning their pain.
There was one study that examined the pain when they were asked about their pain score,
(23:36):
what they were reporting versus how the MDs were actually scoring them.
And there was huge disparities between what black patients were reporting and what white
patients were reporting.
And 47% of the time for black patients, physicians reported lower pain scores for them as opposed
(24:02):
to only about 33% of the time for white patients.
So black patients are not even given the benefit of the doubt as far as how valid the pain
that reporting is.
I think this is really important.
And going forward, something all clinicians really have to keep on their radar for not
(24:23):
only this pain difference, but in the other changes in care.
Recently we talked about pulse oximetry not being as accurate and darker skin patients.
So I think that all is important.
And it also underscores that overall, we still, as a whole, we under treat patients when it
comes to pain.
(24:45):
Mentor of mine, a medical editor in my EMT books, would even in times before there was
big QI, he'd say, okay, well, good, you got the pain from eight down to four with nitroglycerin.
You realize it's still a four.
You know, all of our concepts of analgesia and what we do in EMS probably are still
(25:09):
maturing.
Yes, absolutely.
Cardizan number five, maybe more effective and safer for patients than a denizen.
Correct.
Who doesn't like to give that a denizen and everybody holds their breath?
Man, that's a big thing.
(25:30):
We as providers, we love to give a denizen.
I mean, it's fun to give a denizen, right?
But patients hate being given a denizen.
And they report that feeling of impending doom and they really do feel like they're going
to die.
And we need to start considering that to be an adverse event.
(25:53):
There are people that can actually become traumatized by that sensation.
They don't forget it.
But there was a study done, it was a smaller study, but it compared conversion rates between
Cardizan and a denizen, they looked at 52 patients who were given either Cardizan or
a denizen in some sort of superventricular tachycardia.
(26:16):
And out of those 52 patients broken down into two even cohorts, 100% of them were converted
with Cardizan and about 80% of them were converted with a denizen.
That's not a large compelling study.
But the thing is, is that you should be able to look at the pathophysiology of what's happening
(26:36):
in SVT and reentry rhythms and understand that those are both calcium channel blockers.
And one is converting a denizen by essentially hitting the patient over the head with a shovel
while the other is converting that SVT by giving them a foot massage, which is the Cardizan.
(26:57):
I know the visual for this.
This might be a podcast you'll listen to, but you're not getting it out of the park
today.
That's right.
But it makes pathophysiological sense.
So if you're protesting the size of this study or how underpowered it is, it makes pathophysiological
(27:19):
sense and Cardizan is given all the time in the field and in the emergency room to convert
SVTs.
And it's just a more compassionate way to treat your patient.
They don't need to become asystolic for six seconds and to feel like they're going to
die.
It works very, very well in this regard.
And there's no huge, large, overpowered RCTs, but there are other similar studies that have
(27:44):
demonstrated the same effects.
Again, now you're going to see where I am, the big picture person.
I do think it's fascinating about what you say about what type of event that causes for
our patients.
You know, we're the masters of you're going to feel a little sick with this 16 gauge,
(28:09):
or you're going to, you don't always think about those concepts.
We're used to not an austere environment, but certainly a much different environment
than a hospital and a certain different attitude.
I think it's time that we start considering these things as part of a bigger picture.
Absolutely.
I can remember, it was about two years ago, I had this sudden stomach cramp and it was
(28:37):
so painful.
It wasn't like that sudden bowel urgency, like you see these people that have that
vagal response, but it was just this big cramp.
And suddenly I started getting diaphoretic.
And then I felt like I was going to pass out and I just could feel the world slipping away.
And for, you know, I'm in medicine and I can coach myself through these things.
(28:58):
I knew it was a vagal response, but I was terrified.
That was a year and a half, two years ago.
And I still think about how terrifying it was to see consciousness slipping away from
me.
And I can't imagine what it's like to have already had this condition that you may not
(29:20):
understand.
Maybe you're just having it for the first time, or maybe it's the sixth time you've
had it.
And you're just terrified about having this condition overall and somebody is giving
you this medication that you literally feel like that you're about to die.
I could not imagine the trauma that patients feel.
And I've had patients and a lot of people have had these patients that just would rather
(29:42):
be cardioverted than being given a dentism.
When people write any EMS agency, they don't say, you checked my distal pulses and put
the splint on appropriately, or you chose this medication.
Patients have an objective sense of being taken care of.
(30:03):
And there's a place for that in medicine as well, I think.
Absolutely.
All right, going on to number six.
I think this is one that people are probably going to agree with.
I do a lot of exam preparation, obviously.
Everybody says, well, how do I remember the Glasgow Coma score and what to do?
(30:24):
And under stress, we don't always do judgment or math particularly well.
Glasgow Coma-scaled scores aren't consistent between EMS providers.
And I think in the bigger picture in the healthcare provider scheme, we're certainly
not the best at it.
(30:46):
And what does that mean to us?
So we're not good at it at all.
In fact, not many healthcare providers are very good at it.
