Surgical Intervention

I actually started this post last Friday, but I was interrupted from finishing it. So I will try to do that now.

My mother-in-law had a surgical procedure done while I originally was working on this. She is hoping it will alleviate some issues she has had with infections over the past year or so. Frankly, so am I because it has been difficult to watch her deal with the problems she has had.

I can say that she is much different than my own mother, in terms of her overall health. Where my mom has short-term memory deficits that she can't overcome, my mother-in-law has none of that. She is as sharp as a tack, and it has taken me years to admit it but I actually <i>like</i> talking with her. When I first met her I thought she was a crusty individual, but my opinion of her has changed. She is not nearly as bad as I first had made her out to be; in fact, she has softened in the just over 10 years that I have known her. Her problems are not cognitive; they are physical. And it is just as tough watching her as it is watching my own mom.

So the intervention she had done turned out to be almost exploratory as there wasn't a lot that could be done then. As it is, she will likely have to have more done down the road to take care of the underlying problem she is having, but not right now. Potentially she could be looking at some nasty problems with her health that are more acute, and that will likely override the chronic issue she has been up against. For now, however, we hope that some of the ideas the surgeon has will help her. We'll see.

Infusion

As I write this I am sitting on a moderately uncomfortable chair watching my Mom receive a blood transfusion.

She goes through this approximately once every 10 days now. It had been less frequent, but she is not well. Years ago she was diagnosed with Myelodysplasia, or a loss of ability to produce red blood cells. Coupled with persistent problems with anemia as well as the problems with short-term memory that she has, some days for her are better than others.

When she was diagnosed, it was a vague sort of thing; all we knew was that she was starting to lose the ability to make red cells. As it has gotten more profound, I have to believe that it has been partially responsible for the memory loss. As far as I know, she has not gotten a dementia diagnosis, but I wouldn't be surprised if this is present as well. That said, she has enough wherewithal to continue to live independently; she has no desire to be in any other situation. For now we just let it ride and watch to ensure she doesn't do anything to endanger herself.

For as long as I've been working as an EMS provider, I have always been fascinated with watching IV pumps. Admittedly they are machines, and boring ones at that, but it is still interesting to me to watch them function. The pump my Mom is attached to has a unit of O-positive whole blood running through normal saline. The tubing has a burette chamber in the middle; one would think it is pediatric tubing because of the burette, but it is obvious that this is not the case. To run a unit of blood in takes about 3 hours, and she is getting 2 of them today. So we will be here for a while.

The last time I brought her here was before I was injured; it was an interesting day because on the way to getting her home a truck flipped into the median strip on the highway. It tumbled end-over-end 4 times before coming to a stop on its roof. The driver was still alive; proof that seatbelts do work. He was able to move all of his extremities. The others that stopped wanted to try to get him out of the truck, but there was no way that would happen easily. When Fire and Rescue arrived they had to cut him out of the truck, but with tools they were able to get him out relatively quickly. The State Police closed the highway to land a helicopter, and the driver was taken to one of the trauma centers in Boston, but I don't know which one. Doesn't matter, though; to my knowledge he recovered from his injuries.

Considering how disease processes like this one work, it is a minor miracle that she has survived this long. The memory loss is rough, though; just now she asked me the name of her primary care doctor, one she has been a patient of for close to 4 years. She remembers other things, but they say that the most recent events, people, etc., are the first to be forgotten. And that is the hardest thing to witness.

Now What?

A lot happened last week.

The semester ended. I think I survived it. I will say, however, that Biochemistry was not my best or most favorite science. With reasonable certainty I can say that it wasn't due to the subject matter; I have a grasp on it that is reasonably snug. However, the instructor just piled material on all semester long. And I'm really not complaining about that; it was just hard to keep up with that plus the other demands of the course. Considering I had a full load again this past semester, I think I did okay to pass it with the C+ that I was able to squeak out. And I earned a B in the lab component of the course. Neither of these grades are worth writing home about, but all things considered I think I could have done much worse.

On the other hand, I scored A's in both of my other courses. One of them I wasn't surprised at. The other, I was. Pleasantly, but surprised just the same. I did not expect to earn an A in the second semester Biology course; I would have been happy with a B. The other course - the introduction to infectious diseases - was also an A. Truthfully, I didn't think either of these was nearly as demanding as Biochemistry. This makes me think I could have done better in Biochem without too great a cost to the other courses. That happened last semester with Organic Chemistry; I earned a B in that course, which was at the expense of the other two courses that I took.

