Education can come in many forms. Sometimes it comes from academia, while other times it comes from first-hand experiences. It is with emphasis on the latter in the case of this blog. It’s not very often that we, as transport practitioners, have the chance to interact with our patients after they arrive at their ultimate destination. We frequently administer analgesia, sedation, as well as a host of other medications, and while we can objectively observe what we perceive as positive effects, unless you’ve actually been on the receiving end of these medications, we never truly know how they make our patients feel. To that very point, recently one of my co-workers experienced a cardiac event that resulted in cardioversion, and later, a replacement aortic valve. During one of our water cooler banter sessions, it was quite interesting discussing not only what sedition he received, but which he preferred and why.
While the initial intent of our conversation was to be centered around the sharing of his experiences with analgesia and sedation, as you’ll read, it quickly morphed into discussions about EMS, transport medicine, and some of the experiences he has had during his forty-plus years in the industry. Without further adieu, I present the transcript of our discussion:
DM: So yeah, I started off with a-fib rvr and hypertension which ended up being a stenotic bicuspid aortic valve. They did not go the cardioversion route with me right away because they didn’t know how long I’d been in a-fib, and they didn’t want me to throw a clot. So, the first thing they went in for was an esophageal echo, and cardiac cardioversion afterwards, and that was with Fentanyl and Propofol. After the Propofol, I was out but much more aware of what was going on, and I do remember the thud. And it wasn’t…I don’t know…I just wasn’t as impressed with it.
JP: I think Propofol is one of those that either you love it or you hate it.
DM: Yeah, and obviously it’s dose based. You know, so, I don’t know what the dosing was. Second procedure was the heart cath and that was just Fentanyl and Versed. I remember nothing. Literally, I remember asking them, “What are you giving me?” They said Fentanyl and Versed, and then I was back in my room and that was all they ended up giving me for that.
JP: Did you get Ketamine in there, too, somewhere?
DM: I don’t think so. No, I don’t think I got it. I think we talked about Ketamine, but no.
JP: Any after-effects of any of the medications that were, I guess, less pleasant than others or not really?
DM: Yeah, that Fentanyl and Versed combo was probably the best other than, you know, the anesthesia for the open heart surgery. Even then, I don’t remember what dose I was on for Propofol post-op when I was still intubated. I remember waking up a little bit and don’t recall much else. It was actually kind of fun being on the vent and awake for just a little bit.
JP: So you got to experience what the vent was like?
DM: Sure. I’d looked around to see if it was a Hamilton vent.
JP: Was it?
DM: Yep, it was. It was surprisingly comfortable.
DM: Yeah, it was. You know because, of course, I tried over-breathing it and holding my breath and stuff to see if it actually kicked back in and it did what it was supposed to.
JP: So is that the only time you’ve ever been intubated in your life?
DM: Well, I had knee surgery in the 80s.
JP: Okay. So you couldn’t compare? Because we’ve always heard that the Hamilton is a whole lot easier for you to breathe on.
DM: Yeah, I don’t remember anything from knee surgery. I doubt I was even on a vent. Now the Propofol I know for sure was for the cardioversion. Yeah. But I like the Fentanyl and Versed combo the best.
JP: Fifty and two. I’m telling you, that’s kind of my go-to, and then they’re out.
DM: Absolutely. Ketamine? I still don’t like the Ketamine drip. I think it’s just one of those things that it’s gonna pass.
JP: Have you ever been on it before?
DM: No. Just kind of personal. Just watching patients, the one thing, and I think this goes to anybody that we sedate, is you can’t just give drugs and then see for works. You have to sedate them. In other words, their heart rate was one-twenty and now it’s eighty, and is basically there to me. That’s their sedation range, right? I don’t wait for people to wake up again. When their heart kicks up to ninety it’s time to give some more. Propofol, I think, is a fantastic drug for the ICU, or for procedures, because it wears off so quickly but what I don’t like is that it seems like the bumps and lumps of transport, you’re always jostling people awake. So, by the time you give them enough to actually keep them sedated, the pressure is eighty and then you’re like, “Oh God.”, and you play that game where you’re chasing it, and you’re ripping it off to do your Fentanyl and Versed. Stick with that and then just watch to make sure they’re sedated.
JP: Yeah. I remember what my first experience with Propofol was like. I thought, “Alright, this is good for the hospital, but then you are put into a stimulating environment and it doesn’t do all that well at all.” I know some people swear by this stuff but, you know, maybe it depends on your experience with it.
DM: I mean, if you’re more of an in-hospital person, then yes, but it also depends what the patient is. You cannot compare an awake COPD patient to a head injury patient. You know, they’re different. I mean, let’s face it, some people just don’t wake up. You know, that and that’s the hard part. Also, it seems like some people burn through that stuff like crazy but we’ve also had people that go through ten of vec in twenty minutes. Oh yeah, and then Fentanyl and Versed. You’re like, “Do I have enough?”
JP: I hate to use the analogy of another tool and toolbox but, I mean, medications are not one stop shopping, and cookie cutter patients are rarely cookie cutter. So right, you got to kind of figure out what works. What else are we going to try? We’ve talked about this before, but a year ago, we had that burn patient that got intubated in the hospital, and his pressure kept tanking on the Propofol he was on. They kept turning the Propofol down, but then the guy kept coming out of the bed trying to pull the tube out and it’s like, we got to do something about this. This isn’t going to work flying all the way down to the burn center with this guy. So you know, that’s where we did the Ketamine drip and Fentanyl.
