Choc

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The original French word describing what modern physicians in English call “shock,” was first used by the French surgeon, Henri Francois Le Dran.

It described his observations of what happened to patients who were shot with musket balls. These observations were not limited to blood loss or the delivery of O2, but of the totality of the effects over time.

Shock is my favorite subject in medicine. I read and write a lot about it. I am writing it here because I am getting tired of typing it again and again.

For the last 50 years or so, modern medicine has wrongly simplified and attributed shock to the failure of delivery of O2, by several mechanisms which were given names like “distributive,” “hemorrhagic,” “septic” etc…

Shock is multi-factorial, concurrent processes in the body, most notably triggered by a combination of the failure of delivery of o2, inflammation, and kinin cascades. Shock is not so much a disease as it is a point in time of an underlying disease process.

The chronology of this process is compensation, decompensation, multiple organ dysfunction,  multiple organ failure, and finally death.

What makes shock pathological is that in its decompensated phase, instead of helping to maintain homeostasis, it instead inhibits it.

It is important to understand that shock is a systemic process, it is not restricted to a specific area or system. In fairness, depending on the severity and medical treatment, the obvious clinical effects may not always be significant, however, they still exist, and become more important as both the length of time the patient is in shock as well as the severity of it progresses. It would take me no less than a novel to type out every systemic interaction shock has, but I will give a few examples here. In addition the the obvious ones, like inflammation or bleeding, there are changes in protein composition in brain cells and function, particularly in the limbic area, there are changes in metabolism from an anabolic state to a catabolic state. From sex hormones to all of the blood pressure and fluid retention pathways are altered in some way.

Shock may be acute or chronic.

Acute shock is very easy to see clinically, the signs and symptoms, as well as biochemical findings are well described other places so I will not repeat them here. I don’t know any providers who cannot at least recite many of these. We see it often in every condition from dehydration to massive hemorrhage, chances are if you are reading this, you have experienced being in shock at some point in your life (pretty much unless you live in a bubble in a safe space).

Chronic shock, is seen, but rarely described as such, instead being given the moniker of “early stage” or “compensation” for an underlying disease process. A good example of this is heart failure. Heart failure is a response to stressed myocardial cells. In order to maintain cardiac output, we see compensatory mechanisms like faster heart rate, narrowing of blood pulse pressures, early stage hypertension, late stage hypotension. We see late stage cardio-renal disease, which is just the chronic form of AKI in acute shock, by the same mechanisms. Any person who is suffering from a chronic disease is, for all intents and purposes, at a baseline of compensated shock. As we know, this takes a toll on the body and over time, the victim transitions from well compensated to decompensated, with the entire purpose of medical care and support to slow or reverse this process.

The treatment of shock comes in 2 stages, regardless of whether or not it is acute or chronic. The first stage is organ support. Which is probably more accurately described as “system” or “organism” support. This support is designed to reduce stress on other organs and systems subsequent to the underlying cause. This is best demonstrated in general anesthesia, where shock is induced in the patient, and numerous monitoring and organ support techniques are then applied to maintain the level of shock, preventing both decompensation>MODS>MOF>death, as well as normalization secondary to compensation, aka the patient waking up with full function and awareness.

The second stage of the treatment of shock is the repair or regeneration of the underlying cause which incites it. This may take the form of restoring blood flow and subsequently O2 delivery to an infarcted myocardium. It may be the resolution of an infectious process, surgical reconstruction to maintain homeostasis in some way, such as fixation or amputation. It may be any number of medical treatments, such as mechanical ventilation or antibiotics.

I think the most common mistakes for providers attempting to treat shock patients is the oversimplification of what shock is and the lack of awareness that system support is entirely different from treatment of the underlying cause/cure.

This misperception that shock is a disease process, rather than a point in diseases process drives the over-simplification of both its teaching as well as attempts at treatment. This is seen by patients progressing in decompensation despite various established and long-standing treatments expertly applied as well as numerous conflicting study findings of various treatment modalities when applied to shock patients universally, rather than individually.

Because shock affects every system in the body and the entire purpose of all the body’s systems is to maintain homeostasis, the complexity of this I attempt to describe as a set of scales with multiple parts to balance. Applying any treatment to one part of the scale affects every other one. Contrary to more antiquated thought of “doing as much of nothing as possible”, which in a shock state seems rather negligent, and certainly not expert to me…”Do nothing and if the patient lives take credit, if they die deny responsibility”, I profess that to successfully treat a shock patient, precision of treatment, applied at the proper time is the key to success.

