AUG
08

 “I wouldn’t do this if it was a real incident" (my personal story)

I was going through advanced training with the tactical team that I had recently joined to provide medical support. I was very excited to make the team and wanted to put my best foot forward. We were at a large training facility where all training is performed using simunition, or paint rounds in the weapon systems.

The medical support personnel carry weapons should they have a need to defend themselves. However, we also would perform the same task as everyone else. I would imagine this was largely for team building and confidence. While many of the skills do not transfer directly for medical providers there are translatable lessons that can benefit these drills. 

The current evolution was a simulated hostage rescue in a commercial jet, with “green man” targets being hostages and white silhouette targets being hostiles. I entered the cabin with a seasoned SWAT officer and we began clearing the area. We found a main cabin filled with simulated hostages and a closed door to the cockpit.  We each engaged one hostile in our area of responsibility moving through the cabin. I had no issues target discriminating between friendly and hostile targets in this setting, but I had additional time to do so because the area was large and I had a full view from the time I entered.  

We then encountered a closed door leading to the cockpit. My partner quickly opened the door and I had first eyes in the room. What was revealed to me was a friendly silhouette with a hostile behind them exposing only their head and a portion of the chest. This is to simulate a person being held at gunpoint. I knew that time was of the essence. My eyes quickly focused on the front sight post of my handgun, making it appear crisp over the slightly blurred target. My right index finger moved from resting on the side of the gun, to the trigger and carefully but quickly increased pressure on the trigger until one round fired. I saw a paint round strike the target I had aimed at and it was a good hit! I quickly re-acquired a sight picture and fired another well-placed hit right next to the first - on the head of the target.

The instructor called out “index” signifying the end of the exercise. He complimented me on how quickly and accurately I fired the weapon, but then asked me why I shot the hostage. Looking up I could see two blue paint splotches on the head of the green silhouette.

What changed from the cabin to the cockpit? Is it fair to say there was internal pressure to perform flawlessly and act very quickly? Of course. It is this additional stress and pressure that can transition a person from the stressful situation of clearing the cabin area to something perceived as possibly threatening to neutralize a hostage-taker as quickly as possible. This is no different than what happens during the performance of critical tasks for medical providers.

Up to this point, I had served this police agency as a reserve patrol officer for the past 12 years. Each year I qualified at expert level for various weapons systems, using these same “green man” targets. What I failed to recognize this day was that this had left me with a conditioned response to shoot that target. In a situation with elevated stress and pressure humans will often default to that which is known. Should this default be an undesired action, we refer to this as a “training scar."

 

What Happens When We Process A Sensory Impulse

1. The impulse is channeled through our thalmus by our nervous system. 

2. The thalmus sends the information to our “thinking brain” to form a rational, organized response. At the same time, our hippocampus (responsible for cataloging old memories) searches for a similar scenario that we have already been through to test the response. 

 

Should this cognitive appraisal lead us to feel that we did not have the equipment, ability, and/or prior experience to handle the current situation we feel more threatened than simply challenged.Challenge or arousal can enhance performance to a point, but threats can cause a more emotional than rational response.This is very basic description of the process. The main point of this blog is to help provide understanding of training scars.How many times have you heard, or maybe said yourself:

 

 “I wouldn’t do this if it was a real incident."

 

These words almost always precede moving in the direction of training an undesired response. Humans have proven time and time again that under stress we will perform the way that we train.  For this reason, it is imperative that simulations be as realistic as possible, avoiding a development of bad habits.  This includes both cognitive and psychomotor tasks.  We should try to avoid simply “verbalizing” treatments or medications being administered.  It is important that we perform these skills in context to give useful prior experience to draw upon when time is of the essence. Please keep this in mind when developing training scenarios and your own mental simulations.

There is a happy ending to this story. We are not completely powerless when it comes to how we handle stressful situations. There will be more to come on this in subsequent posts from me. I hope that you have enjoyed this and that it helps you not set yourself up for failure. Fortunately for me, a couple of rounds later, a veteran officer made the same mistake. It is true that sometimes misery loves company!

              

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AUG
03

Mothballs, Crowbars, and Blue People in Kentucky

In 1960, Madison Cawein III was a freshly graduated Hematologist. He was displaced from the hallways and coffee shops of Lexington into the rural hills of moonshine country. He was no longer a doctor in a lab or clinic, he was an investigator chasing a legend. Through small talk amongst his colleagues over meals or in casual get togethers he had heard rumors of a unique family living in Eastern Kentucky. This family dwelling in the hills were your average rural family with one definitive exception; they all had dark blue skin. 

 

I was caught off guard to say the least. What little fluid drained into the bag at the end of the catheter was a dark and rusty brown color.

What had struck me immediately as I first encountered my patient was how cyanotic she was. Her nose, lips, ears and hands were tinged deep purple. Her work of breathing was increased, her shoulders heaving and the muscles around her clavicles tugged with every struggling breath. The smell of vomit lingered in the air and a small quantity of green bile lined the porcelain in the toilet. It had started as a headache, then nausea, then vomiting and abdominal pain. Though she had not noticed, her urine output plummeted. Dehydration, and possibly something more sinister was slowing her kidney function. She called 911 when she couldn’t breath. Now, around 24 hours after her first headache, she was lying on a hospital bed in a rural emergency department. 