DM: Ketamine alone, I think, is where it gets scary. In EMS, we do get used to, you know, throwing somebody into a dissociative state and ten minutes later you’re at the hospital. Throw some narcotics onboard and everything seems fine but on a lot of transports, it doesn’t last and you still have the physiologic effects of the pain. You may forget about it a little bit, but it’s still there.
JP: So has your care of patients changed since you experienced what you experienced?
DM: I have always been a huge advocate of making sure you’re well sedated. I have played the games with the other stuff, but Fentanyl and Versed have kind of been my go-to. Dilaudid? Dilaudid is a great ER drug. It’s not the best drug to throw on somebody in the back of an ambulance and then deal with the puking and the other stuff that comes with it. Others give Fentanyl three times. Morphine? Same thing as Dilaudid. They puke all the time. You know, so Fentanyl seems to be the best.
JP: Yeah that’s kind of been my go-to. The combo of the two of them seem to work really well together. When you tell your patient, who’s clearly in pain, “Hey, I’m going to give you a little something to make the ride a little bit easier” and you can see it kicking in, they’re out cold, and then they get to the hospital say, “I don’t remember a thing”, you know it worked well.
DM: And that’s the best thing. As long as the patient is good, as long as the patient is comfortable, and they’re perfusing, yeah, then we’re doing it right.
JP: If they’re coming unglued off the bed during the whole transport, it’s not helping anybody. Some say “I’m going to give you twenty five of Fentanyl” when their patient is 250 pounds. It’s a good way place to start, and we’ll see where that goes. But…
DM: I don’t think there’s anything wrong with that, but I think that then you have to be ready to give it every four to five minutes until you get to your destination. Just giving twenty-five and walking away, that’s probably not gonna do it. We still have to reassess the pain. And, like said, with what I went through, I don’t know if I got one-hundred and two or fifty and two, but it took me all the way from the procedure to my room.
JP: Oh, nice. So, the whole time, as far as you know, the one shot and you were done?
DM: Yeah, that’s all it was. I talked to the doctor later who called me a lightweight (laughs). I think it’s just like anything else. It’s all cyclical. You know, this new stuff comes up, and while I think there’s a place for it, it’s not my go-to. You always seem to find yourself kind of circling back around to, you know, the good old-fashioned Fentanyl and Versed. I think the thing that we have to remember is we use a lot of tribal knowledge in EMS. “Hey, John’s trying Ketamine. I’m going to try Ketamine. You know, he said it really worked, and the guys started making funny jokes. I want to see that, too.” And I think that, but the important part is, what is the goal and that, you know, we have different tools in the toolbox. I think Ketamine is great for the short term relocation of the shoulder dislocation. One, two, three, look squirrel, and whoa, you’re done. It’s great for that. Propofol? Good for that, too. I mean, that’s another one where you get total relaxation, but then a couple minutes later, they’re like, “What happened?”. But if your goal is an extended transport, with a lot of outside stimulation, I don’t know. I don’t think you get the results with those guys.
JP: So you’ve been around EMS for a few years. When do you start?
DM: I became an EMT in ‘80 and a medic in ‘85.
JP: So you have seen a lot since 1980. Have you seen EMS, as a whole, improve as far as how we treat our patients with all the stuff we have available to us? I know that’s a broad question, but do you think we are moving in the right direction, generally speaking?
DM: Generally speaking, yes. The tools that we have are better, and now the technology of those tools have improved where it’s efficient to do in the field. A 12-lead is not a cumbersome awful procedure to do in the field. Communication has gotten better. I’ll tell you, it’s ironic that the more independent we become now, it actually would be easier to contact the doc with questions. I think sometimes we have so many tools available to us, that sometimes we forget that the goal was to get the patient to the hospital. A lot of patients, it doesn’t matter how long you’re on scene, but I do think that a lot of times we play around too much. It’s like we’re worried “Oh my gosh, it’s a STEMI and we didn’t get a second 12-lead”. You figured it out, it’s a STEMI. You went to a cath lab. Great! It’s a win.
JP: Have you seen things fall out of favor and then kind of come back into favor?
DM: Ketamine was there early on and went away, and now it’s back. Most of the airway stuff went back and forth for a while, however, now that we have the King, the I-gel, video laryngoscope, I think those are going to be the new foundation, but I also think they just work.
Our conversation went on from here for another thirty minutes. We went on to discuss the current state of affairs within the industry, how things have changed over the years, and what we thought the future holds for the EMS and transport medicine industry as a whole.
As specifically called out in the interview, much of EMS is what could be considered tribal knowledge. As such, it is important to learn from those that cut the trails in the industry. This ideology, however, is becoming increasingly difficult as the industry experiences increasing turnover rates with senior practitioners simply pulling the plug after years in the industry. When they leave, all of their years of training, knowledge, and experience go with them. While those shift-change gabbing sessions may seem trivial, and more like a social gathering to some, quite frequently valuable knowledge is shared amongst all the ribbing and joke telling. Take the opportunity to participate in these, dare I say, industry traditions… You might just learn something valuable.