Good examples of this range from treatments such as blood transfusion in hemorrhage to steroids in sepsis, and even catecholamine uses in cardiac arrest. There are no shortages of studies which are inconclusive or conflicting. The 2 things missing from many of these studies however are: 1. the differentiation of patient cohorts, with many being lumped into overly broad categories in order to reach statistical significance and power and 2. The utter lack of account for timing of the studied treatment. If you are treating an illness that changes over time, certainly when you apply that treatment is significant in any observation?

Another aspect of shock treatment that I would say is oversimplified is the focus on fixed time points rather than a continuum. Patients don’t just suddenly go from compensated to decompensated to MODS, MOF, death. There is a steady progression from initial stress response, increased physiologic response, early, middle, and finally late decompensation and then through the MODS>MOF> death pathway.

It is also why I am so opposed to the term “irreversible shock”. When exactly is that? Nobody knows until the post-game wrap up. Irreversible shock is MODS>MOF. A time when organ support and medical treatment can no longer maintain homeostasis. It is at this point in time where biochemical and molecular cascades have progressed passed modern medical intervention.

This leads right in to the importance of early recognition and treatment of shock. Since modern medicine lacks the ability to stop or reverse these biochemical cascades, it becomes more important to recognize and treat patient conditions before they reach that stage. In the modern era, shock is the final stage in a disease process where it is possible to intervene. Hopefully one day that will change, but it will not be in the next few years (probably not the next decade, but I remain hopeful).

If you want to be expert, or even successful at treating shock, you have to really understand it, not just some oversimplified explanation of failure of delivery of DO2. You have to see it as a progression over time, not as fixed points. You must understand and recognize the difference between organ support and curative treatment. Finally, you must be accurate and precise in both the type of treatment as well as the timing of them in order not to unbalance one or more scales attempting to balance 1 or 2 others.

The understanding of shock is a river both a mile deep and a mile wide. I would go as far as to say it could be a medical as well as academic research discipline all to itself. Shock is completely unsuited to protocolized medicine.  Treating it is an art, which requires masterful understanding of basic science, before clinical science can even be applied. Especially because of the different physiology and compensatory responses in different age groups.

I hope this has given you at least an insight as to how complex and underestimated shock really is.

Reliving yesterday’s glory

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Quick correction, this video was shared on the NAEMT website, it was created by DHS. That was my mistake in reading the origin of the original post.

First, a few housekeeping items…

This website keeps track of what countries and IP addresses visit this page. What they read, how often, etc. So I know people from every continent are reading this…

It is ok to comment or even say “hello”, and generally as long as you don’t tell me I have no idea what I am talking about you will likely receive a friendly reply.

If you don’t like what I have to say, in your browser up in the right hand corner, there is an “X” and if you press it, you will not have to be bothered by my writing anymore.

In my mind and learned values, “professionalism” means being honest about short-comings, identifying problems, using peer pressure to change undesirable behaviors, and striving to be better than yesterday, not hiding our mistakes and deficiencies to save face.

If you want to be told how deserving and great you are…ask your mom. (She would probably enjoy a call from you anyway) But I call out bullshit when I see it, in my culture, an honest person is held in higher regard than a liar, even if that lie makes you feel good about yourself.

Now then… Let’s get down to it…

I have done my best to remove myself from EMS on social media, and for the most part I am doing well…I haven’t been embarrassed by being compared to the most inept paramedics in months. I haven’t been told how stupid I am for knowing more about sepsis than lactate measurements and surviving sepsis guidelines. (and if you want to kill a septic patient, “surviving sepsis” is a really good start, and lactate is just a number for administrators to bill for and defend their treatments with.) My blood pressure is lower, and I waste less time “educating” people on social media.

But the fact remains I have many friends still in EMS and the fire service and their posts do show up on my wall…Every now and again, like today, it is usually something so stupid I feel compelled to speak about it. Perhaps it is pride in my history and achievements, perhaps I want to give something back to what has given me so much, perhaps I am just a glutton for punishment, but today something crossed my page that not only embarrasses me, but harms the people and profession that so many work so hard to advance. It is without a doubt the most stupid thing on the internet today, even more so than US presidential politics. Normally I do not grace this kind of stuff with a link, but this was so offensive, I want there to be nothing left to the imagination.

