Avoiding the first Casualty

Polyidiotitis : Diagnosis and Treatment.

It has been said that the first casualty of any war is the truth. Undoubtedly true. During an emergency, the first casualty is usually common sense. During a large-scale event, such as a Hurricane, Polyidiotitis, an insidious and serious disease, runs rampant.

No one is immune, and the symptoms may not always be obvious early on. Even professional responders have been known to contract this oft times embarrassing and sometimes deadly disease. Etiology of this disorder is poorly understood, but clustering of cases is common, suggesting a human-to-human vector.

Person’s afflicted with this disease often exhibit the following symptoms. Rapid pulse, increased blood pressure, rapid, oft times shallow breathing, and bizarre psychiatric manifestations that include, but are not limited to, a feeling of invulnerability or immortality. This may be a dissociative disorder, as victims of Polyidiotitis seem to lose any vestige of situational awareness. They develop a narrow focus, a tunnel vision of sorts, that diminishes their ability to make rational decisions.

Clearly there is a disconnect in the patient between reality and their perception thereof. Victims of this disease may argue, quite convincingly, that there is absolutely nothing wrong. When confronted, they may even become combative.

Those in close contact with these subjects must take care not to become afflicted themselves (see Lemming’s Disease).

A paradoxical response is sometimes seen in Polyidiotitis, characterized by denial and decent into a semi-fugue state. These victims, while not exhibiting the classic symptoms of Polyidiotitis, are just as profoundly affected. They often fail to take action, or prepare, in the face of an advancing threat. Indeed, their dissociation may be so complete that they simply are unable to accept that any threat exists.

While the manifestations of Polyidiotitis can vary widely from subject to subject, there are certain commonalities the clinician must look for. The most widespread of these is an utterance when faced with a clearly dangerous situation, referred to by specialists as “Famous Last Words Syndrome”, that generally involves the phrase, “Hey, guys. Watch me do this!”

This is a devastating, but clearly diagnostic sign. By this time, however, the disease has fulminated to the point of crisis, and the victim may no longer be salvageable.

Early detection and intervention is the key. Watch for these specific warning signs.

If a subject decides to go surfing or swimming within 24 hours of a land falling hurricane, they may have Polyidiotitis.

If a subject stocks up on canned food, selecting items with bulging lids because `there’s more food in those’, they may have Polyidiotitis.

If a subject buys and installs a generator inside their house or garage, they may have Polyidiotitis.

If a subject insists that candles or kerosene lanterns are safer that battery operated lights during a hurricane, they may have Polyidiotitis.

If a subject decides to drive or walk around their neighborhood during the eye of the storm, or travels long distances to view an area of destruction after the storm, they may have Polyidiotitis.

If a subject is found walking about after a storm barefoot, they may have Polyidiotitis.

If a subject fails to evacuate, or board up their home, or check to see if they have adequate supplies on hand to weather the storm, they may have (paradoxical response) Polyidiotitis.

Treatment: Until additional research is completed, treatment options are limited. Containment should be of paramount concern, as the potential for widespread contamination is serious. Talk therapy, or in extreme cases, temporary confinement, appear to be the only courses of action. While victims may be stabilized by such measures, this is not indicative of a cure. Relapses are common.

In summary: Attempts to have Polyidiotitis placed on the CDC’s list of Rapidly Emerging Infectious Diseases has thus far failed. Nevertheless, researchers believe that, given the rate of growth of this disorder, it is only a matter of time before the true depth of this epidemic is fully appreciated.

Today there is no cure. While scattered cases are reported everyday, true outbreaks seem to occur just before, during, and after large-scale natural disasters. Thus far, these outbreaks, much like flare ups of Ebola in equatorial Africa, are self-limiting.

However, it should be noted that the susceptibility to this disease seems to be increasing. Previous generations, while not immune, appear to have had some natural resistance. Environmental toxins (ie. TV, music videos, video games, and unprotected exposure to mass media) may play some part in the development of this disease. More research is clearly needed.