So the lesson here is that it is very difficult to strike a balance, no matter how hard you try. And I could make excuses; goodness knows I had a legitimate one with the issues around my arm, but I won't do that. I'll accept responsibility for the shortcomings I had. When all is said and done, I either stand or fall by my own merits. I have nobody to credit or blame but myself.

As far as my arm is concerned, I was cleared to go back to work for the town of Goffstown. My first shift back with be this Thursday. I'm looking forward to it, but at the same time I am a little bit apprehensive because I don't know how it will be, with respect to skills. I should be fine, but I won't know that for certain until the rubber meets the road, in a manner of speaking. So we'll see what happens.

Plus, I've been approached by one of New Hampshire's other private ambulance services, at least indirectly. The company that covers the area where my son went to college is looking for Paramedics and the principal owner of the company asked one of our mutual friends what my availability was. She contacted me while I was on light duty asking me if I had interest. They must have had some sort of intuition because I was contacted again today. My response was that I will certainly speak with Rob, the owner, if he calls me. I will also take the rest of my life into consideration should I go ahead and pursue this. I have worked for multiple employers in the past (multiple being more than two), and it is hard to keep it all straight sometimes. But it could be worth it. I won't know unless I check it out.

So this begs the question to be asked: what do I do now? I have all of this time on my hands that I didn't have before, and I certainly could use the work. I would like to be able to at least make an effort to get my financial house at least partially in order before the fall semester starts, and it appears I may have an opportunity to do just that. All things considered, if things don't go my way for PA school, I potentially have some opportunities to sort of move forward.

But I need to wait and see what happens. And I won't let my brain sit idle, either. I can't do that.

The URC

URC stands for "Undergraduate Research Conference." It is an event that occurs every year at both UNH-Durham and UNH-Manchester, and I attended the poster presentations yesterday afternoon in Manchester between the last Biology lab of the semester and the CPR recertification I had to go to 47 miles away in Peabody, Massachusetts. It is part of a three-day event where there are speakers, film showings, and a Senior technology symposium. Anyone who is an undergraduate student who has been involved in research projects, either as part of an ongoing body of research work or as students working on projects that are requirements for the Senior seminar and, because of this, requirements for graduation.

The reason I went was because I am required to by one of the classes I'm in this semester - Biochemistry. Also, the second semester Biology course is offering extra credit for attending and writing about an exhibit that was viewed. Actually, it is the same for both classes, but one is required and the other is optional.

I viewed 2 exhibits by Biology majors. One was presented by a future educator, and she did a presentation on her experiences working as a student teacher at one of the middle schools in the city of Concord, NH. The other was by one of my Biochemistry classmates, and she did a presentation on an internship she did in a medical practice - that of the chief of the Neurology department at the Faulkner Hospital in Boston, MA. They were both really well done, and it was obvious to me that there is a great deal of enthusiasm on the part of each one of these two students, both young women, both really knowledgeable and personable, and each was able to present their subject matter quite effectively.

I was impressed with both of them. I also informally looked at a number of others, both science and non-science, and I found a great deal of good work.

There was a weird experience I had, though, that I wanted to mention. One of the poster presentations was a summary of events that surrounded the end of the Korean War, including photos of the people involved: MacArthur, Truman, and others. I was looking at the poster and thinking about the current insanity happening on the Korean peninsula, and standing next to me was an Eastern Orthodox priest - I want to say he is a hieromonk because he was wearing a cassock and a rounded hat rather than a shirt and trousers with a collar. Additionally he was wearing a three-bar pectoral crucifix that is common especially to the Russian church. He had a full long gray beard, and I suspect he had a lot of hair; this is their tradition, and my immediate impression was that he was the genuine article. He also had a cane, which I think had nothing to do with the habit; he was an older gentleman, and I suspect is was a necessary appliance for him to use.  In any case, as I looked at this poster, the student who was responsible for the poster was talking about the events that happened. I said to him, "it certainly looks as though that part of the world has become notable for the level of peril happening there now, hasn't it?", or words to that effect. The priest, very quietly, replied, "indeed it has..." It sort of startled me because I didn't expect to hear him speak, and I just stood there for a minute as he walked along to the next poster.

It was a strange way to end that part of my day....