And to back that up, there was a study conducted by Brian Bledsoe at AL, and everybody should
be familiar with Brian Bledsoe because if you are a paramedic practicing right now,
(31:07):
you have probably learned a lot of what you learned from Brian Bledsoe because he's the
author of many paramedic textbooks.
But he had a study that looked at over 2,000 observations made where a Glasgow Coma score
was factored.
And that was from every single provider.
(31:28):
M.T., paramedic, critical care paramedic, nurse, residents, and ED physicians.
The overall accuracy was 33%.
And there was only about a 9% variability between the three categories.
So they were accurate between 60 to 69% between the three categories.
(31:52):
The lowest scoring was nurses at 29%.
The highest scoring were residents at 51%, probably because they're just brimming with
all that knowledge they just learned.
There was another smaller RCT that looked at just EMS scores, and 60% of their scores
were inaccurate.
And that's even when one cohort was actually given a scoring tool to use.
(32:17):
Their accuracy was still only 57%.
And so it's pretty evident that we just aren't good at accurate GCSs.
Now there may be a utility for GCS for the clinical environments and the surgical environments
and then the trauma room environments.
(32:39):
But there's almost no utility for EMS.
We don't do anything because of GCS other than document it for someone else.
Unless you're still one of these people who are doing GCS less than they innovate, which
is also dogma, not backed by evidence.
So it's really just a cognitive sinkhole for the EMS provider.
(33:05):
Is there value in it clinically?
Not for our clinical practice.
It's the sort of thing that we have to document when we're filling out vital signs.
Or it's a QA requirement, but I have never in my 20-year career made a decision guided
by Glasgow Coma Scale.
I'll go with that.
(33:27):
I think about providers and APCAR scores, how we do those often retroactively.
Nobody is looking right after a birth thinking about APCAR.
No.
How we use these tools and what we do.
I think is certainly open to more discussion.
(33:49):
And it's not something that lends itself to easy memorization, neither the APCAR nor
the GCS.
I've been in EMS for 20 years.
And if you were to tell me right now that I needed a factor, this patient's GCS right
in front of me, I would need a tool.
Because from a cognitive standpoint, I don't have the bandwidth to deal with that because
(34:10):
it doesn't guide my practice.
It is always something that I'm filling out after the fact or put on the spot for by the
emergency room.
And so I've learned to keep something on our action area that I can refer to during
that call in, but it's certainly not something I can calculate quickly.
And I have no problem admitting that.
No, me either.
(34:30):
No, I'm totally there.
I think it's probably also worthy to note that the lower the GCS, the higher the acuity
and the more mental processes are taking taking elsewhere.
Absolutely.
But there are things that can actually still help us guide acuity that are not as complicated
as that.
(34:50):
I mean, GCS was never even intended to be used the way we're using it.
It was used, I think it was post surgery for patients that had head injuries to track how
they were trending following that surgery.
And they were three separate individual scoring systems that were never meant to be combined.
So it's just interesting how it's adapted itself into a very not useful tool for EMS
(35:16):
in spite of that.
All right.
Number seven, and this is of interest to me.
I've talked about the most controversial things like that, but I think that this pegs pretty
high on the relevant scale, even though it's not done all the time.
(35:36):
Number seven, orthostatic vital sign changers aren't as valuable as we thought.
That's correct.
And orthostatics in and of itself for either EMS or for a clinical environment were really
something that were put in place by consensus, not by some sort of body of evidence that
(36:01):
said this provides some sort of great utility, particularly for field providers.
But the formal orthostatic change is that somebody who is in a semi-thaler position
or in a supine position who has been in that position for at least 10 minutes, you would
(36:27):
have them either stand up or put them at a 60 degrees sitting up angle.
And you would be looking for a change of 20 millimeters of mercury for your systolic blood
pressure or 10 millimeters of mercury for your diastolic blood pressure after three
minutes.
(36:48):
It's not sit them up, get your blood pressure, say, oh, their blood pressure dropped, they
are orthostatic.
That is not how it was designed to be used.
And it's not informative in that regard.
And that's not even a pragmatic or practical tool for EMS.
Despite that being the formal changes that we're looking for, there's never been a gold
(37:10):
standard that has been established as far as what a positive change is for us.
We have in the field, we probably say the 10 millimeters of mercury in your blood pressure
or a heart rate change of 10 beats a minute.
But there's no evidence that we're actually getting accurate results even then.
(37:30):
Up to about 50% of healthy patients will have what we call positive orthostatic changes following
the test in the way that we do it in the field.
And then a high number of patients who are actually hypervolemic will have no change at
all.
So you might as well just flip a coin instead of actually doing the test.
(37:54):
Is there any validity in there anywhere?
And I'm sure there are patients, perhaps the elderly, where it might be normal.
We know that I come back from writing textbooks and all the TV days.
And back then you could only do capillary refill on kids.
(38:16):
And the fact is, is that it could be used on adults, but geriatric patients could be
normal at four seconds.