Hurricane Stress: Before, During, and After

While tracking the storm can be an exhilarating pastime, enduring the storm, and it’s aftermath, can be something else entirely. I suspect that long-term, the stress of these storms claim more lives than the winds do. BEFORE: The buildup to the arrival of a Hurricane is probably more stressful today than ever before. Why? Because we know it’s out there. Often for days or weeks in advance. We can track these storms, watch them grow, and we then look around and envision the damage and disruption to our lives that is advancing towards us from just over the horizon. Those of us who live in the path have more at stake financially than ever before. Homes are more expensive, as is the cost of insurance. We depend on our infrastructure more today than at any time in the past. Cable, Internet, phones, electronic banking . . . things that didn’t exist 40 years ago, and are integral to our lives, can be disrupted. We also know, deep in our hearts, that we all live a little closer to the edge financially than our parents. How many people are just one paycheck away from being homeless? A Hurricane, and the disruption to their lives and employment, is an ominous threat to their lives. And of course, for the survivors of previous storms, the specter of going through it again is paramount. If it was bad the last time, will it be as bad this time? If they were lucky the last time, will their luck hold? The mind reels and the stomach turns. Putting up plywood, filling the bathtub with water, and checking evacuation plans are not just mechanical steps taken by those familiar with storms. They are stress-producing reenactments of the last time their lives were altered. And as the stress, and anticipation builds, the body begins to generate adrenalin. Cortisol levels may drop. Emotions may run high. Depression and despair, along with a sense of fatalism, may prevent some from taking appropriate action. DURING: For some, a Hurricane is a grand adventure. A near miss, or a low cat storm can be very exciting, and may not produce an inordinate amount of stress. At least not in everybody. But a big storm, one that forces you onto the road in an attempt to flee to safety, or one that locks you into an interior closet with six relatives for 12 hours, will produce enormous amounts of stress. During a crisis, some people cave, while others rise to the occasion. But make no mistake; even those who act valiantly during a crisis do not go unaffected. They simply delay the effects, suppress the emotions, and will pay, one way or another, at a later date. Cops, firefighters, paramedics, doctors and nurses are often exposed to extreme stress, and most of the time they react admirably during the crisis. They rely on training and the appropriate directing of the adrenalin in their systems. Afterward, what most people rarely see, are the shakes, tears, and vomiting that sometimes comes when the adrenalin bleeds off after a particularly bad call. It isn’t a weakness, or a failure on their part. It is a natural reaction to the chemicals released into the body. Epinephrine and norepinephrine are powerful drugs. The psychological effects last long after the physical ones. Most responders won’t talk about their dreams, but I can assure you, they are not pleasant. And they never go away. The longer a crisis lasts, the harder it is to deal with. And the longer the effects will last. A car accident may only last a few seconds, but can change a person forever. Imagine the effects of lying in debris, your house collapse around your, perhaps with loved ones unaccounted for, for hours. Some people have endured this sort of thing for days. No matter what, no one walks away from a major Hurricane unscathed. AFTER: During WWI and WWII it was called shell shock. Today, we call it PTSD. Post Traumatic Stress Disorder. It doesn’t require being hunkered down in a foxhole during a mortar barrage to get it. Hurricanes, car wrecks, and even long term financial or medical problems can precipitate it. It’s very real, and it produces distinct physical changes in the body. The stress of living in third world conditions for days or weeks, looking for lost friends and relatives, rebuilding, finding a new job, or recovering from injuries is enormous and should not be underestimated. Hormone levels, and naturally occurring opiates released in the brain, along with thyroid levels are all significantly altered by PTSD. Corticotropin releasing factor, CRF, which serves to jumpstart people into acting during a crisis often remains elevated in these people, for months and sometimes for years. They may appear `jumpy’ or `nervous’ to others. It happens more often, and to more people, than you can imagine. And no, you can’t just tell someone to snap out of it. The long-term effects of these storms is poorly understood. How many heart attacks, suicides, or psychiatric disturbances they inspire is unknown. But you can be sure, they are not insignificant. And with the portent of an active season, these costs could be enormous. A great link on PTSD, and the effects of stress is provided at the bottom.

Link: http://www.nmha.org/camh/anxiety/ptsd.cfm

Disaster Medicine : Pearls # 2

Disaster Medicine Pearls # 2

The Realities of CPR.