Trapped In My House

Today there was construction on the road at the corner where the street I live on junctions with the main secondary road it is attached to. I discovered this at about 10:30 this morning when I was going to try to get out for a while to take care of some business; it turned out to be a problem when I couldn't get out of my driveway. Because of this, I couldn't go anyplace. But I was able to get some things done, so maybe it wasn't a bad thing after all.

I haven't written in a while, mostly because I have been buried with the work related to classes. Fortunately the semester ends in a couple of weeks. Plus, my son Jon graduates from college at the end of the first week of May. I'm proud of him; he has done well with his studies, and I think he may have found a job already, but I can't confirm that. Regardless, I know he will do well.

Another note about the impending end of semester: mine ends in a couple of weeks also. I'll be happy when it's over. Not that it was an exceptionally difficult semester academically, but I had a lot of distractions that caused me to not do as well as I personally would have liked. The biggest distraction was the business with my arm; I had to contend with a lot of aggravation because of it, and my ability to concentrate was pretty seriously impeded. But I'm working on getting that all behind me. I have an appointment with the orthopedic surgeon this coming Monday and I truly hope he clears me for full use. But we'll see what happens.

I am also going to attempt to write more; over the past few months I've been a dismal failure. No time and sometimes no inclination. I, however, want to do better with it because it is truly something I enjoy, and I miss not being able to put thoughts down. So I am going to make the effort to get better at that, too.

Well - the road crew has finally left. I could go out if I wanted to, but I don't.

The Epinephrine Debate

I've been following this for quite some time, and the more I read, the more I learn. The more I learn, the more questions I have. The questions lead to doubts, and the doubts, ironically enough, have lead to my sharing an opinion that I originally thought was a form of heresy.

I use the word "heresy" because anyone who doesn't think about what is being said in any of the research or reporting that has been done on this subject, or is not familiar with it, would likely have the same initial gut reaction I did until I started looking at the research for myself.

The first place I saw the debate was on a fellow blogger's site. I have been following Rogue Medic for a long time - as of this writing, it has to be for close to 6 years. He is from somewhere in the eastern United States, and I don't know how long he's been an EMS provider for, but he's been at it for longer than I have. He is extremely well-written, and while he is somewhat controversial in the opinions he has, he also does his homework and backs up everything that he says, without exception. Some might be offended by his manner - he is rather direct in the way he expresses himself - but it isn't intended to be personal. I had to learn that for myself.

I first read a post he'd written about the use of Epinephrine in cardiac arrest about 2 years ago. The main point of the post was that it should not be used because while it may aid in bringing about the return of spontaneous circulation (ROSC), it can cause harm by doing damage to brain tissue as well as other organs, ultimately causing death in some cases.

I remember my initial reaction when I first read what he wrote. I remember thinking, "huh? Why would he makes statements like this? Is he crazy?" Well, maybe it wasn't in all of those words, but it was a visceral reaction. I mean, when someone makes a statement like that, it's a blow to all of those things that many EMS providers - especially anyone who is qualified to perform Advanced Life Support - whose mantra is to "follow the algorithms and do everything by the numbers." However, I have to say that as I read more and did more of my own investigating, I began to see that what he was saying has merit.

One of the things that he (and others) call for is independent randomized controlled trials of Epinephrine and whether or not it has any real effect on ROSC. To see if anything in the way of studies exists, I went up onto the MEDLINE database and searched on the words "epinephrine cardiac arrest trial", and to my surprise, two articles jumped out at me. Needless to say, I was surprised to see the articles, so I downloaded them and reviewed their content.


A little about Epinephrine first. It is naturally occurring in the human body, both as a hormone and a neurotransmitter. It is secreted in the adrenal gland through the conversion of the amino acid Tyrosine. Known as one of three catecholamines (the other two are Norepinephrine and Dopamine) it is responsible for the "fight or flight" response that is generated through the sympathetic nervous system. It is secreted in small amounts - much smaller than the dosages given externally - but we still have that jolt-like sensation whenever fight-or-flight kicks in. If we get that sensation with what our body produces, imagine what a much larger external dose feels like. An example I can use from personal experience is the dose given from an Epi-Pen, which is at a 1:1000 concentration (for one milligram of fluid the amount of Epinephrine present is .001 milligrams) at 0.4 milligrams. I use one as needed - I am allergic to bee stings and to shellfish. The sensation, even though it works to open air passages, is unpleasant. Heart rate is increased, respiratory rate is increased, nausea and sometimes vomiting occur, and chest pain, although brief, does happen from time to time.

It is no wonder Epinephrine has been described by some as a "heart attack in a vial."