Here it is…

EMS has a problem. A big problem. It destroys the people who work in it. Multiple jobs to make ends meet, unsafe working conditions, high stress, largely not included in programs directed at safety forces like Police and Fire, suffering from an identity crisis for about 5 decades, and to top it all off, seemingly hell bent on making sure its workforce can be totally replaced by 2 men and a truck with a computer.

Let us pick it up from the beginning?

There are 2 main philosophies to EMS around the world. The older one was developed by the Germans. The idea of bringing the most advanced care possible to the patient. This is often done with physician level providers, but not exclusively. The EMS providers down in Australia (who in my mind, and others, have the most advanced non-physician EMS in the world by a long shot) decided they were going to make their medics as capable as any doctor. They have achieved that goal by most measures and if anyone is looking for a system to emulate, consider this my endorsement of them. They are determined, forward thinking, have adopted education and scientific research to guide and improve their treatments as well as provider health and safety. They embody all modern EMS should be. They are not perfect, and I have been personally called upon to help with improvements by a few of their folks, but their hearts and minds are in the right place and they will go forward.

The second philosophy, developed in the 1960’s and credited to the USA is the idea of a few minimally trained providers providing “simple, life saving skills” and driving the patient to the hospital, where “definitive care” (whatever the fuck that means…) can be found.

One of my mentors from the fire department, and easily one of the most skilled and greatest fire/medics I have ever met, once said to me “The fire service (and by extension EMS, because we did both) is the last non-military job a non-educated white man could get he could be proud of.” Now without looking into racism and nepotism et al. in the fire service, at the time I thought he couldn’t be more wrong. But I have come to see not only how right he was, but the wisdom in it. One only has to look at the demographics and the many court cases discriminating against women, minorities, etc. to see the truth to the racial component. When I first started on the FD (As my friend from Mumbai once said the first time he got intoxicated at a party, I am “whiter than Casper the friendly ghost”), and my parents could not have been more proud. I could not have been more proud. But in the US, this is not unique to the Fire Service, it extends to Police, and of course…EMS.

Many US EMS leaders (and there are some notable exceptions) are old people. Their idea of EMS education is simply a set of skills, similar to a trade, that anyone with a high school diploma or GED can learn in between 750-1000 hours of non-university level education. They realize, and I fell into the same category myself, it was the best way to get a chance at working in public safety or medicine if you could not go to college (either because you lack the mental capacity or the financial means). Many of them rightfully claim they are pioneers, type A personalities that almost never fit in, who were(are) totally expendable to society, doing things those with higher education do and being successful. They have earned respect, admiration, and thanks, paid for with their very blood and totally consuming their lives.

But those days are over! They are not coming back, and it is time for them to get a lifetime achievement award, a gold watch, and if they want or need to stay (it is not easy to let go of a lifetime that defines a person) removed from leadership and given a more consigliere position.

All over the world, the US EMS philosophy is being proved inferior in patient care, economically unsustainable, and not meeting the needs of the infirm in today’s society. It has run its course and its days are done.

In the 1960s and up until about 1985, medical knowledge was by today’s standards elementary and in many cases outright wrong. We have seen more advances in medicine in the last 20-30 years than the totality of medical advances in history prior. We know the only acute pathologies are some poisonings and trauma (to include burns and other forms of new onset shock). Everything else is either chronic or acute on chronic disease (that includes flora disturbances and neoplastic diseases).

The idea of showing up with lights and sirens on a blazing steed and saving the damsel, or at least the geriatric in distress with a endotracheal tube an 1000ml of normal saline are over. Backboards and all other manner of “life saving” gadgets and ideas are failing fast. Technology is even accelerating this. Today there are hand-held ultrasounds, portable computer tomography being deployed on ambulances all over the world, and machines that can not only analyze, but defibrillate lethal arrhythmias without human intervention. They are even being placed in public spaces and put on drones.  (If you are one of those folks who spends years obsessing over EKG readings and electrophysiology, bad news, that skill is going to be nothing more than a parlor trick in a few years because the computers are getting better at it).

Technology isn’t going to “help” EMS do what it has done for the last 30 years (as in the video), it is going to revolutionize it. It is not going to look anything like what it did. Just as medicine today doesn’t look like it did 30 years ago. EMS providers as the US currently trains and uses them in large sections of the population are going to be replaced by a handheld computer and 2 dudes who can drive and push the stretcher, and will be paid and respected about the same if they continue the practices of yesterday.