A cardiac arrest, or `code’, is the gravest emergency any responder will ever face. Yet, ironically, with proper training, a responder may save a victim with nothing more than his hands, mouth, and brain. Go figure.

To deal with a cardiac arrest you need to take CPR training. Please don’t assume that, by watching ER, or viewing a website, that you know how to perform BLS (Basic Life Support). CPR requires specific motor skills that can only be adequately learned from practice. This pearl will not, therefore, attempt to teach CPR. You need to take a class for that. Instead, I will focus on what your CPR instructor may not tell you.

In CPR class you will learn how to assess a patient, clear an airway, how to position the head, how to monitor vital signs (pulse, respirations, pupils), and how to properly perform compressions and ventilation. You will learn the mechanical skills needed to provide BLS. If you haven’t taken a class, do so immediately. If you haven’t had a refresher course in a few years, take one.

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SAFETY : Electrocutions are a fairly common cause of cardiac arrest. As a BLS provider, ALWAYS inspect the scene before approaching an unconscious patient. Look for wires, water on the floor, or any other hazard that could endanger your life or safety. Don’t endanger yourself while trying to save someone else.

Additionally, some people have been known to attempt suicide by ingesting caustic or poisonous chemicals. DO NOT DO MOUTH TO MOUTH in these cases. If you detect the strong odor of chemicals or pesticides on the patient’s breath , and don’t have an ambu-bag available, accept that the patient got his or her wish.

Please know that working a code is hard work. Two person CPR is easier than one person CPR, but it too can be strenuous. Add to this the adrenalin and stress of dealing with the situation, and a rescuer with a heart condition may be risking THEIR LIFE doing CPR. Sadly, I’ve seen this happen. An ambulance `attendant’ (pre-paramedic days) in his 60’s died in St. Pete doing CPR. Ambulance pulls up to the ER, the driver gets out, opens the back doors, and has a double code on his hands. In that case, neither the patient nor the rescuer survived.

A reasonably healthy person should, however, be able to perform CPR for 20 to 40 minutes without problems. But if you begin to experience chest pains, or difficulty breathing, IT IS TIME TO STOP. Let someone else take over, or call it a day. Don't add to the body count.

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EMOTIONS : During a medical crisis, some people panic and flounder about, while other’s rise to the occasion. Everyone reacts differently. Parents are notoriously bad about dealing with an injured or sick child. Their inclination is to hold or cradle a child instead of rendering substantive aid. You have to learn to detach yourself, at least for the duration of the emergency, in order to be effective. Even when dealing with your own children.

You must put aside your emotions, take a deep breath, and deal with the problem at hand. Otherwise, you are simply part of the problem, not the solution. If you can't handle it, get out of the way and let someone else do it.

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STARTING CPR: The first consideration for a BLS responder is whether it is appropriate to administer CPR. Here we get into an ethical question, and if Dr. Lou has some additional input, I would welcome that. All I can do is offer my opinion.

Generally speaking, unless the patient has been obviously `dead’ for more than 20 minutes, or you know the patient is in the last stage of a terminal illness, or the patient has sustained obviously mortal injuries, CPR should be started immediately.

Sounds simple, but it isn’t. What constitutes a `mortal injury’? How can you tell if someone has been `dead’ for more than 20 minutes? How can you know the patient’s medical history and/or wishes?

First, if anyone is around who knows the patient (relative, friend), ASK!. They can often tell you if Old Max is in the final stage of liver cancer or not. But understand, you can’t know what you can’t know. Better to err on the side of caution and administer CPR than to withhold it from a potentially viable patient.

Mortal injuries generally involve the head. If the head is some distance from the body, you can forget about CPR. If large amounts of gray matter (brains) are beyond the confines of the skull, cover the victim up and move on. But please know that many other, terrible looking injuries, are survivable. If transportation to a trauma center is possible within the first hour, even devastating injuries can sometimes be salvaged.

When faced with a non-breathing, pulseless patient who has been `down’ for an unknown length of time, there are a few clues that can tell you if the patient is viable. No, there is no surefire way to determine if the patient has been in arrest for 15 minutes or 30. But beyond 30 minutes, changes do occur in the body, which are fairly easy to see.