The first article describes a double blind study that was performed in Western Australia. The basic content of this study was that a randomized set of 601 patient with 67 excluded with 271 patients receiving Epinephrine and 262 receiving a placebo. This was done in the context of resuscitation that was being performed on each of these patients including management of their airway and high-quality CPR being performed. The ultimate conclusion that was drawn, based on the results of the study, was that there was no statistically significant difference in the outcome of survival to hospital discharge even though the likelihood of obtaining ROSC increased.

There are a number of limitations and potential sources of error documented in the study. One of the limitations is the number of patients they had; there could have been substantially more available for the study, but four of the five EMS agencies that were supposed to participate didn't. Additionally, there is always human error (when is there not?) to consider, whether it be related to technical problems, clinical issues, or administrative problems, some of these could easily have gotten in the way of getting accurate reporting of results.

The second article was published in 2006 and had a couple of different subjects related to out of hospital cardiac arrest. One was the issue of public access defibrillation. Another was alternative CPR techniques. The third was the use of Epinephrine and Vasopressin compared to Epinephrine only in resuscitation.

Vasopressin is another naturally occurring compound in the human body. Also known as anti-diuretic hormone (ADH), its primary purpose is to become activated when the body's fluid balance is threatened. In higher amounts it has been found to also have properties as a vasoconstrictor, but with a different mechanism of action than Epinephrine - one that is non-adrenergic.

The article hit 5 main points, and from the article, they are as follows - I will address these points within this list:

• Public access defibrillation programs have been shown to improve survival of cardiac arrest patients treated in public places but not in residential settings
• The cost effectiveness of public access defibrillation programs depends on the frequency of cardiac arrest at the location where the program is implemented

With the cost of technology diminishing substantially since this was published, I'm inclined to think that these are moot points. The ability to get access to AED's, or automated external defibrillators, is much easier now than it ever used to be, plus for patients with known arryrthmias, being fitted with an automatic internal cardioversion device (AICD) has also become much more commonplace.

• Vasopressin is superior to Epinephrine in the initial treatment of asystolic cardiac arrest and is equivalent to Epinephrine in the initial treatment of ventricular fibrillation (V-fib) and pulseless electrical activity (PEA)
• Vasopressin in combination with Epinephrine improves outcome of refractory out-of-hospital cardiac arrest compared to Epinephrine alone

This is all well and good, but the study does not address the issue of survival to hospital discharge  as the previous study did. All it says is pretty much what you see in the bullet points. But in understanding what Vasopressin does, the limited point that the study makes is logical.

• There is evidence to support the use of compression-only CPR, intra-abdominal compression CPR, and active compression-decompression devices, although large scale trials are needed to demonstrated their effective for out-of-hospital cardiac arrest

Intra-abdominal compression CPR is not something I am personally familiar with. Active devices (Philips' LUCAS device and the Zoll Auto-Pulse are two that I have worked with) work rather effectively even if they appear to be somewhat barbaric in their action. But the key is that they work, and I would imagine independent studies exist that show their effectiveness.

There are a couple of things I have to say to end this post. First, I've looked at some of Rogue Medic's sources (actually, many of them), and as I said earlier in the post, there is a lot of merit in what he says. I really, truly am starting to think that giving someone Epinephrine whose heart is not working properly in the first place does them no favors, and the organizations who make the decisions to propagate the algorithms we are obliged to follow need to take many more looks at what we are doing. Second, there have to be other better ways to treat someone who is in cardiac arrest that are not going to make either not survive their hospital stay or make them wish they were dead if they do. One that is already in place is high-quality CPR - 100 compressions per minute without interruption. Some of the other things we do - good airway management and access to circulation - are nice, but by far this is the most important. And if we're killing the brain's micro-circulation (or that of other vital organs) with Epinephrine, do we want to continue doing that? One would think not...

The only thing I would say to anyone who has read this post and is scratching their head is this: read the articles yourself. And look at Rogue Medic's blog. His cites considerably more sources in his regular posts than I am in this one. And based on what you read, you can simply draw your own conclusions.

References

Jacobs, I., Finn, J., Jelinek, G., Oxer, H., & Thompson, P. (2011). Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. Resuscitation, 82, 1138-1143. doi: 10.1016/j.resuscitation.2011.06.029

Richardson, L., Kwun, R., McBurnie, M., and Chason, K. (2006). New Approaches to Out-of Hospital Cardiac Arrest. The Mount Sinai Journal of Medicine, 73(1), 440-448. Retrieved from http://www.mssm.edu. 