A ventilator hissed in the corner and an IV pump with two bags of fluid or medication dripped regularly into a green capped catheter in her left arm. The nurse had placed a foley and I had watched the dark fluid run slowly into a foley bag. Labs had been drawn and sent to the lab. No other crews were out on calls so we spent some time in the ED watching and assisting in her care. My curiosity was there and I wanted to know what had driven a healthy 30 year old woman to a ventilator in 24 hours. She had no medical history. Her husband, quiet but visibly scared gave an uneventful history of her health that aside from some minor dental surgery was completely empty. 

The doctor walked in moments later. He scratched his forehead and looked at the sedated patient.

“She has methemoglobinemia”. He said looking back down at his pen and paper. 

“Oh okay cool”, I responded. ”whats methemoglobinemia?”

Truthfully, I knew that methemoglobinemia was a disease. I had heard a few rare stories regarding pediatric cases and knew it was related to teething medicine. And…well yeah that’s it. So coffee in hand and computer open I ventured forward…and called Tyler to ask him what methemoglobinemia is. 

Methemoglobinemia is the condition of having an abnormal percentage of methemoglobin in your total hemoglobin. Why does this matter? Hemoglobin carries oxygen, methemoglobin does not. 

Picture yourself standing in line at a lazy river. As people exit the tubes upstream, the line files into the river as empty float tubes pass by and are snatched up by the people in line. Oxygen binds in a similar fashion to hemoglobin. The opposite charges of the oxygen molecule and the iron molecule attract each other and bind together. Now you have oxyhemoglobin. Your oxygen is on its way to the bodies tissues. 

Illustration by Austin Quillet @QuilletAustin

But now imagine the lifeguard steps into the river and begins placing fence posts into the seats of some of tubes. Now no one can sit in those tubes. So they float unoccupied for another cycle. Meanwhile, people who already have tubes are scared to give there tube up in case they can’t get another one the next go around.  Methemoglobin, its iron heme blocked by two hydrogen ions, cannot host an oxygen molecule, reducing its carrying capacity and causing the remaining 3 hemes to aggressively protect their oxygen binding. 

Methemoglobin occurs naturally in the blood stream. Between 1-2% of hemoglobin at any time. Thats not a big deal! You’re still working with over 90% of your hemoglobin at full carrying capacity. But what happens when more and more hemoglobin begins to take on hydrogen ions and convert to methemoglobin? Your oxygen carrying capacity begins to fall…

When Dr. Cawein arrived in Hazard, Kentucky his saving grace was Ruth Pendergrass. She not only had heard the rumors, but had confirmed them herself. She was a nurse at a small clinic and had treated a woman with blue skin.  What stood out to Ruth was that despite her profoundly cyanotic appearance she had no symptoms of illness or oxygen desaturation. She had only come to the clinic for a routine check. Dr. Cawein had a suspicion that these individuals were suffering from methemoglobinemia. But without bloodwork it couldn’t be confirmed. He needed to find a patient. 

Why did my patient have methemoglobinemia? She was a healthy woman in her thirties who took no medication and seemed to live an active lifestyle. 

I don’t know. Writing this article today, I still don’t. I tried to follow up with the hospital system. I know she lived but I don’t know why she got sick in the first place. But there are a few reasons why people develop this rare disease. 

Medication reaction is the most common. Pain medications utilizing topical anesthetic (benzocaine, lidocaine etc) are a risk factor and are the most common cause in the pediatric population. Certain antibiotics, nitrate containing medications and even Reglan have caused it in adult populations. Naphtalene poisoning from mothball ingestion has been a cause multiple times in suicide attempts and accidental ingestion.  The exact pathophysiology behind this is complex. The point being that these medications and causes although rare have caused incidences of methemoglobinemia. 

The second cause…genetics. 

Madison and Ruth had no luck in locating an individual willing to talk about their blue skin. They made treks into the local community but were either ignored or denied a conversation, no less a full assessment. Stunningly though, a husband and wife presented to the clinic for a routine check up. They were blue, very blue. This middle aged couple ended up being the key. They were open to assessment and research and honest when answering questions although skeptical that a medication called methylene blue would make them turn pink. Although not dangerously inbred, there was some distant relations in that valley between the families that inhabited it. Both sides carried a recessive gene that predisposed this family to methemoglobinemia. Due to the chronic nature of this, they were naturally polycythemic and compensated for the higher levels of the altered hemoglobin. Over time, with occasional treatment with methylene blue, the blue people of Kentucky became a thing of the past. 

I wrote this because I found this entire history fascinating. But I was also highly intrigued by my patient and the disease process. Sometimes there is no initial reason why they develop it…that we can ascertain. These patients need oxygen support. Its basic, but unless you have methylene blue on your ambulance that is your best place to start. Get them to a facility that has access to methylene blue. If the cause is environmental remove the environmental and toxic cause. Simple stuff, and rarely used…maybe it will save a patient’s life. 

 

 

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