Skin color and temperature are big indicators. Deep cyanosis (blue coloration) and cold skin are an indication prolonged cardiac arrest or death. If the body is beginning to stiffen, then rigor mortis has set in, and the patient is long gone. And dark pooling of blood at the lowest point of the body (livor mortis) usually does not occur until several hours after death. But in my experience, the eyes are the best short-term indicator. The pupils will cloud over, dry out, and become lackluster begining about 20 minutes after death. They will be dilated and non reactive to light. That, when combined with other signs, can give you a clue.

If the victim’s skin is cooling, deep cyanosis is present, and the eyes are dilated, fixed, and clouding over, then you are probably too late to the party. But unless you are absolutely certain it is too late, initiating CPR is still appropriate. The `code’ can be stopped by the ALS team when they arrive or by the doctor in the Emergency Room.

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How long should I do CPR?

Under normal (non-disaster) conditions, help can nearly always be summoned (first step: CALL 911) and should arrive within 20 minutes. During a hurricane, or other disaster, help may be hours away. This will make a difference, on a practical level, for what you can reasonably do. The standard recommendation is that once CPR is begun, it be continued until ALS trained rescuers can arrive. If you are isolated, cut off, and no help can be reasonably expected within an hour, you will have some very hard decisions to make.

CPR alone will rarely re-start a heart. Yes, I’ve seen it happen, particularly with a witnessed arrest, but it is an uncommon occurrence. And if it’s going to happen, it will generally happen in the first few minutes of resuscitation. If no help is forthcoming, and the patient has not responded after 30 or 40 minutes, it’s time to think about calling off the code. Cases involving hypothermia, including drowning, have a better chance of survival than other cardiac arrests, even after a significant amount of `down time’. And the younger the patient, the more likely you are to have a good outcome. But even in those cases, if more than an hour has gone by, it’s time to accept the finality of the situation.

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Expectations: Even with ALS equipped and trained personnel on hand, the best we seem to be able to do is a 50% survival rate. In many areas of our country, where response times are long, less than 10% survivability seems to be about average. If ALS is more than an hour away, well . . . let’s just say miracles sometimes do happen.

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Liability : We live in a litigeous society, and many people fear that learning CPR will somehow embroil them in legal liability issues. The lay public has no `duty to act', meaning that no-one can legally force you to use your CPR training, nor can you be held liable for not using it. The Good Samaritan laws in nearly every state protect you if you decide to render assistance, as long as you do so in good faith, without intent to cause harm. Even if you do something wrong, if your intent was to help, you are not liable.

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Dealing with Death : This is something that is rarely covered during CPR class. And in my humble opinion, ought to be.

The odds are, if you are called upon to do CPR, you are probably fighting a losing battle. If ALS help arrives within the first 20 minutes, and you have done timely and effective CPR, a good success rate would be perhaps a 30%. That’s a best-case scenario. Reality is probably less than 20%. A spontaneous re-start of the heart, without the aid of ALS, will happen perhaps 5% of the time. Still, that’s better than zero.

Patients in cardiac arrest, despite the best efforts of their rescuers, often die. You need to be prepared for that.

Know that, by learning CPR, and using it, you gave your patient a chance. A chance they wouldn’t have had if you hadn’t taken the time and the trouble to learn this procedure. If the patient dies, you did not fail. You did all that you could do. You tried. No one could ask for more.

When the loss involves a friend or a loved one, it is 1000 times more difficult to deal with. There are no words I can give that will mitigate this loss. I wish there were.

All I can tell you is that this is the single best reason to learn CPR. Knowing you did everything possible is the only salve that may someday help heal that wound. Don’t put it off. There are some things in life you will never forgive yourself for.

Don’t let this be one of them.

Final Note: If you are at a public place, a hurricane shelter, for example, and a cardiac arrest occurs, check to see if an automatic defibrillator is available. They are often mounted on the walls of auditoriums and other venues. These are truly lifesaving devices, and are very easy to use. Just follow the illustrated instructions on the cover.