P.F.A.

"Engine 3 and Ambulance 2, respond to __ ________ St. for the unconscious party."

Yesterday was my first full 16 hour Saturday since my injury. I'd worked 3 8 hour Saturdays prior to yesterday, but it was my first day with, other than not being able to pick up a stretcher or anything weighing more than 5 pounds, no quarter asked or given. I was on my way to fuel the fly car/command vehicle (a Ford Expedition with lots of horsepower and a complete light show) when the above call came in. I was approximately 5 miles away from the address given and I hadn't made it to get gas yet. Plus, I was the only ALS unit available. So I went.

When I arrived, an engine company and the BLS ambulance that was dispatched were already on scene so I went in. The patient, a 72 year-old female, was not unconscious, as the call was originally dispatched. However, she was not thriving well, mildly dehydrated, and not saying very much. Her husband and daughter were also present, and they were somewhat distraught; the patient - wife and mother that she was - had a history of multiple myeloma and was being treated with chemotherapy. Cytoxan and Revlimid were her chemotherapy drugs, plus she was being given Prednisone and another medication that escapes me. She had a PICC line in place. Family reports no other significant medical history or allergies. Assessment found her to be alert and oriented appropriately, no fever present, but she was tired. Vital signs were acceptable; no hypo/hypertension, no dyspnea, but a slightly elevated heart rate was noted. No complaints of shortness of breath or chest pain, patient denies changes in mental status, nausea, vomiting, or any other complaint other than the fatigue.

The EMT's on the BLS crew felt comfortable transporting her (and I was comfortable with them doing so), and they let me know that they were preparing to go within a few minutes.

While the BLS crew and the firefighters on scene assessed and moved her, I spoke with the family. Her husband, age 76, was visibly upset and extremely anxious. He appeared, at least to me, to need to be talked off a ledge. The daughter was much less of a mess, but she was still having a hard time. They were both going to the hospital with her, and the daughter had planned to drive both herself and her father in. He, however, wanted to be with his wife, which is understandable, but considering the dynamics in play I was concerned that his stress levels would potentially ramp the patient up, which in itself wasn't a good thing.

So I offered to do something I don't do often: I asked him if it would be okay if I drove him into the hospital. He immediately asked me if we would be going with the ambulance, and I assured him we would be. So he rode in with me and we followed the ambulance to the Boston hospital the patient was being transported to.

We got into my vehicle as the BLS crew was loading her onto theirs, and he immediately started talking. It was as though he was unloading his cares, his fears, his life - onto me. So I listened. And I got a lot more than I expected.

This man - I will call him Jacob - and his wife had been married for coming up on 53 years. They had three children, two of which live outside of New York City in addition to his Boston-based daughter. Jacob was a product of the psychology program and UNH where he'd earned his Ph.D. in psychology in 1962 - the year I was born. He'd had a successful psychology practice that he'd retired from approximately 6 years ago. And he was incredibly worried about his wife; the MM diagnosis had been fairly recent - he told me she'd been diagnosed in 2009 - and prior to that she had been remarkably healthy. But the off-and-on treatment she'd been undergoing was taking its toll on her, and he told me she was starting to lose her will to live.

As he was telling me this, the tears were running down his face, and it was all I could do to concentrate on getting through traffic without us becoming victims ourselves. My actions during this incredibly one-sided conversation was to just sit there and listen. Occasionally I asked him a question or validated something he said, but other than that I said very little.

This occurred in an approximately ten minute time frame. When we arrived at the hospital, he and I got out of my vehicle and went to the ambulance where the crew was unloading his wife who, surprisingly, was looking a bit better. And she had a curious smirk on her face that I couldn't quite figure out until she said, "now Jacob, you don't need to worry so much. I feel a little bit better." The poor man's eyes welled up again, and as he walked in to the ED with his wife and the crew, I had to slow down and take a deep breath before I followed them.

It was probably one of the more intense experiences I've ever had providing psychological first aid to a family member of a patient. It happens more often than not that the patient - the person we are called for - is not always the one in need of care. Sometimes family members need it just as much, but usually in a different sort of way.

And I realized afterward that he really did need it; with the limited knowledge I have about MM, I know he will lose her at some point, unfortunately most likely sooner than later. And I'm afraid if this gentleman doesn't have good support from his family, he's going to be lost as well.

If nothing else, one thing is certain: this one will stay with me.