Administration and Leadership, Commentary, EMS Today

Filling the Gaps in Education

A.J. Heightman, MPA, EMT-P

We read, attend conferences, and use educational sessions and street experience to fill gaps in our knowledge.

Events and experiences in my life and career prompt me to address some of the gaps I have encountered in my knowledge base and the knowledge base of others recently.

It’s my goal to connect some of the dots in these gaps.

I do not place blame for any of the gaps on my instructors or yours. They have a limited amount of time to impart their curriculum and knowledge to us.

But the fact is that there are a lot of dots that cannot be connected in EMS classes alone.

This must occur from your absorption of information and thoughtful processing and retention of the information for future use.

Each year, I have the honor of being one of the hosts for two dozen Australia paramedic students who are selected from throughout Australia and travel to the USA to visit large, busy EMS systems; do many hours of ride-alongs; and exchange ideas on patient care.

The Australian students spend at least three years in school and do a “deep dive” on lots of EMS assessment care and research. Because there are few gunshot wounds in Australia, I arrange for them to be trained at Strategic Operations, an amazing Special Forces training facility in San Diego.  They leave there as trauma treatment experts.

I like to meet with the students on the tail-end of their two-week U.S. tour to pick their brains and get their impressions on what they saw and learned.

The past two years, I heard the same message from two different groups.

They said that, although they found the personnel they interacted with to be skillful and competent, they felt many of the paramedics “Know What they Know” but Don’t Know What They Don’t Know.”

I asked them to explain their comments in more detail.

They gave me a few examples:

They noted that their system had a comprehensive approach to assessment and focused a lot on pain management, septic shock, and lots of common problems that affect children and the elderly.

Yet, they found few crews carried or used thermometers in the US or had special pediatric kits or splints to immobilize pelvic fractures.

More concerning was the fact that many paramedics said they “only learned on the job” and were not really interested in learning about things outside their protocols or routine calls.

I began to reflect on my education, the curricula I followed during my career, and the many “gaps” I filled in along the way and wanted to share some perspectives with you.

I remembered attending a mandatory hospital continuing education lecture on trauma one evening when I was a young paramedic and hearing a lecture from a trauma surgeon on “coup contra coup” injuries–contusions to the brain resulting from a strong blow to the head, injuries that caused the brain to slam against the inside of the skull.

The lecture was outside the normal content of my paramedic training but left a lasting impression on me.

In discussing the presenting symptoms, the surgeon also noted what he termed violent “heaving” that brain-injured patients frequently present with.

More on that later.

I went to a pedestrian accident a few months later and, as I assessed the patient, I felt like that surgeon was whispering in my ear, “It’s coup contra coup injury.”

I bypassed several local hospitals to go to the closest Trauma Center, called in a Trauma Alert, and later learned the patient did have bleed that could have killed him if not managed rapidly.

That’s an example of how continuing education helped to educate me and make me a better paramedic.

I want to zero in on a few other life lessons I learned that also have impacted me and other patients and could potentially impact you, your patients, or your family.

First, let’s talk about kidney stones.

Kidney stones were referred to in my 1977 paramedic textbook as renal stones, a “nontraumatic emergency involving an organ due to inflammation, infection or obstruction that presents with excruciating flank pain, often radiating to the groin and perhaps one of the most severe forms of pain a person can experience.”

There was no description of what it was–a sesame seed size piece of salt and mineral in the urine that can feel like a 20-pound piece of kryptonite or broken glass if it gets wedged and blocks urine from passing through your ureter.

It’s one of the most painful conditions a person can suffer. The pain and bladder pressure are unbearable.  

About 15 percent of you will suffer from kidney stones at some point in your life.

And, of those who develop kidney stones, about 70% of you will have a reoccurrence. So, you better have some sympathy for people like me who have suffered from them multiple times.

My protocols back in the ’70s weren’t very responsive to the pain caused by a kidney stone and required us to mix 10 mg (1 cc) of morphine in 9 ccs of normal saline–and administer no more than 3 ccs at a time to a patient. They were afraid that hitting a patient with 10 mg of MS at once could cause them to go into respiratory arrest. Seriously?

The first time I went to the emergency department with a kidney stone, a nurse/paramedic colleague of mine pushed in 10 mgs of MS (untriturated) and I felt immediate relief from the pain, warm all over, and became eternally grateful to her.

