Progress

I’ve seen a number of changes since I first stepped on an ambulance at the age of 15.  Some of them have been good, and some of them not so good.  In this edition of EMS in the New Decade, I want to point out what I feel has been the best piece of equipment and the best treatment that I have seen added to my toolbox mainly in my last eleven years as a paramedic.

My trusty Lifepack 12

1.  The LP 12 Monitor — When I was in paramedic school at Springfield College, I was trained on an LP-10.  We had no way of doing 12-leads besides that old trick of moving that single electrode around the chest to get the pictures that we wanted.  We could look at the inferior leads with the old “hold down the print button” function on the LP-10 to put it in diagnostic mode, but without a little bit of work, we couldn’t get the monitor to do a lot on its own.

Don’t get me wrong, I loved my LP-10, but it was dated, and it was evident to me from the start of my paramedic career that as an industry we had moved past it.  In fact, for the last two years of my career in New Jersey when I was in paramedic school in Massachusetts every LIFE EMS unit that intercepted my BLS ambulance had an LP-12 on it.  I was a bit behind the curve on reading 12-leads due to my inexperience with them, and my trips home brought that glaringly to the forefront.

Adding an LP-12 to my truck somewhere around 2003 when Massachusetts made them a requirement was a huge step in the right direction.  Not only was I able to do 12-leads but I had an O2 Sat machine build into the monitor, and I was able to measure end title CO2 not only on intubated patients but also via a nasal cannula-like detector.  That was technology that our emergency room didn’t have.  In fact, our larger ER still relies on breath sounds and a color metric device.

My scene times may have gotten longer after I packed my LP-10 away, but I viewed that as a good thing.  There was so much more that I could do for my patient and so much more that I could evaluate.  When walking into the ER now, I had a better idea of what was going on, and was more sure of my assessments and the treatment given as a result of my findings.

2.  CPAP — A lot of treatments have changed since I started my paramedic career.  When I put my first ACLS card in my pocket, I still had the mantra “Elephants Like Big Mud Puddles Sometimes” running through my head to help me remember what order to run through my meds in during a cardiac arrest.  That certainly is a thing of the past.

Pulmodyne brand CPAP. Photo taken from www.grandcountyems.com

I struggled with what to pick for my most innovative treatment.  The progress and accomplishments in the improvement of CPR over the last ten years has been staggering.  We’ve moved completely away from airway as the focus and moved to where the problem truly is: the heart.  CPAP though has changed more about how I treat patients with Congestive Heart Failure (CHF) patients specifically than any other treatment I’ve added to my toolbox.

When I started, my CHF algorhythm looked like this: “high flow O2, IV, Monitor.  If they don’t take lasix, give them 40 mg.  If they do, give them twice their PO dose.  Then, give nitro.  Lots of nitro.  Call medical control, and ask for nitro paste and morphine through the IV.  Drive fast.”

CPAP is something that is new to my service.  Again, this is something I saw in New Jersey over ten years ago, but it seemed a lot more complicated then than it is now.  Lasix is out the window.  Once given for anxiety and vasodialation, morphine has returned to my drug box.  Instead, the concentration has moved to vasodialiation mostly through nitro paste, and opening the airway up with CPAP.

Now, we are giving that initial nitroglycerine sublingually, and plugging in our CPAP to our O2 bottle.  Its very easy to use.  Our PEEP is preset, and all we need to do is strap the mask to the patient’s face, and go back to whatever else we have to do.  From there, our job is to monitor vitals, slap an inch of nitro paste on the patient’s chest (which we now have standing orders for) and make sure we don’t run out of oxygen.

The difference in patient turnarounds that I’ve seen is incredible.  In a matter of hours, blood pressures are under control, and the patient’s respiratory drive is under control.  People aren’t getting intubated as much, and (obviously) don’t have to be weened off of ventilators as often.

With these two additions to my toolbox, I have a better idea of what is going on with my patients, and more of them are living longer.  The LP-12 is a great tool for improving the quality of treatment, and CPAP has given EMS a way to improve patient outcomes when leaving the hospital.  Sure, rushing patients to the ER without a more solid assessment and turning over that intubated CHF’er to the ER staff might have been exciting at the time, but isn’t improving outcomes what we’re here for?  It has to be about the patients.

What do all of you think?  What treatments and equipment have had the biggest impact to patient outcomes and been the biggest change for you during your career?