Historically, I always found myself at the change between old and new ways. I was in the fire service during its change, I was in EMS for theirs, I am in medicine for theirs. I was also a child when computers were just starting to be available at home (Got my first TSR 80 MC10, when I was 6, my dad bought it used with a tape recorder to store programs on, and when my mom protested the purchase and I had no idea what to do with it, bluntly stated “this is the future, everyone has to learn how to use this”), and I had an internet account before AOL existed, when there were only 19 different locations on the internet. (Let’s not delve into how that happened, we would have to call it “alt law”). So I understand change.

As proved all over the world, the American EMS system is a dinosaur. Its days are over. The German system of bringing the most advanced care to the patient has proved its superiority hands down. It will no longer be economically or socially valuable to do a few skills and drive to the hospital by 2 people in a modified pickup truck that graduated high school.

The future EMS provider is educated, not only to the 4-5% of conditions that they see and define as “emergencies” by 1970s medicine, but to all forms for chronic and acute exacerbations of chronic disease and how to treat it. They are the “community” healthcare providers, outside of the ivory towers, whose goal is to prevent hospitalization and all of its associated costs. They will be called upon to direct patients to the most appropriate care for both medical and social needs. They will not be high school grads, who got 750 hours of training at “the academy” and OTJ guessing of who needs a hospital and who doesn’t. They will not be these people who 40 years later stumbled through a public safety management course or college credit for life experience. The level of entry will be on par with other civilized countries demanding bacheolor’s and more advanced degrees. They will be expected to not only know what to do and why, but to research, and use technology not as an adjunct, but intrinsic to optimal independent patient care. “This is how it is on the street” and “diesel bolus” where hopefully the nurses and doctors will be able to pick up the slack are likewise over. Particularly when medics are functioning in austere or other remote conditions. A pulse, a cert, and 5 years “experience” will not get the jobs of the future.

That is why I take issue with this video, and why it is so pathetic. Forgetting how EMS might have a self-driving car, but somehow there is a massive accident between other self-driving cars for a second, as safety and technology improves, the role and need for EMS in such incidents will decline. The simplistic triage will be replaced. The need to “transport” patients to the hospital will decrease. If a EMS provider can put on a wireless diagnostic and read a patient’s “vitals” I can equally see them at the hospital in real time and with telemedicine a treatment totally independent of the need for anyone else’s input. I still haven’t figured out why the providers are wearing stethoscopes with such technology, but an ultrasound is nowhere to be seen. In medical school one of my professors once chastised a student “that is not a piece of jewelry around your neck, it has a function and a purpose, learn how to use them!” Will a stethoscope even be needed? I rarely use mine anymore. Don’t even carry it around in the hospital.

High flow O2, a backboard, and driving to the hospital is the medicine of dinosaurs. It is the best idea they could come up with with their limited integration of technology and education. Forget me, imagine what younger generations, people of my daughter’s generation, who had smart phones from the day they were born will do with technology! With Medicine using molecular and genetic manipulation! The education they will need will far in exceed a few hours at “the academy” and their economic stressors will make driving every patient to the ED impossible.

Maybe the NAEMT is just pandering to the lowest common denominator of US EMS provider, for prestige, membership fees, or even just imagining reliving the glory days with a smart phone? Maybe they are just using the political technique of anti-intellectualism in order to appeal to their base of support? But this video shows a gross lack of insight and foresight, and I hope that more capable modern providers and leaders will stop sending money to these people to make their pitiful videos, and spend it on associations that advocate real and substantial education, not 2 day card courses, and a future provider whose value to society exceeds 2 dudes, a truck, and a smart phone.

I haven’t even begun to touch on the integration of EMS fellowships and opportunities for physicians in North America, NPs and PAs in an EMS role, et. al. But I also stand by my position, if the US and other systems using the US skill and transport philosophy do not get their heads out of their asses, in a few years, nursing will completely take it over and they’ll all be “unlicensed techs” at the direction of a nurse on the most critical patients anyway, and their pay and working conditions will reflect their lack of value.

Though there still may be a supervisor on-scene not wearing any safety equipment while the rank and file are doing as they are told and not what they see their leaders do.

In any event, without advancing the education and technology of EMS, it won’t be a job to be proud of much longer. If it even continues to exist independently at all.

Anyway, I am sure I will get every idiot on the internet sending me hate-mail now. They always come out on the EMS posts…