So, the moral of the story is, understand the condition, and eradicate the pain and discomfort!

Now let’s talk about atrial fibrillation.

Atrial fibrillation was presented to me in the ’70s as a rather benign condition–an irregularly irregular rhythm with fibrillatory waves instead of P waves with multiple ectopic pacemaker sites throughout the atria.

Even though my instructors pointed out that in AFib the atria and ventricles didn’t contract in sequence and the ventricles did not fill completely before contracting (with the resultant cardiac output falling by as much as 25%), they taught us that there was usually no treatment in the field and that it was not a true emergency unless the pulse rate increased significantly–at which point cardioversion or digitalis might be required.    

AFib was therefore one of our easiest test questions.

But it was also probably one of the most under-addressed rhythms taught to me. We never did a deep dive into AFib, and I remained relatively ignorant to its consequences until it impacted me personally in 2017.

I was in New Zealand, lecturing at the Paramedics Australasia EMS conference. While walking to and from the conference center and the hotel, I was ashamed to tell my New Zealand and Australian colleagues that I was short of breath and having palpitations and a hard time “keeping up with the pack.”

In reality, I was in Afib and didn’t realize it.

I had all the classic signs and symptoms of AFib but failed to recognize most of them and brushed off those that I did as just jet lag:

  • An irregular pulse
  • A “flip-flopping” feeling in my chest
  • Lightheadedness
  • Dizziness
  • Faintness or confusion
  • Extreme fatigue
  • Chest discomfort
  • Chest pain

The day after I returned to the U.S., I went to a cardiologist who not only found my AFib but also thought I might have thrown a PE during the long flight home.

Instead of hospitalizing me, she sent me home without meds, and two days later, after stuffing my face on Thanksgiving the day before, I awoke with chest pain and shortness of breath.

I was admitted to the hospital that day, experienced all the excitement of the Cath Lab, and was found to have clear arteries with a diagnosis of GERD (Gastro Esophageal Reflux Disease)–something I had never even heard about before–and AFib, with a referral back to my cardiologist.

I switched cardiologists and spent the next 12 months moving through the treacherous “AFib highway,” with periodic heart palpitations, shortness of breath, and some chest pain.

Complications described to me were possible heart failure, dementia, and stroke. That was a bit concerning!

Treatment included meds for BP; rate and rhythm control; and the blood thinner Eliquis to prevent clots from developing, which could cause a stroke.

The big deal was that my new cardiologist told me that my short periods of abnormal heart rate would probably become longer or continuous over time and might require cardioversion and/or cardiac ablation.

Wow! That didn’t sound like the relatively benign condition I was taught about in paramedic class.

In addition, I quickly learned that you can go in and out of AFib regularly once you have it.

I soon began to recognize when I was in AFib because I had connected the dots.

When I felt short of breath or was winded climbing a set of stairs or felt that “flip-flop” of palpitations in my chest, I would take my pulse; verify its irregularity; and, if it lasted a long time, call my cardiologist.  

I paid $100 on Amazon to connect my cellphone to the small CARDIA device. It worked great.

They decided to have me come in for cardioversion.

I got myself mentally prepared for a nasty procedure I had performed a few times in the field but was told not to worry because they would give me Propofol to knock me out before the shock.

I went into the hospital cardiac center and got fully prepped for the cardioversion. But right before the procedure, the nurse came in and said: “You can go home–because you switched back into normal sinus rhythm.”

What a bummer!  All prepared and didn’t get the hit of Propofol I was looking forward to.

Six months later, and eight trips to the cardiologist, the decision was made to have me undergo cardiac ablation because my AFib was returning too frequently, putting me at risk for an MI or a stroke.

In ablation surgery, the cardiac interventionalist goes in and zaps parts of your heart, scarring or destroying specific areas of heart tissue to disrupt faulty electrical signals he can see on the screen that are causing the arrhythmia.

It worked and I felt great as soon as I woke up.

While they were in there, they implanted a tiny Medtronic LINX device in my chest that would monitor me and alert them remotely to other AFib or cardiac abnormalities.

The reason?  AFib can still occur while the scarring isn’t completely healed. And it did. 

A month later, while driving to work, my cardiologist’s nurse practitioner called me and said, “Where are you?”

I said, “I’m in my car, going to my office.”