And geriatric patients may also be more prone to these changes normally or through medication.
And then to wrap up, I'm not getting too long-winded here, is there a benefit when you stamp somebody
(38:38):
up to put them on the stretcher and they say, whoa, I'm dizzy?
That right there means that they're orthostatic.
There is no test required right there.
Any person that has had a sinkable episode or is reporting dizziness standings should
already be considered to be orthostatic.
And between the history that you're taking and the vital signs that you're getting, you
(39:02):
should have a relative suspicion for what their hemodynamic status is relative to that
history.
They may be compensating in a lying down position, but if they tell you they got dizzy standing
up and they've been sick for the last couple of days and they haven't been hydrating, you
don't need to stand them up and take their blood pressure and risk inducing syncope to
(39:24):
confirm their, to confirm that relative hype of a lemak status.
You just got all that information from your history.
To relatively unnecessary and cruel.
That's right.
I just don't find any value in it whatsoever.
And the other thing is, is I see it used inappropriately all the time.
I see it used more often in patients who are already hypotensive.
(39:47):
I get to a call and a responder tells me, yeah, their patient, their blood pressure is
90 over 60.
We stood them up to do a orthostatic and I'm like, why?
What were you looking for?
And I think that happens very frequently.
And so I think that it's something that should just be abolished from our practice.
I don't think it's informative.
(40:08):
And in some cases, I think it's harmful.
All right.
I do think coming back to something we talked about earlier, all providers and certainly
advanced providers should learn the value of this critical thinking and what the appropriateness
and risks are to people.
(40:29):
I think what I'll do, I've got a couple of minutes left here, which makes me happy.
I'm going to throw, I do two things at the end of these.
One, is I give you a last word, but I'm going to pop a question to you first.
Okay.
I'll give you the option.
Maybe we'll cover your last word or not.
I want to say, I want to ask the EMS Avenger.
(40:51):
I say that because I just think that's very cool.
That's the big picture advice that you would give people to not only use this information,
but how do they get this type of information on their own?
I'll plug your TikTok and Instagram and Facebook channels again, because I obviously think
(41:12):
a lot of it and having you hear me select me.
What would you say to people listening this going forward saying, wow, this is really
cool.
How do they do it themselves and how do they implement and practice?
I get that question all the time, which is, how do you get this information?
The short answer is that you have to live and breathe to a certain degree within an EMS
(41:38):
community.
Think of some of the providers that are out there that are doing good work as far as getting
information to people.
Foam frat for one, Tyler Christofouli with foam frat.
Flippery Jed and there's recognizable names with people who work within Flippery Jed.
Eric Bauer, IA med.
(42:01):
All good people.
Gwynni Lawson who works for IA med, great creator.
You just have to start following a couple of these organizations on social media.
This information starts coming to you.
When you start doing that, when you start surrounding yourself with these content creators
and the people who create this content based on evidence-based medicine and best practices,
(42:27):
you start rubbing shoulders with other interested parties and you start learning who else to
follow, who else to talk to.
The crane rises to the top and when you start operating within that community, this information
is always going to rise to the top, the really good vetted information.
(42:47):
Not only that, but the misinformation and the myth-busting of it is also going to rise
to the top.
Simply just being in that community is going to be very helpful and having that information
literally just coming to your phone screen as you're scrolling.
I think that that's great advice.
(43:08):
You certainly mentioned some very talented people.
I think that sometimes it takes one person or a couple of people, even in an agency,
to start these conversations.
You get out there, you join these groups, you listen to people and you bring it back
and then you can be part of a discussion in your own agency.
(43:31):
You can also be a messenger as well.
Absolutely.
And your last word, anything else you'd like to add to this?
I always try to counter discussions on evidence-based medicine with something philosophical.
When I teach, I actually lead with a philosophical talking point first so that we remember to
(43:52):
ground ourselves in something human and real.
I always go back to a conversation I had with somebody who literally asked me, how can I
save more lives?
My answer to that has always been that first and foremost, you have to recognize the innate
value of life in every person that is on your ambulance.
(44:15):
And when you elevate their humanity and when you affirm the value that their life has,
you save more than their life.
You save other lives and you elevate humanity as a whole.
I don't know if I could have picked a better way to end that.
We put some science in with some good humanistic thinking.
(44:37):
I think that's just awesome.
And we're right on time.
There will be a few things we always say.
The show notes will accompany this, will list some of the research that's been referenced,
as well as ways to contact Jimmy, the EMS Avenger through social media sites.
(44:58):
And I think it's also something I'm very happy about that it sounds like you'll be hitting
the comfort circuit a little bit.
And I think that people will benefit from that as well.
This has been Seven Things EMS.
Seven Things Research tells us about EMS practice.
And we look forward to seeing you next time.
(45:21):
Thank you for listening to a Seven Things EMS podcast by Limmer Education.
If you've listened to this podcast on a streaming service and you're interested in getting continuing
education credit, please go to lc-ready.com for more information.
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