She said, “No you’re not. You’ve had several long periods of AFib; so, I want you in here for an EKG and possible cardioversion.”

I went in for two wonderful cardioversion experiences over the next three weeks, quick and easy fixes for post-ablation “retuning of your heart.”

You get prepped, have a mouthpiece put in place, get “gooned up” with Propofol, and receive a low energy shock to put your heart back in normal sinus rhythm.

I had another episode two weeks later, so they had me go in so they could zap that remaining irritable focus in my heart.

Ah–Propofol again!

I’ve been free of AFib for two years.

I began to tell my colleagues about my newfound AFib knowledge. Many of them either had suffered from AFib or now suspected that they might have had episodes.

Passing along my experience and knowledge has probably saved a few lives.

Sadly, I sat across the table from my wonderful colleague, Brian Fass, our beloved EMS fitness guru, at the EMSPire Conference in Greensboro, North Carolina, on September 11 last year.

The topic of AFib did not come up, nor was I aware that Brian had been battling AFib and was contemplating having ablation performed. Sadly, he died two days later, way before his time.      

AFib is the most common arrhythmia diagnosed in clinical practice and one of the most disregarded conditions in many prehospital systems.

Worldwide, 33.5 million people were diagnosed with AFib in 2010.

In 2015, 193,300 deaths resulted from Afib and atrial flutter, up from 29,000 in 1990. That’s a 565% increase in 25 years.

People are living longer. Heredity is playing a role, and there is increasing stress in our lives.

The CDC reports that 9% percent of people ages 65 and older have Afib; and 14% over the age of 80 have it.

If you connect the dots, you quickly understand its relationship to heart-related complications such as blood clots, stroke, and heart failure.

In AFib, disordered or rapid electrical signals cause the atria to contract too quickly and chaotically.

The irregular heartbeat is due to defects or damage to the heart’s structure. Electrical signals in the upper heart chamber (atrium) fire incorrectly and, as a result, the heart beats out of rhythm–often at a heart rate ranging from 100 to 175 beats per minute.

People with AFib are five times more likely to have a stroke because the irregular heart rhythm can cause clots to form and travel to the brain, block blood flow, and cause a stroke.

You’re more likely to develop AFib if you have:

•Family history of AFib

•Abnormal or damaged structure of the heart either at birth or during your lifetime

•Improper functioning of the heart’s natural pacemaker, the sinus node

•High blood pressure

•Heart attacks

•Coronary heart disease or disease of blood vessels of the heart

•Abnormal heart valves

•Metabolic disorders such as overactive thyroid gland, diabetes

•Previous heart surgeries

•Lung and kidney diseases

•Viral infections

And, of course, a few that emergency service personnel possess:

•Exposure to stimulants including certain medications and tobacco;

•Stress or mental health conditions;

•Sleep apnea or sleep disorders;

•Obesity; and

•Alcohol consumption.

So, here’s the message: AFib is a gap in education and our knowledge base.

It’s a serious condition that can occur without any signs or symptoms but result in life-threatening complications if left untreated.

Don’t miss it during assessments. Don’t take it lightly when you or your family members or patients have it.

And dig deep to get a good history from your patients so you can present their full history to the ED staff and they can get the care they need.

Ah, let’s move on to my last amazing knowledge gap and medical adventure.

It was May 16.

I flew home at night from a week of lectures and article interviews in Pennsylvania.

I was tired but felt fine except for a stiff neck that nagged me for weeks. I had gone to my chiropractor for neck adjustment and electrical stimulation to relax my tight muscles before I traveled.

My son, daughter-in-law, and their two young daughters were in town for an unexpected funeral.

I was anxious to see them. Our granddaughters were in bed when I got home, so I enjoyed a few drinks with the adults.

My son and daughter-in-law had just gone upstairs when I suddenly felt the worst headache I had ever experienced.

I told my wife, “I feel like someone just shot me in the head!”

I started to feel strange and began to become very diaphoretic.

I knew something bad was happening and didn’t want my wife to see it happening, so I told her to go up to bed and I would be right up.

After she went upstairs, I tried to get out of my chair but had no feeling or control on my left side and fell to the floor.

I tried to get up but just flopped further to my left on the floor.

My wife heard me fall and came downstairs.

The rest of the evening was an out-of-body experience for me.

I couldn’t believe it; I was suffering a stroke.

No, this can’t be happening to me.

I know all about strokes, and this is not the way I wanted to end up.

I had lectured on strokes and thought I knew all the causes and treatment options.

  • I knew stroke is the fifth leading cause of death for Americans, killing 140,000 Americans each year—1 out of every 20 deaths.
  • Someone has a stroke every 40 seconds and, every 4 minutes, someone dies of stroke.
  • Nearly 1 of 4 strokes happen to people who have had a previous stroke.
  • About 87% of all strokes are ischemic strokes, in which blood flow to the brain is blocked by a clot.  The other 13% can be puzzling occlusions and dissections.
  • Stroke is a leading cause of serious long-term disability and reduces mobility in more than half of stroke survivors ages 65 and over.
  • Amazingly, in 2009, 34% of those hospitalized for stroke were under the age of 65.

It turns out, I had a knowledge gap and luckily fell into that 13% of patients suffering puzzling occlusions and dissections.

I will just briefly describe my out-of-body, “lucky stroke” experience because we are publishing an in-depth article on it soon that will hopefully fill lots of voids in your knowledge base about strokes.

Mine turned out to be a Vertebral Artery Occlusion (VAO) with no clot found or removed.

It was like a sudden clamp was placed on my vertebral artery.

I honestly had never heard or studied about the vertebral artery, let alone occlusions or dissections of them, but they occur rather frequently.

I also didn’t know the two vertebral arteries traverse the vertebrae into the basilar artery. 

Worse yet, I didn’t know that Basilar Artery Occlusions typically have a greater than 90 percent mortality rate.

My son, trained as an EMT, called 911 and did a stroke assessment on me.

The fire department sent an ALS engine and ALS ambulance to my house.

As sick and confused as I was, I vividly remember thinking, “God, these six guys are working on me in my living room with full turnout gear on!”

You might remember last year I told you how upset my father got when he saw firefighters going into homes on EMS calls with their potentially contaminated turnout gear on. That’s probably why my confused brain allowed me to notice it.

Another great teaching moment occurred when a young paramedic looked at me and said, “Sir, do you think you could get up and sit on our stretcher?”

I remember thinking, “I’m having a stroke and can’t move my left arm or leg. If I could do that, I would have done it when you brought the stretcher into the room!”

Much of their assessment and care was a blur to me, but I remember looking around for a suction unit as I started to violently “heave.”

It’s always a pet peeve of mine that crews always bring in their monitor/defibrillator with them but rarely carry in a portable suction unit, the reason “A” proceeds “B” and “C” in the “ABCs.”

I told you earlier about the trauma surgeon discussing critical head injuries and noting what he termed violent “heaving” that often results from them.

FLASHBACK!

I immediately knew I was in trouble–with a serious brain injury that was causing the “heaving.”

The teaching moment continued when I realized that they were running “Code 3” to the hospital and had called in a “Stroke Alert.”

I thought, great job. Now I have a chance.

But when I started to violently heave again, I looked around and saw that there was only one medic in the back of the rig with me.  The engine company peeled off and went back to quarters and left just one paramedic to manage my care.

That solo medic was busy tapping info into his tablet computer and radioing in his report. So, he handed me a little vomit bag to hold with my “good” arm.

There was no airway medic to have suction ready, no one to put an oxygen mask on my face, and no one to set up the IV that finally got inserted as the backup alarm on the ambulance sounded at the ED entrance.

The message: If you go “Code 3,” bring more than one crew member for me!

It was frightening to hear them say to my wife, “He’s had a stroke,” as they rushed me to the CAT scanner.

It was even more frightening when I lay in the Cat Scanner and realized that–if they did find a clot–they would not be able to inject a clot buster because I was on Eliquis and would suffer a cranial bleed.

Fortunately, I had suffered a Ventricular Arterial Occlusion that temporarily shut down blood supply to the left side of my brain.

After two days in the Nero ICU unit, I began to self-heal and regain all motor and visual functions.

The result?  I was one of the lucky 13% who did not have a clot that caused permanent brain damage.

It was my goal to connect a few dots and fill some knowledge gaps for you, with the hope that you will work to pass the information along to others.

I hope you will process and retain some of the “gaps” I illustrated to help you save patients’ lives–and perhaps your own.

I am A.J. Heightman, and I approve this message!